A 46-year-old man (employee) presented with a history of right upper lobectomy of the lung eight years ago due to complicated tuberculosis with hemoptysis. He complained of chronic cough, severe right upper arm and shoulder pain and sweating. His vital signs were as following: Pulse rate=80, respiratory rate=16, body temperature=37.6  C and tuberculin test=1.5 cm. For the past eight years, he has been suffering from sputum production, weight loss and upper thoracic and right limb pain resulting in repeated admissions. Blood analysis upon admission to our referral hospital was as follows: WBC=14.4x103, Hb =15.7 g/dL, Ca=13.5 mg/dL, P=4.6 mg/dL, Alkaline phosphatase 205 IU/L, ESR=86, and normal ABG findings. Three times sputum analysis and examinations were negative for tuberculosis. Computed Tomography (CT) scan of the chest revealed loculated pneumothorax in the right upper lobe with nodular infiltration in the left lower lobe, and tracheal and mediastinal shift to the left hemithorax. Partial pleural thickening and fibrosis, irregular mass formation and calcification were also reported in the right upper lobe fossa (Figure 1). In flexible bronchoscopy, stricture of the right middle lobe and obstruction of the right upper lobe without evidence of tumor were observed.
Electromyography examination of the right arm muscles was in favor of superior sulcus tumor because of severe intolerable right arm and upper shoulder pain. After consultation with a pain clinic, the patient underwent cervicothoracic ganglion block which was performed through 6th cervical transverse process tuberosity with an injection of 10 mL solution of Depo-Medrol (40 mg) + Marcaine 0.05% (4 mg) + fentanyl (10 microg). The infrascapular blockage was performed in prone position. After the emergence of Horner's syndrome and sympathetic block, the patient was scheduled for Transcutaneous Electrical Nerve Stimulation (TENS) therapy and serial blockade. After pain relief, percutaneous transthoracic biopsy was performed from the pleural thickenings. Pathologic examination was negative for the diagnosis of the tumor (Figure 2). The patient was previously hospitalized for 15 days in the Infectious Diseases Ward with diagnosis of TB recurrence; however, BK and cytology examinations of the sputum and BAL smears were negative.
In favor of malignancy, the patient was prepared for thoracotomy procedure. On exploration, severe adhesions caused by the previous operation, and tumor lesion invasion to upper brachial plexus and major subclavian vessels were observed. The tumor was inoperable. After sampling abundant biopsies from the tumor and closing bronchial openings, the chest was closed while one chest tube was located in the right upper hemithorax. Pathologic examination confirmed the diagnosis of squamous cell carcinoma. Consequently, the patient was scheduled for radio-therapeutic protocol.