A 58-year-old smoker with a chronic cough attends out-patient with a history of severe pain in his left shoulder and radiating down his left arm. There is some weakness in the intrinsic muscles of the left hand. Sputum cytology reveals malignant keratinised cells. Most likely diagnosis is:
D. Hypertrophic pulmonary osteoarthropathy
Correct Answer: B. Pancoast's syndrome
This is a complication of an apically placed lung carcinoma which in most cases is of squamous cell variety. The tumor invades directly into anatomical structures situated in this area including ribs, thoracic vertebrae and nerve roots.
Erosion of the ribs results in severe pain in the shoulder.
Infiltration of the lower part of the brachial plexus (C8-T2) results in:
-Pain down the inner surface of the arm and the fourth and fifth fingers.
-Paralysis and wasting of the muscles of the hand and forearm.
-There may also be a unilateral laryngeal nerve palsy and vocal cord paralysis causing a hoarse voice/ bovine cough.
The other well-recognised syndrome is Horners syndrome, caused by involvement of sympathetic fibres as they exit the cord at T1 to ascend to the superior cervical ganglion (miosis, ptosis, enophthalmosis).
Rather confusingly, a Pancoast tumour can lead to both Pancoasts and Horners syndromes.
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