Horner's syndrome as an initial sign of metastatic breast cancer: case report

Background: Horner syndrome is caused by a lesion affecting the sympathetic innervation of the lids and pupil. The most common factor producing the preganglionic Horner's syndrome is malignant tumors. Methods: We report here a case of Horner syndrome in young women with the history of breast cancer. The patient underwent extensive neurological examinations, including MRI of head and neck, together with chest radiograph and CT thorax scan. Results: Present radiographic methods revealed one-sided metastatic pleural effusion as a cause of sympathetic lesion. Conclusion: Metastatic breast disease usually affects lungs, bone, liver, adrenals and skin, and it is highly unusual for ocular involvement to be the first sign of its existence. This report presents a rare case of pleural metastatic breast cancer causing Horner's syndrome/Pancoast syndrome without lung involvement.     

Pancoast syndrome in a patient with malignant lymphoma

Pancoast syndrome is usually secondary to lung cancer. We report a patient with Pancoast syndrome in whom a biopsy specimen of a cervical mass at first thought to be anaplastic carcinoma was found to stain positively for leukocyte common antigen and negatively for keratin, epithelial membrane antigen, and alpha-fetoprotein. A diagnosis of malignant lymphoma associated with Pancoast syndrome was made, and a salutary response was observed after combination chemotherapy. To our knowledge, this is the first reported case of Pancoast syndrome associated with malignant lymphoma. We emphasize the importance of using immunohistochemical stains to define the pathologic condition in difficult cases.     

Pancoast tumour treated with combined radiotherapy and hyperthermia — a preliminary study

Six patients with Pancoast (superior sulcus) tumours were treated with combined radiotherapy and hyperthermia from April 1986 to December 1989. Radiotherapy was performed using 10 MV X-ray, and all patients received total doses of 60–74 Gy, in five fractions per week, during 5.5–15 weeks. Hyperthermia was performed once or twice a week within 30 min after each irradiation, using 8 MHz RF capacitive heating equipment (Thermotron RF-8). Partial response, defined as 50% or more regression of the tumour, was observed in four of the six patients. Three patients are alive 30, 28, and 14 months after their treatments. Radiotherapy combined with hyperthermia appears to be a promising and effective means for treating Pancoast tumours.     

Is There a Standard of Care for the Radical Management of Non-small Cell Lung Cancer Involving the Apical Chest Wall (Pancoast Tumours)?

The term Pancoast tumour encompasses a wide range of tumours that invade the apical chest wall. Although less than 5% of non-small cell lung cancers are Pancoast tumours, they still account for most cases. They often pose a formidable challenge to the multidisciplinary lung cancer team due to their relative rarity, anatomical proximity to vital structures, differing stages of presentation, and their association with smoking-related illnesses. A lack of clinical trials makes comparisons between different treatment modalities very difficult and the management of Pancoast tumours has been largely based on the published retrospective experience of large single institutions. The bimodality approach of induction radiotherapy followed by surgical resection has been the accepted standard of care for the last 50 years, with reported 5-year survival rates of 30% in selected patients. However, two recent prospective multicentre phase II studies using a trimodality approach of induction concurrent chemoradiotherapy followed by surgical resection (followed by two further cycles of adjuvant chemotherapy in one of the studies), have reported 5-year survival rates of 44–56%. This has led to some authorities advocating the trimodality approach as the new standard of care for the management of Pancoast tumours. In this overview, the historical evolution of the management of Pancoast tumours and recent published studies on the trimodality approach are discussed. This is followed by a discussion of whether the trimodality approach should be seen as a new standard of care. Finally, other potential treatment options and the possibilities for future research are deliberated.     

Complete resection of Pancoast tumor while receiving preoperative concurrent chemoradiotherapy (CCRT) as an induction therapy--report of a case

A 60-year-old man complaining of right shoulder pain and numbness of right arm was diagnosed with Pancoast tumor (invasive right apical lung cancer). Chest CT scan showed a tumor, 5 cm in diameter, in the right apex invading the right posterior chest wall. The patient received preoperative CCRT (RT: 40 Gy/20 Fr, cisplatin: CDDP and etoposide: ETP), resulting in tumor regression (PR). The patient underwent right upper lobectomy (ND 2a), partial resection of the 1st-3rd ribs and Th 1 nerve. Pathological examination demonstrated no live cancer cells and organization of necrotic tissue in the lung and intercostal region (Ef. 3). The patient received postoperative chemotherapy (CDDP+ETP) and was discharged. He did well without any tumor recurrence for 1 year postoperatively. CCRT seems effective and is one of the standard treatments for Pancoast tumor.     

Hepatoid pancoast tumor. A case report and review of the literature

A 48-year-old male patient presented with a Pancoast tumor of the right lung and a serum alpha-fetoprotein (αFP) at 39,000 ng/ml. Alpha-fetoprotein is a tumor marker found elevated in patients with hepatocellular carcinoma (HCC), germ cell or stromal tumors of the ovary and nonseminomatous testicular cancer. Occasionally, this tumor marker may rise in non-neoplastic conditions such as cirrhosis and hepatitis and only exceptionally in rare cancers with hepatoid differentiation. We present our case report and review the English literature for αFP-producing lung carcinomas. To the best of our knowledge this is the first report in the literature of an αFP producing Pancoast tumor.     

Pain-relieving posterior rod fixation with segmental sublaminar wiring for Pancoast tumor invading the vertebrae

We describe the case of a 44-year-old male patient with Pancoast lung cancer invading the vertebrae. Because irradiation did not relieve his symptoms, we conducted tumor resection with posterior rod fixation with segmental sublaminar wiring of the vertebrae. This enabled the patient to walk and to discontinue morphine immediately after surgery. Although the tumor recurred within the region of the fixation 4 months after surgery, the patient complained of no pain until his death. Although Pancoast lung cancer with extensive vertebral invasion cannot be cured surgically, posterior rod fixation with segmental sublaminar wiring with tumor resection can improve a patient's quality of life by providing immediate, long-term pain relief.     

Management of Pancoast tumours

Non-small-cell lung carcinomas of the superior sulcus, frequently termed Pancoast tumours, are some of the most challenging thoracic malignant diseases to treat because of their proximity to vital structures at the thoracic inlet. Originally deemed universally fatal, Pancoast tumours are now amenable to curative treatment because of improvements in combined modality therapy and development of new techniques for resection. This review includes discussion of anatomical considerations, initial assessment, multimodality treatment, and surgical approaches for these cancers.     

Concomitant weekly cisplatin and thoracic radiotherapy for Pancoast tumors of the lung: pilot experience of the San Antonio Cancer Institute

Pancoast (superior sulcus tumors) comprise a subset of non-small-cell lung cancers that have a unique clinical presentation by virtue of the locoregional pattern of disease progression. We herein report a brief report on our group's pilot experience in managing these challenging lung neoplasms with an aggressive concomitant modality approach. These results and those of the recent Southwest Oncology-lead Intergroup prospective phase 2 trial (SWOG-9416/INT-0160) support the use of concomitant chemoradiation followed by an attempt at surgical resection.     

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.     

肺上沟瘤的治疗进展

肺上沟瘤(Pancoast瘤)是非小细胞肺癌的一个独特的临床亚型.术前放疗加手术切除经典治疗模式在临床上应用有近40年的历史,但手术完整切除率和5年生存率仍分别徘徊在50%和30%左右.近年来,外科术式的改进使针对不同位置的肿瘤切除有更佳的选择,同时新术式的出现使完整切除受累的锁骨下血管甚至椎体成为可能.术前同期放化疗的应用不仅提高了肿瘤的完整切除率和局部控制率,而且延长了患者的中位生存时间,这种综合治疗方法正逐渐成为肺上沟瘤新的治疗模式.     

肺尖癌26例分析

本文报道医学科学院附属肿瘤医院１９６１年３月－１９７４年７月收治的２６６例肺尖癌，其中５例未予特殊治疗，３例单纯化疗，９例单纯放疗，２例放疗加手术后化疗。各疗法的平均活期各为０．５３个月，１．６８个月、５．２４个月、２１．０４个月及２２．５０个月。治疗效果以综合放疗、手术及化疗为优，术前应对原发灶、邻近纵隔及锁骨上区照射４０００Ｇｙ／４ｗ，休息２－４周手术，术后按病情补充放疗或化疗，单纯放疗者先用     

Non-Hodgkin's tumor and Pancoast's syndrome

A 60-year old man presented with Horner's syndrome, and acute right hand and lower extremity weakness. Chest X-ray and MRI revealed a right apical lung tumor (presumed to be a primary lung cancer), with brachial plexus infiltration and spinal cord compression. Emergent radiotherapy was initiated for spinal cord compression and a biopsy was obtained 24 h later. A careful review of pathology demonstrated a non-Hodgkin's lymphoma. The patient subsequently received chemotherapy, and is now in remission. This case illustrates the importance of a tissue diagnosis before initiating therapy for a Pancoast's tumor.     

Normal tissue tolerance to high LET radiotherapy

Based on the clinical evaluations about over 1800 patients who had been treated with fast neutrons at NIRS, the radiobiological properties of high LET radiations were discussed. The most favorable clinical results by fast neutron treatment had been revealed in such diseases as follows; salivary gland tumors, prostate cancer, Pancoast type lung cancer, osteosarcoma, soft tissue sarcoma. The characteristics of these tumors as to the radiobiological properties and the dose distribution are, 1) relatively slow growing tumors and higher RBE for tumor tissue, and 2) capability of correct delivery of a big radiation doses to the target, without any severe radiation complications. Normal tissue tolerance (NSD formulas) for each tissues were also discussed.     

Fast neutron therapy in the National Institute of Radiological Sciences; 10 years' experience and future study

A total number of 1623 patients were treated with fast neutrons produced by bombarding a thick Beryllium target with 30 MeV deuterons between November 1975 and December 1987. The results of clinical trials with fast neutrons have shown that carcinoma of the salivary gland and the prostate and Pancoast tumor of the lung were indications for fast neutron therapy, and that the patients suffering from osteosarcoma, malignant melanoma and soft tissue sarcoma had indications for fast neutrons when fast neutrons were combined with surgery. Neither carcinoma of the pancreas nor glioblastoma multiforme had indications because of complications of normal tissues. High LET radiation therapy will be evaluated by using heavy ions characterized by Bragg peak combined with biological effects.     

Radiothérapie conformationnelle avec modulation d’intensité dans les carcinomes bronchiques non à petites cellules

Intensity modulated radiotherapy is increasingly used in non-small-cell lung cancers despite a low level of evidence. A literature review was conducted. Several critical physical and dosimetric uncertainties are however unsolved. Methods to circumvent these limitations are being developed. In several retrospective studies, survival rates were at least similar with intensity-modulated radiotherapy as those reported with three-dimensional irradiation. To date, intensity modulated radiotherapy might be authorized in complex anatomical situations such as tumours close to the spinal cord (such as Pancoast Tobias, paraspinal and paracardiac tumours) or with limited motion amplitudes. Dosimetric benefits should also account for 4D dose distribution issues. The reduction of intermediate and high doses in the organs at risk with intensity modulated radiotherapy is advantageous. However, the effect of low doses in large volumes (lung, bone, unspecified tissues along beam paths) and the effect of increasing integral dose are still poorly known. In conclusion, dose–volume correlations need to be better documented and prospective randomized trials should be encouraged.     

Radiotherapy for carcinomatous brachial plexopathy. A clinical study of 23 cases

Twenty-three patients with the clinical or pathologic diagnosis of carcinomatous brachial plexopathy received external irradiation. Significant pain relief was achieved in 77.2% (17/22) of the patients for a median duration of 3 months. The observed objective response rate was 46.1%. The total administered dose (range, 1000 rad/5 fractions-5800 rad/31 fractions) as well as the treatment field width size (range, 5-24 cm) varied. Analysis of these two technical radiotherapy factors indicated that the total amount of delivered dose rather than the therapy-port-width size was the more important factor in the achievement of optimal symptomatic palliation. A literature review summarizes results of external irradiation for this painful disease syndrome, including superior sulcus Pancoast tumor.     

Radiation treatment of superior sulcus lung carcinoma

The survival of patients with superior sulcus lung carcinoma and the effects of treatment were reviewed. From a prospective database of 4123 consecutive new patients with lung carcinoma, 131 (3.2%) cases of superior sulcus lung carcinoma were identified. Seventy-four patients were planned to receive radiation with palliative intent, 53 radical radiotherapy and one was observed only. The remaining three patients, with small-cell carcinoma, were treated with chemotherapy with or without radiotherapy. Of the 53 radically treated patients, nine were treated with pre-operative radiation prior to intended radical resection. Analysis was carried out on the effect on survival of performance status, nodal involvement, weight loss, vertebral body or rib involvement, treatment intent and radical combined modality treatment compared with radical radiation alone. The estimated median survival for the whole group was 7.6 months; for those treated radically it was 18.3 months, while for the palliatively treated patients it was 3.7 months. Radically treated patients with no initial nodal involvement had an estimated median survival of 22 months, while radically treated patients with nodal involvement had an estimated median survival of 8.4 months (P= 0.003). There were no statistically significant differences in survival between radically treated patients grouped according to initial weight loss, performance status, or vertebral body and rib involvement. Patients treated with pre-operative radiation did not survive significantly longer than patients treated with radiation alone, although the numbers are small.     

Pancoast tumour treated with combined radiotherapy and hyperthermia--a preliminary study

Six patients with Pancoast (superior sulcus) tumours were treated with combined radiotherapy and hyperthermia from April 1986 to December 1989. Radiotherapy was performed using 10 MV X-ray, and all patients received total doses of 60-74 Gy, in five fractions per week, during 5.5-15 weeks. Hyperthermia was performed once or twice a week within 30 min after each irradiation, using 8 MHz RF capacitive heating equipment (Thermotron RF-8). Partial response, defined as 50% or more regression of the tumour, was observed in four of the six patients. Three patients are alive 30, 28, and 14 months after their treatments. Radiotherapy combined with hyperthermia appears to be a promising and effective means for treating Pancoast tumours.     

序贯性化疗、放疗和手术切除治疗肺尖癌28例分析

目的 探讨肺尖癌的综合治疗模式。方法 回顾分析我院1989年1月～1997年1月应用化疗(2个周期)、放疗(30～40Gy)加扩大性手术切除治疗肺尖癌28例。结果 化、放疗后CR 6例,PR 18例,MR 4例,总有效率为85.0％。全组出现并发症6例,肿块中心癌细胞变形和残存22例。纵隔淋巴结癌细胞阳性3例。全部达到根治性切除。术后5年生存率为42.8％(12/28)。结论 化疗可以杀灭部分癌细胞,消灭微小转移灶,对放疗起到增敏作用,放疗可以使局部病灶缩小,使患者的TNM分期提前。因此,序惯性化疗、放疗加扩大性手术切除应作为肺尖癌治疗的首选方案。