1. Case Study Masqueraders March 2012 Laura Finucane 2011 © Pancoast Tumour

2. History Present Condition Laura Finucane 2011 © 69 Yr Old male 1 year HO symptoms, constant in the last 6/12 4 visits to the GP over a 6/12 period Initially presented with P&N into R 3 middle finger tips but this had resolved. Initial diagnosis of oesophageal pathology and later as cervical spine pathology

3. GP Visit 1 Laura Finucane 2011 © Patient reported chest pain and right upper arm pain which was worse with indigestion Bloods and GHJT and chest Xray Prescribed lansoprazole and cocodamol Clinical impresssion- oesophageal pathology R/V 3/52

4. GP Visit 2 Laura Finucane 2011 © GHJT Xray- OA ACJ; Chest Xray- scarring R apex Lansoprazole helping Clinical impression- I am concerned this is oesopahgeal pathology R/V 3/52

5. GP Visit 3 Laura Finucane 2011 © Shoulder painful during working day as delivery driver Cocodamol helps with sleep Ibuprofen re awakens oesophagitis Treatment- subacromial injection R/V 3/52

6. GP Visit 4 Laura Finucane 2011 © No benefit with injection No change in symptoms/no worse on lifting TOP R scapular Treatment Tramadol + ibuprofen gel Clinical impression- ?cause of pain not clear-?MSK pain refer MSK service- ?cervical spine in origin

7. Constant 2-8/10 ache Laura Finucane 2011 ©

8. HPC Laura Finucane 2011 © No mechanism of injury and unable to give any aggravating factors Patient aware that the symptoms were worse by the end of the day and at night

9. PMH Laura Finucane 2011 © Fit and well No PH of neck or shoulder pain Ex smoker with mild COPD

10. Physical Examination Laura Finucane 2011 © No evidence of wasting Cervical spine examination normal GHJT examination normal Neuro integrity normal No pain on deep breathing

11. ?red flags Laura Finucane 2011 © Progressive worsening of symptoms Night pain Non mechanical/ Examination normal Ex smoker ?normal xray Clinical Impression- unusual presentation, doesn’t look mechanical. MRI Cx and Tsp urgent

12. Investigations Laura Finucane 2011 © MRI- large Pancoast tumour with bony destruction affecting rib 1 and 2 and possibly 3 Biopsy of tumour Palliative radiotherapy

13. Pancoast tumours Laura Finucane 2011 © Males more than females (50 yrs) History of smoking Rare (3-5% of all lung cancers) Most common non metatastic malignancy 90% present with shoulder symptoms

14. Disease Progression/features Laura Finucane 2011 © 90% present with shoulder pain C8/T1 distribution Atrophy of intrinsic hand muscles Horners syndrome Venous distension Erosion of 1 st and 2nd rib, transverse processes/vertebral bodies Weight loss Cord compression and myleopathy

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16. Figure 1. Normal anatomy of the thoracic inlet. Chiles C et al. Radiographics 1999;19:1161-1176 ©1999 by Radiological Society of North America

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18. Thoracic inlet Laura Finucane 2011 © Structuresymptoms Brachial plexus C8/T1Wasting of intrinsic muscles of the hand Pain in this distribution P&N Subclavian vein/arteryVenous/arterial distension Venous/arterial thrombosis Sympathetic chain/stellate ganglionHorners syndrome Phrenic nerveDiaphragmatic paralysis Strenocleidomatoid scalenei Upper anterior chest wall Axilla and medial and upper arm and shoulder

19. Horner’s syndrome Laura Finucane 2011 © Drooping eyelid (ptosis) Absence of sweating (anhidrosis) Sinking of eyeball (enophthalmos) Constriction of the pupil (miosis)

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26. Differential Diagnosis Laura Finucane 2011 © Thoracic outlet syndrome Shoulder pathology Cervical spine pathology Cardiac pathology

27. Treatment Laura Finucane 2011 © Survival without treatment 3-24 months Palliative radiotherapy Preoperative radiotherapy Radical resection

28. Analysis Laura Finucane 2011 © Atypical presentation Non mechanical features Combination of red flags which raised index of suspicion

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