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