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Dr West

Lung Cancer Special Case: Intro to Pancoast Tumors

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One subtype of lung cancer that we haven’t specifically talked about is called a Pancoast tumor, named for the doctor who first described them. A Pancoast tumor is a NSCLC that is located in a groove called the superior sulcus (Pancoast tumors are also sometimes referred to as superior sulcus tumors), at the top (or apex) of each of the lungs. Here’s the appearance of one on a chest x-ray:

Pancoast tumor CXR

(Click to enlarge)

Typically squamous cancers, they are located high up in the chest and often very close to or actually growing into the chest wall or vertebrae, making it very hard or potentially impossible to remove them surgically. In fact, they were initially described back in the 1950s as unresponsive to radiation, unresectable, and therefore 100% fatal within a couple of years. Fortunately, we have made steady progress and now definitely feel that these tumors are potentially curable, with the evidence now to prove that.

The first baby steps described individual cases of patients who lived for several years after radiation (chemotherapy and the field of medical oncology really were just in their infancy at that time, and this far preceded the time of any effective chemo for lung cancer). A key publication (Haas, JAMA, 1954, too old for an online abstract) was titled, “Radiation Management of Otherwise Hopeless Neoplasm” (yikes!) and described a patient who lived for nearly three years after radiation. A few other encouraging cases trickled in of long-term survivors. In 1956, a report was published (Shaw and colleagues, Annals of Surgery) of a patient received three weeks of radiation and then, three weeks later, went to another institution to see a surgeon who decided to try to resect the cancer. The surgeon noted that the surgery went smoothly, and that the cancer was dead on the periphery but viable in the center. The patient remained alive for more than 5 years afterward. While it was only one patient, it proved what was possible.

And then, based on that experience of one man with a Pancoast tumor happening to go to see a surgeon three weeks after completing radiation and having encouraging early results, the approach of waiting three weeks after radiation and then attempting surgery for similar cases became the thing to do. These were still unusual to rare cases, but a few small studies emerged describing several long-term survivors, including one study in 1975 (abstract here) from 61 resected patients over 19 years at Baylor who were all treated with radiation followed by surgery, with a 5-year survival of 35%. Not as high we we’d like, but much better than the assessment that this was a “hopeless neoplasm” 20 years earlier.

The Modern Era

Although Pancoast tumors are still challenging to treat, we’ve got several new tools, including much better imaging techniques, and chemotherapy. First, the value of newer radiologic tests like CT and PET scans, can provide much better detail of where the cancer is and what it is or isn’t invading:

Pancoast CT and PET

Precise imaging is particularly helpful for radiation oncologist who need to determine exactly what to radiate and what normal tissue to spare, and for surgeons to try to anticipate what they will see and whether the tumor is invading into the vertebrae or other areas that may be very difficult or impossible to remove surgically. And as with PET scans for other lung cancers, they can also detect whether the cancer has spread to other areas that might make surgery inappropriate, such as if metastatic spread to the liver, adrenal glands, etc. is observed. While Pancoast tumors are typically squamous and tend to grow more locally than spread distantly, we certainly see metastatic spread in some patients and wouldn’t want to perform a surgery if it wouldn’t provide a realistic hope of significant benefit. At my institution, for these patients we routinely obtain CT and PET imaging as part of our standard staging workup, as well as a brain MRI, looking for distant spread before undertaking surgery.

I’m not a surgeon, so I won’t go into much detail on the evolution of surgical approaches, but they’ve made advances over the past 15-20 years. The older approach was with a large incision from the back:

Shaw Paulson

But 10-15 years ago, two thoracic surgery groups from France pioneered new approaches from the neck, with the incision either cutting through (abstract here) or below the clavicle (extract here):

Dartevelle Grunenwald Approaches

These new techniques can allow for greater visibility and access to many Pancoast tumors, particularly those toward the anterior, or front, part of the chest:

Pancoast anterior CT

Next we’ll turn to the trimodality approach that includes induction chemo and radiation all followed by surgery, which is now what many would considered our current best treatment approach for patients who can pursue it.


24 Responses to Lung Cancer Special Case: Intro to Pancoast Tumors

  • Kasey says:

    Thanks, Dr. West. I am a 3 year Pancoast survivor and I am hoping to make it much much longer. My surgeon is from NCI (NIH) and he used the anterior approach BUT my incision is from throat down the center of chest, under right breast around to my side. My tumor was considered a challenging one. So I always want to offer hope to pancoast tumor folks that lots can be done. I’ll be looking for more info you may be posting. I’m also glad to share more of my tx plan if desired.

    Kasey

  • sellers says:

    Kasey,
    My husband has recently been diagnosed with Pancoast’s syndrome, superior (pulmonay) sulcus tumor by a Pulmonary Specialist. Our biopsy is tomorrow morning to confirm.

    I am much encouraged that you are a 3 year survivor. I would like to know more….

    Any tips you could give me. How did you manage pain? I feel I need so much help to understand how I can help my husband through this. Any suggestions, help, information you have would be greatly appreciated.

  • Kasey says:

    sellers,

    You can find me on the Lung Cancer Support Community (LCSC) website which is lchelp.org

    If you would go there and find Kasey in your search, you can send me a personal message (PM). I would be more than happy to share all my experiences and answer any questions. I may even be able to offer some ideas for another opinion. Please feel optimistic as I feel I am more than likely going to do well for a very long time. There are a couple of long term survivors there as well……longer than me. One is DonnaG who is a 10 year survivor as of this December and mhutch, around 7. So you see………..HOPE is alive for pancoast tumors!!!!!

    Hope you find me there.

    Kasey

  • DonnaG says:

    I am nearly a 10 year suvivor of a Pancoast Tumor! and THERE IS NO EVIDENCE OF DISEASE!
    I had the more traditional incision from under my arm around to the back and up, they break a couple of ribs to open you up also. I see that my friend Kasey mentioned me already. One good thing your husband won’t be needing to wear the “appliance” over his scar.
    DonnaG

  • Dr West
    Dr. West says:

    Congratulations! Indeed, these aren’t just statistics, but real people living the success stories.

    -Dr. West

  • jojokdz says:

    My husband had a pancoast tumor a year plus a few months ago. They surgically removed it with some of his lung. All was good until his year checkup and they said it spread to his Adrenal Gland. Has anyone out there had a similiar diagnosis? Any input would sure help us?

  • kerri says:

    I was just wondering what kind of symptoms lead up to this as i have been having tingling and numbness in my left hand and arm with pain shooting up into my upper arm, armpit and shoulder like something is grabbing under my breast bone. Had an EMG and nerve condduction study for carpal tunnel but it was negative. It is very painful and hard to work. It is not a constant pain but comes and goes.

  • Dr West
    Dr West says:

    Kerri,

    Pain and hand weakness are probably the most common symptoms of a Pancoast tumor, but lots of people with these symptoms don’t have a tumor. The fact that the pain comes and goes and hasn’t been clearly progressive suggests against it being cancer. An imaging study like a CT of the chest would definitely rule out that possibility, and another option to consider would be an MRI of the shoulder or the brachial plexus, which is a collection of nerves in the lower neck that are traveling from the spinal column in the neck down the arm.

    -Dr. West

  • looking4clarification says:

    I am a 32 yo f with a 15pack year history. I have been having shoulder pain for about 9mths now. Dr #1 did a neck xray and MRI and ruled out pinched nerves and any abnormality in that area. His next suggestion was to do a brain scan. (It seemed strange since he never did any imaging of my shoulder.) 2nd dr. prescribed antiinflammatories and sent me to PT for impingement and possible labrum tear. ( lifting my arm over head was painful, lifting hurt, tingling into my ring and pinky fingers,an occasional ‘cold’ sensation, and the sense of ‘heaviness’ in my left arm.) After 6 weeks PT the tingling and radiating pain subsided but I still had a deep dull ache. 4 more wks PT. Finally did an MRI with contrast and it was ‘normal’. I had a steroid shot that gave me 6 hrs completely pain free and symptoms were less intense for about a wk after that. I guess what my questions is, with the onset of shoulder pain in a pancoast tumor, can symptoms improve with these types of treatment and if the ‘cold’ sensation typical. I see the dr again in 2 wks and am trying to gather as much info as possible so that I may help in the diagnosis of what is wrong. I am tired of hurting and having no explanation.
    Thanks in advance for reading my post and offering some advice.
    GOD BLESS each of you.

  • Dr West
    Dr West says:

    I’m sorry I can’t answer your question. As a website addressing known cancer diagnoses, we can help address treatment considerations for an esstablished Pancoast tumor but not how to diagnose something that is being worked up but isn’t appearing on imaging as a Pancoast tumor.

    It sounds as if a diagnosis of a Pancoast tumor is extremely unlikely if imaging is negative, particularly in a 32 year-old.

    Good luck with finding a diagnosis for your pain.

    -Dr. West

  • grace71 says:

    Morning Dr West,
    My brother had pain that progressed over 9 months to across shoulders, mid back and left side only… inside arm numb feeling down arm and progressed into fingers. It was mostly constant.
    He was diagnosed with Cervical Spondylosis and just given painkillers. The pain was bad.
    Then, one ,morning he woke up and couldnt hardly stand.
    Rang Ambulance in afternoon and was taken to country hospital. That night was rushed to major hospital where he had an emergency operation for a tumour in his spinal colomn. They didnt get it all.

    He was then told he had a primary cancer in the Apex of lung which had spread to the Brachial Plexus, Clavicle, one Lymph Node and then to his Spine.
    Since the partial removal of his Spinal Tumour he has been in hospital for 6 weeks. He’s been told only palliative care is an option and he is in the middle of 10 treatments with radiation to reduce pain.
    For his increasing pain he has progressed on to Slow release Morphine morning and night Gabapentin 300mg x3 daily Paracaetomal, and PRN of Sevredal….Post Op he has lost his gripping ability in his Left hand and cannot weight bear on his feet.
    His bowel isnt working as it should and the sensation of wanting to “pee’ is reduced a lot.

    He is having Physio to learn to ‘walk’ with a Gutter Frame. A hospital Rest home is his discharge Option. Very sad.
    My question is can you tell me ..taking other cases similar into account, what and where is the progress of the cancer likely to be and the time frame?

    They say the Radiation should reduce his pain levels.
    He says he doesnt want to prolong a life of pain
    Any comments would be a help

    Thanks a lot
    Andie

  • Dr West
    Dr West says:

    Andie,

    I’m sorry I can’t help here. Your brother’s case is completely unique, as Pancoast tumors tend to be. His doctors would probably be the only people who can provide any meaningful insight.

    Good luck.

    -Dr. West

  • dgel says:

    Hi I just found this site and left a question under a new topic, but now I’m thinking maybe this is where I should post my question……I am cutting and pasting below. Dr. West, any guidance at all would be appreciated:

    My husband, aged 58, began complaining 2 weeks ago about pain in his shoulder, which continued to get worse and then about a week ago I noticed an apricot sized lump just under his scapula on the same side where the pain is. He went to our GP who referred him to an ortho who took a neck xray and diagnosed him with a pinched nerve and put him on methylprednisolone. Since that time, the pain has increased and also goes from shoulder to down his arm, elbow, top of hand and just tonight under his arm. I have been searching the internet with his symptoms, and as it appears others before me have, I keep running across pancoast syndrome/tumor. My husband has never been a cigarette smoker, but smoked something else in the 70’s. His father was a smoker and passed away of lung cancer in his 50’s.

    He is barely sleeping at night as he cannot lay down on his back or side due to the pain. He tries to sleep sitting up. He also cradles his right arm in his left arm to try to take the pressure off of his right shoulder. I keep seeing how the best prognosis relates to early diagnosis and also that so many people are misdiagnosed by their orthos sometimes for months!!

    I am a 12 year survivor of nonhogkins lymphoma, and understand the necessity of early diagnosis. I am thinking I should call my oncologist and ask his opinion tomorrow. My husband called the ortho today and told them how much pain he is in. They made an appointment for him the day after tomorrow first thing in the morning. I told him to make sure they xray his shoulder AND his chest. Are we doing all we should?

    P.S. We also called our Gen Practitioner who is on vacation until 7/6. Thanks for any info and guidance you can provide.

  • Dr West
    Dr West says:

    The first thing you should know is that worry about Pancoast tumors is about 10-100x more common than actual Pancoast tumors. Thanks to the internet, a huge number of people with shoulder pain decide or at least are very worried they have a Pancoast tumor. Most don’t.

    We here can’t and shouldn’t be making medical recommendations for people who aren’t our patients. I think a chest x-ray would be very likely to identify any lesion causing shoulder pain, and a chest CT would be completely reassuring if it doesn’t show anything suspicious. However, I think it’s appropriate to defer to the orthopedic specialist about whether the clinical picture should lead to that imaging. I don’t think there’s a clear role for your oncologist to direct the workup of someone who doesn’t have a diagnosed cancer and isn’t his patient.

    Good luck.

    -Dr. West

  • dgel says:

    Thank you Dr. West. I was dx’d 12 years ago with primary mediastinal large b-cell non hogkins lymphoma after being misdiagnosed and treated by my gp at the time for what was thought to be a stubborn sinus infection. I guess that experience has made me a stronger or more aggressive patient advocate (and a rather aggressive internet researcher!). That being said, I am reminding myself that there are a multitude of other dx that could be causing the pain, and that the pain one way or another will need to be addressed.

    I am going to my husband’s ortho appointment tomorrow with him so I can at least express my concerns, and will take it from there. I am hopeful that the issue is of a benign/ortho origin. Once again, thank you so much for taking your time to answer my query.

  • lalexander71 says:

    Hi there, I am looking to discuss some things here with Kasey and Dr West.
    If they are still available I will get back on later this evening or tomorrow. My husband is fighting for his life with his pancoast tumor and the Neurosurgeon and Thoracic Surgeon just told him that the surgery is very high risk for him and said more chemo and proton 60 radiation at Loma Linda Cancer center in California, is the best option. I have done tons of research I have don’t and am pretty saavy at the medical needs for Lee.
    I just wonder if we should stand out ground with surgery if they said they can’t resect it all. I do know that chemo and rad concurrent is a must after surgery.

    Help!!!

  • Dr West
    Dr West says:

    I’m sorry about your husband’s diagnosis, and I can understand that you would want to have the cancer removed surgically. However, I would say that it’s a very, very bad idea to insist on a treatment that the doctors are advising against. They aren’t recommending against it as a punishment to deprive him of a great opportunity, but rather because they feel it is very unlikely to be successful and would be prohibitively dangerous. Many people who have a very locally advanced lung cancer, whether a Pancoast tumor or not, are very poorly served by undergoing an ill-advised surgery that leaves the person with residual cancer and/or debilitated by the surgery.

    Please remember that surgeons make their living by doing surgery, and nearly all of them have a strong belief in the power of “hot lights, cold steel”. If they say surgery is a bad idea, it would be extremely unwise to force the issue and have them prove it.

    Chemo and concurrent radiation can also potentially be curative.

    If you remain highly inclined toward surgery, I think it would make far more sense to seek a second opinion from an expert thoracic surgeon. However, if they also advise against surgery, I would take it as the definitive world that surgery would be NOT be in his best interests.

    Good luck.

    -Dr. West

  • lalexander71 says:

    Thank you Dr. West for your input,
    We did take your advice and the Dr.’s advice and decide otherwise, but it is very frustrating as we have been through so much this last year, and with a 2 hospitals that saw him, did xrays on the first hospital, and the 2nd hospital did 2 (Very expensive 5K$ MRI‘s) and dismissed him to it being just a pinched nerve and possible nerve radiaculpathy. They did not listen when I told them this is more than just that, he has lost 50 lbs in one month, and that is NOT normal.
    So the Neurosurgeon, who did not recommend Surgery, recommened Proton 60 at Loma Linda Main Campus- so we met with the Dr. in charge of that program, only to find out that he can’t have Proton 60 because his first round of ChemoRAD they did the Radiation at 60, which I must have asked on 3 different Doc visits asking what level of Radiation they were doing- and WAS ASSURED that it was 45 grey, and that he would be able to have Radiation after surgery (when they stated Surgery was the best next step after the first Chemo RAD), so they had room to do proton 60 to be precise- now we are told can’t do Radiation. So now we are just relying on Chemo.
    Just met with the Oncologist and he is ordering a different direction of Chemo- Opdivo.

    We just moved from WA to CA December of 2014, and have not even been able to unpack our house- it just seems like I am the only one fighting for my husband- and make sure things get done in a timely manner, because everything they order, or want done I have to ask for it to be done stat- I am just wondering why when time is of the essence with this tumor, does it seem like things get done “when they get done”.
    I have done an extreme amount of research on this cancer, and where it is, and how it is spreading……

    I have asked for a 2nd opinion to go meet with the team at City of hope, but even that is taking longer than it should. With the amount I pay for his insurance premiums (580$ month and 90% covered) you would think I could get what he needs in a timely manner.
    On top of all this, I am trying to teach (which is an hour away), so we don’t lose the house and all. (Just finally after 6 months I got his Disability approved- but even that they are trying to short him on, only wanting to pay from January 2016 onward.)

    So incredibly frustrated with the Medical and Insurance world here in Cali.

  • benjiwat72 says:

    Hi I would like to introduce myself, my name
    Is Ben and I am a 43 year old male from the UK.
    I have just found this site and really would like to
    Ask a few questions of my own concerning a pancost
    Tumour. Firstly am I on the right part of this site and secondly
    Would any body medically minded mind answering
    Some questions. Would much appreciate some feed back
    Many thanks in advance,

  • Dr West
    Dr West says:

    You should ask questions here;

    http://cancergrace.org/forum/q-and-a-ask-us/new-questions

    However, I will start by saying that we get an unfathomable number of questions from people who are worried that they have Pancoast tumor because they have shoulder pain but have no imaging and no diagnosis of a Pancoast tumor. It is probably the most overly self-diagnosed issue in cancer.

    If you have a proven diagnosis of a Pancoast lung cancer, we can help provide good information. If you are worried you have a Pancoast tumor based on shoulder pain and your imaging doesn’t show it, you almost certainly DON’T have a Pancoast tumor but have been reading the same web pages that dozens of other people have read and mistakenly concluded that’s the cause.

    Good luck.

    -Dr. West

  • benjiwat72 says:

    Thank you for your reply Dr west, I think that has
    Pretty much summed it up.
    Thank you.

  • adamr says:

    Hey there Dr. West —

    I know it must be incredibly frustrating as I’m sure you and your team are inundated with people self-diagnosing. Please forgive me for adding to that pool, but I have some questions regarding the symptoms of a pancoast tumor:

    How severe is the associated shoulder pain typically?

    How quickly does this type of tumor/cancer spread to other organs?

    I recently went to an orthopedic office with complaints of my left shoulder in discomfort. In all honesty, I’m not in real, intense pain. However, it’s the persistence that concerns me. It is a mild ache that has persisted for a few months. The pain hasn’t intensified at all — but I did have accompanying chest pressure. The ache is located under the scapula, closer to the spine.

    No real numbness or pain present in the corresponding arm, either. I felt a few twinges (tingling) briefly, but just enough to make me paranoid.

    An x-ray didn’t yield anything unusual. But from what I’ve read, x-rays generally can’t be depended on when looking for an early tumor of this nature. I tried requesting for an MRI, but they told me that I have to wait for four weeks to see if this steroidal anti-inflammatory dies anything. I would rather just have piece of mind…

    I do feel ridiculous posting this, and a little bit of a fraud because there are people definitely going through worse than I am; but this is bothering me a lot more than I would like.

    Other information:

    I am a 26 year old male
    Have never been a smoker
    Overweight but otherwise in good health
    Only other health concern I had were kidney stones that were removed via litroscopy (sp?)

    Recently I’ve been having a flank discomfort on my left side rib cage (same side as the shoulder discomfort)

    On a scale of 1-10, how ridiculous am I being right now? I really don’t want to wait four weeks to have an MRI. Thank you for your time, and I hope you have a great day

  • Dr West
    Dr West says:

    Let me state up front that I think your probability of having a Pancoast tumor is only very slightly higher than your chance of being killed by a falling meteor today. I can’t say it’s impossible, but it sounds vanishingly, unfathomably unlikely based on what you’re conveying.

    If you search through the site, the fear of a Pancoast tumor is BY FAR the most erroneously self-diagnosed issue related to cancer that we see — about 5-10 times the level of concern of anything else, so whatever websites are leading so many people to conclude they have a Pancoast tumor must be receiving money from imaging companies that profit from a vast excess of gratuitous scans.

    Pancoast tumors typically cause gradually increasing pain in the shoulder or arm by causing compression and damage to the nerves of the shoulder and arm. The pain typically increases gradually over weeks to months. Pancoast tumors classically take a long time to progress to other parts of the body. While it is possible for a never-smoker to develop a lung cancer, that would be very rare, as would developing a lung cancer at age 26.

    I do understand your concern, especially when online sources fan the flames of anxiety, but it’s about 5000 times more likely that you have a benign (non-cancer) cause of your shoulder pain, which is VERY common from a rotator cuff injury, for instance, than lung cancer.

    Good luck.

    -Dr. West

  • adamr says:

    Thank you so much for your reply, Dr. West. Hopefully my post will serve as a friendly reality check that sometimes google isn’t your best friend when looking at symptoms. To everyone on this site living through any medical challenges, my thoughts are with you and I truly hope for the best for you.

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