Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pancoast Syndrome Clinical Presentation

  • Author: Karl J D'Silva, MD; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
 
Updated: Mar 28, 2014
 

History

Patients with Pancoast syndrome may present with referred pain over the scapula to the shoulder as the result of damage to the afferent pain fibers of the sympathetic trunk. The symptoms are typical of the location of the tumor in the superior sulcus or thoracic inlet adjacent to the eighth cervical nerve roots, the first and second thoracic trunk distribution, the sympathetic chain, and the stellate ganglion.

Initially, localized pain occurs in the shoulder and vertebral border of the scapula. Pain may later extend along an ulnar nerve distribution of the arm to the elbow and, ultimately, to the ulnar surface of the forearm and to the small and ring fingers of the hand (C8). If the tumor extends to the sympathetic chain and stellate ganglion, Horner syndrome and anhidrosis develop on the ipsilateral side of the face and upper extremity.

The pain is frequently relentless and unremitting, and adequate relief often requires administration of narcotics. The patient usually supports the elbow of the affected arm in the hand of the opposite upper extremity to ease the tension on the shoulder and upper arm.

The hand muscles may become weak and atrophic, and the triceps reflex may be absent. The first or second rib or vertebrae may be involved by tumor extension and intensify the severity of pain. The spinal canal and spinal cord may be invaded or compressed, with subsequent symptoms of spinal cord tumor or cervical disk disease.

Many patients are initially treated for presumed local musculoskeletal conditions such as bursitis and vertebral osteoarthritis with radicular pain. Symptoms may persist for many months before evaluation for progression reveals the cause. In a 1994 series by Maggi et al, symptoms lasted 2-36 months, with a mean of 9.7 months.[6] In 1997, Muscolino described plexopathy or radicular symptoms in 53% of 15 patients.[22]

Next

Physical Examination

Physical examination of patients with Pancoast tumor may reveal findings consistent with Horner syndrome, such as ptosis and miosis, which result from paralysis of the dilating sympathetic fibers. Supraclavicular lymphadenopathy may also be observed.

Horner syndrome (Horner’s syndrome) is the result of invasion of the lower cervical and first thoracic ganglia, which frequently fuse into a single ganglion, the stellate ganglion. Horner syndrome is observed in 20-50% of patients at presentation.[16, 6, 22, 18] Decreased sweating on the affected side and ptosis of the denervated lid may be observed. Application of topical cocaine to the miotic eye (contracted pupil) fails to cause pupil dilation, while appropriate dilation is noted in the unaffected eye.[23]

Cough, dyspnea, and hemoptysis, which are signs often associated with lung cancer, are not as common in individuals with Pancoast syndrome because of the peripheral location of the tumor. When present, they are associated with a worse prognosis. Also uncommon but occasionally noted are more advanced tumors with involvement of the recurrent laryngeal nerve, phrenic nerve, or superior vena cava.

Infrequently, a patient with a Pancoast tumor may also have features of a paraneoplastic syndrome. Most of the metabolic manifestations are the result of the secretion of endocrine chemicals by the tumor. Manifestations encompass Cushing syndrome, excessive antidiuretic hormone secretion, hypercalcemia, myopathies, hematologic problems, and hypertrophic osteoarthropathy. The presence of paraneoplastic syndromes does not connote unresectability, but most of these are associated with small cell cancer.

Brain metastasis may be relatively common at the point of diagnosis. The brain is the frequent site of failure for superior sulcus tumors. Preoperative brain imaging studies are highly recommended in patients who are receiving induction therapy for the primary tumor.[24]

Previous
 
 
Contributor Information and Disclosures
Author

Karl J D'Silva, MD Assistant Clinical Professor of Medicine, Department of Hematology/Oncology, Lahey Clinic, Sophia Gordon Cancer Center

Karl J D'Silva, MD is a member of the following medical societies: Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sarah K May, MD Consulting Staff, Department of Hematology-Oncology, Caritas Carney Hospital, Commonwealth Hematology-Oncology PC

Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, FACP, FRCPC Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD, FACP, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Society of Hematology, Central Society for Clinical and Translational Research, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Acknowledgements

Shabir Bhimji, MD, PhD Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals

Shabir Bhimji, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Chest Physicians, American Lung Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Shreekanth V Karwande, MBBS Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Michael Perry, MD, MS, MACP Nellie B Smith Chair of Oncology Emeritus, Director, Division of Hematology and Medical Oncology, Deputy Director, Ellis Fischel Cancer Center, University of Missouri-Columbia School of Medicine

Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Pancoast HK. Importance of careful roentgen ray investigations of apical chest tumors. JAMA. 1924. 83:1407-1411.

  2. Pancoast HK. Superior pulmonary sulcus tumor: Tumor characterized by pain, Horner's syndrome, destruction of bone and atrophy of hand muscles. JAMA. 1932. 99:1391-1396.

  3. Hare ES. Tumor involving certain nerves. Lond Med Gaz. 1838. 1:16-18.

  4. Paulson DL. Carcinomas in the superior pulmonary sulcus. J Thorac Cardiovasc Surg. 1975 Dec. 70(6):1095-104. [Medline].

  5. Pitz CC, de la Rivière AB, van Swieten HA, Duurkens VA, Lammers JW, van den Bosch JM. Surgical treatment of Pancoast tumours. Eur J Cardiothorac Surg. 2004 Jul. 26(1):202-8. [Medline].

  6. Maggi G, Casadio C, Pischedda F, et al. Combined radiosurgical treatment of Pancoast tumor. Ann Thorac Surg. 1994 Jan. 57(1):198-202. [Medline].

  7. Chong KM, Hennox SC, Sheppard MN. Primary hemangiopericytoma presenting as a Pancoast tumor. Ann Thorac Surg. 1993 Feb. 55(2):9. [Medline].

  8. Hatton MQ, Allen MB, Cooke NJ. Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma. Eur Respir J. 1993 Feb. 6(2):271-2. [Medline].

  9. Amin R. Bilateral Pancoast's syndrome in a patient with carcinoma of the cervix. Gynecol Oncol. 1986 May. 24(1):126-8. [Medline].

  10. Mills PR, Han LY, Dick R, Clarke SW. Pancoast syndrome caused by a high grade B cell lymphoma. Thorax. 1994 Jan. 49(1):92-3. [Medline].

  11. Rabano A, La Sala M, Hernandez P, et al. Thyroid carcinoma presenting as Pancoast's syndrome. Thorax. 1991 Apr. 46(4):270-1. [Medline].

  12. Vandenplas O, Mercenier C, Trigaux JP, et al. Pancoast's syndrome due to Pseudomonas aeruginosa infection of the lung apex. Thorax. 1991 Sep. 46(9):683-4. [Medline].

  13. Gallagher KJ, Jeffrey RR, Kerr KM, Steven MM. Pancoast syndrome: an unusual complication of pulmonary infection by Staphylococcus aureus. Ann Thorac Surg. 1992 May. 53(5):903-4. [Medline].

  14. Simpson FG, Morgan M, Cooke NJ. Pancoast's syndrome associated with invasive aspergillosis. Thorax. 1986 Feb. 41(2):156-7. [Medline].

  15. Mitchell DH, Sorrell TC. Pancoast's syndrome due to pulmonary infection with Cryptococcus neoformans variety gattii. Clin Infect Dis. 1992 May. 14(5):1142-4. [Medline].

  16. Ginsberg RJ, Martini N, Zaman M, et al. Influence of surgical resection and brachytherapy in the management of superior sulcus tumor. Ann Thorac Surg. 1994 Jun. 57(6):1440-5. [Medline].

  17. Johnson DE, Goldberg M. Management of carcinoma of the superior pulmonary sulcus. Oncology (Huntingt). 1997 Jun. 11(6):781-5; discussion 785-6. [Medline].

  18. Attar S, Krasna MJ, Sonett JR, et al. Superior sulcus (Pancoast) tumor: experience with 105 patients. Ann Thorac Surg. 1998 Jul. 66(1):193-8. [Medline].

  19. Detterbeck FC. Pancoast (superior sulcus) tumors. Ann Thorac Surg. 1997 Jun. 63(6):1810-8. [Medline].

  20. Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome. N Engl J Med. 1997 Nov 6. 337(19):1370-6. [Medline].

  21. Komaki R, Roth JA, Walsh GL, et al. Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas M. D. Anderson Cancer Center. Int J Radiat Oncol Biol Phys. 2000 Sep 1. 48(2):347-54. [Medline].

  22. Muscolino G, Valente M, Andreani S. Pancoast tumours: clinical assessment and long-term results of combined radiosurgical treatment. Thorax. 1997 Mar. 52(3):284-6. [Medline].

  23. Balcer LJ, Galetta SL. Images in clinical medicine. Pancoast's syndrome. N Engl J Med. 1997 Nov 6. 337(19):1359. [Medline].

  24. Shah H, Anker CJ, Bogart J, Graziano S, Shah CM. Brain: the common site of relapse in patients with pancoast or superior sulcus tumors. J Thorac Oncol. 2006 Nov. 1(9):1020-2. [Medline].

  25. Beale R, Slater R, Hennington M, Keagy B. Pancoast tumor: use of MRI for tumor staging. South Med J. 1992 Dec. 85(12):1260-3. [Medline].

  26. Patz EF Jr. Imaging lung cancer. Semin Oncol. 1999 Oct. 26(5 Suppl 15):21-6. [Medline].

  27. Heelan RT, Demas BE, Caravelli JF, et al. Superior sulcus tumors: CT and MR imaging. Radiology. 1989 Mar. 170(3 Pt 1):637-41. [Medline].

  28. Anderson TM, Moy PM, Holmes EC. Factors affecting survival in superior sulcus tumors. J Clin Oncol. 1986 Nov. 4(11):1598-603. [Medline].

  29. Maxfield RA, Aranda CP. The role of fiberoptic bronchoscopy and transbronchial biopsy in the diagnosis of Pancoast''s tumor. N Y State J Med. 1987 Jun. 87(6):326-9. [Medline].

  30. Paulson DL, Weed TE, Rian RL. Cervical approach for percutaneous needle biopsy of Pancoast tumors. Ann Thorac Surg. 1985 Jun. 39(6):586-7. [Medline].

  31. Shaham D. Semi-invasive and invasive procedures for the diagnosis and staging of lung cancer. I. Percutaneous transthoracic needle biopsy. Radiol Clin North Am. 2000 May. 38(3):525-34. [Medline].

  32. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest. 1997 Jun. 111(6):1710-7. [Medline].

  33. Rusch VW. Management of Pancoast tumours. Lancet Oncol. 2006 Dec. 7(12):997-1005. [Medline].

  34. Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg. 1993 Jun. 105(6):1025-34. [Medline].

  35. Uchino K, Tauchi S, Tanaka Y, Nakai R, Tane S, Yoshimura M. [Treatment of superior sulcus tumor]. Kyobu Geka. 2010 Jan. 63(1):18-22. [Medline].

  36. Detterbeck FC, Jones DR, Kernstine KH, Naunheim KS. Lung cancer. Special treatment issues. Chest. 2003 Jan. 123(1 Suppl):244S-258S. [Medline]. [Full Text].

  37. Hilaris BS, Martini N, Wong GY, Nori D. Treatment of superior sulcus tumor (Pancoast tumor). Surg Clin North Am. 1987 Oct. 67(5):965-77. [Medline].

  38. Stanford W, Barnes RP, Tucker AR. Influence of staging in superior sulcus (Pancoast) tumors of the lung. Ann Thorac Surg. 1980 May. 29(5):406-9. [Medline].

  39. Shaw RR, Paulson DL, Kee JL. Treatment of Superior Sulcus Tumor by Irradiation Followed by Resection. Ann Surg. 1961 Jul. 154(1):29-40. [Medline].

  40. Torre W, Garcia-Franco C, Tamura A, Gurpide A, Lopez-Picazo J, Aristu J, et al. Role of surgery in a multidisciplinary approach to superior sulcus tumors (SST): morbidity and prognostic factors for long-term success after resection. Thorac Cardiovasc Surg. 2009 Sep. 57(6):353-7. [Medline].

  41. Rosell R, Gomez-Codina J, Camps C, et al. A randomized trial comparing preoperative chemotherapy plus surgery with surgery alone in patients with non-small-cell lung cancer. N Engl J Med. 1994 Jan 20. 330(3):153-8. [Medline].

  42. Roth JA, Fossella F, Komaki R, et al. A randomized trial comparing perioperative chemotherapy and surgery with surgery alone in resectable stage IIIA non-small-cell lung cancer. J Natl Cancer Inst. 1994 May 4. 86(9):673-80. [Medline].

  43. Albain KS, Crowley JJ, Turrisi AT, et al. Concurrent cisplatin, etoposide, and chest radiotherapy in pathologic stage IIIB non-small-cell lung cancer: a Southwest Oncology Group phase II study, SWOG 9019. J Clin Oncol. 2002 Aug 15. 20(16):3454-60. [Medline].

  44. Langer CJ. Induction or neoadjuvant therapy in resectable non-small cell lung cancer. Semin Oncol. 1999 Oct. 26(5 Suppl 15):34-9. [Medline].

  45. Peedell C, Dunning J, Bapusamy A. Is there a standard of care for the radical management of non-small cell lung cancer involving the apical chest wall (Pancoast tumours)?. Clin Oncol (R Coll Radiol). 2010 Jun. 22(5):334-46. [Medline].

  46. Tamura M, Hoda MA, Klepetko W. Current treatment paradigms of superior sulcus tumours. Eur J Cardiothorac Surg. 2009 Oct. 36(4):747-53. [Medline].

  47. Hubbard MO, Schroeder C, Linden PA. Routine use of staging thoracoscopy for pancoast tumors without overt radiographic chest wall invasion. Surg Laparosc Endosc Percutan Tech. 2011 Apr. 21(2):111-5. [Medline].

  48. Caronia FP, Ruffini E, Lo Monte AI. The use of video-assisted thoracic surgery in the management of Pancoast tumors. Interact Cardiovasc Thorac Surg. 2010 Dec. 11(6):721-6. [Medline].

  49. Davis GA, Knight SR. Pancoast tumors. Neurosurg Clin N Am. 2008 Oct. 19(4):545-57, v-vi. [Medline].

 
Previous
Next
 
Table. AJCC/UICC Stages for Pancoast Tumors.
Stage T(Tumor) N (Nodes)
IIB T3 N0
IIIA T3 N1
T3 N2
IIIB Any T N3
T4 Any N
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.