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

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

5. Labs

7. Discussion

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

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 %

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