Oncology & Palliative Care
A 55 year old man presents to the Emergency Department complaining of worsening cough and drooping of his right eyelid. He tells you he has lost around 10 kg over the past three months and has also been experiencing pain in his right shoulder. On examination you note anisocoria with right eye miosis, enophthalmos and ptosis. He has a 60 pack-year history of smoking. What is single most likely diagnosis?
Answer:
Pancoast tumour refers to a relatively uncommon situation where a primary lung cancer arises in the lung apex and invades the surrounding soft tissues. Most Pancoast tumours are non small cell cancers and most commonly squamous cell cancer. Pancoast tumors may lead to several other syndromes caused by the compression of surrounding anatomical structures. In this case, the patient has Horner's syndrome characterised by ipsilateral miosis, anhidrosis, ptosis and enophthalmos.Lung Malignancy
Oncology & Palliative Care / Respiratory
Last Updated: 6th September 2022
Risk factors
Risk factors for lung cancer:
- Smoking
- Asbestos exposure and other industrial lung disease
- Increasing age
- History of malignancy
- History of radiation
Clinical features
- Cough
- Shortness of breath
- Haemoptysis
- Persistent chest and/or shoulder pain
- Weight loss
- Anorexia
- Malaise
- Persistent/recurrent chest infection
- Finger clubbing
- Cervical or supraclavicular lymphadenopathy
- Thrombocytosis
Pancoast tumour
Pancoast tumour refers to a relatively uncommon situation where a primary lung cancer arises in the lung apex and invades the surrounding soft tissues. Most Pancoast tumours are non small cell cancers and most commonly squamous cell cancer. Pancoast tumors may lead to several other syndromes caused by the compression of surrounding anatomical structures.
- Horner’s syndrome (compression of the paravertebral sympathetic chain and the inferior cervical ganglion)
- Miosis
- Anhidrosis
- Ptosis
- Enophthalmos
- Superior vena cava syndrome (compression of the SVC)
- Dyspnoea
- Cough
- Headache
- Dizziness/syncope
- Disturbed vision
- Neck, face and arm swelling
- Venous distention over arms, neck and anterior chest wall
- Cyanosis
- Engorged conjunctiva
- Positive Pemberton sign
- Thoracic outlet syndrome (compression of the neurovascular bundle of the upper limb)
- Upper extremity swelling
- Diffuse arm or hand pain and paraesthesia
- Ulceration or venous or arterial gangrene
- Recurrent laryngeal nerve involvement
- Hoarse voice
- Bovine cough
- Brachial plexus involvement
- Severe pain in the shoulder or scapula
- Pain and weakness in muscles of the shoulder, arm and hand
- Phrenic nerve involvement
- Hemidiaphragm paralysis
Investigations
Most lung cancers can be identified on a plain chest X-ray, though false-negatives may occur. Other imaging techniques, especially CT, may be used, though these are generally performed following an indeterminate chest X-ray, or when the person has continuing symptoms and a normal chest X-ray. Definitive diagnosis requires biopsy, usually guided by CT or via bronchoscopy. Sputum cytology is only used in those unable to have biopsy.
Management
Patients with suspected malignancy should be referred urgently to a respiratory specialist.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
