A 63-year-old man presents to his primary care physician with increasing fatigue; general achiness; and unrelenting pain, numbness, and weakness in his right shoulder that radiates down the middle of his arm. He has been experiencing these symptoms for the past two months. The patient has a 40-year smoking history and, other than hypertension that is successfully controlled pharmacologically, has an unremarkable history.

Physical exam reveals slight hepatomegaly and a tender spot on the cervical spine. Further exam of arm weakness and numbness are suggestive of possible brachial plexus impingement. Radiography shows a soft tissue opacity in the apex of the lung. MRI confirms presence of superior sulcus tumor with brachial plexus involvement and shows multiple supraclavicular lymph node lesions and distal bone metastases. The complete blood cell count shows an elevated white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels are elevated.