Review Question - QID 221298

This patient with an extensive smoking history with hemoptysis, weight loss, and shortness of breath most likely has lung adenocarcinoma. The associated paresthesias and Horner syndrome is most likely due to a Pancoast tumor.

A Pancoast tumor is a peripheral lung cancer often caused by lung adenocarcinoma or squamous cell carcinoma. This type of tumor is located in the superior sulcus of the lung where it can cause compression of adjacent structures. Patients present with severe, localized axillary pain due to invasion of the brachial plexus, which can also result in weakness of intrinsic hand muscles with radicular pain and paresthesias in the fourth and fifth digits. Patients may also have Horner syndrome (miosis, ptosis, and facial anhidrosis due to invasion of the cervical sympathetic nerves), hoarseness (due to invasion of the recurrent laryngeal nerve), and edema of the arm with facial swelling (due to compression of the superior vena cava). Treatment is varied and involves a combination of radiation, chemotherapy, and surgery.

Wu et al. studied the role of the tyrosine-kinase inhibitor, osimertinib, in the treatment of completely resected epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NCSLC). They recommend the use of osimertinib in patients with EGFR-mutated NSCLC.

Figure/Illustration A is a chest radiograph that demonstrates an apical lung mass (red circle). This finding is classically seen in patients with a Pancoast tumor.

Incorrect Answers:
Answer 2: Mesothelioma is a neoplasm of the pleura found in people with occupational exposures to asbestos, such as shipyard workers. While this neoplasm can present with hemoptysis and dyspnea, chest imaging of mesothelioma reveals pleural plaques and thickening, not an isolated apical lung lesion.

Answer 3: Syringomyelia is a cyst or cavity in the spinal column that can cause Horner syndrome and fluctuating radicular pain. It is unlikely to cause hemoptysis, weight loss, and the chest imaging findings in this patient.

Answer 4: Thoracic outlet syndrome can also present with upper extremity pain and paresthesias; however, symptoms due to this syndrome typically occur in a postural-dependent manner. The patient would not have a large mass in the lung.

Answer 5: Tuberculosis is a possible diagnosis in this patient with hemoptysis, weight loss, and extensive travel history. Tuberculosis often presents with a fever and does not usually cause shoulder pain.

Bullet Summary:
Pancoast tumor presents with shoulder pain, cervical radiculopathy, Horner syndrome, and hoarseness and should be suspected in a patient with a smoking history and an apical lung mass on imaging.