Pancoast Tumor - Pancoast Tumor

Pancoast Tumor

Superior Sulcus Tumor

General Considerations

A lung tumor arising in the superior sulcus and comprising fewer than 5% of all primary lung cancers
Described by Henry Pancoast in 1932
The majority of the tumor growth is extrathoracic
Directly invades
Adjacent ribs, especially the 1st, 2nd and 3rd
Vertebrae
Brachial plexus
Stellate ganglion
Most are squamous cell carcinomas
Fewer than 5% are small cell carcinomas
Clinical Findings

Shoulder pain is most common presenting symptom
From extension to brachial plexus, vertebral bodies, pleura or ribs
Pain radiates along ulnar nerve distribution to the hand
Muscle weakness, atrophy and paresthesias
Horner’s syndrome in up to 50% due to invasion of the superior cervical sympathetic chain and stellate ganglion
Ptosis
Miosis
Anhidrosis
Superior vena caval obstruction
Phrenic and recurrent laryngeal nerve involvement
Rarely, they may produce paraneoplastic syndromes ranging from Cushing’s to inappropriate secretion of antidiuretic hormone
Imaging Findings

MRI is probably more sensitive than CT in identifying extension of the tumor into adjacent soft tissues and bone
Frontal chest radiographs show
Unilateral apical soft tissue mass
Sometimes the mass can be very flat and plaque-like
It may be difficult or impossible to see on initial radiographs
Local rib destruction is highly suggestive
Occasionally, an AP radiograph of the cervical spine is better at demonstrating the tumor and associated rib destruction than a conventional chest radiograph
Apical lordotic films of the chest may also be helpful
CT scans may assist in evaluating
Bone destruction
Mediastinal adenopathy
Presence of other pulmonary nodules and liver
Differential Diagnosis

Tuberculosis
Plasmacytoma
Mesothelioma
Subclavian artery aneurysms
Treatment

Diagnosis is usually made by trans-thoracic needle biopsy
Because of their location, bronchoscopy is frequently not able to reach tumor
Invasion of adjacent vertebral body, the spinal canal or the upper brachial plexus as well as distant metastases are contraindications for surgery
Preoperative radiation therapy followed by surgical resection is the most common form of treatment
Complications

Surgical complications include
Atelectasis
Chest pain
Spinal fluid leaks
Horner’s syndrome
Prognosis

Most tumors are Stage III at diagnosis
Overall 5 –year survival is around 30%
Right-sided Pancoast tumors have a worse 5-year survival than left-sided lesions