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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 parasthesia
  • 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

Pancoast Tumor. Frontal chest radiograph demonstrates a mass in the left lung apex
(white arrow in left image). There is associated destruction of the left 2nd and 3rd ribs posteriorly (white circle). The close-up photo of the left apex shows the rib destruction (white arrow) more clearly. The combination of an apical mass with rib destruction
is characteristic for a Pancoast Tumor.

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Pancoast Tumor  eMedicine  Melanie Guerrero, MD, Shabir Bhimji, MD.