Post on 07-May-2015
description
CPC Competition 2010
A story about shoulder painFarooq Khan MDCM
PGY1 FRCP-EMMcGill University
April 5th 2010
HistoryHistory
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
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
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
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
Physical examPhysical 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
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
Labs
DiscussionDiscussion
Pancoast tumorsPancoast 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)
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)
Key features on the history
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
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
Shoulder painShoulder 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
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
Neurological symptomsNeurological 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
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
Horner’s syndromeHorner’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 %
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 %
Localizing the origin of Horner’s syndrome
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
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
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