Pancoast tumor
Updates to Article Attributes
A Pancoast tumour otherwise known as superior sulcus tumour refers to a relatively uncommon situation where a primary bronchogenic carcinoma arises in the lung apex and invades the surrounding soft tissues.
Definitions vary from author to author, with some only referring to Pancoast tumours if the histology is of non-small cell lung cancer (NSCLC), and treating other superior sulcal tumours separately (even though the latter can also cause Pancoast syndrome) 8.
Others use the term superior sulcal tumour and Pancoast tumour interchangeably, but limit the use to bronchogenic carcinomas, whilst others include all tumours that involve the superior pulmonary sulcus (whether or not they arise form the lung).
For the sake of simplicity we have taken the middle road. For the purposes of this article superior sulcus tumour and Pancoast tumour are used interchangeably to refer to a primary bronchogenic carcinoma involving the superior pulmonary sulcus.
Epidemiology
Superior sulcus tumours account for 3-5% of all bronchogenic carcinomas, and have similar demographics to other lung cancers (see bronchogenic carcinoma article for discussion of demographics and risk factors) 5, 9.
Clinical presentation
Although classically superior sulcus tumours present with Pancoast syndrome, this is only the case in approximately 25% of cases 1. The missing element is usually Horner syndrome.
The most common symptoms at presentation are chest and/or shoulder pain, with arm pain being also common. Weight loss is frequently present 5.
Pathology
Superior sulcus tumours are usually non-small cell lung cancers (NSCLC). The most common histology encountered historically in the superior sulcus were squamous cell bronchogenic carcinomas 7-8, however more recently, and in keeping with the overall shift in frequency, bronchogenic adenocarcinomas now are more frequently identified 9.
Radiographic features
Plain film
Plain films demonstrate a soft tissue opacity at the apex of the lung. Occasionally rib involvement or extension into the supraclavicular fossa may be evident. Lordotic views may be helpful.
Ultrasound
The role of ultrasound is limited, however it may be useful in aiding percutaneous biopsy as it is able to visualise the external component of the tumour via an intercostal or supraclavicular acoustic window 3.
CT
Although, as is the case with bronchogenic cancer at other locations, CT is the work horse for diagnosis, it has poor sensitivity (60%) and specificity (65%) for accurate local staging 8. It is however excellent at identifying bony involvement.
MRI
MRI is helpful in the assessment of superior sulcus tumours due to its excellent demonstration of soft-tissue involvement, and is far more sensitive (88%) and specific (100%) for local staging 8.
Careful assessment of the brachial plexus is important as involvement of more than the lower trunk or C8 nerve root is usually considered inoperable 8.
The anatomy lends itself particularly to imaging in the coronal and sagittal plane, and the T1 sagittal images offer most of the required information 2,9.
Treatment and prognosis
Treatment depends crucially on the extent of involvement particularly through the apex, as these lesions usually involve the brachial plexus and subclavian vessels. In such lesions radiotherapy is typically administered in an attempt to down-stage the tumour sufficiently to allow for attempted resection 2.
Much controversy nonetheless exists over exact inclusion and exclusion criteria for surgery and the timing and administration of radiotherapy and chemotherapy.
Despite advances in management, prognosis remains poor with an overall 5 year survival of only 36%. Complete resection is the most important factor in determining survival 5:
- complete resection achieved - 45% 5 year survival
- incomplete resection only - 0% 5 year survival
Etymology
Pancoast syndrome as a result of superior sulcus tumours was described in a number of publications (Hare 1838 and Ciuffini in 1911) before Pancoast reported it using the term 'superior pulmonary sulcus tumour' in 1924 5,9:
- Edward Selleck Hare (1812-1838), British physician
- Publio Ciuffini, Italian physician
- Henry Khunrath Pancoast (1875-1939), American radiologist
Differential diagnosis
General imaging differential considerations include
- pulmonary metastases
- mesothelioma
- primary chest wall tumours
- chest wall metastases
- apical pleural thickening secondary to previous pulmonary tuberculosis
In addition a number of plain film mimics should be considered, including:
- vascular lesions - e.g. carotid pseudoaneurym 4
- anterosuperior mediastinal masses
-<p>A <strong>Pancoast tumour</strong> otherwise known as <strong>superior sulcus tumour</strong> refers to a relatively uncommon situation where a <a href="/articles/lung-cancer-3">primary bronchogenic carcinoma</a> arises in the lung apex and invades the surrounding soft tissues.</p><p>Definitions vary from author to author, with some only referring to Pancoast tumours if the histology is of <a href="/articles/non-small-cell-lung-cancer-staging">non-small cell lung cancer (NSCLC)</a>, and treating other superior sulcal tumours separately (even though the latter can also cause <a href="/articles/pancoast_syndrome">Pancoast syndrome</a>) <sup>8</sup>. </p><p>Others use the term superior sulcal tumour and Pancoast tumour interchangeably, but limit the use to <a href="/articles/lung-cancer-3">bronchogenic carcinomas</a>, whilst others include all tumours that involve the superior pulmonary sulcus (whether or not they arise form the lung). </p><p>For the sake of simplicity we have taken the middle road. For the purposes of this article superior sulcus tumour and Pancoast tumour are used interchangeably to refer to a primary bronchogenic carcinoma involving the <a href="/articles/superior-pulmonary-sulcus-1">superior pulmonary sulcus</a>.</p><h4>Epidemiology</h4><p>Superior sulcus tumours account for 3-5% of all bronchogenic carcinomas, and have similar demographics to other lung cancers (see <a href="/articles/lung-cancer-3">bronchogenic carcinoma</a> article for discussion of demographics and risk factors) <sup>5, 9</sup>.</p><h4>Clinical presentation</h4><p>Although classically superior sulcus tumours present with <a href="/articles/pancoast_syndrome">Pancoast syndrome</a>, this is only the case in approximately 25% of cases <sup>1</sup>. The missing element is usually <a href="/articles/horner-syndrome">Horner syndrome</a>.</p><p>The most common symptoms at presentation are chest and/or shoulder pain, with arm pain being also common. Weight loss is frequently present <sup>5</sup>. </p><h4>Pathology</h4><p>Superior sulcus tumours are usually <a href="/articles/non-small-cell-lung-cancer-staging">non-small cell lung cancers (NSCLC)</a>. The most common histology encountered historically in the superior sulcus were <a href="/articles/squamous-cell-bronchogenic-carcinomas">squamous cell bronchogenic carcinomas</a> <sup>7-8</sup>, however more recently, and in keeping with the overall shift in frequency, <a href="/articles/bronchogenic-adenocarcinoma">bronchogenic adenocarcinomas</a> now are more frequently identified <sup>9</sup>.</p><h4>Radiographic features</h4><h5>Plain film</h5><p>Plain films demonstrate a soft tissue opacity at the apex of the lung. Occasionally rib involvement or extension into the supraclavicular fossa may be evident. Lordotic views may be helpful.</p><h5>Ultrasound</h5><p>The role of ultrasound is limited, however it may be useful in aiding percutaneous biopsy as it is able to visualise the external component of the tumour via an intercostal or supraclavicular acoustic window <sup>3</sup>.</p><h5>CT</h5><p>Although, as is the case with bronchogenic cancer at other locations, CT is the work horse for diagnosis, it has poor sensitivity (60%) and specificity (65%) for accurate local staging <sup>8</sup>. It is however excellent at identifying bony involvement.</p><h5>MRI</h5><p>MRI is helpful in the assessment of superior sulcus tumours due to its excellent demonstration of soft-tissue involvement, and is far more sensitive (88%) and specific (100%) for local staging <sup>8</sup>. </p><p>Careful assessment of the brachial plexus is important as involvement of more than the lower trunk or C8 nerve root is usually considered inoperable <sup>8</sup>. </p><p>The anatomy lends itself particularly to imaging in the coronal and sagittal plane, and the T1 sagittal images offer most of the required information <sup>2,9</sup>.</p><h4>Treatment and prognosis</h4><p>Treatment depends crucially on the extent of involvement particularly through the apex, as these lesions usually involve the brachial plexus and subclavian vessels. In such lesions radiotherapy is typically administered in an attempt to down-stage the tumour sufficiently to allow for attempted resection <sup>2</sup>.</p><p>Much controversy nonetheless exists over exact inclusion and exclusion criteria for surgery and the timing and administration of radiotherapy and chemotherapy.</p><p>Despite advances in management, prognosis remains poor with an overall 5 year survival of only 36%. Complete resection is the most important factor in determining survival <sup>5</sup>:</p><ul>- +<p>A <strong>Pancoast tumour</strong> otherwise known as <strong>superior sulcus tumour</strong> refers to a relatively uncommon situation where a <a href="/articles/lung-cancer-3">primary bronchogenic carcinoma</a> arises in the lung apex and invades the surrounding soft tissues.</p><p>Definitions vary from author to author, with some only referring to Pancoast tumours if the histology is of <a href="/articles/non-small-cell-lung-cancer-staging">non-small cell lung cancer (NSCLC)</a>, and treating other superior sulcal tumours separately (even though the latter can also cause <a href="/articles/pancoast-syndrome">Pancoast syndrome</a>) <sup>8</sup>.</p><p>Others use the term superior sulcal tumour and Pancoast tumour interchangeably, but limit the use to <a href="/articles/lung-cancer-3">bronchogenic carcinomas</a>, whilst others include all tumours that involve the superior pulmonary sulcus (whether or not they arise form the lung).</p><p>For the sake of simplicity we have taken the middle road. For the purposes of this article superior sulcus tumour and Pancoast tumour are used interchangeably to refer to a primary bronchogenic carcinoma involving the <a href="/articles/superior-pulmonary-sulcus-1">superior pulmonary sulcus</a>.</p><h4>Epidemiology</h4><p>Superior sulcus tumours account for 3-5% of all bronchogenic carcinomas, and have similar demographics to other lung cancers (see <a href="/articles/lung-cancer-3">bronchogenic carcinoma</a> article for discussion of demographics and risk factors) <sup>5, 9</sup>.</p><h4>Clinical presentation</h4><p>Although classically superior sulcus tumours present with <a href="/articles/pancoast-syndrome">Pancoast syndrome</a>, this is only the case in approximately 25% of cases <sup>1</sup>. The missing element is usually <a href="/articles/horner-syndrome">Horner syndrome</a>.</p><p>The most common symptoms at presentation are chest and/or shoulder pain, with arm pain being also common. Weight loss is frequently present <sup>5</sup>.</p><h4>Pathology</h4><p>Superior sulcus tumours are usually <a href="/articles/non-small-cell-lung-cancer-staging">non-small cell lung cancers (NSCLC)</a>. The most common histology encountered historically in the superior sulcus were <a href="/articles/squamous-cell-bronchogenic-carcinomas">squamous cell bronchogenic carcinomas</a> <sup>7-8</sup>, however more recently, and in keeping with the overall shift in frequency, <a href="/articles/bronchogenic-adenocarcinoma">bronchogenic adenocarcinomas</a> now are more frequently identified <sup>9</sup>.</p><h4>Radiographic features</h4><h5>Plain film</h5><p>Plain films demonstrate a soft tissue opacity at the apex of the lung. Occasionally rib involvement or extension into the supraclavicular fossa may be evident. Lordotic views may be helpful.</p><h5>Ultrasound</h5><p>The role of ultrasound is limited, however it may be useful in aiding percutaneous biopsy as it is able to visualise the external component of the tumour via an intercostal or supraclavicular acoustic window <sup>3</sup>.</p><h5>CT</h5><p>Although, as is the case with bronchogenic cancer at other locations, CT is the work horse for diagnosis, it has poor sensitivity (60%) and specificity (65%) for accurate local staging <sup>8</sup>. It is however excellent at identifying bony involvement.</p><h5>MRI</h5><p>MRI is helpful in the assessment of superior sulcus tumours due to its excellent demonstration of soft-tissue involvement, and is far more sensitive (88%) and specific (100%) for local staging <sup>8</sup>.</p><p>Careful assessment of the brachial plexus is important as involvement of more than the lower trunk or C8 nerve root is usually considered inoperable <sup>8</sup>.</p><p>The anatomy lends itself particularly to imaging in the coronal and sagittal plane, and the T1 sagittal images offer most of the required information <sup>2,9</sup>.</p><h4>Treatment and prognosis</h4><p>Treatment depends crucially on the extent of involvement particularly through the apex, as these lesions usually involve the brachial plexus and subclavian vessels. In such lesions radiotherapy is typically administered in an attempt to down-stage the tumour sufficiently to allow for attempted resection <sup>2</sup>.</p><p>Much controversy nonetheless exists over exact inclusion and exclusion criteria for surgery and the timing and administration of radiotherapy and chemotherapy.</p><p>Despite advances in management, prognosis remains poor with an overall 5 year survival of only 36%. Complete resection is the most important factor in determining survival <sup>5</sup>:</p><ul>
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