Wednesday, December 12, 2007

All That and a Bag of Chips

A 60 year old smoker presents with right shoulder pain that radiates up his neck and down the ipsilateral arm. He complains of dyspnea, non-productive cough, and facial swelling (worse when he bends forward or lies down). Here's another picture:

Here is a CXR of a similar patient (not the same because the finding is on a opposite side).

Challenge: This case has so many random syndromes, it seems almost artificial; it'd be such a good teaching case, you think. What's the final diagnosis? (Be specific - it's named after a Quaker who was, according to Wikipedia, the first professor of radiology).

Related Questions:
1. What's seen on the first image?
2. What's seen on the second image?
3. What's seen on the CXR?
4. Why the shoulder pain?

Images are all shown under fair use.


Alex said...

1. proptosis
2. gynecomastia? vessels?
3. no idea, but usually CXRs show pulmonary edema
4. no idea

anyway, i thought if its a smoker and given the H&P it would be superior vena caval syndrome. Of course, SVC isn't the name of a quaker radiologist, so Im probably wrong.

Craig said...

All That and a Bag of Chips

This is a Pancoast tumor, also known as a superior sulcus tumor. It is a neoplasm at the apical pleuropulmonary groove adjacent to the subclavian vessels. The clinical presentation often includes shoulder pain due to invasion of the brachial plexus. The first image shows Horner’s syndrome (ipsilateral ptosis, narrowing of the palpebral fissure, miosis, enopthalmos, and anhidrosis). This is due to involvement of the paravertebral sympathetic chain. The second image shows superior vena cava syndrome, where the tumor compresses the vena cava. There is venous distention on the neck and chest wall. The CXR shows an asymmetric pleural thickening and mass (left apical opacity with destruction of the third rib).

Sources: UpToDate; Wikipedia. First image from University of Toronto website ( Second image from UpToDate article “Superior Vena Cava Syndrome” (citation Vaibhav). Third image from Robert Wood Johnson Medical School website.