Pancoast tumor is an apical lung cancer having a subpleural localization and accompanied by the germination of the neurovascular bundle, lower cervical vertebrae, upper ribs and other nearby anatomical formations. The manifestations of Pancoast tumor are very specific; they include pain in the shoulder and arm, paresthesia in the fingers of the hand, Gorner syndrome, rough cough, hoarseness of voice, superior vena cava syndrome. The examination begins with an assessment of physical data and lung x-ray; further supplemented by CT / MRI of the chest, bronchoscopy, biopsy. The best results of Pancoast tumor treatment are achieved with neoadjuvant therapy (radiation and chemotherapy), supplemented with surgical intervention.
C34.1 of the upper lobe, bronchi or lung
Pancoast tumor (cancer of the upper lung sulcus) is a peripheral lung cancer that affects the S1 segment (apical) and, due to its localization, is accompanied by a specific symptom complex. It is named after the American radiologist H.K. Pancoast, who in 1924 first described the radiological signs and a complete clinic of this pathology. According to its morphological structure, Pancoast tumor most often corresponds to squamous cell lung cancer. In pulmonology, in addition to a malignant tumor, inflammatory and tumor processes with localization in the region of the apex of the lung can cause similar symptoms (the so-called Pancoast syndrome). Therefore, histological verification of the diagnosis is necessary to confirm the cancer of the Pancoast.
Causes of Pancoast tumor
In general, the causes of Pancoast tumor coincide with those that affect the incidence of lung cancer in general. As in other cases, smoking plays a leading role in the etiopathogenesis of Pancoast tumor in 80-85%. The most important factors in this case are the smoking experience, the daily “norm” of cigarettes smoked and the quality of tobacco. Passive smoking – regular inhalation of tobacco smoke by people surrounding the smoker is just as dangerous as active smoking: in this case, the risk of lung cancer increases by 1.5–2 times.
Harmful industrial and environmental factors contribute to the morbidity statistics. First of all, it is contact with asbestos, arsenic, nickel, chromium, heavy metals, insecticides, pesticides, aeropollutants. Chronic inflammatory and dystrophic processes in the lungs play an important role in the occurrence of pancreatic cancer: previously transmitted tuberculosis, chronic pneumonia, bronchiectatic disease, focal pneumosclerosis, etc. Hereditary predisposition to lung cancer has been proven; the role of viruses in triggering the processes of carcinogenesis is likely.
Symptoms of Pancoast tumor
Pathognomonic symptoms of Pancoast tumor are caused by the apical localization of the tumor, destruction of the upper aperture of the chest, tumor infiltration of the brachial plexus and stellate ganglion. The clinical picture consists of the eponymous Pancoast syndrome and Gorner syndrome. Sometimes both symptom complexes develop simultaneously, in some cases they occur separately.
Pancoast syndrome is caused by the germination of nerve roots at the level of vertebrae C8, Th1-Th2. He is characterized by debilitating aching pain in the shoulder on the side of the tumor, spreading along the ulnar nerve; weakness in the muscles of the arm, paresthesia and numbness of the fingers of the hand, sometimes atrophy of the muscles of the limb. Often, in order to ease the pain in the shoulder, the patient is forced to support the sick arm by the elbow. The pain can be given under the shoulder blade, in the axillary area, in the chest. With germination or compression of the recurrent laryngeal nerve, a rough dry cough and hoarseness of voice occur. Pancoast tumor is often accompanied by the development of superior vena cava syndrome.
Gorner syndrome develops in patients with Pancoast tumor in the case of involvement in the pathological process of sympathetic fibers from the level of the upper cervical ganglion to the Th1 segment. The symptom complex is characterized by drooping (ptosis) of the upper eyelid, pupil constriction (miosis), occlusion of the eyeball (enophthalmos), cessation of sweating (anhidrosis) on the affected side of the face and upper limb. In the late period, a tumor conglomerate is palpated in the supraclavicular fossa.
Specific signs of Pancoast tumor occur against the background of cancer intoxication (malaise, weight loss, fever) and paraneoplastic disorders. Apical lung cancer is characterized by a tendency to destructive growth and early metastasis to the mediastinum, brain, liver, and bones. Pancoasta tumor must be differentiated from other pathological processes accompanied by this syndrome: metastatic lung cancer, lymphogranulomatosis, pleural mesothelioma, echinococcal lung cyst, tumors of the mediastinum and chest wall, tuberculosis.
With complaints of pain in the arm, patients often turn to a neurologist, but after excluding neurological pathology, they are redirected to a pulmonologist, thoracic surgeon or oncologist for further examination.
Radiography of the lungs helps to identify darkening in the upper furrow, thickening of the pleura at the top of the lung; destruction of the I-III ribs, lower cervical and upper thoracic vertebrae is often detected. With the help of CT or MRI of the lungs, the degree of tumor invasion into the vessels, lymph nodes, ribs, vertebrae, and chest wall tissues is determined. This information is extremely important for predicting operability in Pancreatic cancer. To assess the involvement of blood vessels, it is possible to conduct arterio- or phlebography, or contrast computed tomography.
Bronchoscopy helps to obtain additional information about the prevalence of the malignant process. Histological verification of the diagnosis is carried out after performing a transthoracic fine needle puncture biopsy of the tumor or an open biopsy of the lymph nodes. In order to exclude metastases of lung cancer, mediastinoscopy, MRI of the brain, ultrasound of the liver, bone scintigraphy can be prescribed.
Pancoast tumor treatment
Most often, Pancoast tumor is diagnosed at stage III, which imposes its own characteristics on the treatment process. Immediately after diagnosis, it is important to prescribe adequate anesthesia to the patient, up to narcotic analgesics. Blockades of the staircase muscle have a good analgesic effect. In the practice of oncology, a three-component approach is considered the most acceptable, including radiation therapy, chemotherapeutic and surgical treatment. Neoadjuvant therapy is prescribed to reduce the prevalence of the tumor and increase operability.
The volume of resection in upper lung cancer usually includes pneumonectomy with mediastinal lymphadenectomy, removal of all involved structures (vessels, branches of the brachial plexus, affected ribs and vertebral bodies). In the postoperative period, chemoradiotherapy is again performed. For patients with metastatic process, treatment is palliative in nature.
With the detection of Pancoast tumorat an early stage and radical combined treatment, the prognosis can be considered conditionally favorable. With three-component treatment, the five-year survival rate is 30-46%. The germination of a cancerous tumor into the lymph nodes of the mediastinum, sympathetic nodes, subclavian artery, vertebral body, ribs, the development of Gorner syndrome aggravate the prognosis for Pancoast tumor. To reduce the likelihood of developing lung cancer allows complete cessation of smoking, exclusion of contact with harmful chemical compounds.
- Pancoast’s tumor: multi-disciplinary treatment and combined cervico-thoracic approach. Merlini M, Narakas A, Livio JJ, Wellmann D, Schindler AM. 1989 Jan;55(5):727-30. link
- Treatment of superior sulcus tumor (Pancoast tumor). Hilaris BS, Martini N, Wong GY, Nori D. Surg Clin North Am. 1987 Oct;67(5):965-77. link
- Superior pulmonary sulcus carcinoma. Urschel HC Jr. Surg Clin North Am. 1988 Jun;68(3):497-509. link
- New approaches to Pancoast and chest wall tumors. Urschel HC Jr. Chest. 1993 Apr;103(4 Suppl):360S-1 link
- Surgical treatment of Pancoast tumours. Pitz CC, de la Rivière AB, van Swieten HA, Duurkens VA, Lammers JW, van den Bosch JM. Eur J Cardiothorac Surg. 2004 Jul;26(1):202-8 link