You are in: eMedicine Specialties > Radiology > CHEST Pancoast TumorArticle Last Updated: Apr 14, 2004AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Melanie Guerrero, MD, Fellow, Pulmonary and Critical Care Medicine, Walter Reed Army Medical Center Melanie Guerrero is a member of the following medical societies: American College of Chest Physicians and American College of Physicians-American Society of Internal Medicine Coauthor(s): Scott C Williams, MD, Section Chief, Nuclear Medicine Associate Attending Radiologist, Advanced Radiology Consultants, Bridgeport Hospital Editors: Judith K Amorosa, MD, FACR, Clinical Professor and Program Director, Department of Radiology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Consulting Staff, Department of Radiology, Robert Wood Johnson University Hospital; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Eric J Stern, MD, Director of Thoracic Imaging, Professor of Radiology and Medicine, Departments of Radiology and Internal Medicine, Harborview Medical Center, University of Washington School of Medicine; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Eugene C Lin, MD, Consulting Staff, Department of Radiology, Virginia Mason Medical Center Author and Editor Disclosure Synonyms and related keywords: superior sulcus tumor, superior pulmonary sulcus tumor, apical pleuropulmonary groove neoplasm, non–small cell carcinomas, NSCCs, squamous cell carcinomas, SCCs, adenocarcinomas, large cell carcinomas, LCC, lung cancer, cancer of the lung INTRODUCTIONSection 2 of 12
  BackgroundPancoast tumors are neoplasms of pulmonary origin located at the apical pleuropulmonary groove (superior sulcus). By direct extension, they typically involve the lower trunks of the brachial plexus, intercostal nerves, stellate ganglion, adjacent ribs, and vertebrae. PathophysiologyMore 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). Small cell carcinomas are seen in fewer than 5% of cases. Staging of Pancoast tumor involves the tumor, node, and metastasis (TNM) classification 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 metastasis. 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. FrequencyUnited StatesFewer than 5% of all primary lung cancers are located in the superior sulcus. Mortality/MorbidityPredictors of 5-year survival are weight loss, supraclavicular fossa or vertebral body involvement, stage of the disease and surgical treatment. A recent study by an M.D. Anderson group reported the following findings:
RaceThe differences among race are correlated with smoking prevalence. In white male smokers, the reported incidence of lung cancer is 15-30 times higher than that in nonsmokers. Since the early 1980s, the prevalence of tobacco use has decreased among white men but not among black men, and, as a result, lung cancer mortality rates in 1990 have been higher among black men than in white men. SexLung cancer is the leading cause of death in both men and women. The ratio of men to women is 2:1. To the authors' knowledge, no studies have shown any difference in prevalence in those with Pancoast tumors. AgeCancer of the lung in general occurs in individuals aged 40-70 years, with a peak incidence in those aged 50-70 years. Only 2% of all cases appear in persons younger than 40 years. AnatomyThe tumor is located at the extreme apex of either the right or left lung, in what is called the pleuropulmonary groove or superior sulcus near the subclavian vessels. It frequently invades the second and third ribs, intercostal nerves, brachial plexus, stellate ganglion superiorly, and vertebral bodies posteriorly. Clinical DetailsThe most common initial symptom is shoulder pain. This is usually due to tumor extension into any of these adjacent structures: brachial plexus, parietal pleura, endothoracic fascia, vertebral bodies, and first three ribs. Weakness, atrophy, and paresthesias of the hand, arm, and forearm are resultant symptoms. In as many as 25% of patients, compression of the spinal cord and paraplegia develop when the tumor extends into the intervertebral foramina. Horner syndrome, which is described as ptosis, miosis, and anhidrosis, is reported to occur in 14-50% of patients. This is caused by invasion of the paravertebral sympathetic chain and stellate ganglion. Less common manifestations include phrenic nerve and recurrent laryngeal nerve involvement. Superior vena cava (SVC) syndrome, which is compression of the SVC with resulting dyspnea and facial and upper extremity edema, is also uncommon. Preferred ExaminationCompared with other examinations, MRI is more accurate in identification of the extent of tumor involvement; it is superior to CT scanning in the detection of invasion of adjacent organs (eg, vertebral bodies, brachial plexus, subclavian vessels). Histologic diagnosis is made in 95% of the cases by means of percutaneous transthoracic needle biopsy with fluoroscopic, ultrasonographic, or CT localization. Among other considerations, CT or MRI of the brain is recommended in the initial evaluation, because distant metastases to the brain are not infrequent, and diagnosis of these is necessary for staging. Limitations of TechniquesNoninvasive 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), and possibly surgical assessment of the mediastinum with lymph node sampling, should be strongly considered before curative surgery is attempted. DIFFERENTIALSSection 3 of 12
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| Media file 1: 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 shows asymmetry of the apices (superior sulcus). The right apex is more opaque than the left. When the image is enlarged, the partially destroyed second and third right posterior ribs near the costovertebral junction can be seen. | |
 | View Full Size Image | Media type: X-RAY |
| Media file 2: Pancoast tumor. Axial nonenhanced CT image of the upper dorsal spine demonstrates a soft tissue mass destroying the vertebra on the right and the right posterior elements, including the pedicle and part of the posterior spinous process. | |
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| Media file 3: 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. | |
 | View Full Size Image | Media type: MRI |
| Media file 4: Pancoast tumor. Sagittal gradient-echo T2-weighted MRI demonstrates a soft tissue mass involving C7, T1, and T2, with collapse of the vertebrae and moderate cord compression. | |
 | View Full Size Image | Media type: MRI |
| Media file 5: Pancoast tumor. Axial T1-weighted image shows cord compression caused by a large, enhancing mass. The right subclavian artery is not involved. | |
 | View Full Size Image | Media type: MRI |
Article Last Updated: Apr 14, 2004
