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 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.