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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
- 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
- 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.
For these same photos without the arrows, click here and here
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Pancoast Tumor eMedicine Melanie Guerrero, MD, Shabir Bhimji, MD.
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