Original Editors - Paul Clark and Sam Holzknecht from Bellarmine University's Pathophysiology of Complex Patient Problems project.
- 1 Definition/Description
- 2 Prevalence
- 3 Characteristics/Clinical Presentation
- 4 Associated Co-morbidities
- 5 Medications
- 6 Diagnostic Tests/Lab Tests/Lab Values
- 7 Etiology/Causes
- 8 Systemic Involvement
- 9 Medical Management (current best evidence)
- 10 Physical Therapy Management (current best evidence)
- 11 Differential Diagnosis
- 12 Case Reports/ Case Studies
- 13 Resources
- 14 References
A pancoast tumor is an uncommon lung cancer that arises at the level of the superior sulcus and is limited to the apical segment of either lung.  This is a form of non-small-cell carcinomas (NSCLCs) that are very difficult to treat because of their proximity and frequent metastasis to adjacent structures such as the subclavian vessels, lymphatic system, brachial plexus, spine, second and third ribs, stellate ganglion, and the sympathetic nervous system.  NSCLCs generally grow and spread slower and are divided into three different forms of cancer: squamous cell carcinomas (45-50%), adenocarcinomas (36-38%), or undifferentiated large-cell carcinomas (11-13%).  Rather than invading underlying lung tissue, this tumor presents as an abnormal patch of tissue over the lung apex and initially involves the chest wall structures. This can be treated if caught early on before it spreads and moves to the lymph nodes. Pancoast tumors are often mis-diagnosed and/or diagnosed too late.
Pancoast tumors may occur in the three compartments of the thoracic inlet and symptoms are related to the location.
Anterior Middle Posterior
"Lung cancers are the leading cause of death in both men and women in North American." In 2011, there was an estimated new diagnosis of 221,130 new cases of lung cancer with 156,940 deaths relating to lung cancer. Lung cancer accounts for more deaths when compared to prostate/breast, colon, and pancreatic cancer combined. Of the number of new lung cancer diagnosis, approximately 5% can be attributed to pancoast tumors. The highest occurrence is found in men between the ages of 40 and 60 with a history of smoking.
Pancoast tumors are very difficult to diagnosis early on. This is based on their low prevalence rate and many differential diagnosis'. "Typical" symptoms of lung cancer such as cough, dyspnea, and hemoptysis are less frequent.
Pancoast syndrome includes: "(1) severe pain in the shoulder region radiating toward the axilla and scapula along the ulnar aspect of the muscles of the hand, (2) atrophy of hand and arm muscles, (3) Horner syndrome (ptosis, miosis, hemianhidrosis, enophthalmos), and (4) compression of the blood vessels with edema."
Common presentations include:
- Pancoast syndrome
- Neck pain
- Pain is relieved by propping up arm on table or holding with other arm
- Radiating pain to the ulnar side of the arm and hand (55-60%)
- Horner's syndrome (30%)
- Parasthesias of the hand
- Between the ages of 40-60
- Male > Female 
- Muscle atrophy
- Cervical radiculopathy
- Horner's Syndrome
- Vertebrae compression
- Bone cancer
Pharmacotherapy goals are to induce remission, reduce morbidity, and prevent complications
Opioid Analgesics: Primary treatment of pain that can be combined with NSAIDs and may be a short-acting potent opioid such as oxycodone or an immediate-release morphine or methadone.
Antineoplastic agents: Inhibit cell growth and proliferation and are used in a variety of different cancers including head, neck, breast, testicular and ovarian cancer .
Cisplatin (Platinol): Alkylating agent causing intrastrand and interstrand cross-linking of DNA that leads to strand breakage. It has a broad range of antitumor activity and forms backbone of currently available approved combination chemotherapy regimens that cause Pancoast syndrome. Its administered via IV in isotonic sodium chloride solution (0.9%) or sodium chloride and glucose. Adequate hydration must be maintained up to 24 hours after a dose and Renal, hematological, auditory, and neurological function must be monitored .
Etoposide (Toposar, VePesid):' Semisynthetic derivative of podophyllotoxin with antineoplastic properties interferes with topoisomerase II function thus inhibiting DNA synthesis .
Diagnostic Tests/Lab Tests/Lab Values
Diagnosis is often difficult and delayed due to the typical absence of lung cancer symptoms and includes a combination of CT scans and MRI followed by a biopsy confirmation .
Chest x-ray: Difficult early detection due to limited visualization of the top of the lung but may reveal asymmetries like a small, uniform patch of tissue or pleural thickening on the apex of one lung, invasion of the ribs or vertebrae and enlargement of the mediastinum  (Apical lordotic films may be more revealing) .
MRI: Most accurate at displaying the extent of the involvement and invasion of nearby structures including the brachial plexus, subclavian vessels, spine, and neural foramina. Contrast can be used to better display the local extent of the damage .
CT scan: Displays involvement of the brachial plexus, chest wall, mediastinum, liver, adrenal glands, pulmonary nodules, vertebra, vena cava, trachea, and esophagus and contrast can be utilized to see involvement of blood vessels under the clavicle. CT scan is less expensive, more available and more effective than the MRI at assessing the mediastinum to determine if the tumor has involved the lymph nodes . This is essential in detecting N2 mediastinal lymphadenopathy which has a significant adverse effect on survival but only present in 20% of cases .
(Pictures can be seen above under description)
MRI and CT scan of the brain is often performed at the initial evaluation to check for distant metastases to the brain which is the most common site of metastasis and failure in pancoast tumor 
Arteriogram or a venogram: Look at the involvement of the subclavian artery/vein under the clavicle 
Bronchoscopy: Involvement of the tracheal and bronchial cavities and used in excluding unsuspected concurrent endobronchial lesions 
Biopsy: 90% of patients can be correctly diagnosed based on clinical and radiological findings alone but 95% can be diagnosed through percutaneous, supraclavicular fine-needle aspiration biopsy that’s fluoroscopy or CT guided . Transthoracic needle biopsy with CT guidance has a high yield of 95% and some tumors maybe only evaluated by open or video assisted thoracotomy.
Mediastinoscopy: Samples of lymph nodes are taken at the lowest part of the neck behind the breastbone to determine if the tumor has spread into the mediastinum.
Sputum cytology: results are positive in fewer than 15% of patients .
PET scans: Help identify involved lymph nodes and the distant spread of cancer  and is used in staging non–small cell lung cancer.
Liver and bone scans: determine if the cancer has spread .
Staging: Based on scalene node biopsy results of palpable lymph nodes or mediastinoscopy findings . American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC) have adopted the International System for Staging Lung Cancer that’s based on characteristics and distribution of the tumor… 
• T describes the size and invasiveness of the primary tumor
o T3 = tumor of any size that invades the chest wall (parietal pleura).
o T4 = tumor of any size that invades the vertebral body, neural or vascular structure, mediastinum, esophagus, or trachea.
• N describes the distribution of positive lymph nodes:
o N1 = metastasis to ipsilateral peribronchial or hilar nodes
o N2 = spread to ipsilateral mediastinal and/or subcarinal nodes
o N3 = metastasis to nodes of the contralateral hilar and mediastinal areas or scalene or supraclavicular nodes, either ipsilateral or contralateral.
• M describes the extent of distant metastasis:
o M0 = no identifiable metastatic disease
o M1 = (Stage IV) designates the presence of distant metastasis (brain, bone, liver)
The amount of nerve-root involvement and careful neurological investigation of the arm and shoulder function is also important and very informative .
Common risk factors include (similar to lung cancer):
- Secondhand smoke
- Asbestos exposure
- Exposure to industrial elements like gold or nickel
- Diesel exhaust
Pancoast tumors are often mis-diagnosed or diagnosed too late to prevent metastasis to adjoining structures. This form of lung cancer is very dangerous because of its close proximity to other structures that include:
Brachial plexus- this is commonly invaded at the ulnar distribution (C8-T1), thus atrohpy/parasthesia of the ulnar distribution is reported. This is often the patient's primary complaint/presentation to therapy with shoulder pain that radiates down to the 4th and 5th digit.
Subclavian vessels- metastasis to the subclavian artery or adjoining structure may lead to deterioration or compression of blood vessels causing edema.
Stellate ganglion- This is a large ganglion located at the bottom of the cervical spine in connection with the thoracic spine and is related to the sympathetic nervous system. Invasion of this may result in Horner's Syndrome.
Adjacent vertebral bodies- If the tumor is able to metastasize the vertebral bodies, this may lead to permanent paralysis of the affected area.
Medical Management (current best evidence)
Complete resection of these tumors is a necessity for long term survival and this is made complicated due to their complexity and involvement of the structures around them that include the brachial plexus, subclavian vessels and the spine. Because of this, a multimodal approach is often needed to ensure removal while minimizing any further complications or recurrences .
Initially pancoast tumors were viewed as inoperable and incurable and treatment for them was radiotherapy with a palliative intent. It wasn’t until 1956 when resection with radiotherapy was attempted by Chardack and MacCallum which consisted of an upper lobe lobectomy with en-bloc chest wall and nerve root resection followed by adjuvant chemotherapy. This patient lived for 5 years without recurrence and further trials of induction radiotherapy and en-bloc resection conducted by Shaw & Paulson in 1961, confirmed a 5 year survival rate of 30% with complete resection in about 60% of patients. Preoperative radiation followed by surgery became the standard of care  for the next 30 years until more and more complications were starting to be seen and other surgical techniques began developing in the late 80s and early 90s to addressed tumors invading the spine and the subclavian vessels. The first was the anterior (Anterior transclavicular approach) approach developed by Dartevelle which was later modified by Grunenwald who developed an anterior clavicular sparring approach (hemi-clamshell incision with supraclavicular extension). Its purpose was to optimize exposure by providing direct visualization of vascular structures, brachial plexus, sympathetic chain and stellate ganglion . This became very popular yet 5 year survival rates still remained around 30% and local recurrence was observed in 40% of all operated patients. The posterior approach was later developed by Shaw-Paulson to target tumors situated in the posterior superior sulcus that did not invade the anterior structures of the thoracic inlet but may invade the vertebral bodies or the brachial plexus (C8 and T1 nerve roots are most common).
Anterior transclavicular (Dartevelle) 
'Anterior approach (Grunenwald approach) '
The multimodal treatment approach (chemoradiation followed by surgical resection) became the standard during this time and resulted in much improved outcomes as can be seen by the studies listed below . However, due to poor performance status and advanced tumor stages, only 30-40% of patients are eligible for multimodal treatment. 
Other surgical approaches include:
- Hemiclamshell or Trapdoor Incision 
Contraindications to surgery: presence of extra-thoracic sites of metastasis, histologically confirmed N2 disease, extensive invasion of the cervical trachea, esophagus and the brachial plexus above the C7 nerve root (indicates that the tumor is locally too extensive to achieve a complete resection or that limb amputation is necessary), massive vertebral invasion that’s diagnosed preoperatively. 
Surgical complications:S pinal fluid leakage, Horner’s syndrome and nerve deficits, Hemothorax, Chylothorax & Prolonged ventilator support 
Prognosis Factors: 
The current treatment of choice is complete removal of the tumor by en bloc chest wall resection combined with lobectomy and node staging and it may include resection of the paravertebral sympathetic chain, stellate ganglion, lower trunks of the brachial plexus, subclavian artery, or portions of the thoracic vertebrae depending on its involvement. Radiation and chemotherapy can address individual adverse findings and for local and systemic control and induction chemoradiotherapy is used with potentially resectable tumors and surgery is undertaken 2-4 weeks after radiation therapy. A combined thoracic-nonsurgical approach is used for tumors invading the brachial plexus and/or the spine. 
Brachial Plexus block: Used in combination with local anesthetics and steroids as an adjunct to drug treatment for rapid relief of pain or to control breakthrough pain . A study don’t by Peláez and colleagues purpose that in aggressive tumors compressing the brachial plexus that do not respond to conventional treatment or regional anaesthesia, utilizing the addition of a paravertebral nerve block to the plexus could substantially reduce the patients pain without impacting longevity . This is also supported in a study by Vranken and colleagues who purposed a reversible, non destructive, continuous nerve blocking technique involving administration of local antsthetics through an axillary cathter into the brachial plexus. This resulted in a significant decrease in the patients visual analog pain score and an increase in performance skills and QOL without any side effects in 4 patients .
Radiofrequency Destruction of the Brachial Plexus: Last resort treatment involving destruction of the brachial plexus via a radiofrequency lesion under biplanar fluoroscopic guidance. 
Dorsal Root Entry Zone Lesioning (DREZ): Major neurosurgical procedure used as a last resort when all other branchial plexopathy treatments have failed 
Physical Therapy Management (current best evidence)
When it comes to pancoast tumors, the primary role of the Physical Therapist is post operative treatment to prevent respiratory complications including atelectasis and pneumonia, and control the patient’s pain levels. The patient is immobilized the first post op day with attention to chest Physiotherapy and bronchoscopic suctioning may be necessary to clear secretions in patients with ineffective cough . Intensive respiratory care should be implemented and chest expansion measurements should be taken to ensure... 
- Adequate ventilation using mechanical support (if necessary)
- Satisfactory chest tube function
- Clearance of secretions by mobilizing, coughing, chest physiotherapy, nasotracheal or orotracheal or bronchoscopic suctioning, or a temporary tracheostomy
- Adequate analgesia
- Increased transpulmonary pressure with incentive spirometry or continuous positive airway pressure mask.
Avoid fluid overload and use diuretics judiciously to avoid acute respiratory distress. Chest tubes remain in place until all air leaks have stopped, there is complete lung expansion and almost no fluid drainage present .
Other roles of the PT are to maintain function and ADLs and search for and treat shoulder issues that include subluxation and adhesive capsulitis . Laser therapy in combination with and individualized wellness program is also effective in treating this condition and can improve the patients overall health and wellbeing. 
"In all patients it is crucial to obtain histological proof before initiating treatment since not only NSCLC can present as on apical mass but also tumors of other origin such as metastases, sarcomas, lymphomas, tuberculosis or even echinococcus can present with similar clinical and radiological features."
"Paraneoplastic syndromes are rare disorders that are triggered by an altered immune system response to a neoplasm. They are defined as clinical syndromes involving nonmetastatic systemic effects that accompany malignant disease."
Case Reports/ Case Studies
Cancer Treatment Centers of America (CTCA): http://www.cancercenter.com/?OVMTC=Phrase&site=&creative=1144020265&OVKEY=cancer%20treatments%20of%20america&url_id=144968219&adpos=1t1&gclid=CIKGr7CNm68CFYNo4AodeCYUdg
Medscape: Paraneoplastic Syndromes. http://emedicine.medscape.com/article/280744-overview.
About.com: Lung Cancer http://lungcancer.about.com/od/typesoflungcancer/f/pancoasttumor.htm
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