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 Lung Cancer  



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Author18 Posts
  #1

A 68 year old man with a 80 pack/year smoking history is admitted for chronic cough, marked hemoptysis, and a 25 pound weight loss over the last 6 months. He has had an increase in the amount of morning wheezing, and complaints of left arm pain, numbness, and weakness that have gotten progressively worse over the last 4 months. Which of the following syndromes describes this patient's left arm difficulites?

A. Cushing Syndrome
B. Goodpasture syndrome
C. Horners syndrome
D. SIADH
E. Superior vena cava syndrome

Please explain WHY you think your answer is right.





  #2

D. Low sodium, muscle weakness.


  #3

E





  #4

dr.wad wrote:
E



how do you explain that there is no facial and upper extremity edema?



  #5

I think it is C. The most likely dx is Pancoast tumor (in the apex of left lung). This kind of lung cancer is very aggresive and is destructing brahial and symphatetic plexus. This is why our patient has pain in left arm. He could also have pain in the left shoulder, ptosis, conctricted pupil and abscence of sweating on the left side of face. These simptoms will probably develop as time goes by.


  #6

neurom wrote:
D. Low sodium, muscle weakness.



How do u explain that the weakness is present only in left arm, and not in the other extremities



  #7

Agree that pancoast tumor explains better the arm pain but the arm pain is not due to Horner's syndrome

Not sure but i will go with E arm sweelling can explain the pain



  #8

Ivonne wrote:
Agree that pancoast tumor explains better the arm pain but the arm pain is not due to Horner's syndrome

Not sure but i will go with E arm sweelling can explain the pain

I agrie that pain is not due to Horner's syndrom, but the pain in arm comes together whit Horner's syndrom in patient with pancoast.
I'm not sure...


  #9

The right answer is C. Horners syndrome

Lung cancer-- Pancoast Tumor --impingment on the sympathetic nerves and also the Left Recurrent laryngel nerve--- so this guy has hoarseness.

WHY is it NOT SVC syndrome?
This would present as edema of the upper chest, neck and face.

My question here is this:
If this patient has a pancoast tumor producing Horners Syndrome, wouldn't he also present with Ptosis, Anhydrosis, and Miosis??? I thought these three were essential for the diagnosis of horners, yet they didn't mention even one of them in the presentation.



  #10

I picked my answer by method of exclusion. If ASSUME that there is an arm swelling as Ivonne said then i go with E.


  #11

When I did the question, I picked E too, but it was wrong.



  #12

I disagree Horner syndrome does not describe arm pain as part of the syndrome. Does it?

Pancoast syndrome...yes

I dont agree with the answer



  #13

nod
Ivonne wrote:
I disagree Horner syndrome does not describe arm pain as part of the syndrome. Does it?

Pancoast syndrome...yes

I dont agree with the answer




  #14

Ivonne wrote:
I disagree Horner syndrome does not describe arm pain as part of the syndrome. Does it?

Pancoast syndrome...yes

I dont agree with the answer


I don't agree with the answer either... that's why I posted it here... maybe someone could reason it out WHY SVC syndrome is actually wrong, and why Horners is the better answer, as I'm not satisfied with the given explanation.



  #15

DrVirgo wrote:
Ivonne wrote:
I disagree Horner syndrome does not describe arm pain as part of the syndrome. Does it?

Pancoast syndrome...yes

I dont agree with the answer


I don't agree with the answer either... that's why I posted it here... maybe someone could reason it out WHY SVC syndrome is actually wrong, and why Horners is the better answer, as I'm not satisfied with the given explanation.

ok, it is not horner's itself that causes left arm difficulties, so the question is not quite accurate... sympathetic nerve impingenet leads to arm pain---> thay should have pancoast then..



  #16

Well this is a clear case of pancoast syndrome and the pain might be due to damage to the afferent fibers of the sympathetic trunk or involvement of the lower brachial plexus, the eigth cervical nerve or the first thoraxic nerve.

SVC syndrome is a forced answer too.

So answer none of the above gringrin



  #17

To me it looks like pancoast Sy, it can lead to shoulder and/or arm pain. Arm pain isn't part of Horner's Sy, but it can be present simultaneously, and pancoast cancer can go with shoulder or arm pain and Horner Sy.

Even hand swelling can be caused by pancoast tumour due to compression onto blood vessels.

So, Horner Sy is a triad ptosis, myosis, anhydrosis. Pancoast tumour has specific localization and thus can lead to Horner's Sy, but to other symptoms as well. Pain can be due to sympathetic nerves damage, but also due to brachial plexus injury as indicated by the fact that the patient has left arm weakness.

From eMedicine: "...Patients may present with referred pain over the scapula to the shoulder as the result of damage to the afferent pain fibers of the sympathetic trunk. Pain in an ulnar nerve distribution along the medial aspect of the arm to the fingers results from involvement of the lower brachial plexus, the eighth cervical nerve, and the first thoracic nerve. This may be associated with hand weakness."


However, pancoast isn't offered in answers.

Amond other offered answers, only SVC Sy is associated with compression which can cause some of those symptoms, but I'm not sure it is the best option.



  #18

(C)
although C does not fit the case presentation, all other options are even less suitable... Pain is due to brachial plexus tumor infiltration. Classic ptosis, miosis, anhydrosis, enophthalmus, and conjunctival and facial congestion will come later as these are the symptoms of the VERY ADVANCED disease...





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