A 64-year-old man comes to the office due to 2 months of weight loss, dry cough, and progressive pain in his right arm. He was treated for community-acquired pneumonia a year ago. The patient has a history of type 2 diabetes mellitus and hypertension. He used to travel internationally for work but retired several years ago. The patient has a 30-pack-year smoking history but quit 5 years ago. He drinks alcohol occasionally. Vital signs are normal. Physical examination is unremarkable. Imaging of the chest is shown below. Which of the following is most likely responsible for this patient's symptoms?

Question

A 64-year-old man comes to the office due to 2 months of weight loss, dry cough, and progressive pain in his right arm.  He was treated for community-acquired pneumonia a year ago.  The patient has a history of type 2 diabetes mellitus and hypertension.  He used to travel internationally for work but retired several years ago.  The patient has a 30-pack-year smoking history but quit 5 years ago.  He drinks alcohol occasionally.  Vital signs are normal.  Physical examination is unremarkable.  Imaging of the chest is shown below.  Which of the following is most likely responsible for this patient's symptoms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d304_648e_bc81_258dbe559e56_MD0003_00 This patient with weight loss, dry cough, and arm pain has imaging evidence of a superior pulmonary sulcus (Pancoast) tumor. Pancoast tumors occur in the apical pleuropulmonary groove and are generally caused by adenocarcinoma or squamous cell carcinoma of the lung. Smoking is the single greatest risk factor. Manifestations generally arise when the tumor compresses or invades adjacent structures, leading to: superior pulmonary sulcus (Pancoast) tumor Shoulder pain due to invasion of the brachial plexus, pleura, ribs, or vertebral bodies. Because shoulder pain is common and often due to a benign cause (eg, osteoarthritis), the diagnosis of Pancoast tumor is frequently delayed. Horner syndrome (eg, miosis, ptosis, anhidrosis) due to invasion of the paravertebral sympathetic chain or stellate ganglion. Neurologic manifestations (eg, weakness/atrophy of hand muscles, paresthesia/pain) in an ulnar distribution due to invasion of the inferior (C8-T1) portion of the brachial plexus Hoarseness due to recurrent laryngeal nerve invasion Superior vena cava syndrome Weight loss is also common; pulmonary symptoms (eg, cough) do not typically occur until the tumor is large (as in this patient). (Choices A and F) Reactivation tuberculosis can cause nodules or cavitary lesions in the lung apex that may be colonized by Aspergillus species, creating an aspergilloma. However, arm pain would be very atypical because invasion into adjacent structures is highly uncommon in immunocompetent patients. In addition, most patients have fever. tuberculosis aspergilloma (Choice B) Bronchial carcinoid tumors are rare and usually occur centrally in the central airways, not the lung apex. Most cases present with hemoptysis, cough, or dyspnea from denudation/obstruction of the airway. (Choice C) Cryptogenic organizing pneumonia causes dry cough and systemic symptoms that last for months. Cross-sectional chest imaging usually demonstrates ground-glass infiltrates (typically bilateral) rather than a solid mass. Cryptogenic organizing pneumonia (Choice D) Mesothelioma is a malignant neoplasm derived from the mesothelial lining of the thoracic cavity. It is strongly linked to asbestos exposure and usually presents with cough, chest pain, and dyspnea. Chest imaging typically reveals pleural thickening with an effusion. Mesothelioma Educational objective: Superior pulmonary sulcus (Pancoast) tumors arise in the apical pleuropulmonary groove and typically present with shoulder pain, Horner syndrome, or neurologic manifestations in the arm due to invasion of adjacent structures (eg, brachial plexus, paravertebral sympathetic chain). References: Pancoast tumors: characteristics and preoperative assessment. (http://www.ncbi.nlm.nih.gov/pubmed/24672686)

A 64-Year-Old Man Comes to the Office Due to 2