D range of motion in all directions. She had a medical

D range of motion in all directions. She had a medical history of melanoma in situ on her mid-back, which was status post-excision 6 years ago. She had exposure to asbestos at work of unknown duration. She had never smoked or drunk alcohol in her life. She had no weight loss, fever or night sweats. Her physical examination revealed no erythema, swelling or warmth on the right shoulder joint. However, her right subacromial bursa and acromioclavicular joint were tender. Her drop arm test was positive. She also had no abnormal skin lesions such as melanocytic nevi. An X-ray of her right Staurosporine upper extremity showed no fracture. She was referred to an orthopedist because of unresolved right shoulder pain. She did not respond to methylprednisolone injections. She underwent physical therapy for her right shoulder joint, but without pain relief. She also did not tolerate immobilization with a sling. MRI of her right upper extremity showed a permeative, destructive lesion of the right scapula (Figure 1). Because of persistent pain in her right shoulder, the patient underwent computed tomography (CT) of her right shoulder, which showed no fracture, dislocation or pathologic bone lesion on her right shoulder but incidentally revealed a rounded, 2cm, right lower lobe lung mass (Figure 2). As the solitary pulmonary nodule was suggestive of malignancy on chest CT, positron emission tomography-computed tomography (PET-CT)Figure 1 Magnetic resonance imaging scan of the patient’s right shoulder shows permeative destruction of the right scapula (black arrow).Tun and Oza Journal of Medical Case Reports 2014, 8:142 http://www.jmedicalcasereports.com/content/8/1/Page 3 ofFigure 2 Computed tomography scan of right shoulder without intravenous contrast incidentally shows a rounded 2cm right lower lobe pulmonary mass (white arrow) with no pathologic lesion on right shoulder.was performed, which showed osseous metastasis of the right scapula, multiple liver metastatic nodules and a 1.7cm right-lower-lobe pulmonary nodule (Figure 3A-B). The patient was then referred to an oncologist. She was found to have non-tender hepatomegaly. Therefore, referred pain to the right shoulder from underlying hepatomegaly versus bone pain from metastasis was suspected. Tumor load was found to be high in the liver and bone with a solitary malignant lung nodule. Widespread metastases of underlying cancer with an unknown primary site were found. Because the liver was the most easily accessible organ with multiple metastases in this case, the patient wasreferred for a liver biopsy. A core biopsy of the mass in the left lobe of her liver showed a high-grade, poorly differentiated neuroendocrine carcinoma. Histologically, the differential diagnosis consisted of small-cell carcinoma (Figure 4A-B). However, immunohistochemical staining was positive for neuron-specific enolase, synaptophysin and chromogranin A in tumor cells, confirming neuroendocrine cancer. As most small-cell carcinomas may originate from the lung, the patient was recommended to undergo CTguided biopsy of the right lung mass, which also showed poorly differentiated carcinoma with mixed small-cell and non-small-cell lung cancer features (Figure 5A-B).Figure 3 A Position emission tomography scan in coronal view shows metastasis to right scapula (green arrow), a 1.7cm right lower lobe lung nodule (red arrow) and multiple liver metastases PubMed ID:https://www.ncbi.nlm.nih.gov/pubmed/7500280 (blue arrow). B Position emission tomography-computed tomography fusion scan in coronal vie.

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