PANCOAST TUMOUR WITH SPINE RESECTION - CASE REPORT

Pancoast tumours are defined as tumours arising from the upper lobe and invading the thoracic inlet,representing less than 5% of all lung cancers. Clinical features depend on the involved structures. For many years invasion of the spine was considered unresectable and fatal. Due to the progress in spine surgery, en bloc resection including the spine is nowadays possible. We report the first case of a successful en bloc vertebral resection of a Pancoast tumour in a 66 year-old male, with a squamous cell carcinoma, treated at our department in a multidisciplinary setting, after induction chemoradiotherapy. An en bloc resection including the left upper lobe, the first three ribs and the vertebral body of D2, was performed through a Paulson incision after posterior cervico-dorsal arthrodesis. A complete R0 resection was confirmed on the pathology specimen. Currently, one year after surgery, although no local recurrence has occurred, the patient is being treated with immunotherapy due to disease progression in the right acetabulum which was irradiated (20Gy) and then submitted to iliac resection and prothesis reconstruction.

Bone single photon emission computed tomography (SPECT) in a patient with Pancoast tumor: a case report

CONTEXT

Non-small cell lung carcinomas (NSCLCs) of the superior sulcus are considered to be the most challenging type of malignant thoracic disease. In this disease, neoplasms originating mostly from the extreme apex of the lung expand to the chest wall and thoracic inlet structures. Multiple imaging procedures have been applied to identify tumors and to stage and predict tumor resectability in surgical operations. Clinical examinations to localize pain complaints in shoulders and down the arms, and to screen for Horner's syndrome and abnormalities seen in paraclinical assessments, have been applied extensively for differential diagnosis of superior sulcus tumors. Although several types of imaging have been utilized for diagnosing and staging Pancoast tumors, there have been almost no reports on the efficiency of whole-body bone scans (WBBS) for detecting the level of abnormality in cases of superior sulcus tumors.

CASE REPORT

We describe a case of Pancoast tumor in which technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs. In describing this case, we stress the clinical and diagnostic points, in the hope of stimulating a higher degree of suspicion and thereby facilitating appropriate diagnosis and treatment. From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended.

[A case of lung adenocarcinoma of pancoast type successfully treated with concurrent chemoradiotherapy]

We reported a case of lung adenocarcinoma of Pancoast type that was successfully treated with chemoradiotherapy. A 66-year-old man was admitted to our hospital because of back pain. Chest computed tomography (CT) showed a Pancoast tumor on the left side. Using transbronchial needle aspiration, we diagnosed lung adenocarcinoma (cT3N0M0). The patient received chemoradiotherapy simultaneously(carboplatin AUC5 and irinotecan 60 mg/m2). There are no findings of tumor recurrence 8 years after chemoradiotherapy. This patient was successfully treated with concurrent chemoradiotherapy, which is suggested to be a useful therapy for Pancoast tumor.

[Pancoast tumor with rheumatic symptoms without Pancost's syndrome--case report]

About 5% of pulmonary lesions are the apical lung tumors, which can be divided in tumors producing and non-producing Pancoast's syndrome. The authors present a case of a 45-year-old male with ambulatory non-diagnosed Pancoast tumor demonstrating with rheumatic symptoms without typical signs of Pancoast's syndrome. Performing a routine chest X-ray after complete treatment of pulmonary inflammatory diseases, as well as in rheumatic disorders was proved fundamental.

Delay by patients and doctors in treatment of Pancoast tumor

PURPOSE

Long delays in diagnosis and treatment of Pancoast tumor have been reported but the reasons for these delays have yet to be fully considered. The aim of this study was to assess recent delays in diagnosis and treatment of Pancoast tumor and to determine the reasons for the delays.

PATIENTS AND METHODS

We identified Pancoast tumors in patients with lung cancer referred to the radiation department of a city hospital between September 1999 and August 2004. From interviews conducted by a radiation oncologist and review of the medical records, delay due to a patient was calculated as the interval between the onset of symptoms and presentation to a physician, and delay due to a doctor as the interval between the presentation and the definitive treatment. The overall treatment delay was calculated as the sum of those delays. Radiological workups were also reviewed for errors, and the effect of any errors on the delays was estimated.

RESULTS

The study population included 42 men and six women with a median age of 65.5 years at presentation. Treatment delay ranged widely from 38 to 400 days (mean 164.0): delay due to patients ranged from 0 to 371 days (mean 55.8), accounting for 34% of the mean treatment delay; delay due to doctors ranged from 14 to 349 days (mean 108.2), and accounted for the remaining (66%) mean treatment delay. In 166 radiological studies reviewed, 98 radiological errors (59%) were identified in 28 patients (58%). These patients waited an additional mean of 88.4 days for correct radiological interpretation, accounting for 48% of the mean doctors' delay. Thus, the mean doctors' delay with radiological errors was significantly longer than that without radiological errors (p < 0.05).

CONCLUSIONS

Treatment delay for Pancoast tumor was relatively long, and approximately two-thirds of the delay was due to doctors, mainly because of errors in radiology.

Elimination of Pancoast tumor by carboplatin, paclitaxel, and concurrent radiation

Preoperative chemoradiotherapy with carboplatin (AUC 1.5), paclitaxel (40 mg/m2), and concurrent extracorporeal radiation (40 Gy) was used to treat a Pancoast tumor (clinical T3N0M0), without causing adverse events. Then left upper lobectomy was performed along with mediastinal lymph node dissection plus resection of the chest wall and Th1 nerve root. Histological examination revealed a pathological complete response. This multimodal regimen was feasible and achieved a good response, so it seems worthwhile to evaluate the clinical effectiveness of the therapy in a cohort study.

Cervicobrachialgia and pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis

Ten patients diagnosed with Pancoast tumor were studied retrospectively. The definitive diagnosis was made between 2 and 24 months after the onset of pain. Pain localization was hard to pinpoint; some patients reported pain in four different sites (neck, shoulder, arm, and scapula). Five patients had previously been diagnosed with degenerative, inflammatory, or infectious diseases of the cervical spine or shoulder. In the remaining five patients, the diagnosis was made during the first clinical visit. In three patients, an orthopedic surgeon made the diagnosis by viewing a standard anteroposterior (AP) cervical radiograph. The radiographic evidence arousing suspicion of a Pancoast tumor was the lack of pulmonary air at the top of the affected lung. Furthermore, a parallel study was conducted on 100 consecutive patients seeking treatment for neck pain. By examining the AP radiographs of their cervical spines, the third rib and the top of both lungs were observed in all cases. This study stresses the value of standard AP cervical radiographs in the diagnosis of Pancoast tumor.

[Thoraxsonography--part 2--Subpleural lung lesions]

In many cases of pulmonary diseases extending up to the pleura, ultrasound helps to identify the etiology of the lesion. There are several sonomorphological criteria to differentiate peripheral pulmonary consolidations. The sonomorphology of pneumonic lung infiltration reveals typical changes: bronchoaerogram, fluidobronchogram, parapneumonic effusion, abscess formation. The extent of infiltration is sometimes underestimated due to artefacts. In sonography lung cancers are echopoor, rounded and polypoid, show sharp and serrated margins. The accuracy of ultrasound-guided transcutane biopsy in carcinomas is higher than 90%. The rate of pneumothorax is 2.6%, those requiring drainage are about 1%. Haemoptyses occur 1-2% of the punctures, most commonly in cases of chronic pneumonia. When a pulmonary embolism develops, thoracic sonography in 70-90% reveals subpleural sound-permeable lesions: embolism-related alveolar edemas and hemorrhages--early reperfusionable infarcts and triangular late infarcts. In compression atelectasis there usually is a homogeneous, hyperechoic transformation, shaped like a pointed cap or a wedge.

Pancoast's syndrome due to metastatic carcinoma from the stomach

We describe here a case of Pancoast's syndrome due to metastatic carcinoma from the stomach. Although obtaining a tissue diagnosis is often difficult with apical lesions, transbronchial or percutaneous needle biopsy is the procedure of choice since a certain number of these cases are potentially curable.

[Pierre-Marie-Bamberger syndrome - a paraneoplastic syndrome of lung cancer - a case report]

The Pierre-Marie-Bamberger syndrome is a rare paraneoplastic syndrome caused by bronchial carcinoma. Typical signs are symmetric periostoses on the diaphyses of the long tubular bones, clubbed fingers and toes with eye-glass shape of the nails, neuro-vegetative disturbances and dysproteinemia. We report a 37-year-old patient with long-term nicotine abusus, who attracted attention by symptoms of a Pierre-Marie-Bamberger syndrome. Further diagnostics revealed a tumor in the apex of the left lung. After lobectomy of the upper lobe of the left lung the symptoms are completly disappeared.

Pitfalls and delay in the diagnosis of Pancoast tumour presenting in orthopaedic units

Pancoast tumours present a difficult and peculiar problem. Their clinical manifestations may be extrapulmonary. The underlying lesion may be missed in patients presenting with predominantly orthopaedic symptoms. We present four consecutive cases, which were referred to our clinic and the diagnosis was made with mean delay of 18.5 months from the beginning of symptoms.

[Imaging of non-small-cell pulmonary tumors. Therapeutic strategy]

In this work the imagery of non-small cell primary bronchial cancers are reviewed. The standard chest x-ray of the thorax remains irreplaceable for the early detection of these pathologies. On the other hand, progress in imagery has propelled thoracic computed tomographic scanning to the pole position for assessing the local and regional extension of the disease as well as for distance spread of these cancers. The latest developments with spiral CT have again improved the performance of CT scanning. Magnetic resonance imaging has a few precisely defined roles in assessing the extension of bronchopulmonary cancers. In particular with involvement of the apices, the chest wall and in the extension into the cardiovascular system. In this article the emphasis is on the illustration of non-small cell bronchial cancers on computed tomography and on magnetic resonance imaging.

Non-Hodgkin's lymphoma presenting as Pancoast's syndrome

Pancoast's syndrome is generally caused by primary or metastatic epithelial tumors. Other causes of the syndrome are unusual but well described. The present case report describes a rare case of Pancoast's syndrome caused by non-Hodgkin's lymphoma. This report emphasises the importance of establishing a firm pathologic diagnosis of the etiology of Pancoast's syndrome before instituting treatment.

[Staging of pulmonary apex tumors. Computerized tomography versus magnetic resonance]

Apical lung cancers account for about 5% of pulmonary lesions and can be divided into two groups: Pancoast and non-Pancoast lesions. Recently, the use of MRI has been suggested in combination with CT to stage this kind of lung cancer. In this paper the authors' experience is reported relative to the current role of MRI and CT in the staging of apical lung cancers. Twelve male patients (mean age: 60.5 years) with apical lung cancers underwent conventional X-ray, CT and MR examinations of the chest. CT and MR images were studied by two independent radiologists with specific experience; surgery was the gold standard in three patients and MR and clinical symptoms in the patients not referred for surgery. In 15/108 cases (13.8%) CT and MR findings were in disagreement but in 93/108 cases (86.2%) they were in agreement. The highest disagreement rate was observed in the study of apical chest wall infiltration (33.3%), while in the study of anonymous vein involvement CT and MRI were always in agreement. The correct assessment of the regional extent of apical lung cancers is mandatory for treatment planning. In this kind of tumors MRI can be considered the method of choice thanks to its high contrast resolution and multiplanar imaging capabilities.

Pancoast tumor as a cause of reflex sympathetic dystrophy

Reflex sympathetic dystrophy of the upper extremity can be triggered by a wide variety of factors. Pancoast tumor should be added to the list of precipitating conditions which can induce this syndrome.

Positron emission tomography for treatment evaluation and recurrence detection compared with CT in long-term follow-up cases of lung cancer

Two cases of lung cancer were studied with positron emission tomography (PET) using L-[methyl-C-11]methionine (C-11 Met) and CT scans five to six times during long-term follow-up after radiotherapy. In a large cell carcinoma with mediastinal invasion, C-11 Met tumor uptake showed a rapid decrease after radiotherapy, corresponding to clinical improvement, and detected recurrence at 11 months, as confirmed by biopsy. Tumor volume by CT showed no significant changes during this time. A squamous cell carcinoma of the superior sulcus (Pancoast type) showed rapid changes in C-11 Met tumor uptake and similar changes in tumor volume during two courses of radiotherapy and recurrence over a period of 25 months. PET evaluation of tumor viability seems to be valuable for treatment evaluation, and results match the tumor volume changes measured by CT.

[Needle tract metastasis following sonographically guided puncture of a mesenteric lymph node metastasis in Pancoast's tumor]

Peripheral bronchial carcinoma with infiltration of the right lateral thoracic wall (Pancoast tumour) was demonstrated in a 60-year-old man with breathing-related pain in the right thoracic wall of two months' duration. As part of tumour staging needle puncture of an intra-abdominal space-occupying lesion was performed, guided by ultrasonography. Histological examination confirmed it as a bronchial carcinoma metastasis. Combined radio- and chemotherapy hardly influenced tumour growth. Three months later a subcutaneous lesion became palpable in the area of the previous needle puncture which on excision proved to be a metastasis. The patient died 10 months later from the bronchial carcinoma. Percutaneous puncture of potentially malignant space-occupying lesions must be strictly indicated. The frequency of needle tract seeding is not exactly known.

Pancoast's syndrome due to Pseudomonas aeruginosa infection of the lung apex

A case of Pancoast's syndrome was caused by Pseudomonas aeruginosa infection of the lung apex. The infection extended to extrapleural structures of the thoracic inlet.

Pancoast tumour treated with combined radiotherapy and hyperthermia--a preliminary study

Six patients with Pancoast (superior sulcus) tumours were treated with combined radiotherapy and hyperthermia from April 1986 to December 1989. Radiotherapy was performed using 10 MV X-ray, and all patients received total doses of 60-74 Gy, in five fractions per week, during 5.5-15 weeks. Hyperthermia was performed once or twice a week within 30 min after each irradiation, using 8 MHz RF capacitive heating equipment (Thermotron RF-8). Partial response, defined as 50% or more regression of the tumour, was observed in four of the six patients. Three patients are alive 30, 28, and 14 months after their treatments. Radiotherapy combined with hyperthermia appears to be a promising and effective means for treating Pancoast tumours.

Pancoast tumor presenting as cervical radiculopathy

A case of Pancoast tumor presenting as cervical radiculopathy is reported, including the clinical, EMG, and radiologic findings. A 64-year-old man with a two-month history of left shoulder pain and left arm numbness at the medial aspect of the hand and forearm presented for electrodiagnostic examination, and a severe C8 radiculopathy was documented. Subsequent radiologic evaluation (myelogram and routine chest x-ray) yielded the diagnosis of left apical lung tumor (Pancoast tumor), eroding through the C7 and T1 pedicles and T1 vertebral body, with cut-off of the left C8 nerve root. Pancoast tumor has long been implicated as a cause of brachial plexopathy. The EMG presentation of isolated cervical radiculopathy, however, has not been previously reported, despite the tumor's known tendency for local invasion which may include the nerve roots and even the spinal canal in its advanced stages. This patient's normal sensory studies argue against any significant coexisting lower brachial plexopathy. The possibility of Pancoast lesion should be considered not only in the presence of brachial plexopathy, but also when C8 or T1 radiculopathy is found.

Pancoast's syndrome due to staphylococcal pneumonia

Images

Superior pulmonary sulcus tumors: radical resection and palliative treatment

Between 1963 and 1987, 56 patients with Superior Pulmonary Sulcus Tumors (SPST) were seen at our Institution. Fifteen inoperable patients were treated by radiotherapy. Forty-one patients underwent surgery: 32 received preoperative irradiation and in four of these postoperative radiotherapy was also administered: in nine cases (non radical resection) radiotherapy was administered postoperatively only. Paulson's approach was employed in 30 cases and Dartevelle's procedure in 11. The resection was considered curative in 22 patients (53.7%) achieving complete palliation of pain in 68.2% of cases. In non-resectable patients 2-year survival was 6%. Five-year survival was 11.1% for patients with non radical resection and postoperative irradiation and 34% for patients undergoing preoperative irradiation and radical resection. Four patients underwent pre- and postoperative irradiation and they are alive 23, 20, 15 and six months after operation. Five-year survival for N0, N1 and N2 patients was 38.1%, 14.3% and 0% respectively. In conclusion, SPST can be radically resected, with the appropriate surgical approach and after preoperative radiotherapy, achieving good long-term survival and pain relief. Postoperative irradiation is advisable for prevention of local recurrence and longer pain relief.

[The value of CT in carcinoma of the lung apex]

The CT findings in 34 patients with histologically confirmed tumours at a lung apex are described. CT, compared with conventional methods, provides more comprehensive information regarding the localisation and extent of the tumour and of local metastases. On the basis of CT examinations, 28 patients were treated by radiotherapy and in six patients surgery could be carried out.

[Computed tomography of Pancoast tumor]

Computed tomography (CT) and chest radiography of 14 patients with Pancoast tumor were reviewed. The cross-sectional format and superior contrast resolution of CT demonstrated the relationship of the tumor to significant adjacent structures (ribs, vertebral bodies, root of spinal nerves, mediastinum and brachial plexus) better than conventional chest radiographies. CT provided additional information to the latter technique in all patients studied. An accurate assessment of the local extent of tumor was also provided by CT. Our study suggests that the obliteration of the fat plane between scalene muscles on CT indicates the tumor invasion of the brachial plexus. CT is useful in the evaluation of the patient with Pancoast tumor.

Ultrasonography of Pancoast tumor

Eleven patients with Pancoast tumor, who failed to yield diagnostic materials by conventional sputum cytology and fiberoptic bronchoscopy, were studied by real-time linear-array and sector ultrasonography. The sector scanner through the supraclavicular approach adequately visualized the external profile and the internal texture of the lesions in all 11 patients, which is a significant improvement (p less than 0.05) over what can be accomplished with linear-array scanner through the intercostal approach. All patients received percutaneous transthoracic aspiration under ultrasound guidance. Positive cytologic diagnosis was established in ten of the 11 patients (91 percent). Additional biopsies performed in seven patients under similar ultrasonic guidance also provided concordant results. No complications were observed in this series. This study has clearly shown that ultrasound-guided aspiration biopsy can be a safe and useful means for obtaining materials for pathologic confirmation of Pancoast tumor. It may also assist in defining the tumor extension to pleura and adjacent structures.

The combined neurosurgical-thoracic management of superior sulcus tumors

Thirty patients with superior sulcus carcinoma were prospectively evaluated over an 18-month period. All patients underwent complete neuroradiological evaluation by computed tomography (CT) and myelography. Prior to operation, brachial plexopathy was noted in 20 patients (67%), and invasion of the spine in eight (27%). Using a team approach, gross total resection of tumor was achieved in 17 of 26 patients (65%) undergoing thoracotomy. There was no operative mortality. The use of a team approach allows extended surgical resection, especially when the spine is involved. In patients presenting with brachial plexopathy or cord compression, de novo surgery before radiation may provide better long-term palliation and pain relief.

[Current role of echography in the study of thoracic pathology]

Echotomographic examinations were performed in 64 patients suffering from thoracic wall, pleural, pulmonary and mediastinal diseases, after preliminary examinations using standard radiographic techniques. The value of echography in the detection and evaluation of the location and extent of the lesion is assessed. Particular stress is placed on the physical difficulties involved in the detection and correct evaluation of the relationship with the adjacent organs. The importance of echography in detecting the type of the lesion is under-lined and the semeiological criteria for its correct location are given.

Hemifacial gustatory sweating due to Pancoast's tumor

Facial sweating associated with eating develops occasionally after thoracic sympathectomy. Its occurrence has never been previously documented in association with a tumor in the upper chest. This report describes the first case of Pancoast's tumor presenting as hemifacial gustatory sweating.

Radiology of the pleura

Radiologic imaging of the pleura has undergone dramatic changes in the past 5 years. This can be primarily attributed to the availability and better understanding of computed tomography and, to a lesser extent, ultrasonography. When used in the proper clinical-radiologic environment, abnormalities of the pleural space can be quickly identified, localized, and often diagnosed in a rapid efficient manner.

The solitary pulmonary nodule and staging of lung cancer

More favorable survival rates are encountered when a bronchogenic carcinoma is identified and resected at the asymptomatic, small, circumscribed, nodular stage. The only two reliable radiologic criteria for benignity are the long-term absence of growth and certain characteristic patterns of calcification. With the advent of computed tomography, the preoperative radiographic staging of non-small cell bronchogenic carcinoma can accurately select those patients for potential surgical care.

Pancoast's tumor

Until 1956, surgical attempts to remove a Pancoast tumor had proven futile, since the neoplasm invades the endothoracic lymphatics, the sympathetic chain, intercostal nerves, ribs, bodies of the vertebrae, and subclavian vessels. In 1956, a man believed to have a nonresectable tumor received 3,000 rads over the upper right chest. Three weeks later, his superior sulcus tumor had shrunk to one-half its original size. At operation, en bloc resection of portions of the upper three ribs, along with the upper lobe of the lung, was accomplished. The patient is alive 27 years later and has only minor complications. Several other patients were successfully treated with this combined therapy, although those with distant metastases, supraclavicular tumefaction, obvious erosion of the transverse processes, extensive involvement of the brachial plexus, and vena caval obstruction are not suitable candidates for this approach.

Shoulder pain and Pancoast tumor: a diagnostic dilemma

Shoulder pain with radiation into the arm and hand in an ulnar nerve dermatomal pattern should be an indicator to the possible existence of a Pancoast tumor. The chiropractic physician should be aware of this malignant tumor and the characteristic clinical syndrome it produces. The physician should furthermore make every possible effort to include the apical region of the lung on any shoulder or cervical spine radiographs performed. By this careful technique and detailed interpretation of the films, the early and accurate diagnosis of a Pancoast tumor with appropriate referral can be made.

Pulmonary amyloid nodule simulating pancoast tumor

Solitary pulmonary amyloid nodules may be confused with a bronchogenic carcinoma. The diagnosis may be suspected from the presence of calcification within the nodule and confirmed by trephine or needle aspiration biopsy.

CT, including sagittal and coronal reconstruction, in the evaluation of pancoast tumors

Seventeen patients with histologically proved bronchogenic carcinoma involving the superior pulmonary sulcus (Pancoast tumors) were evaluated by computed tomography (CT), including sagittal and coronal image reconstruction. Compared to conventional radiography, axial transverse CT images provided, in all cases, additional information regarding local tumor extension and metastatic spread. Mediastinal involvement either by lymphangitic spread or direct tumor extension was present in 11 cases. In 4 patients plain films clearly showed mediastinal disease; however, CT more clearly delineated overall tumor extent, thus facilitating improved therapy planning. In a further 4 cases CT showed mediastinal involvement after plain films had been read as normal, and in an additional 3 instances metastatic involvement was either greatly underestimated (2 patients) or overestimated (1 patient) on the plain films. Reconstructed images in sagittal and coronal planes lacked detail but facilitated a three-dimensional concept of tumor extent and relationship of tumor to adjacent structures, particularly major blood vessels.

Thoracic computed tomography in superior sulcus tumors

Computed tomography (CT) can be helpful in the preoperative evaluation of patients with a superior sulcus (Pancoast) tumor. The cross-sectional format and tissue resolution of CT better demonstrate the relationship of tumor to significant anterior structures (subclavian artery and vein, trachea, and esophagus) and posterior structures (chest wall and vertebral bodies) than do conventional techniques. Invasion of the subclavian vessels, mediastinum, or vertebral bodies contraindicates surgery.