A 56-year-old male smoker is referred with symptoms of weakness, dizziness, and right chest pain after playing with his grandson. He admits to having pain in the right shoulder and axilla off and on for the prior 6 mo. He denies any exposure to TB and has a negative PPD skin test. Routine laboratory tests are normal. CXR is shown.Associated findings will include

This x-ray shows a right upper lobe homogeneous opacity merging with the right paratracheal area in the apical segment. This is consistent with a Pancoast tumor. The right clavicle is obscured in its medial aspect but does not show any fracture or erosion. Underlying hyperinflation is seen in all lung fields. The intercostal spaces in the right upper lobe region are diminished. The soft tissue shadows are similar bilaterally above the clavicles. The homogeneous opacity in the apical region is consistent with superior sulcus tumor (Pancoast tumor). This tumor invades the brachial plexus locally and is often associated with pain in the ulnar nerve distribution. It is also associated with Horner syndrome, i.e., anhydrosis, myosis, and ptosis. Lofgren syndrome is associated with sarcoidosis and is a triad of polyaicular ahritis, erythema nodosum, and bilateral hilar adenopathy. Sjogren syndrome may be primary or secondary to another connective tissue disorder and is also known as the sicca syndrome (due to its attendant triad of xerostomia, dry eyes, and ahritis). Heford syndrome is a uveoparotid fever associated with sarcoidosis. The chest x-ray finding is inconsistent with any of the latter conditions mentioned.