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ROENTGENOGRAM OF THE MONTH
ROENTCJ1::,\OGRAl\l OF THE l\10:\:TH
IimAM
T
C.
L. KISER M.D. St. Louis, Missouri
POLK, Ja., M.D.,* JOHN
HIS 78-YEAR-OLD WHITE MAN WAS
admitted to the hospital with a painful mass overlying the medial portion of the right clavicle, of one week's duration. Four weeks previously, he noted unremitting pain in the right lower neck associated with a non-productive cough. Fever, weight loss, From the Departments of Surgery and Medicine, Bames Hospital and Washington University School of Medicine. *Senior Clinical Trainee, Cancer Control Program, United States Public Health Service (CST 196-64). Present Address: Department of Surgery, Jackson Memorial Hospital, Miami. Florida.
AND JACK
G.
WALLACE, M.D.
anorexia, hoarseness, and neurologic symptoms were absent. An abdominal aortic aneurysm was resected and replaced with a synthetic graft eight years before. He had angina and dyspnea on exertion for four years. He was plethoric with a fixed, raised, tender mass 3 cm. in diameter, arising from the medial aspect of the right supraclavicular space. There was neither lymphadenopathy nor evidence of Homer's syndrome. Examination of the heart and lungs was unremarkable.
FIOUU
547
1
Diseases of the Chest
POLK, KISER AND WALLACE
Diagnosis:
SUPRACLAVICULAR ABSCESS
The thoracic roentgenogram (Fig. 1) demonstrates a smooth, rounded shadow at the apex of the right hemithorax without evidence of costal or clavicular destruction. The trachea is displaced slightly to the left. An incision was made above the medial portion of the right clavicle and an abscess cavity evacuated of 30 mi. of thick, greenyellow pus. The cavity extended well into the thorax and biopsy of the wall was not performed in consideration of the structures in immediate proximity thereto. Washings of the cavity contained no neoplastic cells nor did those obtained at bronchoscopy. Smear of the pus showed only leukocytes. Cultures for aerobic, anaerobic, fungal, and acid-fast organisms produced no growth. The patient has remained well. A subsequent roentgenogram (Fig. 2) shows essentially resolution of the inflammatory process in the right apical region. The concept of the superior sulcus tumor evoked by Pancoast' has been broadened to include any neoplasm so located, with or without evidence of extrapleural extension. Such lesions may invade the lower cords of the brachial plexus, the vertebrae, clavicle, apical chest wall and ribs, and/or the superior cervical ganglion. Signs and symptoms include pain and atrophy in the appropriate brachial plexus distribution, intercostal neuralgia, and Homer's syndrome. Bony erosion is often evident roentgenographically, especially when grid films and tomograms are obtained. The hopeless prognosis generally accepted for the superior sulcus tumor must stand revision in the light of improved survival and apparent cure following intensive ra-
FIGUaE 2
diotherapy and subsequent en bloc excision of the tumor and contiguous structures.· The roentgenographic appearance of a superior sulcus tumor was simulated by an inflammatory process of undetermined cause in this patient. A previous report indicates that such a syndrome rarely may be produced by non-neoplastic processes.· REFERENCES 1 PANCOAST, H. K.: "Superior Pulmonary Sulcus Tumor," JAMA, 99: 1391, 1932. 2 SHAW, R. R., PAULSON, D. L. AND KEE, J. L., Ja.: "Treatment of the Superior Sulcus Tumor by Irridiation fonowed by Resection," AIIII. Surg,. 154: 29, 1961. 3 ASHE, W. M., McDONALD, J. R. AND CLAGETT, O. T.: "Nonspecific PneumonitiJ of the Left Upper Lobe (Simulating the "Middle Lobe Syndrome" and Producing an Early Superior Pulmonary Sulcus Tumor)," J. Thor. Surg., 21: I, 1951. BENJAMIN FELSON, M.D., Editor HAROLD Sprrz, M.D., Co-Editor For reprints, please write Dr. Pollt, Department of Surgery, Jackson Memorial Hospital, Miami 33136.
1leJden are i.D"iled to IIIbmit articles for the Roentaenoaram of the Mooth. Pl_ IIIbmit a brief abstract of JOur cue to Beoiami.D PeIIOD. M.D•• Departmeol of Radiolocy. Ciociooati General Hospital. Ciociooati. Ohio.
IimAM
T
C.
L. KISER M.D. St. Louis, Missouri
POLK, Ja., M.D.,* JOHN
HIS 78-YEAR-OLD WHITE MAN WAS
admitted to the hospital with a painful mass overlying the medial portion of the right clavicle, of one week's duration. Four weeks previously, he noted unremitting pain in the right lower neck associated with a non-productive cough. Fever, weight loss, From the Departments of Surgery and Medicine, Bames Hospital and Washington University School of Medicine. *Senior Clinical Trainee, Cancer Control Program, United States Public Health Service (CST 196-64). Present Address: Department of Surgery, Jackson Memorial Hospital, Miami. Florida.
AND JACK
G.
WALLACE, M.D.
anorexia, hoarseness, and neurologic symptoms were absent. An abdominal aortic aneurysm was resected and replaced with a synthetic graft eight years before. He had angina and dyspnea on exertion for four years. He was plethoric with a fixed, raised, tender mass 3 cm. in diameter, arising from the medial aspect of the right supraclavicular space. There was neither lymphadenopathy nor evidence of Homer's syndrome. Examination of the heart and lungs was unremarkable.
FIOUU
547
1
Diseases of the Chest
POLK, KISER AND WALLACE
Diagnosis:
SUPRACLAVICULAR ABSCESS
The thoracic roentgenogram (Fig. 1) demonstrates a smooth, rounded shadow at the apex of the right hemithorax without evidence of costal or clavicular destruction. The trachea is displaced slightly to the left. An incision was made above the medial portion of the right clavicle and an abscess cavity evacuated of 30 mi. of thick, greenyellow pus. The cavity extended well into the thorax and biopsy of the wall was not performed in consideration of the structures in immediate proximity thereto. Washings of the cavity contained no neoplastic cells nor did those obtained at bronchoscopy. Smear of the pus showed only leukocytes. Cultures for aerobic, anaerobic, fungal, and acid-fast organisms produced no growth. The patient has remained well. A subsequent roentgenogram (Fig. 2) shows essentially resolution of the inflammatory process in the right apical region. The concept of the superior sulcus tumor evoked by Pancoast' has been broadened to include any neoplasm so located, with or without evidence of extrapleural extension. Such lesions may invade the lower cords of the brachial plexus, the vertebrae, clavicle, apical chest wall and ribs, and/or the superior cervical ganglion. Signs and symptoms include pain and atrophy in the appropriate brachial plexus distribution, intercostal neuralgia, and Homer's syndrome. Bony erosion is often evident roentgenographically, especially when grid films and tomograms are obtained. The hopeless prognosis generally accepted for the superior sulcus tumor must stand revision in the light of improved survival and apparent cure following intensive ra-
FIGUaE 2
diotherapy and subsequent en bloc excision of the tumor and contiguous structures.· The roentgenographic appearance of a superior sulcus tumor was simulated by an inflammatory process of undetermined cause in this patient. A previous report indicates that such a syndrome rarely may be produced by non-neoplastic processes.· REFERENCES 1 PANCOAST, H. K.: "Superior Pulmonary Sulcus Tumor," JAMA, 99: 1391, 1932. 2 SHAW, R. R., PAULSON, D. L. AND KEE, J. L., Ja.: "Treatment of the Superior Sulcus Tumor by Irridiation fonowed by Resection," AIIII. Surg,. 154: 29, 1961. 3 ASHE, W. M., McDONALD, J. R. AND CLAGETT, O. T.: "Nonspecific PneumonitiJ of the Left Upper Lobe (Simulating the "Middle Lobe Syndrome" and Producing an Early Superior Pulmonary Sulcus Tumor)," J. Thor. Surg., 21: I, 1951. BENJAMIN FELSON, M.D., Editor HAROLD Sprrz, M.D., Co-Editor For reprints, please write Dr. Pollt, Department of Surgery, Jackson Memorial Hospital, Miami 33136.
1leJden are i.D"iled to IIIbmit articles for the Roentaenoaram of the Mooth. Pl_ IIIbmit a brief abstract of JOur cue to Beoiami.D PeIIOD. M.D•• Departmeol of Radiolocy. Ciociooati General Hospital. Ciociooati. Ohio.