Fig. 1
Chest radiogram of a patient with pleural mesothelioma in the anterior-posterior projection. The examination confirmed hydrothorax on the right side up to the fourth rib, thickened parietal rib pleura and parietal mediastinum pleura. Cardiac silhouette is enlarged with pericardial effusion – neoplastic infiltration of pericardium. Reflexive left bend of the spinal axis due to shoulder ring pain
Fig. 2
Chest radiogram of a patient with pleural mesothelioma in the anterior-posterior projection. Right lung completely shadowed by accumulating fluid
After the initial diagnostics at a regional hospital, further treatment took place at the Thoracic Surgery Clinics in the cities of Cracow and Zakopane in Poland. Surgeries of different extend were made, from thoracoscopy with biopsy up to lung resection. Chemotherapy was part of standard treatment. In the shoulder ring pain group videothoracoscopy was carried out in four patients, thoracotomy in two, chemical pleurodesis in three, and pleuropneumonectomy with partial resection of the diaphragm and pericardium in another two patients. In six cases, chemotherapy, involving cisplatin, pemetrexed, or adriablastin, and in three cases radiotherapy were used.
Overall, cancer dissemination was found after a few months in all mesothelioma patients presenting with shoulder ring pain. Metastases to the second lung were found in five cases. In two cases, neoplasmatic infiltration of the mediastinum was confirmed, including one patient with an additional infiltration of the esophagus. Metastases to the peritoneal cavity, with accompanying ascites, were present in two patients. One of them also had liver metastases and the other had liver and colon metastases. The adrenal gland was infiltrated in one case. Concerning the motor system, pelvic bone metastases were confirmed in one case, muscles in the area of the pelvic girdle were infiltrated in two patients. Three of the patients had metastases to the abdominal integuments. One patient suffered from the armpit metastases with brachial plexus compression, which resulted in the subluxation of the shoulder joint. The location of metastases is summarized in Table 1. The neoplasm progression and dissemination also were found in the reference group, although it was mostly limited to the lung and pleura on the other side.
Table 1
Metastases in mesothelioma patients with shoulder ring pain
Localization | Number of patients |
|---|---|
Lung on the other side | 2 |
Mediastinum | 2 |
Esophagus | 1 |
Peritoneal cavity | 2 |
Liver | 2 |
Colon | 1 |
Adrenal glands | 1 |
Pelvis | 1 |
Pelvis muscles | 2 |
Abdominal integuments | 3 |
Armpit | 1 |
3 Results
The shoulder pain was a presenting complain in all seven patients and made them see an orthopedician. The pain was characterized as diffuse, radiating to the scapula or the neck. Its intensity was rated between 3 and 6 on an analog pain scale, where 0 was no pain and 10 denoted unbearable pain. Three patients rated the pain intensity at 3 points, three other at 4 points, and one at 6 points. Five patients suffered from reduced mobility of the shoulder ring, which was confirmed in physical examination. In one case, the mobility limitation and shoulder joint dysfunction were significant. The ulnar nerve neuralgia of the upper limb was found in two patients; with an additional involvement of the medial and radial nerves in one of them. The following accompanying symptoms were found during the initial work-up: chest pain (5 cases), dyspnea (4 cases), cough (4 cases), weight loss (2 cases), appetite loss (2 cases), and fatigue (3 cases). The exact distribution of symptoms is shown in Table 2. Physical examination showed a pain-related left bend of the spinal axis in one patient, which was confirmed by chest X-ray (Fig. 1). The average survival time, from the time of diagnosis, of the patients with the shoulder ring involvement was 25.4 months (range 12–48 months).
Table 2
Motor system and other symptoms reported to the orthopedician during the initial work-up
Shoulder ring complaints | Upper limb neuralgia | Other complaints | |||||||
|---|---|---|---|---|---|---|---|---|---|
Pain | Limited mobility | Chest pain | Dyspnea | Cough | Weight loss | Appetite loss | Fatigue | ||
Patient 1 | Yes | Yes | No | Yes | No | Yes | Yes | Yes | Yes |
Patient 2 | Yes | No | No | No | Yes | Yes | Yes | Yes | No |
Patient 3 | Yes | Yes | No < div class='tao-gold-member'>
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