Pancoast Tumor
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Pancoast’s Tumor
Sallie Ruth Coleman
December 15, 2008
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Outline
What is it? What else could it be? Clinical Presentation Imaging Work-Up Treatment Prognosis What next?
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Introduction
Henry Pancoast: early 20th century
One region…Many names
Location
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Differential Diagnosis
Malignant Tumor Pancoast’s Tumor Mesothelioma Lymphoma Metastatic Disease
Benign Tumor (most commonly Neurofibroma
Pleural Thickening Status post radiation Infection (i.e. TB,
fungi, hydatid cysts)
Pleural effusion (loculated at apex)
Hematoma Extrapleural from
aortic rupture Vascular aneurysms Iatrogenic (i.e. after
attempted CVC placement)
Associated with rib or vertebral fracture
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Clinical Presentation
Arm/shoulder pain Horner’s syndrome Weakness/atrophy or hand muscles
Pancoast’s Syndrome
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Radiographic findings
X-RayUnilateral cap > 5mmAsymmetry of bilateral caps > 5 mmApical massBone destruction
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Radiographic findings
X-Ray Unilateral cap > 5mm Asymmetry of bilateral caps > 5 mm Apical mass Bone destruction
CT Presence of satellite nodules, parenchymal disease,
mediastinal lymphadenopathy
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Radiographic findings
X-Ray Unilateral cap > 5mm Asymmetry of bilateral caps > 5 mm Apical mass Bone destruction
CT Presence of satellite nodules, parenchymal disease, mediastinal
lymphadenopathy
MRI Evaluation of brachial plexus, subclavian vessels, vertebral bodies,
spinal canal, and chest wall involvement
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Diagnostic Work-Up
Bronchoscopy and sputum cytology? Percutaneous needle biopsy VATS Thoracotomy
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Pathology
Mostly non-small cell lung cancerMainly squamous cell carcinoma
Small cell carcinoma: 5% of cases
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Staging/Preoperative Assessment
Staging same as with NSCLC’s (TMN staging)
PET scan Mediastinoscopy Brain Imaging
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Treatment
Multimodality therapy Radiation therapy followed by en bloc
extended surgical resection Chemotherapy/chemoradiotherapy
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Prognosis
Overall 5-year survival rates with preoperative RT and surgical resection: 30% Patients with uninvolved lymph nodes: 30-40% Patients with incomplete resection, mediastinal nodal
involvement, or T4 vertebral body invasions: <10% 2/3 patients will have recurrent disease Poor prognostic factors:
Presence of Horner’s syndrome Extension of tumor into the base of the neck, great
vessels, or vertebral bodies Involvement of mediastinal lymph nodes
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Post-Therapy Surveillance
Little data to support evidence-based guidelines for routine surveillance following therapy
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Further Recommendations
Whenever possible, patients with superior sulcus tumors should be enrolled in prospective clinical trials so that the optimal therapy may be determined.
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