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< Presentation of a
Case >
A
51-year-old male, with a smoking history of 1 pack per day for
more than 30 years, started to experience right back pain and
soreness for half a year before this admission that was
associated with paresthesia and weakness of the right arm and
hand. A radiograph at an outside hospital suggested herniated
intervetebrate disc (HIVD) of the C-spine. He received
analgesics intravenously for several times. However, his right
back pain persisted. Three months prior to admission, he
developed ptosis and blurred vision of the right eye.
Operation for HIVD of the C-spine was done. The pain
persisted, however. During that hospital course, the chest
radiogram showed lesions at the right upper lung (Figure.
1). CT of the chest showed a cavitary mass and infiltrates
of the right lung apex (Figures 2
and 3
). Pulmonary tuberculosis was
impressed, though acid-fast stains (AFS) of the sputum
specimens were negative on 3 occasions. Anti-TB drugs were
administered. Then, he was referred to a TB center.
AFS of the sputum specimens
were repeated, which remained negative. He felt chest
discomfort after taking anti-TB drugs, and, therefore, anti-TB
drugs were discontinued. Because of the eccentric cavitation
with corona radiata sign and presence of Horner syndrome
(ptosis and miosis) in addition to cough, malignancy of the
lung was suspected. He was admitted to this hospital.
On admission, physical
examination showed a man of 158 cm in height and 43 kg in
weight. His temperature was 37.2o C, blood pressure was 127/63
mmHg, pulse rate was 80 beats per minute, and respiratory rate
was 21 breaths per minute. His consciousness was clear. His
conjunctivae were pink, and the sclerae were anicteric. The
pupils were anisocoric (right, 3 mm and left, 8 mm) with
prompt light reflexes, but slow to dilate right pupil. The
neck was supple with a right supraclavicular lymphadenopathy
that was about 2 cm in size and was freely movable without
tenderness. The jugular veins were engorged. The chest wall
expansion was symmetric, and breath sounds were clear but
bronchial sound was heard at the right upper lung field. The
heart beats were regular without murmur. The abdomen was soft.
Bowel sounds were normoactive and liver and spleen were
impalpable. His extremities were freely movable without edema,
but the muscle power was about 3~4/5 of his right hand, arm
and forearm. He felt paresthesia while light touch was
applied.
< Laboratory Data
>
CBC/DC and biochemistry:
|
WBC |
Hb |
Hct |
MCV |
Platelet |
Seg |
Eos |
|
K/μL |
g/dL |
% |
fL |
k/μL |
% |
% |
|
13.2 |
11.3 |
37.6 |
77.4 |
475 |
76.8 |
0.2 |
|
Baso |
Mon |
Lym |
ALB |
T-Bil |
AST |
ALT |
|
% |
% |
% |
g/dL |
mg/dL |
U/L |
U/L |
|
0.2 |
7.3 |
15.5 |
3.6 |
0.49 |
24 |
11 |
|
BUN |
Cr |
LDH |
Na |
K |
CRP |
Glucose |
|
mg/dL |
mg/dL |
U/L |
mmol/L |
mmol/L |
mg/dL |
mg/dL |
|
8 |
0.8 |
233 |
145.7 |
4.53 |
|
83 |
------------------------------------------------------------------------
Stool
OB:
3+
-------------------------------------------------------------------------
**
免疫檢查 **
CEA [Carcinoembryonic antigen]:
2.22 ng/mL
SCC [squamous cell carcinoma] antigen:
1.79
ng/mL
-------------------------------------------------------------------------
PPD
skin test: 10 mm
-------------------------------------------------------------------------
**
細菌學檢查 **
Sputum AFS and cultures for
M. tuberculosis were negative for 3 sputum samples and
bronchial brushing and lavage
samples.
-------------------------------------------------------------------------
**
細胞學檢查 **
Sputum: no evidence of malignant cells.
Bronchial brushing and lavage (BAL): a few cells with glandular structure and
enlarged nuclei, highly suspected of
adenocarcinoma.
-------------------------------------------------------------------------
** 病理學檢查 **
Adenocarcinoma
-------------------------------------------------------------------------
< Course and
Treatment >
During the hospital course, pain
control was given. AFS of sputum samples were repeated which
remained to be negative. Bronchoscopy was done. Tumor markers
were within normal limits but cytology of BAL showed atypical
cells with enlarged nuclei. A right supraclavicular lymph node
was noted. Sonography-guided aspiration of the lymph node and
aspiration and biopsy of the right lung apex were performed,
which showed a few cells with glandular structure, highly
suspected of adenocarcinoma. He was referred to a medical
center. Operation was done, and the pathology reported
adenocarcinoma. Chemotherapy was
scheduled.
<
Discussion >
Pancoast (Superior Sulcus) Tumors
肩膀及相關上半身疼痛是臨床上常見的問題。其造成的原因很多，也因此能否正確地鑑別診斷其真正的原因是很重要的。有時候，我們會面臨兩難的窘境。是否僅單純地把它看做是一般的骨科問題，還是要當做其它更嚴重的問題來處理（如上述個案之情形）？[1-3]
Pancoast syndrome 的特徵包括：手臂肩膀疼痛（最常見的初發症狀），Horner's
syndrome，以及手部小肌肉的萎縮。它最早是由 Hare 在西元1838年描述所提及；然而更詳盡的描述則是於1932年由
Tobias 及 Pancoast 提出。[4]
儘管如此，個體間仍會因進一步侵犯的組織不同而在症狀上存在著差異。此外，咳嗽、呼吸困難及咳血是一般肺癌患者常有的徵象。然而、對於
Pancoast tumor 的患者而言，相對上不是那麼常見。主要是因為 Pancoast tumor
位於肺部周邊的緣故。一旦出現這些症狀時，通常預後也已較差了。[5]
在檢查方面，基本的X光檢查就有可能在肺尖發現明顯的腫瘤。只不過在很多時候，也僅僅只是在肺尖上呈現出些許濃度上的增加而常常被不小心忽略掉。相較之下，
CT scanning 的敏感度較高。而MRI 是最佳的選擇，特別是在確認腫瘤對周遭器官侵犯的程度方面
(例如脊椎、臂神經叢以及鎖骨下的血管)，尤其優於 CT scanning。[4, 6, 7]
很多疾病都可能導致 Pancoast
syndrome。因此在開始確定治療之前，組織學的診斷是必要的。而超音波導引下的抽吸切片則能提供一安全且有效的方法來得到病理學上的確認。[8]
Pancoast tumors 有超過95%
屬於非小細胞型，而其中大部分是鱗狀細胞癌 (52%) 及腺細胞癌和大細胞癌
(大約各佔23%)，以及其它小細胞型僅少於5%。其它必須考慮的尚包括 mesothelioma, lymphoma,
plasmacytoma, metastatic malignancies (thyroid, larynx),
lymphomatoid granulomatosis, cervical rib syndrome,
tuberculosis, 及 fungal infections. [9]
最近的資料顯示在此部位的非小細胞型癌仍保有其淋巴結及遠端轉移的特性。 事實上，在定義上 Pancoast tumors
在分期上至少為第 IIb 期以上。縱膈腔或鎖骨上淋巴結的侵犯可能多達 55%，也代表較差的預後。因為Superior
sulcus tumors 在位置上靠近 thoracic
inlet，很容易早期侵犯數處對痛敏感的結構，所以相對上也較其它非小細胞型癌早些被發現。[4]
< References
>
- Spengler, D.M., M.M. Kirsh, and H.
Kaufer, Orthopaedic aspects and early diagnosis of superior
sulcus tumor of lung (Pancoast). J Bone Joint Surg Am, 1973.
55(8): p. 1645-50.
- Ziporyn, T., Upper body pain:
possible tipoff to Pancoast tumor. JAMA, 1981. 246(16): p.
1759, 1763.
- Kovach, S.G. and E.L. Huslig,
Shoulder pain and Pancoast tumor: a diagnostic dilemma. J
Manipulative Physiol Ther, 1984. 7(1): p. 25-31.
- Margolis, M.L., Non-Small Cell Lung
Cancer-Clinical Aspects, Diagnosis, Staging, and Natural
History.
- Karl J D'Silva, M., Pancoast
syndrome. 2007.
- Hirakata, K., H. Nakata, and H.
Yoshimatsu, [Computed tomography of Pancoast tumor]. Rinsho
Hoshasen, 1989. 34(1): p. 79-84.
- Beale, R., et al., Pancoast tumor:
use of MRI for tumor staging. South Med J, 1992. 85(12): p.
1260-3.
- Yang, P.C., et al., Ultrasonography
of Pancoast tumor. Chest, 1988. 94(1): p. 124-8.
- Melanie Guerrero, M., Pancoast tumor.
2004.
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Case Discussion
繼續教育考題