Musculoskeletal
Doris Descorbeth, DO
Resident Physician
NYU Langone
Flushing, New York, United States
Sara Mermelstein, DO
Resident Physician
NYU Langone
New York, New York, United States
Chun Maung, DO
Resident Physician
NYU
Elmhurst, New York, United States
Yingrong Zhu, MD
Director of Oncologic Rehabilitation
NYU Langone Health
Harrison, New Jersey, United States
Doris Descorbeth, DO
NYU Langone
Flushing, New York, United States
A 48-year-old female with history of metastatic melanoma, status post complete left axillary lymphadenectomy with resection of the pectoralis minor and transposition of the latissimus dorsi muscle. Postoperatively, she developed lymphedema of the left upper extremity and chest wall, radiation-induced fibrosis with increased tonicity, and peripheral neuropathy. This case spotlights the complications of melanoma treatments and the essential role of physiatrist in recognizing and managing these sequelae to improve patient function and quality of life. Fibrosis and hypertonicity can occur after tumor resections and radiation, and botulinum toxin injections under ultrasound guidance should be considered as an effective treatment option.
The patient was subsequently treated with a series of therapeutic botulinum toxin injections under ultrasound guidance, receiving 50 units each to the left pectoralis major and repositioned latissimus dorsi. Following the procedure, she reported marked symptomatic improvement with increased shoulder mobility, neck mobility, and reduced tightness allowing her to resume swimming and continue physical therapy.
Discussions: Melanoma and basal cell carcinoma resections can produce unique physiologic consequences depending on location. Axillary or inguinal resections may result in lymphedema and chronic neuropathic pain, while resections involving digits or subungual regions often impair mobility due to residual skin tightness. Radiation treatment further increases the risk of fibrosis. However, there is limited research describing hypertonicity of the pectoralis and latissimus dorsi following axillary melanoma resection, and little evidence regarding the therapeutic use of botulinum toxin in this setting.
This case introduces a unique presentation of hypertonicity from post-radiation fibrosis and surgically altered anatomy, and the benefit of botulinum toxin in managing these symptoms. Ultrasound guidance was critical in this case, given altered anatomy from pectoralis minor resection and latissimus dorsi transposition. Real-time visualization allowed accurate targeting and differentiation of muscles for injection.
Conclusions:
