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Right Shoulder Pain in an Older Man

Right Shoulder Pain in an Older Man

For 6 months, a 69-year-old man has experienced pain in his right shoulder; he takes NSAIDs for relief. During the last month, the pain has worsened, weakness and tingling have developed in his right hand, and the skin on the right side of his face has become dry. The patient also reports a 1-month history of melanotic stools. He had smoked 1 pack of cigarettes a day for 50 years before quitting last year. Right-sided ptosis (Figure 1), constriction of the right pupil, and weakness of the right hand are noted on examination. The patient has no respiratory symptoms. A chest film demonstrates right apical density that is asymmetric with the contralateral side (Figure 2); this finding signals the need for further investigation. A CT scan of the thorax reveals a right apical mass that extends medially into the adjacent vertebral body and spinal canal and, more superiorly, infiltrates the brachial plexus and extends into the cervical ribs and thoracic vertebrae (Figure 3). These findings are consistent with a Pancoast tumor. A CT-guided needle biopsy confirms the diagnosis of squamous cell carcinoma of the right apex of the lung. The patient's melanotic stools are secondary to a gastric ulcer, which resulted from NSAID abuse. The suppression of the initial musculoskeletal pain by the use of analgesics delayed the diagnosis. PANCOAST SYNDROME Pancoast tumor, also called pulmonary or superior sulcus tumor, is associated with Pancoast syndrome, which most commonly presents with shoulder pain and the ocular signs and unilateral facial flushing of Horner syndrome. On histologic examination, 52% of Pancoast tumors are squamous cell carcinomas, 23% are adenocarcinomas, 23% are large cell carcinomas, and the remainder are small cell carcinomas.1 The pain is secondary to the tumor's invasion into the brachial plexus or to its extension into adjacent parietal pleura, first and second ribs, or vertebral bodies. The ipsilateral ptosis, miosis, and anhidrosis of Horner syndrome are caused by the tumor's involvement in the paravertebral sympathetic chain and the inferior cervical ganglion. In our patient, Horner syndrome was attributed to the Pancoast tumor's involvement of the apex of the right lung. Between 44% and 96% of patients present with shoulder pain on the affected side as their initial symptom. Many are treated for osteoarthritis or bursitis; thus the diagnosis of superior sulcus tumor is often delayed for 5 to 10 months.2,3 Because the tumor is located in the periphery of the lung, patients rarely present initially with pulmonary symptoms. Cough, hemoptysis, and dyspnea may develop later in the course of the disease.4TREATMENT The most common treatment consists of preoperative radiation to reduce tumor size followed by en bloc extended surgical resection.2 The 5-year survival among patients who undergo this regimen is approximately 20% to 35%. For patients treated with primary radiotherapy, reported 5-year survival ranges from 0% to 29%.1,5OUTCOME OF THIS CASE Our patient was a poor candidate for surgery because of probable tumor invasion of the upper thoracic vertebral bodies and first and second ribs posteriorly, which was revealed on a bone scan. An 8-week regimen of carboplatin and paclitaxel and a 4-week course of radiation therapy were initiated. Because pancytopenia developed and the patient had difficulty in tolerating the drugs, continued chemotherapy was administrated intermittently. Recently, a salvage gemcitabine regimen (3 weeks on, 1 week off) was initiated. Pain control has been complicated by oversedation from narcotic agents. No evidence of distant metastases from the tumor has been detected.

References

REFERENCES:
1. Komaki R, Mountain CF, Holbert JM, et al. Superior sulcus tumors: treatment selection and results for 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. Combined radiosurgical treatment of Pancoast tumor. Ann Thorac Surg. 1994;57:198-202.
3. Zoporyn T. Upper body pain: possible tipoff to Pancoast tumor. JAMA. 1981;246:1759, 1763.
4. Komaki R. Preoperative radiation therapy for superior 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 treatment of 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.
 
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