A Patient With Pancoast Tumor Presenting With Cervical Radiculopathy: A Case Report

Abstract

Objective

The purpose of this report was to describe a patient with a Pancoast tumor who presented for chiropractic care with neck and arm pain.

Clinical Features

A 52-year-old male patient with right-sided cervicothoracic pain and numbness in the right upper extremity presented to a chiropractic office for care. The patient reported an occupational history of repetitive lifting motions and overuse injuries. The patient denied history of smoking at the time of presentation.

Intervention and Outcome

Radiographic imaging revealed tracheal deviation. A chest computed tomography image demonstrated a large lesion in the apex of the right lung, suggestive of bronchogenic carcinoma. The patient was referred to an oncology clinic, where he admitted to having a 20-year history of smoking. The diagnosis of adenocarcinoma was made via biopsy, and the oncologist's evaluation confirmed the cancer to be stage IIIC. The patient received palliative care treatments, as the advanced state of his condition determined that he was not a candidate for surgical intervention.

Conclusion

Chiropractors and other first-contact health care providers must keep in mind unusual presentations masquerading as common conditions. This case demonstrates the importance of including apical lung tumors in the differential diagnosis of unilateral arm and neck pain and neurologic deficits of the upper extremity. This case demonstrates the importance of thorough follow-up on images ordered, including the ordering clinicians viewing the images themselves.

Introduction

Although doctors of chiropractic are thought to address patients with conditions that are mechanical in their nature, such as neck pain or lower back pain, there are occasional patient presentations that appear benign but require a higher level of scrutiny in their evaluation and management.¹ Pancoast tumors, also called superior sulcus tumors, represent a range of primary cancers that may invade the apex of the lung and metastasize to the spine and chest wall.² The location of this tumor creates potential for invasion of the lower brachial plexus, the sympathetic chain, vertebral bodies, ribs, and subclavian vascular structures.³ When evaluating arm or shoulder pain, this pathology must be considered if the patient also presents with paresthesia, any indications of Horner syndrome (ptosis, miosis, anhidrosis), or has a history of smoking.³ Diagnosis of a Pancoast tumor is typically made using the combination of a specific clinical presentation (unilateral shoulder pain, arm pain, motor weakness, paresthesia),³ along with the radiographic findings of a lesion in the apex of the lung and potential infiltration into the spine, chest wall or ribcage.³ This pathology shares similarities in clinical presentation with cervical radiculopathy, a term used to define pain, numbness, or weakness in the upper limb due to compression of one or more cervical nerve roots.⁴ This disorder can be caused by a number of pathologies that involve neuroforaminal encroachment, such as space-occupying lesions or arthrosis of the spine, as well as disorders that compress the neurovascular bundle, most commonly referred to as thoracic outlet syndrome.⁵

According to the World Health Organization's 2018 report on cancer, primary lung carcinoma is the leading cause of cancer-related deaths and the most common cancer diagnosis globally and in the United States. In that report, lung cancer accounted for 48% of cancer diagnoses in men, with higher rates in the African American population than any other ethnic group.⁶ Pancoast tumors account for 3% to 5% of primary lung carcinomas.⁷ Management of Pancoast tumors is determined on a case-by-case basis and is most substantially influenced by the vascular invasion and the stage of the disease.⁷

At present, there is a limited number of case reports that describe patients with Pancoast tumors presenting to chiropractors.^8,9, 10, 11, 12, 13, 14 Therefore, the purpose of this report is to describe the presentation of a patient with neck and arm pain and signs of radiculopathy due to an underlying Pancoast tumor.

Case Report

A 52-year-old African American male postal worker presented to a chiropractic office with a chief complaint of right-sided cervicothoracic pain, shoulder pain, and numbness in the right upper extremity that extended to the third through fifth digits. He noted that his symptoms began 4 weeks prior, initially rated as a 2 out of 10 on the Numeric Rating Scale (NRS) that progressed to a level of 7 out of 10 by the time of his initial visit. He reported that his initial onset of pain followed excessive lifting and pushing and pulling heavy packages at work and that the pain came on gradually following a few weeks of increased workload. The patient also noted that repeated overhead lifting and forward shoulder flexion with 5-pound packages increased his pain. Alleviating factors included rest of the right arm, as well as nonsteroidal anti-inflammatory drugs, 400 to 600 mg, taken 2 to 3 times per day. The patient denied a history of smoking at this time, reported no incidence of coughing, night pain, or night sweats, and denied any recent unintended weight loss.

Inspection of the skin, thoracic cavity, and cervical spine anatomy was unremarkable. On palpation, the patient noted tenderness at the spinous processes but denied tenderness of the ribs. No additional upper extremity symptoms were present on palpation. Physical examination showed forward head carriage and anterior shoulder rotation bilaterally, as well as postural patterns consistent with upper crossed syndrome. Cervical spine range of motion analysis demonstrated mild bilateral restriction of cervical rotation. Active rotation resulted in right-sided neck pain and mild pain that referred into the right trapezius muscle. Upper extremity myotome tests were +5 bilaterally. Dermatome and sensory testing showed reduced sensation on both sharp and dull tests in the C7 and T1 dermatome regions on the right side. The patient experienced mild local cervical spine pain relief with cervical distraction in a supine position, as well as an increase in symptoms with an upper limb tension test of the median nerve, an orthopedic test that increases tension on the median nerve to determine replication of symptoms. Positive findings with this test indicate nerve entrapment or an increase in neural tension due to postural habits and positioning.¹⁵ The positive neural-tension test and increase in symptoms with cervical rotation were hypothesized at the time to be a result of the patient's upper crossed syndrome, and, given the patient's increase of symptoms with overhead lifting, a potential diagnosis of thoracic outlet syndrome, a disorder that can be caused by multiple different pathologies or anatomic variants that result in compression of the neurovascular bundle exiting through the thoracic outlet.⁵

Based on a working diagnosis of cervical radiculopathy and segmental and somatic dysfunction of the cervical spine, the patient was treated 3 times in approximately 10 days. Treatments included diversified chiropractic manipulative therapy. The patient was provided with an at-home regimen of scapular retraction exercises to be performed several times per day to tolerance. Chiropractic manipulative therapy included bilateral index pillar push adjustments (levels C4-C7) and an anterior adjustment (levels T1-T3). Each treatment was well tolerated with no adverse response. After the first 3 treatments, the patient reported that his pain had reduced to 5 out of 10 NRS, and his cervical range of motion was no longer limited. Upon returning for his fourth treatment, 10 days after his initial presentation, the patient stated that while his pain had again reduced, his right arm numbness had worsened. Subsequent neurologic evaluation of the patient revealed sensory loss in the right upper extremity specific to the C7 and C8-T1 dermatomes, reduced muscle strength of the right triceps (4/5), grip strength (3/5) and right triceps reflex (1+). Given the new neurologic symptoms that were not evident at the initial examination 10 days prior, the patient was referred to a local imaging center for a cervical spine radiographic series, which included oblique views to evaluate for foraminal encroachment due to cervical spine osteoarthrosis or a space-occupying lesion.

The radiology report, which was generated by a board-certified medical radiologist, was faxed to the chiropractic office from the outside imaging center and stated “mild degenerative changes” as the only remarkable finding. Upon review of the images, the chiropractic clinician noted severe left-sided tracheal deviation at C7 to T3, with non-calcified opacification of the right lung apex, and osteolytic destruction of the first rib head on the right that was not noted in the radiology report (Fig 1). A chest radiographic series was then ordered and obtained 5 days later, which demonstrated a non-calcified soft tissue mass in the right paratracheal region with contralateral deviation of the trachea (Fig 2). Additionally, there was a single region of segmental consolidation within the right upper lobe abutting the superior aspect of the horizontal fissure without deviation. At this point, the differential diagnosis included a primary lung neoplasm, thyroid goiter, and lymphadenopathy.

Fig 1.

AP lower cervical radiographic projection demonstrating left-sided tracheal deviation at the level of C7-T3 with opacification of the right lung apex and destruction of the head of the first rib. AP, anteroposterior.

Fig 2.

PA chest (A) and lateral chest (B) radiographs demonstrating right apical lesion with contralateral tracheal deviation. There is additional opacification abutting the superior aspect of the horizontal fissure without deviation of the fissure, consistent with segmental consolidation. PA, posteroanterior.

A follow-up chest computed tomography with intravenous contrast was ordered and obtained within 10 days by the patient's primary care physician, which demonstrated an infiltrating, minimally enhancing, non-calcified, slightly heterogeneous mass with soft tissue attenuation (30-75 HU) located in the medial aspect of the right upper lobe, which extended superiorly into the right neck and inferiorly into the hilar region (Fig 3). This mass measured 11.5 cm superior to inferior by 7.5 cm anterior to posterior by 7.5 cm medial to lateral. The mass encased and narrowed the azygous arch and partially encased the superior vena cava. Additionally, there was direct superior, middle, and posterior mediastinal invasion by the mass with partial encasement of the right side of the trachea and esophagus. Direct invasion with osteolytic destruction of the right posterior first rib, posteromedial second rib, portions of the T1 right lateral body, pedicle, and transverse process, as well as extension into the right spinal canal at T1 to T2, was noted (Fig 4).

Fig 3.

Computed tomography of the chest in soft tissue window with intravenous contrast; axial (A) and coronal (B) planes at the level of the superior vena cava (SVC) demonstrating tumor encasement of the SVC, right side of the trachea, and right subclavian region. SVC, superior vena cava.

Fig 4.

Computed tomography of the chest in the bone window with intravenous contrast; axial plane at the level of T1 demonstrating osseous destruction of the vertebral body and rib as a result of direct metastasis.

Two enhancing lesions were noted in the liver, the larger in the left lobe, measuring 2.5 cm. Additional sclerotic lesions were seen within the manubrium. The liver and sternal lesions were concerning for hematogenous metastatic disease. The patient was subsequently referred to a local oncology clinic the week following computed tomography imaging. During the history and examination at the oncology clinic, the patient admitted to having a 20-year history of smoking. The diagnosis of adenocarcinoma was made via biopsy, and the oncologist's evaluation confirmed the cancer to be stage IIIC. The patient received palliative care treatments, as the advanced state of his condition determined that he was not a candidate for surgical intervention.

The patient completed a 10-day course of radiation treatment, along with additional pharmacological intervention, which resulted in mild reduction in the mass size. These interventions reduced his overall pain levels to 3 out of 10 NRS, and his motor function improved to 5 out of 5 bilaterally. There was no change in the paresthesia and sensory loss on the affected side. The patient returned to work at his place of employment and regained some limited use of his right upper extremity despite neurologic deficits and diminished muscle strength.

The patient's prognosis was terminal. Due to the complexity of the tumor location, surgery was not an option, though the growth of the tumor stopped with radiation treatment. At the time of publication, 3 years post-diagnosis, the patient continued to work full time with manageable pain levels and a NRS rating of 3 to 4 out of 10. Consent was given by the patient to publish his personal health information in this report.

Discussion

This case describes an initial presentation of cervical radiculopathy in a patient with a likely mechanism of injury. Imaging suggested a more concerning presentation, indicating urgent referral. Given the location of Pancoast tumors, the most common initial clinical presentation typically involves “nagging” shoulder and arm pain rather than chest pain or hemoptysis.² The peripheral nature of these tumors causes patients to present without a cough or shortness of breath, which can falsely steer practitioners away from thinking along the lines of a primary lung neoplasm.¹⁶ The tumor often encroaches on the entire thoracic inlet, so practitioners should be aware of the likelihood of positive thoracic outlet syndrome orthopedic tests.⁸ The vast range of symptoms in this pathology combined with the lack of “typical” bronchogenic carcinoma indicators often results in patients being seen by multiple practitioners. Additionally, symptoms are usually too mild to be considered “red flags,” and the disease is often late-stage by the time imaging is ordered to rule out other underlying pathologies.¹⁷ These factors, combined with the complex nature of surgical resection given the anatomical location of this tumor, makes the case management of this pathology very difficult.

While it may seem cautious to include a Pancoast tumor in the differential diagnosis list for a patient over 45 years of age who is presenting with a seemingly straightforward case of cervical radiculopathy or thoracic outlet syndrome, it will better serve the patient always to keep this differential in the forefront of clinical thinking, as early detection is key in the successful management of this pathology. If a patient is not responding to care, the treating clinician must evaluate any additional changes in symptoms. Rapid deterioration of neurologic function is a red flag, and ancillary testing should be performed. Patients will not always present with red flags at the onset of symptoms that indicate the need for immediate referral and intervention. A known limitation of case reports is the lack of ability to generalize for all patients, making it difficult to establish a cause-and-effect relationship.

This case also illustrates the importance of patient compliance and accuracy when it comes to obtaining an accurate medical history, specifically regarding smoking. This patient would have met the guidelines for preventative screening, and this information early on in the case would have made for a straightforward treatment plan and differential diagnosis.¹⁸ It is worth noting that this patient would have qualified for preventative screening prior to developing symptoms, based on the current Centers for Disease Control and Prevention lung cancer screening guidelines.¹⁸ Presently, the resection of Pancoast tumors is evaluated based on the involvement of the brachial plexus and vascular structures, as well as nodal involvement and extent of metastasis.² Early detection and treatment is critical for successful intervention and survival.³

Also of note, the rates of error in radiology reports are around 3% to 5% in daily practice.¹⁹ While this data is not new, it represents an area of health care that has not evolved in terms of establishing protocols to reduce the rates of error.¹⁹ Doctors who order images based on their clinical workup of a patient should be responsible for assessing the images in addition to reading the report in order to confirm that they agree with the assessment of the radiologist and to reduce the risk of missed diagnoses.

While the goal of this report is to reduce diagnostic time for Pancoast tumors by encouraging clinicians to include them on the list of differential diagnoses, it is difficult to say whether or not these tumors are diagnosable before they are at an advanced stage. Given the complexity of the anatomical structures of the area where this pathology occurs, early diagnosis is challenging, even with astute clinical reasoning and decision-making.⁹

Limitations

This is a case study and thus is a report for only 1 patient. The findings and circumstances are unique to this particular case situation. Therefore, extrapolation of this case to other patients or clinical situations is not possible.

Conclusion

Chiropractors and other first-contact health care providers must keep in mind unusual presentations masquerading as common conditions. This case demonstrates the importance of including apical lung tumors in the differential diagnosis of unilateral arm and neck pain and neurologic deficits of the upper extremity. This case demonstrates the importance of thorough follow-up on images ordered, including the ordering clinicians viewing the images themselves.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): C.P.F.

Design (planned the methods to generate the results): E.K.B.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): E.K.B.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): E.T.S.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): L.J.T.

Literature search (performed the literature search): E.K.B.

Writing (responsible for writing a substantive part of the manuscript): E.K.B.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): L.J.T

Practical Applications.

• •First-contact health care providers must be aware of unusual presentations masquerading as common conditions.
• •This case emphasizes the importance of including Pancoast tumors in the differential diagnosis of unilateral arm and neck pain.
• •This case demonstrates the importance of clinicians viewing the images that they order.

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