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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor=William J Gibson
|QuestionAuthor=William J Gibson (Reviewed by  {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Anatomy
|MainCategory=Anatomy
Line 8: Line 8:
|MainCategory=Anatomy
|MainCategory=Anatomy
|SubCategory=Neurology, Oncology, Pulmonology
|SubCategory=Neurology, Oncology, Pulmonology
|MainCategory=Anatomy
|MainCategory=Anatomy
|MainCategory=Anatomy
|MainCategory=Anatomy
|MainCategory=Anatomy
Line 20: Line 21:
|MainCategory=Anatomy
|MainCategory=Anatomy
|SubCategory=Neurology, Oncology, Pulmonology
|SubCategory=Neurology, Oncology, Pulmonology
|Prompt=A 42-year-old male smoker presents to his primary care physician for excessive sweating on the right side of his face after eating. Three months later, the patient returns complaining of severe pain and tingling in his right arm. The rest of the physical exam is normal except for right-sided ptosis and miosis. Chest x-ray reveals an apical mass.  Biopsy of the mass reveals an adenocarcinoma with an EML4-ALK fusion.  Which of the following neurological structures is most likely directly disrupted in this disorder?
|Prompt=A 42-year-old male smoker presents to his primary care physician for excessive post-prandial sweating on the right side of his face. Three months later, the patient returns with complaints of severe pain and tingling in his right arm. Physical examination is remarkable for right-sided ptosis and miosis. Chest x-ray demonstrates an apical mass.  Biopsy of the mass demonstrates an adenocarcinoma with an ''EML4-ALK'' fusion.  Which of the following neurological structures is most likely directly disrupted due to this patient's disease?
|Explanation=The patient in this vignette has a lung adenocarcinoma, located in the apex of the right lung. These apical lung tumors are collectively referred to as pancoast tumors.  Because of their location next to the stellate ganglion, these tumors can cause of spectrum of neurological symptoms called Horner’s syndrome. Horner's syndrome is the combination of drooping of the eyelid (ptosis) and constriction of the pupil (miosis) on the same side as the lesion.   It is sometimes accompanied by decreased sweating (anhidrosis).   
|Explanation=The patient in this vignette has a lung adenocarcinoma in the apex of the right lung. Apical lung tumors are collectively referred to as pancoast tumors.  Because of their location next to the stellate ganglion, these tumors can cause a spectrum of neurological symptoms called [[Horner’s syndrome]]. Horner's syndrome is the combination of drooping of the eyelid (ptosis) and constriction of the pupil (miosis) on the same side as the lesion. It is sometimes accompanied by decreased sweating (anhidrosis).   
 
[[File:Sympathetic_plexuses_2_14_14.png]]
 
'''Educational Objective:'''  Horner syndrome can be caused by a pancoast tumor that impinges on the stellate ganglion.
 
'''References: '''
First Aid 2014 page  610


Friedman JH. Hemifacial gustatory sweating due to Pancoast's tumor. Am J Med. 1987;82(6):1269-71.
[[File:Sympathetic_plexuses_2_14_14.png | 400px]]
|AnswerA=Right stellate ganglion
|AnswerA=Right stellate ganglion
|AnswerAExp='''Correct:'''  This patient has Horner’s syndrome and thoracic outlet syndrome due to an apical lung adenocarcinoma.  The symptoms of Horner’s syndrome are caused by compression of the right stellate ganglion.
|AnswerAExp=This patient has Horner’s syndrome and thoracic outlet syndrome due to an apical lung adenocarcinoma.  The symptoms of Horner’s syndrome are caused by compression of the right stellate (cervicothoracic) ganglion.
|AnswerB=Left stellate ganglion
|AnswerB=Left stellate ganglion
|AnswerBExp='''Incorrect:'''  Horner’s syndrome causes ipsilateral symptoms, not contralateral.   Furthermore, this patient experienced thoracic outlet syndrome due to tumor compression. His symptoms were all on the right side.
|AnswerBExp=Horner’s syndrome causes ipsilateral symptoms, not contralateral. Furthermore, this patient experienced thoracic outlet syndrome due to tumor compression. His symptoms were all on the right side.
|AnswerC=Right ciliary ganglion
|AnswerC=Right ciliary ganglion
|AnswerCExp='''Incorrect:'''  While Horner’s syndrome causes ocular symptoms, the ciliary ganglion is not directly impinged on by the tumor.
|AnswerCExp=While Horner’s syndrome causes ocular symptoms, the ciliary ganglion is not directly impinged on by the tumor.
|AnswerD=Left ciliary ganglion
|AnswerD=Left ciliary ganglion
|AnswerDExp='''Incorrect:'''  While Horner’s syndrome causes ocular symptoms, the ciliary ganglion is not directly impinged on by the tumor.
|AnswerDExp=While Horner’s syndrome causes ocular symptoms, the ciliary ganglion is not directly impinged on by the tumor.
|AnswerE=Right superior cervical ganglion
|AnswerE=Right superior cervical ganglion
|AnswerEExp='''Incorrect:'''  While lesions of the right superior cervical ganglion can cause Horner’s syndrome, in this particular case the stellate ganglion is affected.  The superior cervical ganglion does not lie in the thorax and is not lesioned due to pancoast tumors.  The superior cervical ganglion instead lies adjacent to C2 & C3 in the neck.
|AnswerEExp=While lesions of the right superior cervical ganglion can cause Horner’s syndrome, in this particular case the stellate ganglion is affected.  The superior cervical ganglion does not lie in the thorax and is not lesioned due to pancoast tumors.  The superior cervical ganglion instead lies adjacent to C2 and C3 in the neck.
|EducationalObjectives=Horner syndrome can be caused by a pancoast tumor that impinges on the stellate ganglion.
|References=Friedman JH. Hemifacial gustatory sweating due to Pancoast's tumor. Am J Med. 1987;82(6):1269-71.<br>
First Aid 2015 page 617.
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=Ganglion, Cancer, Tumor, Pancoast, Lung cancer, Horner syndrome, Sympathetic, Nerve
|WBRKeyword=Ganglion, Cancer, Tumor, Pancoast, Lung cancer, Horner syndrome, Sympathetic, Nerve
|Approved=Yes
|Approved=Yes
}}
}}

Latest revision as of 02:36, 28 October 2020
Author [[PageAuthor::William J Gibson (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Anatomy
Sub Category SubCategory::Neurology, SubCategory::Oncology, SubCategory::Pulmonology
Prompt [[Prompt::A 42-year-old male smoker presents to his primary care physician for excessive post-prandial sweating on the right side of his face. Three months later, the patient returns with complaints of severe pain and tingling in his right arm. Physical examination is remarkable for right-sided ptosis and miosis. Chest x-ray demonstrates an apical mass. Biopsy of the mass demonstrates an adenocarcinoma with an EML4-ALK fusion. Which of the following neurological structures is most likely directly disrupted due to this patient's disease?]]
Answer A AnswerA::Right stellate ganglion
Answer A Explanation AnswerAExp::This patient has Horner’s syndrome and thoracic outlet syndrome due to an apical lung adenocarcinoma. The symptoms of Horner’s syndrome are caused by compression of the right stellate (cervicothoracic) ganglion.
Answer B AnswerB::Left stellate ganglion
Answer B Explanation AnswerBExp::Horner’s syndrome causes ipsilateral symptoms, not contralateral. Furthermore, this patient experienced thoracic outlet syndrome due to tumor compression. His symptoms were all on the right side.
Answer C AnswerC::Right ciliary ganglion
Answer C Explanation AnswerCExp::While Horner’s syndrome causes ocular symptoms, the ciliary ganglion is not directly impinged on by the tumor.
Answer D AnswerD::Left ciliary ganglion
Answer D Explanation AnswerDExp::While Horner’s syndrome causes ocular symptoms, the ciliary ganglion is not directly impinged on by the tumor.
Answer E AnswerE::Right superior cervical ganglion
Answer E Explanation [[AnswerEExp::While lesions of the right superior cervical ganglion can cause Horner’s syndrome, in this particular case the stellate ganglion is affected. The superior cervical ganglion does not lie in the thorax and is not lesioned due to pancoast tumors. The superior cervical ganglion instead lies adjacent to C2 and C3 in the neck.]]
Right Answer RightAnswer::A
Explanation [[Explanation::The patient in this vignette has a lung adenocarcinoma in the apex of the right lung. Apical lung tumors are collectively referred to as pancoast tumors. Because of their location next to the stellate ganglion, these tumors can cause a spectrum of neurological symptoms called Horner’s syndrome. Horner's syndrome is the combination of drooping of the eyelid (ptosis) and constriction of the pupil (miosis) on the same side as the lesion. It is sometimes accompanied by decreased sweating (anhidrosis).


Educational Objective: Horner syndrome can be caused by a pancoast tumor that impinges on the stellate ganglion.
References: Friedman JH. Hemifacial gustatory sweating due to Pancoast's tumor. Am J Med. 1987;82(6):1269-71.
First Aid 2015 page 617.]]

Approved Approved::Yes
Keyword WBRKeyword::Ganglion, WBRKeyword::Cancer, WBRKeyword::Tumor, WBRKeyword::Pancoast, WBRKeyword::Lung cancer, WBRKeyword::Horner syndrome, WBRKeyword::Sympathetic, WBRKeyword::Nerve
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