Download Differential diagnosis of superior pulmonary sulcus tumor and

Differential diagnosis of cervical radiculopathy and superior pulmonary sulcus tumor:
10 cases review
Gu Rui, Kang Mingyang, Gao Zhongli*,Zhao Jianwu,Wang Jincheng
Department of Orthopaedics, China-Japan Union Hospital of Jilin University,
Changchun, 130033, China
Corresponding author：Gao Zhongli, Telephone:0431-84995001, Fax:0431-84641026,
E-mail：[email protected]
【Abstract】Objective: To study the differential diagnosis methods between cervical
radiculopathy and superior pulmonary sulcus tumor (Pancoast tumor).
Methods:
Clinical manifestations, physical and radiological findings of 10 patients, whose main
complaints were radiating shoulder and arm pain and later were diagnosed with
superior pulmonary sulcus tumor, were reviewed and compared with those of cervical
radiculopathy. Results: Superior pulmonary sulcus tumor patients have shorter mean
history and fewer complain of neck pain or limitation of neck movement range.
Physical exam showed almost normal cervical spine range of motion.
neck compression test was negative in all patients.
Spurling’s
Anteroposterior cervical
radiographs showed the lack of pulmonary air at the top of the affected lung in all
cases and first rib encroachment in 1 case. The diagnosis of superior pulmonary
sulcus tumor can be further confirmed by CT and MRI. Conclusions: By the method
of combination of history, physical exam and radiological findings, superior
pulmonary sulcus tumor can be efficiently differentiated from cervical radiculopathy.
Normal motion range of cervical spine, negative Spurling’s neck compression test and
the lack of pulmonary air at the top of the affected lung in anteroposterior cervical
radiographs should be considered as indications for further chest radiograph exams.
Key Words: Superior pulmonary sulcus tumor (Pancoast tumor); Cervical
radiculopathy; Physical exam; Anteroposterior cervical radiograph; Differential
diagnosis
Superior pulmonary sulcus tumor (Pancoast tumor) is a kind of malignant tumor with
relatively low incidence.
tumors.1,2
It approximately accounts for 5% of all pulmonary
The superior pulmonary sulcus tumor may cause symptoms of pain or
radiating pain in neck and upper extremity, motor weakness, atrophy of the intrinsic
muscles and sensory disturbunce in certain cervical nerve root dermatomes which
mimic the symptom of cervical radiculopathy by encroaching intervertebral foramens,
vertebral bodies, or brachial plexus.3,4
surgeon first.
Such patients tended to consult a spinal
The result would be disastrous if the tumor were misdiagnosed as
degenerative cervical spine diseases.
The pathological and radiological findings of
the superior pulmonary sulcus tumor that may produce the symptom of cervical
radiculopathy has been reported in a few papers.3-5
But to our knowledge, the
differential diagnosis method that combined history, physical and radiological
findings aiming at scalping superior pulmonary sulcus tumors in patients suspected of
cervical radiculopathy has not been reported before.
The current study was
undertaken to investigate the differential diagnosis method that may identify superior
pulmonary sulcus tumor among the patients with complaints of neck pain, radiating
shoulder and arm pain in the out-patient of spinal disorders by the reviewing of 10
such cases.
Methods
From March 1998 to March 2005, 7132 patients with main complaints of neck pain
and radiating shoulder and arm pain visited the out-patient department of spinal
disorders in the China-Japan Union Hospital of Jilin University in Changchun, China.
Among them, ten cases (0.14%) were diagnosed with superior pulmonary sulcus
tumors later and transferred to the thoracic surgery department.
Diagnose were
further confirmed by needle biopsy. Clinical manifestations, physical and radiological
findings of these 10 patients were reviewed and compared with those of the cervical
radiculopathy.
Results
The general condition, history of disease and main complains are shown in Table 1.
Anterior-posterior, lateral and oblique view radiograph were administered in 4
patients (case 2, 4, 6, 7) in other hospitals before they visited us.
They were
diagnosed as degenerative cervical diseases or cervical radiculopathy. Two patients
(case 2, 4) underwent systematic conservative treatment (collar fixation, band traction
and nonsteroidal anti-inflammatory drugs) 15 and 45 days respectively, but the
symptom deteriorated and patients went to our hospital.
All patients referred the pain localized in scapular or interscapular region.
There
was no tenderness in cervical spine region. The cervical motion range was normal in
all patients, except case 9.
Spurling’s sign was negative in all patients.
Physical
findings are shown in Table 2.
A-P view, lateral view and oblique view cervical spine radiographs were
administrated in all patients. The curvature of the cervical spine became straight in 4
cases. Mild degenerative changes were found in 7 cases.
Anteroposterior cervical
radiographs showed the lack of pulmonary air at the top of the affected lung, which
made the asymmetry of superior margins of the pulmonary opacity, as shown in figure
1, in all 10 cases.
Encroachment of 1st rib in the affected side was found in a patient
(case 7). All patients went on to receive chest radiographic exam because of the
abnormalities found above.
Posteroanterior (PA) chest radiographs showed
unilateral apical opacity in all cases.
Diffused tumorous shadows in the unilateral
lung were found in 1 patient (case 4). MRI was administrated in 2 patients (case 2
and 6). The encroachment of vertebral bodies and brachial plexus were clearly
shown on coronary planes (Fig. 2).
After consulting with thoracic surgeons, all
patients were transferred to the department of thoracic surgery.
Transthoracic
aspiration needle biopsy confirmed epidermoid carcinoma in 5 cases (case 1,3,6,8,10) ,
adenocarcinoma in 4 cases(case 2,5,7,9) and small cell lung cancer in 1 case(case 4).
Discussions
Cervical Radiculopathy is one of the most common diseases in the cervical spine
disorder clinic.
Most patients would undergo conservative treatments including
band traction, physical therapy, collar fixation and nonsteroidal anti-inflammatory
drugs once the diagnosis were made.6
Superior pulmonary sulcus tumor (Pancoast
tumor) is a malignant tumor lesion developed at the apices of lungs with relatively
lower incidence but much poorer prognosis.1,2,4,7
As mentioned above, the tumor
may produce the symptom that mimic the symptom of cervical radiculopathy by
encroaching intervertebral foramens, vertebral bodies, or brachial plexus. So, it is
very important for a spine doctor to understand some clues or hints that may lead to
the diagnosis of superior pulmonary sulcus tumor among patients whose diagnose
would be cervical radiculopathy otherwise.
In the current study, the mean history of the disease was 2.7 months, which was
significantly shorter than degenerative cervical radiculopathy. Some patients also
complained nonspecific malignant tumor symptoms of night pain, fever and losing
weight.
In contrast to typical cervical radiculopathy, physical exam showed almost normal
cervical spine range of motion and negative Spurling’s sign in all patients.
In
cervical radiculopathy, the nerve root is compressed by a herniated disc or spur at the
entrance of the foramen.8
In the extension and lateral bending position, the
decreased volume of the foramen may exaggerate the symptom of radiculopathy. 9
Authors believe, such mechanism may not exist if the root is compressed by the tumor
from out-let of the foramen.
Villas et al.10 reported retrospective study of 10 patients diagnosed with superior
pulmonary sulcus tumor.
Five out of these 10 patients had previously been
diagnosed with degenerative, inflammatory, or infectious diseases of the cervical
spine or shoulder.
They pointed out that the lack of pulmonary air at the top of the
affected lung on a standard anteroposterior (AP) cervical radiograph may indicate
suspicion of a superior pulmonary sulcus tumor.
The current study confirmed Villas’
opinion in that the radiographic changes in cervical spine AP view were found in all
cases. Authors recommend chest radiographic examination should be administrated
if asymmetry of superior margins of the pulmonary opacity was observed on AP
cervical radiograph.
Conclusions
The application of combining medical history, physical exams and radiograph studies
could effectively improve the detection rate of patients, whose main complaints were
radiating shoulder and arm pain and later were diagnosed with superior pulmonary
sulcus tumor.
The history of disease was significantly shorter than the degenerative disease, during
this course, there were night pain, fever, fatigue, weight loss and other symptoms; The
physical exams found that the cervical motion range was normal, pain and tenderness
points were not clear, neck compression test was negative, but brachial plexus traction
test was positive, paresthesia area was located in the upper limb and ulnar palm, and
might be associated with decreased elbow extension and grip power.
The lack of pulmonary air at the top of the affected lung in anteroposterior cervical
radiographs should be considered as indications for further chest radiograph exam.
Patients with superior pulmonary sulcus tumors who were diagnosed by chest
radiograph exam should accept CT or MRI for further diagnosis. Pathological biopsy
was used to confirm the lesion.
Reference
1. Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome.
N Engl J Med 1997; 337: 1370-6.
2. Khosravi Shahi P. Pancoast's syndrome (superior pulmonary sulcus tumor):
review of the literature. An Med Interna 2005;22:194-6.
3. Owen TD, Ameen A. Cervical radiculopathy: pancoast tumour? Br J Clin Pract
1993;47:225-6.
4. Kraut MJ, Vallieres E, Thomas CR: Pancoast (superior sulcus) neoplasms. Curr
Probl Cancer 2003; 27: 81-104.
5. Vargo MM, Flood KM. Pancoast tumor presenting as cervical radiculopathy. Arch
Phys Med Rehabil 1990;71:606-9.
6. Kokubun S, Sato T, Ishii Y, Tanaka Y. Cervical myelopathy in the Japanese. Clin
Orthop 1996; 323: 129-38.
7. Komaki R, Roth JA, Walsh GL, et al: Outcome predictors for 143 patients with
superior sulcus tumors treated by multidisciplinary approach at the University of
Texas M. D. Anderson Cancer Center. Int J Radiat Oncol Biol Phys 2000; 48: 347-54.
8. Tanaka Y, Kokubun S, Sato T. Cervical radiculopathy and its unsolved problems.
Curr Orthop 1998;12:1-6.
9. Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral discs. A
common cause of shoulder and arm pain. Surg Gynecol Obstet 1944; 78: 350-8.
10. Villas C, Collia A, Aquerreta JD, et al. Cervicobrachialgia and pancoast tumor:
value of standard anteroposterior cervical radiographs in early diagnosis. Orthopedics
2004;27:1092-5.
Table 1 General data, History and Complaints
Case
No.
Age (yr)
Sex
History
(mo)
Complaint
Night Pain
Cough
and Fever
Losing
weight
1
74
M
5．0
A
＋
＋
＋
2
71
M
1．5
B
＋
3
74
F
0．8
A
4
55
M
2．5
C
5
77
M
1．0
A
＋
＋
6
72
M
3．0
A
7
43
M
3．3
B
8
68
F
4．5
A
9
63
F
3．0
C
10
74
F
2．4
B
Mean
67．1
＋
＋
＋
＋
＋
＋
2．7
Complaint A: Unilateral radiating pain and numbness in shoulder and upperarm.
Complaint B: Unilateral Neck and shoulder pain.
Complaint C: Unilateral radiating pain and numbness in neck, shoulder, upperarm, arm and hand.
Table 2 Physical Examination Findings
Triceps
tendon
reflex
Triceps
power
Grab power
Atrophy of
intrinsic
muscle
Posterior and medial arm and 4
fingers in medial side
decrease
Ⅲ
Ⅴ
＋
Medial upperarm
normal
Ⅴ
Ⅲ
Medial arm and little finger
decrease
Ⅳ
Ⅳ
Posterior arm and index, long
fingers
no
Ⅲ
Ⅴ
＋
Posterior and medial arm and 4
fingers in medial side
no
Ⅲ
Ⅴ
＋
Medial arm and little finger
normal
Ⅳ
Ⅲ
＋
Posterior arm and index, long
fingers
decrease
Ⅳ
Ⅴ
8
Medial arm and little finger
no
Ⅲ
Ⅴ
9
Posterior and medial arm and 4
fingers in medial side
decrease
Ⅲ
Ⅳ
Posterior arm and index, long
fingers
no
Ⅲ
Case
No.
1
Brachial
plexus
traction test
＋
2
3
＋
4
5
6
7
10
＋
Sensory disturbance
＋
＋
＋
＋
＋
＋
Ⅳ
＋
L
Fig. 1 The asymmetry of superior margins of the pulmonary opacity (arrows).
pulmonary air at the top of the right lung.
Note the lack of
Fig. 2 The encroachment of vertebral body and brachial plexus by the tumor is shown on coronary
plane of MRI.