Introduction

Pancoast syndrome ^{[1] is a clinical constellation of an apical lung lesion and neurologic sequelae caused by compression of the adjacent lower trunk of the brachial plexus and sympathetic trunk in the superior pulmonary sulcus. Non–small cell lung cancer is the most common etiology of Pancoast syndrome (Pancoast's syndrome). Other causes include nonepithelial neoplasms, infections, lymphomatoid granulomatosis, vascular aneurysms, amyloid nodules, and cervical rib syndrome. Because of the wide variety of diseases that can produce Pancoast syndrome, a histologic diagnosis is mandatory before initiating definitive treatment. There is only one other reported similar case reported in the medical literature [2].}

Case Report

A 60 yr old Caucasian female with Past Medical History of dyslipidemia presented with Left shoulder pain described as constant, dull in nature, radiating down her left arm, not associated with motion. She denies any history of trauma. No fever, chills, redness or swelling or weight loss. She had a smoking history. She denied any alcohol or illicit drug use. She worked as a clinical psychologist and she was happily married. She admitted to having a chronic cough with intermittent arthralgias and morning stiffness. Her physical exam was unremarkable. Her complete blood count and comprehensive metabolic profile was unremarkable and revealed no evidence of any anemia or renal disease. Urinalysis revealed hematuria but no casts or proteinuria.

Radiographs done revealed evidence of multiple pulmonary nodular densities in the Left superior pulmonary sulcus, the left lower lobe and the right upper lobe. CT Scan [Figure 1] confirmed the presence of a 9.5 × 8.3-cm right middle lobe mass, 3.7 × 2.9-cm and 3.1 × 2.2-cm right lower lobe masses, a 3.6 × 2.0-cm left upper lobe mass, and many diffuse smaller nodules throughout the lung fields. Pathology of CT guided biopsy specimens revealed chronic granulomatous inflammation and no neoplastic process. ESR was 73 and C-ANCA was positive. Other collagen vascular diseases blood tests like Rheumatoid factor levels, Anti-Nuclear Antibody titers, P-ANCA, anti-myeloperoxidase and protease-3 abs were negative.

Diagnosis of Wegener’s granulomatosis was made and the patient was started on corticosteroids and oral cyclophosphamide 1 mg/kg/day which resulted in resolution of pulmonary nodules. Subsequently patient had resolution of her previously persistent left shoulder pain.

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Discussion

Pancoast syndrome is an entity that is most commonly associated with bronchogenic carcinomas ^{of the lung apex, most frequently squamous cell carcinoma, followed by adenocarcinoma and large cell carcinoma, and only rarely small cell lung carcinoma. Because of their peripheral location, the initial presentation of these tumors is dominated by features referable to invasion of local structures, principally nerves and the body wall.}

Shoulder pain is the most common presenting symptom, related ^{to the involvement of the lower trunk of the brachial plexus, the first 3 ribs, the vertebrae, or the parietal pleura. Horner’s syndrome, recurrent laryngeal and phrenic nerve involvement are less common features. Pulmonary manifestations, such as cough, hemoptysis, and dyspnea, occur less often than with centrally located endobronchial lesions. [3]}

Nonneoplastic conditions include neurogenic thoracic outlet ^{syndromes and inflammatory conditions (eg, Wegener granulomatosis and amyloidosis).}

Wegener’s Granulomatosis presenting as Pancoast syndrome ^{has only once been previously reported in the literature.}

Wegener’s Granulomatosis

Diagnosis

Our case report highlights the management difficulty presented by ^{multiple pulmonary masses in which a tissue diagnosis proves elusive. Diagnosis of pulmonary masses relies on cytologic, histologic, and microbiologic examination of tissue. This is vital because not only does it help in diagnosis but it also impacts on treatment. For apical tumors, percutaneous biopsy is reported as the modality of choice. [5]}

Conclusion

Although the initiation of treatment for apical lung lesions ^{was once advocated without the acquisition of a precise histologic diagnosis, [6] the recognition that Pancoast syndrome can be caused by a wide variety of conditions mandates that an accurate diagnosis is made in any pulmonary mass that appears clinically and radiologically to be a bronchogenic carcinoma. CT-guided percutaneous biopsy remains the best modality of choice, but where the diagnosis remains elusive and uncertain, open biopsy is required.}