Apical Lung Mass

 

a) Differential:

      - Bronchogenic carcinoma (typically non-small cell)

      - Mesothelioma

      - Lymphoma

      - Anterior mediastinal mass (thymoma, germ cell tumor, thyroid cancer)

      - Metastatic disease

      - Vascular aneurysm

      - Granulomatous infection (TB, fungal)

 

 

b) Superior sulcus tumor: located at apical pleuropulmonary groove, superior to first rib

      - Given location, associated with the following symptoms:

         - Shoulder and arm pain from invasion of brachial plexus

         - Horner's syndrome (ptosis, miosis, anhidrosis) from invasion of paravertebral sympathetics and stellate ganglion

         - Upper extremity weakness (triad of these three sx known as Pancoast's tumor)

         - Can also cause phrenic and recurrent laryngeal neuropathy, SVC syndrome

         - Pulmonary symptoms typically develop later, given peripheral location of tumor

 

 

c) Workup:

      - Key is to obtain tissue - preferred site is typically the least invasive (supraclavicular node in this patient)

      - Options:

         - FNA: can be done at bedside, but does not preserve histologic architecture, thus may be suboptimal if lymphoma suspected

         - Needle core: requires incision, but preserves architecture

         - Excisional: best at preserving architecture, but most invasive

         - Given peripheral location of superior sulcus tumors, percutaneous needle biopsy is of higher yield than broncoscopic procedure

 

 

(Christopher Woo MD, 8/27/10)