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A middle-aged man with a 25-pack-year history of cigarette smoking was in his usual state of health when he developed excessive coughing with hemoptysis, which spontaneously resolved. Two months later, he presented to a hospital with complaint of shortness of breath, cough, and chest pain. A computed tomographic image of the chest (Figure 1) identified a large, 12-cm left upper lobe mass abutting the anterior chest wall pleura and extending into the mediastinum, with mediastinal lymphadenopathy as well as several liver lesions. A biopsy revealed poorly differentiated carcinoma, consistent with a primary tumor in the lung. On presentation to our multidisciplinary clinic, he reported constant, bothersome sweating of the left forehead. On physical examination, a well-demarcated area of erythematous, perspiring skin on the left forehead was noted.
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Apical non–small cell lung cancer with sympathetic nerve involvement
B. Impingement of the left sympathetic trunk
Apical lung cancers with sympathetic nerve involvement may manifest with Horner’s syndrome, the classic triad of miosis, ptosis, and anhidrosis.1 Eccrine sweat function and thermoregulation of the face is modulated by the sympathetic nervous system via 3-neuron autonomic relays. The axons of first-order neurons within the hypothalamus project through nerve tracts of the brainstem and the lateral gray column of the spinal cord.2 The preganglionic nerve fibers from T1 through T4 spinal cord levels join the sympathetic trunk, traveling in close proximity to the apex of the lung before synapsing in the superior cervical ganglion.2 Postganglionic fibers from third-order neurons then form a nerve plexus and surround the common carotid and downstream vessels to supply sympathetic innervation to the head and neck.2
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Corresponding Author: Russell Kenneth Hales, MD, Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Bayview Medical Center, 300 Mason Lord Dr, Baltimore, MD 21224 (firstname.lastname@example.org).
Published Online: November 15, 2018. doi:10.1001/jamaoncol.2018.4597
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank our illustrator, Tim Phelps, MS, Department of Art as Applied to Medicine, Johns Hopkins University. He was compensated for his contribution.
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