Pancoast tumors

Brachial and Lumbosacral Plexopathies

The brachial and lumbosacral plexuses are complex neural structures that transmit sensory, motor, and autonomic information between the spinal cord and the extremities. Plexus disorders can be particularly disabling because lesions in the plexus usually affect large groups of nerve fibers originating from several spinal levels. Electrodiagnostic studies are often required to confirm a plexus lesion and determine the extent of injury and prognosis. Magnetic resonance is the imaging modality of choice for detecting intrinsic nerve abnormalities; recently, high-resolution ultrasound has emerged as an alternative method for dynamic evaluation and visualization of internal nerve architecture. Once a plexopathy is confirmed, the list of possible etiologies is relatively limited and includes traumatic and nontraumatic causes. Treatment relies on symptom management and physical rehabilitation unless a treatable underlying condition is found. Surgical approaches, including nerve grafts or tendon transfers, may improve limb function when spontaneous recovery is suboptimal.

Current Concepts in the Management of Neurogenic Thoracic Outlet Syndrome: A Review

Thoracic outlet syndrome is a constellation of signs and symptoms due to compression of the neurovascular bundle of the upper limb. In particular, neurogenic thoracic outlet syndrome can present with a wide constellation of clinical manifestations ranging from pain to paresthesia of the upper extremity, resulting in a challenge to correctly diagnose this syndrome. Treatment options range from nonoperative treatment, such as rehabilitation and physical therapy, to surgical correction, such as decompression of the neurovascular bundle.

Methods

Following a systematic review of the literature, we describe the need for a thorough patient history, physical examination, and radiologic images which have been reported to correctly diagnose neurogenic thoracic outlet syndrome. Additionally, we review the various surgical techniques recommended to treat this syndrome.

Results

Postoperative functional outcomes have been shown to be more favorable in arterial and venous thoracic outlet syndrome (TOS) patients when compared with neurogenic TOS patients, likely due to the ability to completely remove the site of compression in cases of vascular TOS as compared with incomplete decompression in neurogenic TOS.

Conclusions

In this review article, we provide an overview of the anatomy, etiology, diagnostic modalities, and current treatment options of correcting neurogenic TOS. Additionally, we offer a detailed step-by-step technique of the supraclavicular approach to the brachial plexus, a preferred approach for decompressing neurogenic TOS.

ACR Appropriateness Criteria® Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. Compression of each of these structures results in characteristic symptoms divided into three variants: neurogenic TOS, venous TOS, and arterial TOS, each arising from the specific structure that is compressed. The constellation of symptoms in each patient may vary, and patients may have more than one symptom simultaneously. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes is important in choosing and interpreting radiological imaging performed to help diagnose TOS and plan for intervention. This publication has separated imaging appropriateness based on neurogenic, venous, or arterial symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, new symptoms may arise altering the need for specific imaging as compared to preoperative evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment

Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Practitioners must consider the pathology of thoracic outlet syndrome in their differential diagnosis for shoulder and upper extremity pain symptoms so that patients are directed appropriately to timely therapeutic interventions. Patients with a definitive etiology who have failed conservative management are ideal candidates for surgical correction. This manuscript will discuss thoracic outlet syndrome, occurrence, physical presentation, clinical implications, diagnosis, and management.

Conservative Management of Neuropathic Pain in a Patient With Pancoast-Tobias Syndrome: A Case Report

Pancoast-Tobias syndrome characterizes the signs and symptoms of a superior pulmonary sulcus tumor, and includes arm and shoulder pain, atrophy of intrinsic hand muscles, and ipsilateral Horner syndrome. The rarity and overall poor prognosis of patients with superior pulmonary sulcus tumors associated with Pancoast-Tobias syndrome has led to few reports detailing pain management strategies with adjunctive therapies, such as continuous infusions of ketamine and lidocaine, chemotherapy, radiation, and multimodal oral medication regimens. This case highlights the diagnosis and treatment of pain in a patient with Pancoast-Tobias syndrome.

Clinical Prediction of Pathologic Complete Response in Superior Sulcus Non-Small Cell Lung Cancer

BACKGROUND

Management of superior sulcus non-small cell lung cancer (NSCLC) continues to evolve, with preoperative chemoradiotherapy (CXRT) followed by surgical intervention supported by several studies. Rates of pathologic complete response (pCR) have varied, and previous attempts to identify clinical predictors of pCR have been unsuccessful. We analyzed our experience with resected superior sulcus NSCLC to elucidate clinical features suggestive of pCR among patients after preoperative treatment.

METHODS

A multiinstitutional retrospective review was performed in patients who underwent resection for superior sulcus NSCLC between January 1988 and July 2013. Data pertaining to comorbidities, staging, therapy, imaging, and outcomes were collected. Logistic regression was performed to identify predictors of survival and pCR.

RESULTS

During the study, 102 patients underwent preoperative therapy, consisting of CXRT in 75 (73.5%), chemotherapy in 15 (14.7%), and radiotherapy in 12 (11.8%). After median follow-up of 18.0 months, overall and disease-free survivals were 51.0% and 45.1%, respectively. On multivariate regression, independent predictors of survival included pCR (p = 0.001; hazard ratio [HR], 0.243; 95% confidence interval [CI], 0.106-0.555) and age (p = 0.007; HR, 1.049; CI, 1.013-1.085). Among those who received CXRT, 24 of 75 (32%) achieved pCR. Multivariate regression analysis of the CXRT group revealed that pCR was independently predicted by extent of size reduction on imaging (p = 0.015; HR, 1.042; CI, 1.008-1.078), with histologic examination showing a trend toward significance (p = 0.073).

CONCLUSIONS

Preoperative chemoradiation frequently resulted in pCR, and treatment response on imaging was associated with the likelihood of achieving pCR. Future investigations are warranted to further predict pCR from preoperative clinical variables such as symptom resolution, as identification of accurate predictors may ultimately permit the application of selective surgical intervention in superior sulcus NSCLC.

Nerve injuries about the elbow in the athlete

The athlete's elbow is a remarkable example of motion, strength, and durability. The stress placed on the elbow during sport, including the throwing motion, may lead to soft-tissue ligamentous and nerve injury. The thrower's elbow illustrates one example of possible nerve injury about the elbow in sport, related to chronic repetitive tensile and compressive stresses to the ulnar nerve associated with elbow flexion and valgus position. Besides the throwing athlete, nerve injury from high-energy direct-impact forces may also damage nerves around the elbow in contact sports. Detailed history and physical examination can often make the diagnosis of most upper extremity neuropathies. The clinician must be aware of the possibility of isolated or combined nerve injury as far proximal as the cervical nerve roots, through the brachial plexus, to the peripheral nerve terminal branches. Electrodiagnostic studies are occasionally beneficial for diagnosis with certain nerves. Nonoperative management is often successful in most elbow and upper extremity neuropathies. If conservative treatment fails, then surgical treatment should address all potentially offending structures. In the presence of medial laxity and concurrent ulnar neuritis, the medial ulnar collateral ligament warrants surgical treatment, in addition to transposition of the ulnar nerve. The morbidity of open surgical decompression of nerves in and around the elbow is potentially career threatening in the throwing athlete. This mandates an assessment of the adequacy of the nonsurgical treatment and a thorough preoperative discussion of the risks and benefits of surgery.

Multiple metastatic tumors in the oral cavity

Metastatic lesions to the oral region are uncommon and account for approximately 1% of all malignant oral tumors. In 25% of the cases, oral metastases are found to be the first sign of the metastatic spread; and in 23% of the cases, it is the first indication of an undiscovered malignancy at a distant site. Metastases to oral soft tissues are even less frequent than jaw bones. Because of its rarity, the clinical presentation of a metastatic lesion in the oral cavity can be deceiving, leading to a misdiagnosis of a benign process; therefore, in any case where the clinical presentation is unusual, especially in patients with a known malignant disease, a biopsy is mandatory. Here, we are presenting a rare case of multiple secondary tumors in the attached gingiva in an otherwise apparently healthy patient with no other symptoms of the primary tumor. It subsequently led to the diagnosis of Pancoast tumor (bronchoalveolar carcinoma) metastasizing simultaneously to multiple sites in the oral cavity and bilateral adrenal glands.

Malignant cell infiltration in the peripheral nervous system

The peripheral nervous system can be affected by malignancies involving different mechanisms. Neoplastic nerve lesion by compression, invasion, and infiltration is rare and occurs in particular in leukemia (neuroleukemiosis) and lymphoma (neurolymphomatosis). Its occurrence is much rarer in cancer, and even less so in sarcoma. The neoplastic infiltration of peripheral nerves by solid tumors is characterized by specific topographical sites such as the base of the skull, the ear, nose and throat region, and the cervico-brachial plexus as well as the lumbar and sacral plexus. Rarely malignant invasion affects the cranial nerves of the face where it can spread centripetally. Autonomic nerves and ganglia can also be affected. The retrograde spread of cancer in nerves is a bad prognostic sign. The clinical diagnosis is determined by tumor type, the pattern of involvement, and often pain.

Screening for head, neck, and shoulder pathology in patients with upper extremity signs and symptoms

NARRATIVE REVIEW: Conditions of the head, neck, thorax, and shoulder may occur simultaneously with arm pathology or produce symptoms perceived by the patient to originate in the elbow, wrist, or hand. Identification of the tissue disorder and associated impairments, followed by matching the rehabilitative intervention to address these issues, leads to optimal outcomes. With this goal in mind, the hand therapist needs to recognize clinical findings that signal potentially serious medical conditions of the brain, cervical region, chest, or shoulder. Additionally, less serious but potentially debilitating, musculoskeletal or neurogenic pain from proximal sources must also be differentiated from somatic pain originating in the elbow, wrist, or hand so that the clinician can decide to further examine and intervene or refer to an appropriate health care provider. This article describes clinical findings that suggest the presence of serious medical pathology in the head, neck, or thorax and presents a screening algorithm to assist in discriminating pain derived from local structures in the distal arm from referred pain originating in the more proximal regions of the shoulder, thorax, neck, or brain.

LEVEL OF EVIDENCE

5.