[Do we inspecting the patient face who has shoulder pain?] / Omuz agrisi olan hastanin yüzünü de muayene ediyor muyuz?

A Pancoast or superior sulcus tumor is a rare, bronchogenic carcinoma. In the early period, shoulder pain is the most common symptom. In this case, the patient had presented with complaints of shoulder and arm pain at other outpatient clinics and was examined primarily for musculoskeletal causes and radiculopathy. The patient had no complaints of facial symptoms and Horner's syndrome signs, such as anhidrosis of the face and neck region, were not noticed. Advanced imaging of a patient with preganglionic Horner's syndrome is important. Fewer than 50% of patients with a Pancoast tumor have a resectable lesion at the first diagnosis. Diagnosis is often delayed or there may be a misdiagnosis because musculoskeletal disorders are the focus and there are few lung-related complaints. A detailed examination and anamnesis is very important in patients with arm and shoulder pain.

Pancoast tumour presenting as shoulder pain with Horner's syndrome.

A 54-year-old man presented to the emergency department with a 4-week history of right shoulder pain radiating down his arm, with some associated sensory loss. Further questioning and examination in the department revealed a classical Horner's syndrome; miosis, partial ptosis and hemifacial anhidrosis. An initial chest X-ray was deemed to be unremarkable; however, further review by a radiologist noted asymmetrical right apical thickening. A subsequent high-resolution CT scan of the chest revealed a right-sided Pancoast tumour. This case highlights the importance of a thorough history and examination in identifying a rare cause of shoulder and/or back pain.

El quiste hidatídico como causa del síndrome de Pancoast: extraña asociación / Hydatid cyst causing Pancoast syndrome: A rare settlement

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[Modern Management of Pancoast Tumour]. / Modernes Management des Pancoast-Tumors.

Pancoast or superior pulmonary sulcus tumour is a subset of lung carcinoma that invades the structures of the thoracic inlet - first ribs, distal roots of the brachial plexus, stellate ganglion, vertebrae, and subclavian vessels. The first symptom is usually shoulder pain; consequently, most patients are initially treated for osteoarthritis. Late diagnosis is common. Success of therapy depends on an accurate staging: standard imaging with CT scan of the chest, PET-CT scan, brain MRI are needed to rule out distant metastases, endobronchial ultrasound-guided needle biopsy (EBUS-TBNA) or mediastinoscopy are mandatory for reliable nodal staging. An MRI of the thoracic inlet allows to clearly define the boundaries of local invasion. Modern management of Pancoast tumour includes induction concurrent chemoradiotherapy followed by surgical resection. As compared with historical series treated by preoperative radiation, a trimodally approach did enhance complete resection rates and perhaps long-term survival - from about 30% 5-year survival rate to 60% in R0-resected patients. In patients who have unresectable but non-metastatic Pancoast tumours and appropriate performance status, definitive concurrent chemoradiotherapy and radiotherapy are recommended options.

Robotic Hybrid Approach for an Anterior Pancoast Tumor in a Severely Obese Patient.

Several different surgical approaches to anterior Pancoast tumors have been proposed. The osteomuscular-sparing transmanubrial approach allows optimal exposure and control of apical chest wall structures, but it requires an additional thoracotomy to perform the lobectomy with radical lymph node resection. The presented technique combines the osteomuscular-sparing transmanubrial approach with robotic-assisted upper lobectomy in a severely obese patient, thereby reducing the invasiveness of the surgical approach and the postoperative complications.

Pleural lipoma clinically mimicking the presentation of superior sulcus tumour upon initial evaluation.

Here we present a case of a large pleural lipoma which presented with paresthesias of the hand. This is an unusual presentation of an uncommon tumour.

Extracorporeal Lung Support as a Bridge to Airway Stenting and Radiotherapy for Airway-Obstructing Pancoast Tumor.

Venovenous (V-V) extracorporeal membrane oxygenation (ECMO) is used for respiratory failure that is suspected to be reversible (bridge to recovery), or as a bridge to lung transplantation. Patients with proximal airway obstruction due to endobronchial malignancy can develop acute respiratory failure, and may benefit from V-V ECMO as a bridge to airway intervention, further treatment, and eventual recovery. We describe a case of a superior sulcus tumor with tracheobronchial and superior vena cava invasion causing both respiratory failure and superior vena cava syndrome. This was treated successfully with V-V ECMO, bronchial stenting, and radiotherapy.

Intraoperative Neurophysiological Monitoring (IONM) for Cordotomy Procedures.

This case illustrates the benefits of utilizing intraoperative neurophysiological monitoring (IONM) for preventing injury to sensory/motor pathways of the spinal cord during a cordotomy procedure to relieve pain. Cordotomy has been used effectively in the treatment of visceral pain but comes with a high risk of damaging motor and sensory pathways due to close proximity of lesion. The subject is a 47-year-old female with a pancoast tumor of the left lung, left brachialplexopathy, and severe neuropathic pain syndrome, refractory to medical therapy. A palliative cordotomy procedure was elected for pain control. Baseline bilateral posterior tibial and median nerve somatosensory evoked potentials (SSEP) were present except in the left upper extremity. Transcranial electric motor evoked potential (TCeMEP) baselines were present in all extremities except the left upper. Total intravenous anesthesia was used. The spine was exposed at C2-C3 and a right single anterolateral cordotomy was performed with an immediate drop in TCeMEPs (70-80% amplitude reduction) in the right upper and right lower extremities. The surgeon decided to stop the cordotomy at that point. Postoperatively, the patient had no sensory or motor deficit. In this patient, TCeMEPs were used effectively to guide the surgeon in preventing damage to the spinal cord that could lead to motor deficits.

Superior sulcus tumor resection with multiple pulmonary arteriovenous fistulas.

The authors present a case of a 66-year-old male presenting with a superior sulcus tumor and severe hypoxemia due to bilateral multiple pulmonary arteriovenous fistulas. The unilateral pulmonary arterial occlusion test was useful before surgery because it enabled evaluation of the feasibility and safety of intraoperative pulmonary artery clamp and one-lung ventilation during lung resection. Results facilitated safe resection of the superior sulcus tumor using the modified transmanubrial osteomuscular sparing approach, providing an excellent surgical field.

Pancoast's tumour presenting as shoulder pain in an orthopaedic clinic.

A 71-year-old lady was referred by her general practitioner to an orthopaedic clinic for management of shoulder pain. The patient complained of pain in the shoulder and chest region but also described reduced sensation and power in her arm and a worsening of her respiratory symptoms. These prompted further investigation with an isotope bone scan which showed a large soft tissue mass posteriorly in the apex of the right lung with chest wall extension and destruction of adjacent ribs. A subsequent CT scan identified Pancoast's tumour. This case highlights the importance of considering non-musculoskeletal causes of shoulder region pain.

CT-guided percutaneous cordotomy for intractable pain in what is more than a disease: lung malignancies.

AIM: Lung cancer is the leading cause of cancer-related mortality worldwide. Pain is a common problem in these patients, yet inadequate or dissatisfactory management is prevalent. MATERIAL AND METHODS: Between 1987 and 2012, 224 patients with intractable pain were treated with computerized tomography (CT)- guided cordotomy. Among them, 210 had intractable pain due to malignancies. The majority of the cases were diagnosed as pulmonary malignancies (108 patients). Sixty-seven were pulmonary carcinoma, 26 mesothelioma and 15 Pancoast tumors. RESULTS: After cordotomy, 98.13% of cancer patients reported initial pain relief. Minimum and maximum preoperative scores of the Karnofsky Performance Scale were 20 and 70, versus postoperative scores of 40 and 90 (p < 0.001). The median preoperative VAS score was 8 (6-9). On the first postoperative day, the score dropped sharply to 0 (0-8) (p < 0.001). In this selected series of 108 percutaneous cordotomy procedures, as well as in the total series of 224 patients, there was no mortality or major morbidity. CONCLUSION: CT-guided percutaneous cordotomy is an effective procedure that should be used in the treatment of cancer-related pain problems. We suggest that cordotomy should be preferred as soon as possible in patients who fail to respond to the classic analgesic therapy.

Cervicobraquialgia: síntoma inicial del síndrome de Pancoast / Cervicobrachialgia: initial symptom of Pancoast syndrome

El síndrome de Pancoast está producido por un tumor en el ápex pulmonar, con extensión local al plexo braquial inferior, cadena simpática paravertebral, cuerpos vertebrales y primera, segunda y tercera costillas. La mayoría de los casos de síndrome de Pancoast son causados por el carcinoma broncogénico de células no-pequeñas, principalmente por el carcinoma escamoso, seguido del adenocarcinoma y del carcinoma de células grandes. Las lesiones en el surco superior pueden dar lugar a dolor en el hombro y el brazo, síndrome de Horner y atrofia de los músculos de la mano. Debido a la ubicación periférica del tumor, síntomas tales como la tos, hemoptisis y disnea, son poco frecuentes hasta fases más avanzadas de la enfermedad (AU)

Pancoast syndrome is caused by a tumour in the pulmonary apex, with local spreading to the lower brachial plexus, paravertebral sympathetic chain, vertebral bodies, and first, second and third ribs. Most Pancoast syndrome cases are caused by non-small cell bronchogenic carcinoma, mainly by squamous cell carcinoma, followed by adenocarcinoma and large cell carcinoma. Lesions in the superior pulmonary sulcus can give rise to shoulder and arm pain, Horner syndrome and muscle atrophy of the hand. Owing to the peripheral location of the tumour, symptoms such as coughing, hemoptysis and dyspnoea are uncommon until more advanced stages of the illness (AU)

[A man with progressive neck and shoulder pain]. / Een man met progressieve pijn in nek en schouder.

A 66-year-old man was referred to the hospital with progressive neck and right shoulder pain. Conventional radiographs and a thoracic CT-scan demonstrated destruction of the first rib on the right side due to a tumour invading the apical chest wall. The patient was diagnosed with a Pancoast tumour (i.e. superior sulcus tumour).

Shoulder pain and isolated brachial plexopathy.

Pancoast syndrome, classically considered as a constellation of (1) pain along the C8-T2 dermatomes, (2) weakness and atrophy of the hand and (3) Horner's syndrome, often presents a diagnostic challenge. In fact, it may manifest as a singular orthopaedic complaint, prompting a futile barrage of tests and referrals. The authors present the case of an elderly man who initially presented with severe shoulder pain. Due to progressive pain and weakness, he was referred to rheumatology and was treated with corticosteroid injections for a presumed musculoskeletal lesion. Ultimately, he manifested gross muscular atrophy and worsening pain, prompting a referral to neurology. An electromyogram (EMG) suggested a lower brachial plexopathy, and a follow-up brachial plexus MRI identified a large Pancoast tumour. Unfortunately, his disease was rapidly progressive, and he passed away within 2 months. While the MRI remains the gold standard for diagnosing Pancoast syndrome, an EMG can facilitate diagnosis in difficult cases such as this one.

Tumor del vértice pulmonar derecho que produce un síndrome de Pancoast. Descripción de un caso clínico / Tumour of the right lung vertex that produced a Pancoast syndrome: description of a case

Se describe el caso clínico de una paciente, mujer de 80 años de edad, con antecedentes de enfermedad de Alzheimer, que acudió por presentar dolor en hombro derecho, parestesias y disminución de la fuerza en miembro superior derecho, ptosis palpebral en el ojo derecho, tos y disfagia. Tras la realización de exploración y pruebas complementarias se objetivó una gran masa en el lóbulo superior y vértice del pulmón derecho y adenopatías metastásicas supraclaviculares. La histología de la punción aspiración de la masa mostró un carcinoma poco diferenciado de células no pequeñas. Se remitió a Oncología que indicó tratamiento quimioterapéutico (AU)

We describe a clinical case of an 80 year-old woman, with a history of Alzheimer's disease, who presented with right shoulder pain, numbness and decreased strength in the right arm, with right eye ptosis, cough and dysphagia. The chest X-Ray and thoracic-abdominal computed tomography scan showed a large mass in the upper lobe and apex of the right lung, supraclavicular metastatic lymph nodes. In the fine needle aspiration biopsy: poorly differentiated non-small cell carcinoma. She was referred to Oncology to start chemotherapy treatment (AU)