Pancoast Tumour : a case report
NICOLA PUGH
Clinical Lead Physiotherapist
King’s College Hospital NHS Foundation Trust
Mr. A, a 57-year-old gentleman, was referred to MCATS by his GP in November 2013, for worsening neck and right sided shoulder pain.
Mr. A was a poor historian and subjective questioning proved challenging. He revealed an 18-year history of worsening right-sided neck, shoulder blade and arm pain. This started following a heavy object landing on his shoulder whilst working in construction. He received physiotherapy several times with little benefit.
He described a constant, varying severity, aching pain in his shoulder with pins and needles and numbness in the medial aspect of his upper arm. He denied left-sided symptoms. Using the arm above his head aggravated symptoms and sitting supported eased them. There was no daily pattern to the pain and he was waking regularly at night due to the pain and had been for over 6 months.
Mr. A worked as a chef. He reported feeling low in mood and argued persistently with his wife throughout the appointment.
His past medical history was unremarkable. He smoked one packet of cigarettes per four days and described his general health as okay.
He denied night sweats or fever or any other joint pains. He reported others had told him he had lost weight but he did not agree. He reported having blood tests ordered by the GP, which had returned normal.
A chest x-ray in January 2013 was unremarkable (Figure 1) and a recent cervical MR scan showed multilevel cervical spondylosis with probable nerve root irritation.
Figure 1: Chest x-ray January 2013
He was taking Paracetamol, Diclofenac and Pregabalin regularly, which he found ineffective in managing his symptoms.
On examination, he had reduced active range of movement of the cervical and thoracic spine in all directions, limited by pain. The right glenohumeral joint was limited actively to 160° flexion, 150° abduction and three quarter range external rotation. Hawkins-Kennedy and Empty Can Test reproduced symptoms and he was tender on palpation throughout the cervical and thoracic spine. Upper limb neurological examination was unremarkable.
Primary diagnosis at that time was cervical spondylosis with nerve root irritation with likely overlapping rotator cuff tendinopathy.
Given his presentation and previous management, he was referred for a glenohumeral ultrasound scan. This was performed in January 2014. This confirmed supraspinatus tendinopathy with focal calcification and low-grade articular sided and bursal sided fraying. He had a corticosteroid injection at that time.
He returned to clinic in March 2014 describing worsening symptoms despite the injection. He had been prescribed Morphine and anti-depressants by his GP. He continued to be low in mood and complained regarding his work.
Given the scan results and poor response to injection, it was hypothesised that the cervical spine was the primary source of pain. Given the poor ability to control the pain and perceived yellow flags, a referral to the Pain Clinic was made.
Mr. A attended A&E in April 2014 with ongoing severe pain and was discharged with analgesics. He re-attended in May 2014 with acute abdominal, groin and leg pain and complained of an inability to open bowels for the last week. At this time, he was admitted and had further investigations.
A repeat chest x-ray revealed a right hilar mass with first rib destruction (Figure 2).
Figure 2: Chest x-ray May 2014
Repeat bloods revealed:
WBC 15 (4-11 10^9/L)
RBC 2.94 ¯ (4.5-5.8 10^12/L)
Hb 77 ¯ (130-165 g/L)
Total Protein 58 ¯ (60-80 g/L)
CRP 230.8 (<5 mg/L)
Alkaline
Phosphatase 297 (30-120 IU/L)
Gamma-glutamyl Transferase 268 (1-55 IU/L)
CT Thorax/abdomen/pelvis showed: widespread malignancy with nodal, visceral, subcutaneous, and muscular metastases with primary right upper lobe cancer.
He was admitted and diagnosed with metastatic Pancoast tumour. He sadly died ten days later, following a cardiac arrest.
Discussion
Pancoast tumours are rare and represent 3-5% of all lung cancers (Panagopoulos et al. 2014).
They demonstrate a predilection for distant metastasis and if extensive and diagnosed in late stages, are considered to have a poor prognosis (Bisbinas & Langkamer 1999).
Men are affected more commonly than women, with the average presenting age within the sixth decade. Cigarette smoking is a major risk factor (Panagopoulos et al. 2014).
Patients often present with shoulder and neck pain, brachialgia and distal neurological signs, particularly in an ulnar nerve distribution. This may result from invasion of the parietal pleura, upper ribs, brachial plexus, endothoracic fascia, or the adjacent vertebral bodies (Bisbinas & Langkamer 1999).
Mr. A exhibited these signs and symptoms and given his age, sex and smoking history was within a high-risk group.
Other clinical findings may include supraclavicular fullness, Horner’s syndrome, and prominence of the superficial jugular venous system, discoloration and oedema of the upper extremity (Bisbinas & Langkamer 1999).
Early Pancoast tumours are often not detected on plain chest x-rays (CXR) as they can be hidden behind the clavicle and first rib. As the disease progresses, a CXR may reveal asymmetry of the pulmonary apices or pleural thickening, bone destruction or even thoracic wall and spinal invasion according to the stage (Panagopoulos et al. 2014).
Following initial concern of weight loss and worsening pain, reassurance by normal bloods and chest x-ray swayed clinical reasoning towards a more musculoskeletal cause to his pain. Positive findings on shoulder and cervical imaging reinforced this hypothesis, as well as the duration of symptoms and mechanism of injury. His demeanor, low mood and identifiable yellow flags (relationship dynamics and work view) appeared to further suggest a persistent pain picture.
Literature suggests that failure to consider Pancoast tumour in the differential diagnosis appears to be the most common cause for delay in diagnosis. One paper quoted an average of 18.5 months from the beginning of symptoms, to correct diagnosis (Bisbinas & Langkamer 1999). As in this case, the patient has often seen several different clinicians, prior to diagnosis.
The high incidence and common observation of cervical spondylosis, shoulder pathology, or both, in this population group should make us exercise caution when attributing the symptoms to those conditions. Care should be taken not to over attribute symptoms to a potential ersistent pain picture, even in the presence of negative investigations. There is a need to continually monitor the clinical picture and respond accordingly.
References
Bisbinas, I. & Langkamer, VG. (1999) ‘Pitfalls and delay in the diagnosis of Pancoast tumour presenting in orthopaedic units’ Annals Royal College Surgeons England 81(5), 291-295
Panagopoulos, et al. (2014) ‘Pancoast tumors: characteristics and preoperative assessment’ Journal Thoracic Disease 6(Suppl 1): S108-S115