A 55-year-old man with a history of chronic low back pain comes to the physician with a 3-week history of progressive right shoulder pain and a 1-week history of worsening lower back pain. He has tried several over-the-counter medications without significant relief. He smokes 2 packs daily and consumes alcohol occasionally. A chest x-ray reveals a right superior lobe mass. Which of the following additional findings, if present, would indicate a worse prognosis requiring urgent intervention?

Question

A 55-year-old man with a history of chronic low back pain comes to the physician with a 3-week history of progressive right shoulder pain and a 1-week history of worsening lower back pain.  He has tried several over-the-counter medications without significant relief.  He smokes 2 packs daily and consumes alcohol occasionally.  A chest x-ray reveals a right superior lobe mass.  Which of the following additional findings, if present, would indicate a worse prognosis requiring urgent intervention?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c169_f66e_8f63_cf2caa4e510f_MD0005_00 The description in the vignette is consistent with superior pulmonary sulcus (Pancoast) tumor, generally a subset of non-small cell lung cancer. Shoulder pain is the most common initial presentation. The history and physical examination may assist in assessing the extent of neoplastic spread and determining prognosis. Pancoast syndrome consists of shoulder pain (50%-90%), Horner's syndrome (15%-50%), and hand muscle atrophy and weakness (10%-20%). However, asymmetric lower-extremity deep-tendon reflexes, particularly in the setting of back pain, suggest that the tumor has spread to the spinal cord. Spinal cord compression develops in up to 25% of patients with Pancoast tumor during the course of the disease and may result in paraplegia. Early recognition and appropriate therapy (which may include corticosteroid therapy, surgery, and radiation) is imperative to preserve neurologic function and patient autonomy. 11ec2b69_c169_f66f_8f63_f5cbf37a4d07_MD0005_00 (Choices A and B) Brachial plexopathy is a typical complication of superior sulcus tumor that may lead to atrophy of the internal muscles of the hand and asymmetric upper-extremity deep-tendon reflexes. (Choice D) Pupil size asymmetry and asymmetric palpebral fissures result from invasion of the paravertebral sympathetic chain (Horner's syndrome). Horner's syndrome is considered to be a poor prognostic sign, but it is not immediately dangerous. (Choice E) Streaky hemoptysis and weight loss are typical symptoms of lung cancer that are not dangerous per se. Given the peripheral location of Pancoast tumors, pulmonary symptoms tend to occur at a more advanced stage. Educational objective: Spinal cord compression develops in up to 25% of patients with Pancoast tumor during the course of the disease. Early recognition and appropriate therapy are imperative to preserve neurologic function and patient autonomy. References: Superior pulmonary sulcus tumors and Pancoast's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/9358132)

A 55-Year-Old Man with a History of Chronic Low Back