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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 1^st, 2^nd 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

Pancoast Tumor. Frontal chest radiograph demonstrates a mass in the left lung apex (white arrow in larger image). There is associated destruction of the left 2nd and 3rd ribs posteriorly (white circle). The smaller, 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