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CPC Competition - Pancoast Tumor
1. CPC Competition 2010
A story about shoulder pain
Farooq Khan MDCM
PGY1 FRCP-EM
McGill University
April 5th
2010
2. History
ID: 60 y.o. male
cc: Right shoulder pain
PMH:
Hypercholesterolemia,
Depression,
Fall 6 years ago with rib fracture and pneumothorax
Meds:
Ezetrol 10 mg po qd Lipitor 40 mg po qd
Prevacid 30 mg po qd Wellbutrin 300 mg po qd
Remeron 15 mg po qd Rivotril 0.5 mg qhs prn
Prozac 10 mg po qd Diclofenac 75 mg po bid
Allergies: no known
3. HPI: Right shoulder pain radiating down right arm
of 4 months duration. No fall/trauma. Seen by a
rheumatologist who prescribed NSAIDs for pain.
Has noted progressive weakness and
paresthesias of the right arm and decreased grip
strength for the last month.
Social/Habits:
IT manager
Ex-smoker since 6 years, 30 pack-year history
Family History: unremarkable
4. Physical exam
Well appearance, NAD. Ht 184 cm. Wt 195 lbs
VS: BP: 148/102 P: 102 T: 36.1°C R: 16 Sat:100% on r/a
H + N: Anisocoria, right ptosis
Resp : Lungs clear, good air entry bilaterally, no crackles
or wheezing
CV: Normal S1 S2, no murmur
Abdo: Soft, non-tender, no masses, normal bowels
sounds
MSK: Right shoulder: no swelling or deformity, tender over
medial scapula and rhomboid insertion, tender T1
vertebra. No limitation in range of motion and not
reproducing pain. Impingement tests negative, Normal
rotator cuff testing.
Neuro: Decreased grip strength on right side. Numbness
in right ulnar nerve distribution
10. Pancoast tumors
Uncommon and comprise fewer than 5% of
all lung cancers
Majority of superior sulcus tumors are
NSCLCs
The differential diagnosis of superior sulcus mass lesions includes
adenoid cystic carcinoma, hemangiopericytoma, mesothelioma, lymphoma,
plasmacytoma, and metastatic malignancies from the cervix, larynx, liver,
bladder, and thyroid gland
Lymphomatoid granulomatosis
vascular aneurysms
amyloid nodules
cervical rib syndrome
various infections (eg, tuberculosis, fungi, hydatid cysts, sequelae of
bacterial pneumonia)
11. Key features on the history
Shoulder and arm pain (in the
distribution of the C8, T1, and T2
dermatomes)
Weakness and atrophy of the muscles
of the hand
Horner's syndrome
This constellation of symptoms is
referred to as Pancoast's syndrome
12. Shoulder pain
Most common initial symptom of superior sulcus tumors is
shoulder pain, present in 44 to 96 % of patients
Caused by
invasion of the brachial plexus
extension of the tumor into the parietal pleura, endothoracic fascia,
first and second ribs, or vertebral bodies.
Pain can radiate
Up to the head and neck
Down to the medial aspect of the scapula, axilla, anterior chest
Down ipsilateral arm in the distribution of the ulnar nerve
Patients frequently receive treatment for presumed cervical
osteoarthritis or shoulder bursitis, resulting in a delay in
diagnosis of five to ten months
13. Neurological symptoms
Extension of tumor to the C8 and T1 nerve roots
results in upper extremity neurologic findings in
approximately 8 to 22 % of cases
May result in
Weakness and atrophy of the intrinsic muscles of the
hand
Pain and paresthesia of the 4th
and 5th
digits and the
medial aspect of the arm and forearm
Abnormal sensation and pain in the T2 territory
14.
15. Horner’s syndrome
Caused by involvement of the
paravertebral sympathetic chain and
the inferior cervical ganglion
Prevalence in patients with superior
sulcus tumors ranges from 14 to 50 %
16.
17.
18. Localizing the origin of Horner’s
syndrome
Brainstem signs (diplopia, vertigo, ataxia, lateralized
weakness) suggest a brainstem localization
Myelopathic features (bilateral or ipsilateral weakness, long
tract signs, sensory level, bowel and bladder impairment)
suggest involvement of the cervicothoracic cord
Arm pain and/or hand weakness typical of brachial plexus
lesions suggest a lesion in the lung apex.
Ipsilateral extraocular pareses, particularly a sixth nerve
palsy, in the absence of other brainstem signs localize the
lesion to the cavernous sinus.
An isolated Horner's syndrome accompanied by neck or
head pain suggests an internal carotid dissection
19. References
• Ginsberg RJ, Martini N, Zaman M, et al. Influence of surgical resection and
brachytherapy in the management of superior sulcus tumor. Ann Thorac
Surg. Jun 1994;57(6):1440-5. [Medline].
• Johnson DE, Goldberg M. Management of carcinoma of the superior
pulmonary sulcus. Oncology (Huntingt). Jun 1997;11(6):781-5; discussion
785-6. [Medline].
• D´Silva KL, May SK. Pancoast Syndrome. E Medicine World Medical.
Section 1-10, 2005. http://emedicine.medscape.com/article/284011-
overview
• Guerrero M, William SC. Pancoast Tumor. E Medicine Specialties Com,
Section 1-12, 2004. http://emedicine.medscape.com/article/359881-
overview
• Kedar S, Biousse V, Newman NJ. Horner's syndrome. In: UpToDate, Rose,
BD (Ed),. UpToDate, Online, ed. 2009:Vol 2010
• Arcasoy S, Jett JR. Pancoast's tumor and superior (pulmonary) sulcus
tumors. UpToDate Online, 12.3 ed. 2009:Vol 2010
Pictures
• http://bjsm.bmj.com/content/40/4/e10/F1.large.jpg
• http://www.nature.com/eye/journal/v20/n12/fig_tab/6702363f1.html