Download Case 035: Hemoptysis, shoulder pain, and weight loss. 1. What are

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Case 035:
Hemoptysis, shoulder pain, and weight loss.
Authors:
Gregory E Antonio MD, FRANZCR
David C Chung MD, FRCPC
Thomas YK Chan MD, PhD, FRCP
Affiliation:
The Chinese University of Hong Kong
A 65-year-old male patient presented to the outpatient clinic with complaints of
hemoptysis, pain around his right shoulder, and weight loss. He has been a onepack-a-day smoker for more than 40 years and had a “smoker’s cough” for as long
as he could remember. The cough was usually worst in the morning; the sputum it
produced was usually grayish-white; but it was mixed with flecks of blood on several
days in the last month. The onset of shoulder pain was insidious and he described it
as a gnawing sensation accentuated by movement. He lost 9 kg over the past 6
months and attributed it to lack of appetite. He was diagnosed to have pulmonary
tuberculosis (TB) in 1962 and received a course of drug therapy for 2 years.
Otherwise there was no history of hypertension, ischemic heart disease, and
diabetes. He was not on any medications and he had no allergy.
On examination the patient looked thin and gaunt but not in distress. His vital signs
were: Oral temperature 36.6 oC, BP 134/80 mmHg, pulse rate 80/min, respiratory
rate 20/min. There was no cyanosis or clubbing. Auscultation of the chest revealed
diffused inspiratory and expiratory wheezes together with bronchovesicular breath
sound in the right apex. The right shoulder was normal to examination; there was no
cervical lymphadenopathy. There was obvious ptosis of the right upper eyelid; the
right pupil was smaller than the left; the right side of his face was warm and dry in
comparison to his left. Otherwise, his heart sounds were normal; abdomen was soft
with no organomegaly; power of the extremities was normal; mental status was clear.
1. What are the differential diagnoses?
When a patient presents with hemoptysis, efforts should be directed at
differentiating where the blood comes from: from the lungs, the upper airway, or
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the upper gastrointestinal (GI) tract. It is quite possible for blood from the upper
airway or regurgitated blood from the upper GI tract to drip down the trachea to
be coughed up again to mimic hemoptysis. With our patient the blood is mixed
with the sputum, making it more likely to have come from the lungs. Together
with weight loss and history of TB and smoking, reactivation of old TB or lung
cancer are the most likely diagnoses. Besides symptoms and signs referable to
the respiratory system, this patient also has signs of a right Horner’s syndrome,
suggesting involvement of the stellate ganglion of the right sympathetic chain by
the disease process. Whatever this disease process is, the patient needs further
investigation, including a chest x-ray which is shown below:
2. What are the abnormalities seen on this chest x-ray?
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This frontal chest radiograph shows background lung changes of Chronic
Obstructive Pulmonary Disease, i.e. hyperinflated and lucent lungs
(emphysematous changes). There is a mass (large arrow) in the right apical
region which is non-specific but in this clinical setting is suggestive of a neoplastic
lesion. There are numerous small nodules (small arrows) in the mid and upper
zones of both lungs, which may represent granulomata (from previous
tuberculous infection) but metastatic deposits cannot be excluded.
Progress of the Case: Biopsy at bronchoscopy and mediastinoscopy proved that the
tumor was malignant. A malignant tumor at this location is called a Pancoast tumor.
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3. What is a Pancoast tumor?
A Pancoast tumor (superior sulcus tumor) is nothing more than a bronchial
carcinoma situated at the superior sulcus of the upper lobe of the right lung. It
was first reported by Dr. HK Pancoast in 1924 and thus acquired his name. By
virtual of its location, the tumor can invade adjacent structures and bring on the
Pancoast syndrome with its associated manifestations:
Structures involved
Manifestations
2nd and 3rd ribs
Upper chest pain and shoulder pain
Stellate ganglion
Horner’s syndrome
C8 & T1 roots of brachial plexus
Hand weakness & atrophy / parasthesia
Subclavian vein / superior vena cava
Venous obstruction
Phrenic nerve
Palsy of right diaphragm
Recurrent laryngeal nerve
Hoarseness
Besides bronchial carcinoma, rarer causes of the Pancoast syndrome include:
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Metastatic tumors.
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Hematological malignancies.
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Infections.
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Cervical rib.
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Pulmonary amyloid nodules.
4. What is the treatment of superior sulcus bronchial carcinoma?
When a patient presents with the Pancoast syndrome from superior sulcus
bronchial carcinoma, invasion of adjacent structures has occurred and prognosis
is guarded. However progress in surgery, chemotherapy, and radiation therapy—
either alone or in combination—has brought a ray of hope in recent years. The
patient should be referred to a specialist center for further evaluation and
treatment.
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Further reading
Archie VC et al. Superior sulcus tumors: A mini-review. The Oncologist 2004;9:550.