eMedicine Specialties > Oncology > Carcinomas of the Lung and Other Intrathoracic Carcinomas

Pancoast Syndrome: Treatment & Medication

Author: Karl J D'Silva, MD, Fellow in Hematology/Oncology, Department of Internal Medicine, Breslin Cancer Center, Michigan State University
Coauthor(s): Sarah K May, MD, Consulting Staff, Department of Hematology-Oncology, Caritas Carney Hospital, Commonwealth Hematology-Oncology PC
Contributor Information and Disclosures

Updated: Aug 26, 2008

Treatment

Medical Care

In patients with a Pancoast tumor (Pancoast’s tumor, an uncommon subset of lung cancer), a multimodality approach seems to be optimal, involving chemoradiotherapy and surgical resection, provided appropriate staging has been conducted. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. Such patients, however, seem to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone when carefully staged and selected.

Today, in accordance with Rusch and colleagues' 2001 trial findings, most centers use cisplatin-based chemotherapy with etoposide and concurrent radiotherapy as neoadjuvant treatment, followed by surgical resection, as the standard of care for this group of patients.28 One cautionary note is that this trial mandated a negative mediastinoscopy result. The preoperative radiotherapy dose was 4500 cGy in 25 fractions.

Surgical Care

  • Historically, Pancoast tumors (Pancoast’s tumor, an uncommon subset of lung cancer) have been difficult to treat. In the 1950s, they were considered inoperable.
    • In 1956, Chardack and MacCallum reported the first 5-year survival of a patient treated with resection and postoperative radiation therapy.
    • The combination of radiation and surgery was further evaluated, and, in 1961, Shaw and Paulson published a report of 18 patients treated with preoperative radiation therapy and surgical resection. They found a significant increase in resectability and cure; thereafter, preoperative radiation followed by surgery became the standard of care.29
  • In many centers, the current practice is to individualize a treatment plan for each patient. Frequently, treatment decisions are made by a multidisciplinary thoracic oncology group with attention to adverse prognostic factors.
    • The surgical treatment of choice is complete removal of the tumor by en bloc chest wall resection combined with lobectomy and node staging.4 Depending upon the extent of local invasion, surgical treatment may require resection of the paravertebral sympathetic chain, stellate ganglion, lower trunks of the brachial plexus, subclavian artery, or portions of the thoracic vertebrae.
    • Radiation and chemotherapy may benefit local and systemic control by addressing individual adverse findings.
    • In many centers, neoadjuvant or induction chemoradiotherapy is administered to patients with potentially resectable tumors. Important factors include T category, nodal status, presence of Horner syndrome, and completeness of resection.4,30,31,5,8,9 Surgery is generally undertaken 2-4 weeks after the completion of radiation therapy.
    • For tumors that invade the brachial plexus, the spine, or both, a combined thoracic-neurosurgical approach is warranted.
  • A lung intergroup trial (SWOG 0220) is studying induction therapy with cisplatin, etoposide, and radiotherapy with 45 Gy, followed by resection if possible, and postoperative docetaxel.

Medication

The goals of pharmacotherapy for Pancoast tumor (Pancoast’s tumor, an uncommon subset of lung cancer) are to induce remission, reduce morbidity, and prevent complications.

Antineoplastic agents

These agents inhibit cell growth and proliferation. Treat head, neck, breast, testicular, and ovarian cancer; Hodgkin and non-Hodgkin lymphoma; neuroblastoma; sarcomas; bladder, gastric, lung, esophageal, cervical, and prostate cancer; myeloma; melanoma; mesothelioma; small cell lung cancer (SCLC); osteosarcoma; acute nonlymphoblastic leukemia (ANLL); hepatoma; rhabdomyosarcoma, mycosis fungoides, uterine carcinoma, histiocytosis; gestational trophoblastic disease; Ewing sarcoma, Kaposi sarcoma, Wilms tumor, and brain tumors.


Cisplatin (Platinol)

Alkylating agent causing intrastrand and interstrand cross-linking of DNA, leading to strand breakage. Has broad range of antitumor activity. Forms backbone of currently available approved combination chemotherapy regimens for NSCLC and SCLC that cause Pancoast syndrome.
Administered by IV infusion in isotonic sodium chloride solution (0.9%) or sodium chloride and glucose. The manufacturers recommend that higher doses be administered in 2 L of chloride-containing infusion fluid over at least 1-2 h and that an infusion time of 6-8 h may further reduce toxicity. In practice, volumes of less than 2 L have been used in expert centers. To aid diuresis and protect the kidneys, 37.5 g of mannitol (eg, 375 mL of mannitol [10%]) is usually added to the infusion, or is infused separately, immediately before cisplatin. In order to initiate diuresis, the patient is usually hydrated by the infusion of 1-2 L of a suitable fluid over several hours before the administration of cisplatin. Adequate hydration must also be maintained for up to 24 h after a dose. Renal, hematological, auditory, and neurological function should be monitored during therapy and administration adjusted accordingly.

Adult

PE (cisplatin-etoposide) regimen: 25 mg/m2 IV on days 1-3 of cycle; repeat q3-4wk for 4-6 cycles

Pediatric

Not established

Increases toxicity of bleomycin and ethacrynic acid; other nephrotoxic drugs (eg, aminoglycosides, amphotericin B, cyclosporine) increase nephrotoxicity; bleomycin, cytarabine, methotrexate, and ifosfamide may accumulate owing to decreased renal excretion; may worsen cytotoxicity of etoposide; mesna and sodium thiosulfate directly inactivate cisplatin; dipyridamole increases cytotoxicity by enhancing cellular uptake; paclitaxel-related peripheral neuropathy may be increased in patients previously treated with cisplatin

Documented hypersensitivity; preexisting renal insufficiency; myelosuppression; hearing impairment

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Administer adequate hydration before and for 24 h after cisplatin dosing to reduce risk of nephrotoxicity; myelosuppression, ototoxicity, nausea, and vomiting may occur; peripheral blood cell counts and serum electrolyte levels should be monitored; requires close monitoring of pretreatment creatinine level and CrCl and posttreatment magnesium levels; neurologic examination should be performed regularly; major dose-limiting toxic effect is peripheral neuropathy; can cause acute or chronic renal failure in up to one third of patients treated, but this can usually be prevented by vigorous hydration and saline diuresis; renal tubular wasting of potassium and magnesium is common (monitor closely); cellulitis and fibrosis have rarely occurred after extravasation; avoid aluminum needles


Etoposide (Toposar, VePesid)

A semisynthetic derivative of podophyllotoxin with antineoplastic properties; it interferes with the function of topoisomerase II, thus inhibiting DNA synthesis, and is most active against cells in the late S and G(2) phases of the cell cycle.

Adult

PE regimen: 100 mg/m2 IV on days 1-3 of cycle; repeat q3-4wk for 4-6 cycles; administer by slow IV infusion, over at least 30 min, as a solution in isotonic sodium chloride solution (0.9%) or glucose (5%) injection
Single-agent regimen: 50 mg PO bid for days 1-14 of cycles; repeat cycle q3-4wk for 4-6 cycles; adjust dose in hepatic or renal dysfunction
Total bilirubin (TB) = 1.5-3 mg/dL: 50% dose reduction
TB = 3.1-4.9 mg/dL: 75% dose reduction
TB > 5 mg/dL: Avoid use
CrCl = 15-50 mL/min: 25% dose reduction

Pediatric

Not established

May prolong effects of warfarin and increase clearance of methotrexate; cyclosporine has additive effects in cytotoxicity of tumor cells; high dose of cyclosporine (serum concentration >2000 ng/mL) decreases clearance, leading to increased risk of neutropenia; zidovudine increases serum concentration, resulting in increased toxicity

Documented hypersensitivity; IT administration (may cause death)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Bleeding, severe myelosuppression, nausea, vomiting, hypotension, allergic reaction, and alopecia may occur; reduce dose in hepatic (eg, increased TB) or renal (eg, decreased CrCl) impairment

More on Pancoast Syndrome

Overview: Pancoast Syndrome
Differential Diagnoses & Workup: Pancoast Syndrome
Treatment & Medication: Pancoast Syndrome
Follow-up: Pancoast Syndrome
References
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Further Reading

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Keywords

Pancoast syndrome, Pancoast’s syndrome, lung cancer, Horner syndrome, Horner’s syndrome, shoulder pain, superior sulcus tumor, Ciuffini-Pancoast syndrome, Ciuffini-Pancoast-Tobías syndrome, Hare's syndrome, Pancoast's apex syndrome, Pancoast's disease, Pancoast's pain syndrome, Pancoast-Tobías syndrome, Tobías' syndrome, Bernard-Horner syndrome, ptosis, miosis, hemianhidrosis, anhidrosis, enophthalmos, non–small cell lung cancer, NSCLC, non–small cell bronchogenic carcinoma, squamous cell carcinoma, SCC, adenocarcinoma, Pancoast tumor, Pancoast’s tumor, malignant neoplasm

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Contributor Information and Disclosures

Author

Karl J D'Silva, MD, Fellow in Hematology/Oncology, Department of Internal Medicine, Breslin Cancer Center, Michigan State University
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.

Medical Editor

Michael Perry, MD, MS, MACP, Nellie B Smith Chair of Oncology, Professor, Department of Internal Medicine, Division of Hematology and Oncology, University of Missouri at Columbia/Ellis Fischel Cancer Center
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 Hematology, Missouri State Medical Association, Southern Association for Oncology, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, and American Society for Therapeutic Radiology and Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting

 
 
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