Learning point for clinicians
Pancoast syndrome is not always synonymous with lung cancer. The search for infectious diseases such as hydatid cyst must be systematic in endemic areas especially for patients with no known risk factors of lung cancer.
Case history
A 42-year old man, non-smoker, consulted for a 20 years progressive left lower-cervical mass. Physical examination revealed a hard rubbery left lower cervical mass 12 cm in diameter, filling the left supraclavicular fossa with intrathoracic extension. The mass was fixed to both deep and superficial structures, non-tender with normal overlying skin. Muscle atrophy, decreased muscle power and paresthesia of the left upper limb was also noted. A chest X-ray showed a left apical opacity (Figure 1A). A cervicothoracic computed tomography scan revealed a large left apical mass containing calcification with cervical extension (Figure 1B). Given the presence of neurological signs and the apical localization of mass, a magnetic resonance imaging (MRI) of the cervico thoracic region was performed revealing infiltration C5 and C6 foramina infiltration. Although the brachial plexus roots were free, they were surrounded by the mass. Surgical exploration by an anterior cervicothoracic approach revealed a hydatid cyst in the apical portion of the lung apex. The cyst was completely resected. Postoperative finding was satisfactory with total recovery of muscle power after 2 weeks. Chemotherapy on albendazole at a dose of 10 mg/kg once daily was given for a period of 1 year following surgery.
Figure 1.
(A) Anteroposterior chest radiograph showing apical left opacity. (B) Cervicothoracic computed tomography showing a huge left apical mass with cervical extension, containing some calcifications.
Discussion
Pancoast syndrome remains a rare disease, most often a revealing lung cancer. Other malignant causes have been sporadically described; such as thyroid cancer, cervical cancer metastasis, multiple myeloma. Infectious etiologies like hydatid cyst, aspergillomas, staphylococcal or lymphoid granulomatosis have been reported.1,2 Despite the high incidence of hydatid cyst in endemic areas such as Morocco, its clinical manifestation through Pancoast syndrome is exceptional.3,4 The case of our patient is particular in that he presented with neurological signs and chronicity of his illness. The presence of an apical opacity suggests more the diagnosis of a Pancoast syndrome. Given the patient’s young age, the absence of risk factors, the endemic context and the results of MRI an immediate surgery was performed permitting us to discover a cystic lesion which when dissected showed the presence of a hydatid membrane.
Conflict of interest: None declared.
References
- 1.Collins PW, De LC, Newland AC. Pancoast's tumor due to aspergilloma. Lancet 1990; 336:1595 [DOI] [PubMed] [Google Scholar]
- 2.Mitchell DH, Sorrell TC. Pancoast's syndrome due to pulmonary infection with Cryptococcus neoformans variety gattii. Clin Infect Dis 1992; 14:1142–4. [DOI] [PubMed] [Google Scholar]
- 3.Alaoui-Yazidi A, Sibaï H, Kafih A, El Meziane A, Bartal M. Syndrome de Pan-coast et Tobias d’étiologie hydatique. Rev Mal Respir 1995; 12:49–52. [PubMed] [Google Scholar]
- 4.Beji M, Ben Messaoud M, Louzir B, Bouzaïdi K, M’hiri Ben Rhouma N, Cherif J, et al. Localisation cervico-thoracique d’un kyste hydatique. J Radiol 2004; 85:135–7. [DOI] [PubMed] [Google Scholar]