Practice Essentials
Pancoast tumors are neoplasms of pulmonary origin located at the apical pleuropulmonary groove (superior sulcus).[1, 2] By direct extension, Pancoast tumors typically involve the lower trunks of the brachial plexus, intercostal nerves, stellate ganglion, adjacent ribs, and vertebrae. As a result, patients may present with severe pain, often of neuropathic characteristics radiating toward the ipsilateral upper extremity and accompanied with sympathetic symptoms (like the Horner syndrome) caused by invasion of the cervicothoracic sympathetic ganglion. These manifestations may appear months prior to the diagnosis of the underlining disease.[3, 4, 5, 6]
Pancoast syndrome is characterized by by ipsilateral shoulder and arm pain, paresthesias, paresis and atrophy of the thenar muscles of the hand, and Horner syndrome (ptosis, miosis, and anhidrosis).[7]
More than 95% of Pancoast tumors are non–small cell carcinomas, most commonly squamous cell carcinomas (52%) or adenocarcinomas and large cell carcinomas (approximately 23% for each subtype).[1] Small cell carcinomas are seen in fewer than 5% of cases.[8]
Staging of Pancoast tumor involves the tumor, node, and metastasis (TNM) classification system, in which T indicates site and size of the primary tumor, N is related to nodal involvement according to site, and M indicates the presence or absence of distant metastases. These tumors are, at a minimum, T3N0M0 (T3 for chest wall invasion, stage IIB), and they are considered T4 lesions if the brachial plexus, mediastinal structures, or vertebral bodies are involved at the time of presentation. When supraclavicular nodes are involved, they are designated as N3 nodes, although they may be the first nodal station involved. Metastatic tumor in the ipsilateral nonprimary-tumor lobe of the lung or metastases to other organ systems is considered M1.[9]
(Pancoast tumors and their associated morbidities are presented in images below.)
 View Image | Pancoast tumor. A 53-year-old man with a 50 pack-year history of smoking began experiencing upper back pain for several weeks. PA chest radiograph sho.... |
View Image | Pancoast tumor. Axial nonenhanced CT image of the upper dorsal spine demonstrates a soft tissue mass destroying the vertebra on the right and the righ.... |
View Image | Pancoast tumor. Sagittal fast spin-echo T2-weighted MRI shows collapsed vertebrae and cord compression at C7, T1, and T2 caused by a soft tissue mass..... |
Preferred examination
Magnetic resonance imaging (MRI) is more accurate than computed tomography (CT) scanning and radiography in iidentification of the extent of tumor involvement and detection of invasion of adjacent organs (eg, vertebral bodies, brachial plexus, subclavian vessels).[10, 11, 12, 13] Histologic diagnosis is made in 95% of the cases by means of percutaneous transthoracic needle biopsy with fluoroscopic, ultrasonographic, or CT scan localization.[5, 14, 15] Among other considerations, CT scanning or MRI of the brain is recommended in the initial evaluation, because distant metastases to the brain are not infrequent, and diagnosis of these metastases is necessary for staging.[16, 6, 7]
Noninvasive preoperative evaluation of the mediastinum with CT or MRI is limited by substantial false-positive and false-negative results (30-40%, depending on the criteria used to define enlarged lymph nodes and the patient population). Positron emission tomography (PET) scanning and, possibly, surgical assessment of the mediastinum with lymph node sampling should be strongly considered before curative surgery is attempted.
Intervention
Preoperative radiation therapy at doses of 2000-6500 cGy, followed by surgical resection, is the most common form of treatment for Pancoast tumors. The overall 5-year survival rate in patients treated with preoperative radiation therapy and surgery is reported to be 20-35%.[1, 17, 18, 6, 7]
Radiation therapy at a dose of 6000 cGy or greater has been used as a primary treatment modality for inoperable tumors, with successful palliation of pain in as many as 90% of patients. The reported 5-year survival rate is 0-29% in these patients, which is likely a result of extensive disease involvement at initial presentation.
The routine use of intraoperative and postoperative radiation therapy is not currently recommended, except in patients in whom unresectable tumors are found at the time of surgery.
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