A 68-year-old female smoker is admitted with progressive weakness, weight loss, and dysphagia. Physical exam: pulse 110 bpm; temperature normal; respirations 18/min; blood pressure 110/60 mm Hg. The patient appears cachectic on general exam. Laboratory data: Hb 9 g/dL; Hct 27%; BUN 13 mg/dL; creatinine 0.4 mg/dL; sodium 124 mEq/L; potassium 3.8 mEq/L. Chest x-rays are shown . An associated symptom that may signal mediastinal involvement and inoperability is

The PA view shows a large, well-defined opacity in the right hilum. The ascending aoa shadow is not silhouetted, suggesting that this is a posterior opacity. The left hilum and the left PA appear normal. This large posterior mediastinal mass is an esophageal lesion, and the presence of steady, constant, boring pain is indicative of mediastinal involvement and therefore inoperability. Cough may be due to aspiration or laryngeal reflux; clubbing can at times be seen in both benign and malignant lesions of the esophagus and does not indicate mediastinal involvement or inoperability