Project Title

Pancoast Tumor in a Case of Newly Diagnosed Non-small Cell Lung Cancer

Authors' Affiliations

James Kim, Division of Oncology, Department of Medicine, East Tennessee State University Hakam Khazrik, Division of Oncology, Department of Medicine, East Tennessee State University Bahaaeldin Youssef, Department of Pathology, East Tennessee State University Kanishka Chakraborty, Division of Oncology, Department of Medicine, East Tennessee State University Devapiran Jaishankar, Division of Oncology, Department of Medicine, East Tennessee State University

Faculty Sponsor’s Department

Internal Medicine

Medical Oncology

Type

Oral Non-Competitive

Classification of First Author

Medical Resident or Clinical Fellow

Project's Category

Cancer or Carcinogenesis, Pulmonary Diseases

Abstract Text

Pancoast tumors are a distinct entity seen mostly in non-small cell carcinoma of the lung. We present a case of a Pancoast tumor in newly diagnosed squamous cell carcinoma of the lung. A 56-year old female with a 40-pack year smoking history, presented with several weeks duration of right shoulder pain, radiating down her arm. Symptoms were aggravated with movement and slightly improved with rest and non-steroidal analgesics She had no other known medical history. Physical therapy provided little relief. Subsequently, magnetic resonance imaging (MRI) of the cervical spine from an outside facility revealed a large right apical lung mass, involving the T2 thoracic spine and sternum. She denied chest pain, shortness of breath, weight loss, or edema of the face or neck. Range of motion of right upper extremity was limited due to pain. Ptosis and miosis of the right eye were detected. Days after the MRI, the patient presented to the hospital for intractable right upper extremity pain. Comprehensive imaging including positron emission tomography scan and MRI of the brain were done. The right apical lung mass was suggestive of a Pancoast tumor, measuring 5.3 x 5.5 x 6.9 cm in size, extending into the medial portion of the upper mediastinum. The tumor abutted the apical pleura and partially encased the right subclavian artery. There was destruction of the first and second ribs and portions of the right T1 and T2 vertebral bodies along with right hilar and lower paratracheal adenopathy. Biopsy of the mass confirmed moderately differentiated, invasive squamous cell carcinoma of the lung, assessed to be Stage IIIB and unresectable. Pain control was achieved, and the patient was discharged. Treatment was initiated with concurrent radiation and chemotherapy with cisplatin and etoposide. Pancoast tumors, also known as superior sulcus tumors, were first noted in 1838 but not well defined at the time. In 1924 and 1932, American radiologist, Henry Pancoast, further described them as carcinomas of unknown origin of the chest apex. They occur in 3-5% of lung cancers, most commonly in non-small cell carcinoma. By definition, a Pancoast tumor must invade parietal pleura and cause pain, paresthesia, or neurologic dysfunction. Less than 50% of these tumors are resectable. They may involve the lower cervical and/or upper thoracic spines, first and second ribs, brachial plexus, and subclavian vessels. Involvement of paravertebral sympathetic chains can lead to Horner syndrome with a prevalence up to 40%. Neurologic compromise may cause upper extremity weakness, muscular atrophy, and paresthesia. In 5% of cases, they can cause spinal cord compression and paraplegia. Five-year survival is reported to be less than 10% if there is vertebral body invasion. In locally advanced lung cancers including Pancoast tumors, treatment can include neoadjuvant chemoradiation with subsequent resection. However due to the extensiveness and complexity of this patient’s tumors, resection was not amenable. Evaluation for Pancoast tumor may be warranted in those with lung cancer risk with acute musculoskeletal/neurologic complaints. Treatment is initiated promptly, based on stage and histology.

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Pancoast Tumor in a Case of Newly Diagnosed Non-small Cell Lung Cancer

Pancoast tumors are a distinct entity seen mostly in non-small cell carcinoma of the lung. We present a case of a Pancoast tumor in newly diagnosed squamous cell carcinoma of the lung. A 56-year old female with a 40-pack year smoking history, presented with several weeks duration of right shoulder pain, radiating down her arm. Symptoms were aggravated with movement and slightly improved with rest and non-steroidal analgesics She had no other known medical history. Physical therapy provided little relief. Subsequently, magnetic resonance imaging (MRI) of the cervical spine from an outside facility revealed a large right apical lung mass, involving the T2 thoracic spine and sternum. She denied chest pain, shortness of breath, weight loss, or edema of the face or neck. Range of motion of right upper extremity was limited due to pain. Ptosis and miosis of the right eye were detected. Days after the MRI, the patient presented to the hospital for intractable right upper extremity pain. Comprehensive imaging including positron emission tomography scan and MRI of the brain were done. The right apical lung mass was suggestive of a Pancoast tumor, measuring 5.3 x 5.5 x 6.9 cm in size, extending into the medial portion of the upper mediastinum. The tumor abutted the apical pleura and partially encased the right subclavian artery. There was destruction of the first and second ribs and portions of the right T1 and T2 vertebral bodies along with right hilar and lower paratracheal adenopathy. Biopsy of the mass confirmed moderately differentiated, invasive squamous cell carcinoma of the lung, assessed to be Stage IIIB and unresectable. Pain control was achieved, and the patient was discharged. Treatment was initiated with concurrent radiation and chemotherapy with cisplatin and etoposide. Pancoast tumors, also known as superior sulcus tumors, were first noted in 1838 but not well defined at the time. In 1924 and 1932, American radiologist, Henry Pancoast, further described them as carcinomas of unknown origin of the chest apex. They occur in 3-5% of lung cancers, most commonly in non-small cell carcinoma. By definition, a Pancoast tumor must invade parietal pleura and cause pain, paresthesia, or neurologic dysfunction. Less than 50% of these tumors are resectable. They may involve the lower cervical and/or upper thoracic spines, first and second ribs, brachial plexus, and subclavian vessels. Involvement of paravertebral sympathetic chains can lead to Horner syndrome with a prevalence up to 40%. Neurologic compromise may cause upper extremity weakness, muscular atrophy, and paresthesia. In 5% of cases, they can cause spinal cord compression and paraplegia. Five-year survival is reported to be less than 10% if there is vertebral body invasion. In locally advanced lung cancers including Pancoast tumors, treatment can include neoadjuvant chemoradiation with subsequent resection. However due to the extensiveness and complexity of this patient’s tumors, resection was not amenable. Evaluation for Pancoast tumor may be warranted in those with lung cancer risk with acute musculoskeletal/neurologic complaints. Treatment is initiated promptly, based on stage and histology.

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