Adult Female With Malignant Pain

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• Diagnosis
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[Ann Emerg Med. 2011;57:203.]

A 54-year-old woman presented to the emergency department, complaining of severe back and left shoulder pain. She had a history of metastatic non-small-cell lung cancer refractory to radiation and chemotherapy. She was in moderate distress: tachycardic, tachypneic, and diaphoretic. Her physical examination demonstrated ipsilateral eyelid ptosis and pupillary miosis, along with left-sided facial anhidrosis, which was profound in comparison with the diaphoresis observed on the rest of her body (Figure 1). The patient had a recent outpatient positron emission tomography computed tomographic scan performed (Figure 2).

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• Figure 1. 

  Patient presentation.

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• Figure 2. 

  Recent PET scan.

Used with permission of Christine Whylings, DO, and Bryan G. Kane, MD, Department of Emergency Medicine, Lehigh Valley Health Network, Bethlehem, PA.

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Diagnosis 

Horner's syndrome as a result of a Pancoast tumor. The superior pulmonary sulcus tumor was first described by Pancoast¹ in 1932 as characterized by Horner's syndrome, pain, and bony destruction. These tumors are non-small-cell carcinomas that progress to involve the surrounding bony, vascular, and neural structures at the apex of the lung. They often extend into the thoracic inlet, leading to shoulder or arm pain because of impingement on the C8 and T1 nerve roots.² As these tumors invade the cervical sympathetic plexus adjacent to the trachea, they also produce a group of findings classically known as Horner's syndrome, which consists of ptosis, miosis, and anhidrosis on the same side as the lesion.³

This patient displayed all of these classic findings: a non-small-cell pulmonary sulcus tumor and the clinical triad of Horner's syndrome. She had observed left eyelid droop, and her primary physician had commented on her left fixed pupil soon after her original diagnosis. The anhidrosis was made prominent by her distress. On this visit, she was admitted for pain control, discharged to outpatient hospice, and died soon thereafter.

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References 

1. Pancoast HK. Superior pulmonary sulcus tumor. JAMA. 1932;99:1391–1396
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2. Johnson DH, Blot WJ, Carbone DP. Cancer of the lung: non-small cell lung cancer and small cell lung cancer. In:  Abeloff MD,  Armitage JO,  Niederhuber JE, et al. editor. Abeloff's Clinical Oncology. 4th ed.. Philadelphia, PA: Churchill Livingston; 2008;
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3. Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome. N Engl J Med. 1997;337:1370–1376
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