Pancoast syndrome: A rare presentation of non-Hodgkin's lymphoma
A 16-year-old female presented with a painful swelling on the left side of the neck for 2 months, and gradually increasing weakness and numbness of left upper limb with drooping of the left an upper eye lid for 1 month. She had sharp, shooting pain in the neck and left shoulder, radiating along the inner aspect of the left arm, associated with tingling and numbness of her left forearm extending to the tips of her fourth and fifth fingers, ulnar aspect of the forearm and hand. The pain was not relieved by simple analgesic and her sleep was disturbed because of intense pain. Neck swelling was irregular in shape and progressively increasing in size; initial size was 2 cm × 3 cm. There was no history of fever, weight loss, and anorexia. She was normotensive and non-diabetic. There was no past history of the tuberculosis.\nOn general examination, there was a firm, tender, irregular swelling of 4 cm × 4 cm size in the left side of the neck extending to left supraclavicular area. The swelling was fixed to underlying structures and lower margin was not delineated. Temperature was not raised and overlying skin was normal. Fluctuation was absent and transillumination test was negative. There was no other peripheral swelling in the body. Clubbing and anemia were absent and her axillary temperature was 97°F, pulse rate 100 beats/min, respiratory rate 20 breaths/min, and the blood pressure was 110/70 mmHg.\nOn examination of the respiratory system, the movement of the chest wall was restricted over left supraclavicular and infracalvicular areas along with fullness in the same areas. There was no venous engorgement over the chest wall. Trachea was shifted to the right without shifting of cardiac apex. Percussion note was dull over left second and third intercostal spaces and sternal percussion was also dull. Diminished vesicular breath sound and decreased vocal resonance were noted over left supraclavicular and infraclavicular areas.\nEye examination revealed the partial ptosis of left upper eye lid with ipsilateral miosis, but the vision was preserved with normal light and accommodation reflexes. Ocular movement was normal in all directions.\nOn neurological examination of upper extremity, the hypothenar muscles of the left hand were wasted. There was a decrease in power of all muscle groups in this hand (grade 2/5). Fine touch and pain sensation were decreased in the C8 and T1 segmental distribution in his left hand and arm. Triceps jerk was diminished.\nComplete hemogram and blood biochemistry were normal, except elevated serum lactate dehydrogenase level (340 U/L). Chest X-ray (P.A. view) showed a huge anterior mediastinal mass, compressing left lung and extending to the thoracic inlet, but no rib erosion. Sputum smear for acid fast bacilli was negative. Incisional biopsy from the neck swelling was inconclusive. Contrast enhanced computed tomography (CT) thorax showed heterogeneous huge anterior mediastinal necrotizing mass extending through thoracic inlet to the neck, but no rib erosion []. CT guided fine needle aspiration cytology (FNAC) was inconclusive. Excision biopsy from the left supraclavicular swelling revealed malignant round cell tumor involving lymph nodes. Histopathological examination of CT guided tru-cut biopsy of mediastinal mass showed effacement of normal architecture of lymph gland, which was replaced by sheets of atypical large lymphoid cells admixed with the histiocytes and plasmacytoid cells. Scattered immunoblasts were present. No Reed Sternberg cell or its variant was found []. Hence, histopathology ultimately confirmed the tissue diagnosis of NHL. Immunohistochemistry further substantiated the diagnosis of diffuse large B-cell phenotype of NHL, as the tumor cells expressed CD20 and CD10, but were immunonegative for CD3, CD5, CD23, and CD30 []. Bone marrow biopsy was within normal limit. Ultrasound of whole abdomen was normal. Hence, he was finally diagnosed as a case of diffuse large B-cell phenotype of NHL. The size of the lesion regressed following six cycles of combination chemotherapy, comprising of cyclophosphamide, doxorubicin, vincristine, and prednisolone.