Pancoast tumour: a case report

Patients presenting with shoulder and arm pain can be a diagnostic challenge to the attending chiropractor. Although the majority of conditions presenting to a chiropractor are benign, occasionally a malignant life threatening one will present. One such condition is a Pancoast tumour, a cancerous growth developing in the lung apex. The resultant clinical entity, the Pancoast syndrome, presents as severe pain in the neck, shoulder and arm, and a Horner’s syndrome. It typically affects middle aged men who have a history of smoking. Pancoast tunours are frequently missed resulting in a delayed diagnosis. Appropriate chest radiographs are imperative in making the diagnosis. This report presents the clinical presentation and a case of Pancoast tumour, and emphasizes the importance of its inclusion in the differential diagnosis of patients presenting with persistent neck and shoulder pain.     

Pancoast syndrome: an unusual complication of pulmonary infection by Staphylococcus aureus.

Pancoast syndrome, which comprises a lower brachial plexus lesion and Horner's syndrome, usually results from local invasion beyond the confines of the lung by an apical lung carcinoma. Other causes are rare. We report the unusual occurrence of a case of Pancoast syndrome caused by a destructive sclerosing fibrosis after pulmonary Staphylococcus aureus infection.     

Pancoast syndrome caused by a high grade B cell lymphoma

The case history is presented of a 20 year old man with Pancoast syndrome caused by a high grade B cell lymphoma.     

Pitfalls and delay in the diagnosis of Pancoast tumour presenting in orthopaedic units

Pancoast tumours present a difficult and peculiar problem. Their clinical manifestations may be extrapulmonary. The underlying lesion may be missed in patients presenting with predominantly orthopaedic symptoms. We present four consecutive cases, which were referred to our clinic and the diagnosis was made with mean delay of 18.5 months from the beginning of symptoms.     

Pancoast (Superior Sulcus) Tumors

Primary carcinomas arising in the apex of the lung (Pancoast tumors) have attracted attention because of the characteristic syndrome that is produced by local extension into the chest wall and the brachial plexus. This article reviews the history of the treatment of this disease, the natural history of untreated patients, and the diagnosis of Pancoast tumors. The published data on results, prognostic factors, and technical aspects of treatment with combined irradiation and operation are examined, as well as those pertaining to treatment with irradiation alone.     

Pancoast tumours: clinical assessment and long-term results of combined radiosurgical treatment

BACKGROUND: Many oncologists have now accepted a combined radiosurgical approach as the treatment of choice in patients with Pancoast tumour but most reports show an incorrect assessment of the disease. METHODS: Stage III lung cancer was classified as Pancoast tumour if the pulmonary extent was limited to the upper apical segment and if at least one of the features of Pancoast syndrome, indicating tumour spread to the para-apical structures, was present. Between 1984 and 1988 15 consecutive patients were treated with primary radiotherapy followed by surgery or with primary excision and subsequent radiotherapy in the absence of an initial histological diagnosis. RESULTS: The mortality of patients given the combined treatment was 6.6% (one death due to pulmonary embolism), and the five year survival rate was 26.6% for all patients and 57% for those who underwent complete resection without N2 disease. Long-term survival was 0% for those cases with incomplete resection, N2 disease, or malignant invasion of the first rib. CONCLUSIONS: Stage III lung cancer, classified as Pancoast tumour according to strict, consistent criteria, is best treated by primary radiotherapy; combined treatment should be used only for patients with potentially resectable cancer without N2 disease and/or malignant invasion of the first rib.


     

Pancoast''s syndrome associated with invasive aspergillosis.

The combination of lower brachial plexus root pain in the shoulder and arm and of ipsilateral Horner's syndrome was described by Pancoast in 1932 and is usually caused by a malignant tumour at the apex of the lung. We describe a case in which the syndrome occurred in an immunosuppressed patient and was due to invasive fungal infection.     

Carcinomas in the superior pulmonary sulcus.

Carcinomas in the superior pulmonary sulcus produce a clinical pattern peculiar to their location. Pancoast (1932) defined tumors in this precise location and described a characteristic group of clinical findings now known as the Pancoast syndrome. Experience with a total of 92 patients with primary carcinomas in the superior pulmonary sulcus treated by combined preoperative irradiation and extended resection in 61 patients (66 per cent) reveals 16 of 46 patients eligible surviving over 5 years (34 per cent) and eight of 30 patients alive over 10 years (29 per cent). Stage of nodal involvement, extent of the tumor, cell type, and pathological effects of preoperative irradiation in the resected specimens are the important factors in prognosis.     

Diagnosis of a thoracic inlet tumour by transbronchial biopsy.

A 67-year-old man presented to the pulmonary service with left shoulder and arm pain. Examination disclosed a left Horner's syndrome. Supraclavicular exploration at another hospital was not helpful. Transbronchial biopsy through a flexible fibreoptic bronchoscope retrieved tissues showing poorly differentiated carcinoma. There are no previous reports of the use of the technique in the diagnosis of a Pancoast tumour with a normal standard chest radiograph.     

Pancoast tobias syndrome revealing primary epithelioid pleuro-pericardial angiosarcoma: A case report and review of the literature

Epithelioid angiosarcoma is a rare malignant vascular tumor with poor prognosis. Pleural or pericardial angiosarcomas are usually secondary tumors. We report a unique case of primary epithelioid angiosarcoma of the pleura and the pericardium in a 28-year-old man who was admitted for Pancoast Tobias syndrome. Thoracoscopy revealed a multifocal neoplasm and pleural biopsy showed a malignant tumor which histological and immunophenotypical features were characteristic of epithelioid angiosarcoma.     

High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival

OBJECTIVE: We sought to study the clinical characteristics and outcomes of patients treated with a surgery-inclusive multimodality approach for Pancoast tumors. METHODS: Clinical records of patients with Pancoast lung cancer who were enrolled for multimodality treatment between 1993 and 2003 at our institution were reviewed retrospectively. RESULTS: Thirty-six patients completed neodjuvant chemoradiation followed by en bloc surgical resection, whereas one patient received high-dose radiation alone followed by surgical intervention. There were 22 men and 15 women. Thirty-four lobectomies and 3 pneumonectomies were performed. Pretreatment non-small cell lung cancer stages were IIB, IIIA, IIIB, and IV (presenting with solitary brain metastasis) in 18, 8, 6, and 5 cases, respectively. R0 resection was achieved in 36 (97.3%) patients. Operative mortality was 2.7% (n = 1). High-dose radiotherapy was successfully tolerated in all but 1 patient. Mean total radiation dose was 56.9 Gy. Pathologic complete response was found in 40.5% (n = 15) of patients. Recurrences were found in 50% (n = 18) of patients. Brain metastasis was the most common recurrence (n = 9), followed by other distant recurrences (n = 4) and local recurrences (n = 5). Median survival time for the group is 2.6 years, and median survival time (pathologic complete response) is 7.8 years. It is noteworthy that median survival time of patients with positive pretreatment lymph nodes (12 patients) was not reached. CONCLUSIONS: Surgical resection of Pancoast tumors after neoadjuvant high-dose radiation and chemotherapy can be safely performed. High-dose radiation in trimodality treatment is well tolerated and might be beneficial. Similar to other studies, late central nervous system relapse is problematic and indicates a need for assessing the role of prophylactic cranial irradiation in this disease.     

Posterior midline approach for single-stage en bloc resection and circumferential spinal stabilization for locally advanced Pancoast tumors. Technical note

The treatment of Pancoast (superior sulcus) tumors that extensively invade the vertebral column remains controversial. Different surgical approaches involving multistage resection techniques have been previously described for superior sulcus tumors that invade the chest wall and spinal column. Typically a posterior approach to stabilize the spine is followed by a second-stage thoracotomy (posterolateral or trap door) for definitive en bloc resection of stage T4 Pancoast tumors. The authors report and elaborate on a surgical technique successfully used for an en bloc resection as well as spinal stabilization through a single-stage posterior approach without any added morbidity. Two patients with histologically proven Pancoast tumors were treated by single-stage resection and stabilization through a posterior approach at the H. Lee Moffitt Cancer Center. A wedge lung resection or lobectomy was performed by the chest surgeon utilizing the chest wall defect. Placement of an anterior cage (in one case) and posterior cervicothoracic spinal instrumentation (in both cases) was performed during the same operation. Average blood loss was 675 ml and surgical time was 7 hours. The median hospital stay was 9 days (range 7-11 days). Both patients did well postoperatively and were free of recurrence at the 2-year follow-up. Radical resection of Pancoast tumors including lobectomy, chest wall resection, costotransversectomy, and partial or complete vertebrectomy with simultaneous instrumentation for spinal stabilization can be performed through a posterior single-stage approach.     

Cervicobrachialgia and pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis

Ten patients diagnosed with Pancoast tumor were studied retrospectively. The definitive diagnosis was made between 2 and 24 months after the onset of pain. Pain localization was hard to pinpoint; some patients reported pain in four different sites (neck, shoulder, arm, and scapula). Five patients had previously been diagnosed with degenerative, inflammatory, or infectious diseases of the cervical spine or shoulder. In the remaining five patients, the diagnosis was made during the first clinical visit. In three patients, an orthopedic surgeon made the diagnosis by viewing a standard anteroposterior (AP) cervical radiograph. The radiographic evidence arousing suspicion of a Pancoast tumor was the lack of pulmonary air at the top of the affected lung. Furthermore, a parallel study was conducted on 100 consecutive patients seeking treatment for neck pain. By examining the AP radiographs of their cervical spines, the third rib and the top of both lungs were observed in all cases. This study stresses the value of standard AP cervical radiographs in the diagnosis of Pancoast tumor.     

Treatment results of pancoast tumor

To study the clinical characteristics, treatment modalities, and outcome of patients with Pancoast tumors who underwent surgery over 11-year period. From January 1994 to May 2005, 13 patients (12 men, 1 woman) with Pancoast tumor and histology of non-small cell lung cancer underwent surgical resection. Nine patients were received induction therapy (8 chemoradiation, 1 radiation only), and there were no treatment-related deaths. Twelve lobectomies, 1 pneumonectomy, and none of wedge resections or partial resection were performed. The number of ribs resected ranged from 2-6 (median 2.8). Chest wall reconstruction was performed in 2 patients, total vertebrectomy in 2, bronchoplasty in 2, and pulmonary arterioplasty in 1. Twelve of 13 patients (92.3%) had a complete resection. Pathologic stages were IB, IIB, IIIA and IIIB in 1, 7, 2, and 1, respectively, and pathologic complete responses was noted in 1. After a median follow-up of 34 months, the 3-year survival was 78.6% for all 13 patients and 85.7% for patients who had a complete resection. It is thought that induction chemoradiation for Pancoast tumors have potential to be able to become the treatment strategy in the future.     

Antero-superior approaches in the practice of thoracic surgery

Objective: To review our experience using antero-superior approaches for resection of a heterogeneous group of tumors, both benign and malignant, involving the thoracic inlet and adjacent structures. These included Pancoast type bronchial carcinomas, primary neurogenic tumors, soft-tissue neoplasms, and metastases from a variety of primary sites. Methods: Between October 1993 and January 1998 we undertook 22 operations on 21 patients using a variety of antero-superior approaches. The anterior cervical-transsternal approach was used in 11 operations, the Dartevelle technique was used in five cases, the modification described by Nazari in one patient and that described by Grunenwald in five cases. Results: 21 of the 22 operations were considered to be complete resections with negative margins. There were no intraoperative or postoperative deaths. Major complications occurred in five patients; acute respiratory distress syndrome (n=4), and thrombosis of the arterial graft and acute respiratory distress syndrome (n=1). Chronic morbidity was observed in 12 patients; prolonged arm pain (n=1), arm edema (n=2), motor and sensory deficits (n=2), phrenic nerve paresis (n=1), disfigurement and instability of the pectoral girdle (n=4), and disturbances in shoulder girdle function (n=2). Conclusions: The anterior cervical-transsternal approach we previously described provides adequate exposure for the resection of neurogenic tumors originating in the brachial plexus and sympathetic chain, and for metastatic nodal disease at the base of the neck or in the superior mediastinum. We have found it to be associated with little morbidity, the postoperative stay has been short, and it has proven flexible enough to cope with the changed circumstances found at surgery. For Pancoast type bronchogenic carcinomas and other malignancies with extensive invasion of major structures at the thoracic inlet, we believe the best present option is the clavicle sparing antero-superior technique described by Grunenwald as a modification of the Dartevelle approach. When operating for lung cancer we presently feel that the antero-superior approach should be combined with a posterolateral thoracotomy, to accomplish complete intraoperative staging and undertake anatomical pulmonary resection under optimal conditions.     

Surgical treatment of Pancoast tumours.

Due to its localisation in the apex of the lung with invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, a superior sulcus tumour causes characteristic symptoms, like arm or shoulder pain or Horner's syndrome. If rib invasion is the only feature, lysis of the rib must be evident on the chest radiograph; otherwise the tumour cannot be defined as a Pancoast tumour. It is important to adequately stage the tumour, because staging significantly influences survival. Survival is better for T3 than T4 tumours and mediastinal lymph node involvement has been found to be a negative prognostic factor. Also Horner's syndrome and incompleteness of resection worsen survival. The management of superior sulcus tumours has evolved over the past 50 years. Before 1950 it was considered to be inoperable and uniformly fatal. Shaw and Paulson introduced combined modality treatment and for many years, this combination of radiotherapy and surgery was the treatment of choice with a mean 5-year survival of approximately 30%. Postoperative radiotherapy or brachytherapy does not improve survival in patients with complete or incomplete resection. The tumour can be resected through the classic posterior Shaw-Paulson approach or the newer anterior transcervical approach, introduced by Dartevelle. This method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels. Regarding the extent of pulmonary resection, en bloc resection of the involved ribs with a lobectomy is recommended. Recent multimodality studies, involving chemoradiotherapy and surgical resection, show promising results regarding completeness of resection, local recurrence and survival, provided that appropriate staging has been carried out. However, careful patient selection and adequate perioperative management with protection of the bronchial stump or anastomosis are important to achieve reasonable rates of morbidity and mortality. As brain metastases remain one of the most common forms of relapse, further studies are needed to examine the role of prophylactic cranial irradiation in patients with complete resection. Also the addition of other chemotherapy agents or biologic agents such as angiogenesis inhibitors or tyrosine kinase inhibitors gives a new perspective in the treatment of Pancoast tumours.     

Hybrid video-assisted and limited open (VALO) resection of superior sulcus tumors

Purpose

To compare the postoperative recovery of patients with superior sulcus tumors (Pancoast tumors) following conventional open surgery vs. a hybrid video-assisted and limited open approach (VALO).

Methods

The subjects of this retrospective study were 20 patients we operated on to resect a Pancoast tumor. All patients received induction chemo-radiation followed by surgery, performed via either a conventional thoracotomy approach (n = 10) or the hybrid VALO approach (n = 10). In the hybrid VALO group, lobectomy and internal chest wall preparation were performed using a video technique, with rib resection and specimen removal through a limited incision.

Results

There was no mortality in either group. Two patients from the thoracotomy group required mechanical ventilation, but there was no major morbidity in the hybrid VALO group. The operative times were similar for the two procedures. The average length of hospital stay was shorter and the average pain scores were significantly lower in the hybrid VALO group. The incidence of chronic pain was 10 % in the hybrid VALO group vs. 50 % in the thoracotomy group.

Conclusions

Hybrid VALO resection of Pancoast tumors is feasible and safe, resulting in faster patient recovery and a significantly lower incidence of severe chronic pain than open thoracotomy. We conclude that centers experienced with video-assisted lobectomy should consider hybrid VALO surgery as the procedure of choice for Pancoast tumors.

     

Combined resection of the adjacent tissue and lung in advanced lung cancer

The prognosis of lung cancer patients who underwent combined resection of adjacent tissue and the lung was examined. In lung resections with chest wall, pericardial and diaphragmatic resections where radiation was added pre- or postoperatively, the prognosis of patients with squamous cell carcinoma was favorable. In addition the possibilities of extending operative indications for lung cancer, such as Pancoast tumor, combined resection of vertebra, left atrium, pulmonary artery and aorta was discussed.     

Lung carcinoma with metastasis to biceps muscle: report of a case and review of literature

A case of intramuscular metastasis in biceps muscle due to a squamous cell carcinoma of the lung (Pancoast) is presented. One year after treatment of the lung disease, the patient complained of pain and a sensation of swelling in the anterior aspect of her right arm. The excision of the infiltrated muscles showed proliferation of carcinomatous tissue.     

Cavernous sinus meningioma presenting as orbital apex syndrome. Diagnostic methods of dynamic MRI,spoiled GRASS (SPGR) image

Orbital apex syndrome is a symptomatologic complex. In this paper, the usefulness of several clinical diagnostic MR methods in preparing for surgery is discussed. These include dynamic MRI and the spoiled GRASS (SPGR) image for a cavernous sinus meningioma presenting with orbital apex syndrome. A 53 year old man, who had right cavernous sinus tumor presenting with orbital apex syndrome, was examined by several new MRI techniques. The tumor was partially removed and fibroblastic meningioma was confirmed pathologically.