Pancoast Syndrome Workup

  • Author: Karl J D'Silva; Chief Editor: Jules E Harris, MD   more...
 
Updated: Aug 15, 2011
 

Imaging Studies

  • Imaging and biopsy are the cornerstones of evaluation of Pancoast tumor (Pancoast’s tumor, an uncommon subset of lung cancer).
  • The apex of the lung can be difficult to investigate because it is bounded laterally by the first rib, posteriorly by the first rib and the vertebral bodies, and anteriorly by the costal cartilage of the first rib and the manubrium. Plain radiographs of the chest frequently show no change or an asymmetry or thickening of the apical cap. Apical lordotic films may be more revealing. CT scans and MRIs have become standard imaging techniques.
  • CT scans are less expensive than MRIs and much more available. CT scans can help assess bone destruction, and they are useful in the general imaging of the lung for the evaluation of mediastinal adenopathy, other pulmonary nodules, and liver involvement. MRIs may be more accurate in evaluating chest wall invasion, examining vascular structures, and assessing the brachial plexus for invasion.[20, 21, 22]
  • Additional staging studies should be considered. Mediastinoscopy should be performed to evaluate mediastinal nodes. The presence of N2 mediastinal lymphadenopathy has a significant adverse effect on survival. A CT scan or MRI of the head to exclude occult metastasis should be performed if treatment with curative intent is planned. A CT scan of the chest can be extended to include the liver and adrenal glands.
  • Since positron-emission tomography (PET) scanning is US Food and Drug Administration–approved for staging of non–small cell lung cancer in general, it is also being used in the setting of Pancoast syndrome.
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Procedures

  • Tissue diagnosis should be performed. However, if a patient presents with supraclavicular lymph node enlargement, then a fine-needle aspiration biopsy of enlarged supraclavicular lymph nodes or an ipsilateral supraclavicular fullness procedure is a fast, safe, and inexpensive means of confirming the diagnosis.
  • Sputum cytology results are positive in fewer than 15% of patients.[23] Fiberoptic bronchoscopy findings are more often positive, but only in 20-30% of patients, because of the peripheral location of the tumor.[24] Bronchoscopy, however, can be useful in excluding otherwise unsuspected concurrent endobronchial lesions.
  • Transthoracic needle biopsy by CT guidance has a high yield, up to 95% in some series.[25, 23, 26] Some tumors may be evaluated only by thoracotomy, either open or video assisted.
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Staging

The American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC) have adopted the International System for Staging Lung Cancer.[27] This classification stages lung cancers by describing tumor characteristics and tumor distribution.

The T designation describes the size and invasiveness of the primary tumor. T3 indicates a tumor of any size that invades the chest wall (the parietal pleura). T4 is a tumor of any size that invades the vertebral body, neural or vascular structure, mediastinum, esophagus, or trachea.

The N designation describes the distribution of positive lymph nodes. N1 indicates metastasis to ipsilateral peribronchial or hilar nodes. N2 indicates the spread to ipsilateral mediastinal and/or subcarinal nodes. N3 indicates metastasis to nodes of the contralateral hilar and mediastinal areas or scalene or supraclavicular nodes, either ipsilateral or contralateral.

The M designation describes the extent of distant metastasis. M0 indicates no identifiable metastatic disease, and M1 designates the presence of distant metastasis (eg, brain, bone, liver). Any M1 findings indicate stage IV disease.

Table. AJCC Stages for Pancoast Tumors (Open Table in a new window)

StageT (Tumor)N (Nodes)
IIBT3N0
IIIAT3N1
T3N2
IIIBAny TN3
T4Any N

Attar and coworkers reviewed their experience with 105 patients treated from 1955-1997. They found that 30% of patients presented with T3 N0 disease (stage IIB), 26% with T4 N0 (stage IIIA), and 25% with metastatic disease (M1, stage IV). In their review of 124 patients, Ginsberg and colleagues found that 58% of patients had T3 N0 disease, 16% had T3 N2, and only 1% had T3 N1. In addition, 6% of patients had T3 N3 disease, 18% had T4 N0, and 1% had T4 N.[4]

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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 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.

Specialty Editor Board

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

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.

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, 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; 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

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Table. AJCC Stages for Pancoast Tumors
StageT (Tumor)N (Nodes)
IIBT3N0
IIIAT3N1
T3N2
IIIBAny TN3
T4Any N
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