A Case of Pancoast's tumour

AN INTERESTING CASE OF LUNG MASS

Dr. NAMITHA NARAYANAN

Prof.DHANDAPANI’S UNIT

CASE SUMMARY CHIEF COMPLAINTS:• 51 years old male admitted with complaints of

pain right side of the chest -45 days.• Loss of appetite – one month. HISTORY OF PRESENTING COMPLAINTS:• Apparently normal 45 days back. Developed

pain right upper chest wall and right shoulder. pain radiating to right arm .

• Pain aggravated by deep inspiration, coughing and on movement of right upper limb.

Case summary• Associated with breathlessness.• History of loss of appetite and loss of weight

present.• No left sided chest pain, palpitation or

giddiness. PAST HISTORY:• Pulmonary TB 5 years back. completed

treatment. Not a known case of DM, SHT, CAD or BA.

CASE SUMMARY PERSONAL HISTORY:• Chronic smoker and alcoholic. ON EXAMINATION:• Conscious, oriented and afebrile.• Thin built and poorly nourished.• Generalized muscle wasting present.• Mild pallor +• Clubbing +• Muddy conjunctiva• No cyanosis or lymphadenopathy.

CASE SUMMARY• Difficulty in getting up +• Painful movements of right upper limb +• Vitals stable. SYSTEMIC EXAMINATION:• Trachea deviated to right.• Drooping of right shoulder and hollowing of

right supra and infraclavicular region present.• Chest movements and expansion decreased

on right side.• Scoliosis with concavity to right side present.

CASE SUMMARY• Tenderness present in right upper thoracic

region, right supraclavicular and infraclavicular region.

• On percussion dull note on the above areas+• On auscultation: bilateral NVBS +• CVS and per abdominal examination- normal.• CNS- pain and touch sensation decreased on

T1-3 dermatomal areas. PROVISIONAL DIAGNOSIS:• ? PT SEQULAE. To rule out MALIGNANCY

INVESTIGATIONS• Hb-11G%• TC-6200 cells/mm3• ESR-2/5 mm(30 mts and 60mts)• PCV- 33%• PLATELETS-

100000/mm3• Blood Sugar- 88 mg%• Blood Urea- 21mg%• Serum Creatinine- 0.6mg

%

• Serum Electrolytes:• Na- 135Meq/L• K- 3.3 Meq/L• HIV- non-reactive• VDRL- non-reactive• Urine routine- normal• CT- 5 minutes• BT- 1 minute and 45 sec

INVESTIGATIONS CT Scan Chest:• Hetero -dense contrast enhancing lesion with

central non-enhancing areas noted occupying the upper lobe of right lung.

• Lesion causes encasement of mediastinal vessels.

• Erosion of the ribs and vertebrae noted on right side.

• Chest wall invasion noted.• Left side normal. S/O PANCOAST TUMOR (R) UPPER LOBE

Chest Physician’s Opinion:• Scar Ca right upper lobe.• Suggested Bronchoscopy and sputum

cytology. Bronchoscopy:• Trans nasal route under LA• Vocal cords, trachea and larynx normal.• Left bronchial systems normal.• Right upper lobe bronchus- segmented lesion,

extrinsic compression and no intraluminal lesion.

Suggested CT guided biopsy

• USG guided FNAC of the right upper lobe mass

• Moderately cellular smear showing numerous groups and clusters of malignant epithelial cells on a hemorrhagic and keratinous background.

• IMP: SQUAMOUS CELL CARCINOMA. ONCOLOGIST’S OPINION- suggested

Radiotherapy

• FINAL DIAGNOSIS

PANCOAST TUMOR

INTRODUCTION

• In 1932 Henry Pancoast defined - superior pulmonary sulcus tumor.

• A mass growing at the thoracic inlet that produces a constant and characteristic presentation of pain in C-7 or T-1 thoracic trunk distribution.

• Are subset of lung cancer that invades the apical chest wall.

• Various other tumors produces a similar clinical presentation because of their location at thoracic inlet as they invade the adjoining structures.

• Bronchogenic Carcinoma arising in or near the superior sulcus and invading the adjacent extra thoracic structures –most common.

• Invade the lymphatics in the endothoracic fascia, the intercostal nerves, lower roots of brachial plexus, stellate ganglion, sympathetic chain, adjacent ribs and vertebrae.

FREQUENCY:• Much less common than other lung tumors.• 1-3% of all lung cancers.• May not be visualized in on an initial chest

radiograph.• Usually present as advanced stage disease. ETILOGY: Risk factors same as that of lung cancer. includes smoking, secondary smoke exposure,

exposure to asbestos and industrial chemicals.

PATHOPHYSIOLOGY

• The mass is an extension of lung cancer.• Mostly squamous cell carcinomas or adeno

carcinomas.• 3-5% are small cell carcinomas.• Involvement of the phrenic or recurrent

laryngeal nerve or SVC obstruction is not representative of the classic Pancoast tumor.

PRESENTATION SYMPTOMS:• Symptoms are typical of the location of the

tumor.• Neuralgic pain due to involvement of the C-7,

T-1& 2 Nerve roots.• Symptoms due to involvement of the stellate

ganglion and sympathetic chain- Ipsilateral Horner’s syndrome.

• Pt. usually supports the elbow of the affected side.

• Wasting of the hand muscles, absent triceps reflex.

• Symptoms of spinal canal tumor or cervical disc disease if the spinal cord is invaded or compressed.

• Paraneoplastic syndrome- ( Cushing syndrome, hypercalcemia, excessive ADH secretion, myopathies, hematological problems, HOCM).

• Brain metastasis is frequent.

DIFFERENTIAL DIAGNOSIS

• Primary tumors of the Thyroid, Larynx and Pleura.

• Infectious disorders of the lung,• Aneurysms of the subclavian vessels• Amyloid of pleura • Multiple myeloma.• Thoracic outlet syndrome• Cervical disc disease.

DIAGNOSIS

• Diagnosis - based on clinical and radiological findings(90% of cases)

• Transthoracic needle biopsy.• Bronchoscopy is less useful as tumors are

peripherally located.• Liver, bone and brain scans- to rule out

metastasis.• Open biopsy - through a supraclavicular

incision.

STAGING• Staging is based on the location of the lesion

and its metastasis.• True pancoast tumor is T-3 disease.(extension

through the visceral pleura to the parietal pleura and chest wall).

• T-4 when mediastinal invasion, cervical invasion or both have occurred.

• Mediastinoscopy-to delineate the metastasis to mediastinal lymph nodes.(performed if lymph nodes appear > 1 cm on a CT scan).

• If mediastinal lymph nodes are present– poor prognosis.

• If CT does not reveal LN –patient is deemed operable.

WORKUP LABORATORY STUDIES:• CBC• BUN/ creatinine levels.• WBC count• Urine analysis.• Coagulation profile(PT, aPTT and platelet count).• Cross matching.• Tumor markers are non-specific (CEA, beta-2

micro globulin, bombesin, neuron specific enolase, tumor oncogenes).

WORKUP• Chest radiographs.(small homogenous apical

cap, or pleural thickening, plaque, or mass).• Apical lordotic views(better visualization).• Bony erosion of posterior 1-3 ribs.• Vertebral body erosion.• Mediastinal involvement.• CT scanning and MRI:(of neck, chest and upper

abdomen)• MRI is useful for evaluating the resectability.• CT scan- helps to identify the invasion of the

brachial plexus, chest wall and mediastinum CECT –to assess the subclavian vessel involvement.

WORKUP• MRI findings more accurate than CT findings

for assessing the involvement of the cervical structures and vertebral bodies.

• ARTERIOGRAM or VENOGRAM.• ECG.• Bronchoscopy- diagnostic yield is low.• Tissue diagnosis – by percutaneous biopsy.• Mediastinoscopy and scalene node biopsy.

TREATMENT SURGERY:(Curative vs palliative)• Should be considered for surgery after the

appropriate diagnostic evaluation is completed.

• Perfect candidate is one with lesion restricted to chest(T3N0M0).

• Right upper lobe lesion with intranodal metastasis and T3N2M0.( RARE EXCEPTION)

SURGERY CONTRAINDICATIONS:• Distant metastasis• Extensive involvement of brachial plexus. • Involvement of paraspinal region.• Involvement of lamina of vertebrae body• Involvement of mediastinal lymph node• Subclavian venous obstruction• Co-morbid conditions like heart failure, recent

MI and unstable angina.

SURGERY PREOPERATIVE DETAILS:• Evaluation of pulmonary function, high risk

patients benefit from supervised pulmonary rehabilitation.

• Prophylactic heparin and antiembolic stockings.

• Encouragement to stop smoking at least 2 weeks prior to surgery.

• Assessment of the cardiac status

SURGERY IRRADIATION:

• purpose of pre-operative irradiation: to shrink the tumor and to temporarily block lymphatic spread.

• 30-40 Gy of radiation administered over 2-3 weeks.

• After 4 weeks all patients are reassessed for surgery.

CHEMOTHERAPY:• Induction chemotherapy combined with hyper

fractionated accelerated radiotherapy prior to surgery may be effective in improving the long term survival and local recurrence rates.

SURGICAL PRINCIPLES OF CURATIVE RESECTION:• Excise the entire first rib and posterior segments

of the second and third ribs.• excise the corresponding thoracic nerve roots up

to the intervertebral foramen.• Excise portion of the upper thoracic vertebrae,

including the transverse process if necessary.

SURGERY• Excise the lower trunk of brachial plexus.• Excise part of the stellate ganglion and the

thoracic sympathetic chain.• Lung resection can be either wedge or

lobectomy.• Radical mediastinal lymph node resection can

be performed. POSTOPERATIVE COMPLICATIONS:• Atelectasis• Severe chest pain

Surgical complications• Air leaks • Spinal fluid leaks• Horner’s syndrome.• Pain

POST-OP RADIOTHERAPY• not indicated for patients who undergo complete

resection and have no nodal metastasis.• Benefit for post op RT for patients with nodal

disease.

PRIMARY RADIATION THERAPY• For patients with unresectable tumors and for

those who are not surgical candidates.• It provides excellent pain relief.• No long term survival occurs if the primary

tumor is not controlled.

THANK YOU