CPC Competition - Pancoast Tumor


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Clinical Pathological Case Presentation on patient with a Pancoast tumor presenting with shoulder pain to the ED.

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CPC Competition - Pancoast Tumor

  1. 1. CPC Competition 2010 A story about shoulder pain Farooq Khan MDCM PGY1 FRCP-EM McGill University April 5th 2010
  2. 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. 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. 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 
  5. 5. Labs
  6. 6. Discussion
  7. 7. 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)
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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 %
  12. 12. 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
  13. 13. 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