Right Shoulder Pain in an Older Man

For 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year.Right-sided ptosis (Figure 1), constrictionof the right pupil, and weaknessof the right hand are noted on examination.The patient has no respiratorysymptoms. A chest film demonstratesright apical density that is asymmetricwith the contralateral side (Figure 2);this finding signals the need for furtherinvestigation. A CT scan of the thoraxreveals a right apical mass that extendsmedially into the adjacent vertebralbody and spinal canal and, more superiorly,infiltrates the brachial plexus andextends into the cervical ribs and thoracicvertebrae (Figure 3). These findingsare consistent with a Pancoasttumor. A CT-guided needle biopsy confirmsthe diagnosis of squamous cell carcinomaof the right apex of the lung.The patient's melanotic stools aresecondary to a gastric ulcer, which resultedfrom NSAID abuse. The suppressionof the initial musculoskeletal painby the use of analgesics delayed thediagnosis.PANCOAST SYNDROMEPancoast tumor, also called pulmonaryor superior sulcus tumor, is associatedwith Pancoast syndrome,which most commonly presents withshoulder pain and the ocular signs andunilateral facial flushing of Horner syndrome.On histologic examination, 52%of Pancoast tumors are squamous cellcarcinomas, 23% are adenocarcinomas,23% are large cell carcinomas, and theremainder are small cell carcinomas.¹The pain is secondary to thetumor's invasion into the brachialplexus or to its extension into adjacentparietal pleura, first and secondribs, or vertebral bodies. The ipsilateralptosis, miosis, and anhidrosisof Horner syndrome are caused bythe tumor's involvement in the paravertebralsympathetic chain and theinferior cervical ganglion. In our patient,Horner syndrome was attributedto the Pancoast tumor's involvementof the apex of the right lung.Between 44% and 96% of patientspresent with shoulder pain on theaffected side as their initial symptom.Many are treated for osteoarthritisor bursitis; thus the diagnosis of superiorsulcus tumor is often delayed for5 to 10 months.^2,3Because the tumor is located inthe periphery of the lung, patientsrarely present initially with pulmonarysymptoms. Cough, hemoptysis,and dyspnea may develop later in thecourse of the disease.⁴TREATMENTThe most common treatmentconsists of preoperative radiation toreduce tumor size followed by enbloc extended surgical resection.2The 5-year survival among patientswho undergo this regimen is approximately20% to 35%. For patientstreated with primary radiotherapy,reported 5-year survival ranges from0% to 29%.^1,5OUTCOME OF THIS CASEOur patient was a poor candidatefor surgery because of probabletumor invasion of the upper thoracicvertebral bodies and first and secondribs posteriorly, which was revealedon a bone scan. An 8-week regimenof carboplatin and paclitaxel and a4-week course of radiation therapywere initiated. Because pancytopeniadeveloped and the patient had difficultyin tolerating the drugs, continuedchemotherapy was administratedintermittently.Recently, a salvage gemcitabineregimen (3 weeks on, 1 week off)was initiated. Pain control has beencomplicated by oversedation fromnarcotic agents. No evidence of distantmetastases from the tumor hasbeen detected.

References:

REFERENCES:

1.

Komaki R, Mountain CF, Holbert JM, et al. Superiorsulcus tumors: treatment selection and resultsfor 85 patients without metastasis (Mo) at presentation.Int J Radiat Oncol Biol Phys. 1990;19:31-36.

2.

Maggi G, Casadio C, Pischedda F, et al. Combinedradiosurgical treatment of Pancoast tumor.Ann Thorac Surg. 1994;57:198-202.

3.

Zoporyn T. Upper body pain: possible tipoff toPancoast tumor. JAMA. 1981;246:1759, 1763.

4.

Komaki R. Preoperative radiation therapy forsuperior sulcus lesions. Chest Surg Clin N Am. 1991;1:13.

5.

Attar S, Krasna MJ, Sonett JR, et al. Superior sulcus(Pancoast) tumor: experience with 105 patients.Ann Thorac Surg. 1998;66:193-198.

FOR MORE INFORMATION:

• Lee JD, Ginsberg RJ. The multimodality treatmentof stage III A/B non–small cell lung cancer:the role of surgery, radiation, and chemotherapy.Hematol Oncol Clin North Am. 1997;11:279-301.