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Clinical Kit 13/11/2012 - Red Flag Tumor 1

Posted by on in Clinical Kit Newsletters
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This is the first in a series of tumor case studies that I have been associated with while in clinical practice. This is not an area of my expertise, rather interest and I provide these case studies to alert other primary contact practitioners

of the importance of a heightened clinical awareness and client followup in unusual situations. The other case studies can be accessed via these links;

Clinical History 1 (64 yo male)

24 May Initial Physiotherapy Appointment
S/E 2/12 intermittent right suprascapular, post upper arm pain, intermittent P & N sensations in little and ring fingers. Works levers on heavy machinery and has been worse since lifting heavy farm gate. Thought he had strained his shoulder and slow to settle. No other treatment, seems to be more frequent.
O/E Cervical Active Movement Rotation R=L=70
Shoulder Active Movement Flexion 160, POS and Abd same
Palpation C56 right and Infraspinatus right painful. Upper thoracic spine very stiff, tight anterior chest muscles
Rx Cervical 56 R & L dry needling (DN), Thoracic 1 - 4 unilateral R & L G3 mobilisations. Commence home upper trapezius and infraspinatus stretching

29 May Physiotherapy
S/E Isq.
O/E Active Movements Isq.
Palp C56 good, T12 stiff and sore
Neuro Reflex C67 reduced right, Power C6/7 right & left reduced, C8 & T1 R reduced, Sensation reduced upper inner arm
Rx DN T12 R & L, T12 (Mobilisations with movement) MWM to left for increased right rotation, postural education.

7 June Physiotherapy
S/E Good after last treatment, trap shooting all day at competition (National level) and stirred up shoulder again plus lower ribs from repeated gun recoils.
O/E Active Movements Isq.
Small mass midline supraclavicular fossa (SCF), non-tender, smooth and immobile. Wasn’t aware of it. ? Bump from gun stock recoil?
Palp T12 painful R. No chest pain, no cough, no haemoptysis
Rx Mobilisation and DN as before. XR requested. Report XR Cervical 6/7 degeneration. Soft tissue density in the SCF
Letter to GP requesting follow-up investigations

13 June G.P. notes
S/E Presented with R shoulder pain, tingle in little finger and ulna forearm. Worse driving truck. Developed over several months. Health good, weight steady, 2/600 national trap shooting championships
O/E Local, hard mass SCF R, non motile

14 June G.P. notes
O/E Chest XR. Mass present in apex of R lung. Erosion of the posterior margin of 1st rib.

7 June Department of Respiratory Medicine
O/E CT scan. Showing mass of 6 * 4 cm, invades both first and second ribs and transverse process of T1. Additional metastases were found at different vertebral levels.
Biopsy also performed. Referred for oncology review, MRI and blood scans

21 June Physiotherapy Phone call
S/E Improving pain, P & N little finger and ulna boarder forearm. Seated more upright in loader.

1 August Department of Respiratory Medicine
Oncology treatment commenced using; Cisplatin (a chemotherapy drug that is given as a treatment for some types of cancer, most commonly testicular, bladder, lung) & Etoposide (chemotherapy drug that is given as a treatment for various types of cancer, most commonly lung, ovarian and testicular cancer). Repeated*3

1 September
Commence high dose radiotherapy. Started Docetaxel (treatment for symptoms of locally advanced or metastatic breast and lung cancer)

1 November
Radiotherapy to left lung

11 December
Passed away

What Did I Learn?

I included this case study because it would have been easy to justified this pain presentation with the clinical history of heavy manual labour, his age, repeated jarring from shooting and poor posture. There were no other key flags; past Ca history, non responsive to treatment, unremitting pain.
It was the appearance of the small raised area, that I thought hadn't been there the week prior, even though he felt that it was in response to the all day shooting. I could have delayed further investigations for a couple of more treatments, to gauge changes, but wasn't satisfied with the clinical picture and requested an XR on this suspicion. The XR demonstrated an already advanced nature pancoast tumor, confirming diagnosis.


Pancoast tumors are lung cancers that begin at the top of the lung and invade the chest wall. They are also called superior sulcus tumors. Pancoast tumors often come along with unique symptoms known as “pancoast syndrome,” which consists of pain in the shoulder and the inside of the arm and hand. Most pancoast tumors are non-small cell lung cancers, usually stage 2B.


Pancoast tumors are much less common than other lung cancers.In past series, the rate of Pancoast tumors varied from 1-3% of all lung cancers. A major issue with Pancoast tumors is the delay in diagnosis. The apical lung cancer may not be visualized on an initial chest radiograph, and, by the time the patient presents with symptoms, the tumor has almost always invaded nearby structures. In addition, the symptoms produced by the disorder can be mimicked by numerous neurological or musculoskeletal disorders, thus delaying diagnosis.


The risk factors for almost all lung cancers are similar.These include prior prolonged asbestos exposure, exposure to industrial elements (e.g. gold, nickel), smoking, and secondary smoke exposure.


The mass in the superior sulcus is an extension of a lung tumor;most of it lies outside the lung and involves the chest wall, nerve roots, lower trunks of the brachial plexus, sympathetic chain, stellate ganglion, ribs, and bone. Most Pancoast tumors are squamous cell carcinomas or adenocarcinomas. Only 3-5% are small cell carcinomas. Squamous cell carcinoma occurs more frequently, although large cell and undifferentiated types are also common. Adenocarcinoma is sometimes found in this location and can be metastatic.


The symptoms are typical of the location of tumors in the superior sulcus or thoracic inlet adjacent to the C8 –T2, nerve roots, the sympathetic chain, and the stellate ganglion. Initially, localized pain occurs in the shoulder and vertebral border of the scapula. Pain is frequently relentless and unremitting, may extend along the ulnar nerve distribution to the elbow and ulnar surface of the forearm plus small and ring fingers. The patient may support the elbow of the affected arm in the hand of the opposite upper extremity to ease the tension on the shoulder and upper arm.
If the tumor extends to the sympathetic chain and stellate ganglion, Horner syndrome and anhidrosis develop on the ipsilateral side of the face and upper extremity.
The hand muscles may become weak and atrophic, and the triceps reflex may be absent. Confusion with thoracic outlet syndrome and cervical disk disease is common in the early clinical course. Careful neurologic examination, electromyographic studies, and ulnar nerve studies are performed to verify the precise diagnosis. The first or second rib or vertebrae may be involved by tumor extension and intensify the severity of pain. The spinal canal and spinal cord may be invaded or compressed, with subsequent symptoms of spinal cord tumor or cervical disk disease.

All the best,

Doug Cary FACP

Specialist Musculoskeletal Physiotherapist

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