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• Pancost Tumor Epidemiology and Histology
  professor Pranab Kumar Bhattacharya
  Published on: 21 August 2019
• Pancoast Tumor
  Professor Pranab Kumar Bhattacharya
  Published on: 21 August 2019

• Published on: 21 August 2019

  Pancost Tumor Epidemiology and Histology

  • professor Pranab Kumar Bhattacharya, Professor of Pathology calcutta school of Tropical Medicine 108 CR Avenue kolkata 73 West Bengal India

  The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic...

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  The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic behavior as lung carcinomas located in the lung parenchyma. Consequently, their diagnosis, staging, and treatment follow the same principles as for any other lung cancer. The unique characteristics of Pancoast tumors are related to the anatomy of the region where these tumors occur (thoracic inlet) and not to their biologic behavior.
  Epidemiology
  Pancoast tumors are a relatively rare subset of non-small cell lung cancers (NSCLC), accounting for fewer than 5% of all lung cancers. At least 50% of cases are histologically seen as adenocarcinomas, while the rest are squamous cell and large-cell carcinomas. Small cell carcinoma occurs rare. Patients often present with complaints of pain distributed to the upper anterior chest wall. These tumors may manifest with signs and symptoms related to the compression or infiltration of the middle and lower trunks of the brachial plexus such as shoulder and arm pain (in the distribution of the C8, T1, and T2 dermatome). The peripheral location of these tumors minimizes standard lung cancer symptoms such as cough, hemoptysis, and dyspnea and is the main reason why patients with Pancoast tumors present at a later stage of diagnosis . Diagnosis is established through biopsy of the mass. Given their location, these lesions are amenable to CT or ultrasound-guided fine-needle aspiration. Because of the peripheral location of the tumor, fiberoptic bronchoscopy is only able to establish the diagnosis in less than 30% of cases (unless there is nodal involvement). A tissue diagnosis via video-assisted thoracoscopy (VATS) may be indicated when other investigations are negative and to eliminate the possibility of pleural metastatic disease. Axillary minithoractomy is an alternative to VATS to obtain a tissue diagnosis of the mass in small apical tumors.
  As with other lung carcinomas located in the lung parenchyma, it is imperative to stage the mediastinum with Pancoast tumors. Metastases to the mediastinal nodes is a major negative prognostic factor — 5-year survival rates in the presence of N2 disease are below 10%.4 According to the 2013 ACCP guidelines, before surgery for Pancoast tumors, an endobronchial ultrasound with transbronchial needle aspiration or a cervical mediastinoscopy is warranted to exclude N2/N3 disease, even in the absence of involved nodes in CT or PET scans. Pancoast tumors are by definition T3 or T4 tumors. Most of the lesions are classified as T3 tumors because they invade only the chest wall and/or the sympathetic chain. The rest invade brachial plexus, vertebral bodies, and vascular structures, and are classified as T4 tumors. According to the new staging system for lung cancer developed by the International Association for the Study of Lung Cancer (IASLC), their final stage, in the absence of distant metastases, depends on the N status of the tumor:
  IIB if T3NO,
  IIIA if T3N1-2, or T4NO-1,
  IIIB if T3N3 or T4N2-3.
  Therefore, even the earliest of these lesions are staged at least IIB. Invasion of the ipsilateral supraclavicular nodes in the setting of lung cancer is classified as N3 disease. In superior sulcus carcinomas the importance of supraclavicular node involvement is quite different because it is considered to represent a locoregional lymph node extension.

  References
  1] Pancoast H.K. Superior pulmonary sulcus tumor. JAMA. 1932;99:1391.

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  Conflict of Interest:
  None declared.

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• Published on: 21 August 2019

  Pancoast Tumor

  • Professor Pranab Kumar Bhattacharya, Professor of Pathology Calcutta school of Tropical Medicine 108 Chittaranjan Avenue; Kolkata 70073 West Bengal India

  The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic...

  Show More

  The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic behavior as lung carcinomas located in the lung parenchyma. Consequently, their diagnosis, staging, and treatment follow the same principles as for any other lung cancer. The unique characteristics of Pancoast tumors are related to the anatomy of the region where these tumors occur (thoracic inlet) and not to their biologic behavior.
  Epidemiology
  Pancoast tumors are a relatively rare subset of non-small cell lung cancers (NSCLC), accounting for fewer than 5% of all lung cancers. At least 50% of cases are histologically seen as adenocarcinomas, while the rest are squamous cell and large-cell carcinomas. Small cell carcinoma occurs rare. Patients often present with complaints of pain distributed to the upper anterior chest wall. These tumors may manifest with signs and symptoms related to the compression or infiltration of the middle and lower trunks of the brachial plexus such as shoulder and arm pain (in the distribution of the C8, T1, and T2 dermatome). The peripheral location of these tumors minimizes standard lung cancer symptoms such as cough, hemoptysis, and dyspnea and is the main reason why patients with Pancoast tumors present at a later stage of diagnosis . Diagnosis is established through biopsy of the mass. Given their location, these lesions are amenable to CT or ultrasound-guided fine-needle aspiration. Because of the peripheral location of the tumor, fiberoptic bronchoscopy is only able to establish the diagnosis in less than 30% of cases (unless there is nodal involvement). A tissue diagnosis via video-assisted thoracoscopy (VATS) may be indicated when other investigations are negative and to eliminate the possibility of pleural metastatic disease. Axillary minithoractomy is an alternative to VATS to obtain a tissue diagnosis of the mass in small apical tumors.
  As with other lung carcinomas located in the lung parenchyma, it is imperative to stage the mediastinum with Pancoast tumors. Metastases to the mediastinal nodes is a major negative prognostic factor — 5-year survival rates in the presence of N2 disease are below 10%.4 According to the 2013 ACCP guidelines, before surgery for Pancoast tumors, an endobronchial ultrasound with transbronchial needle aspiration or a cervical mediastinoscopy is warranted to exclude N2/N3 disease, even in the absence of involved nodes in CT or PET scans. Pancoast tumors are by definition T3 or T4 tumors. Most of the lesions are classified as T3 tumors because they invade only the chest wall and/or the sympathetic chain. The rest invade brachial plexus, vertebral bodies, and vascular structures, and are classified as T4 tumors. According to the new staging system for lung cancer developed by the International Association for the Study of Lung Cancer (IASLC), their final stage, in the absence of distant metastases, depends on the N status of the tumor:
  IIB if T3NO,
  IIIA if T3N1-2, or T4NO-1,
  IIIB if T3N3 or T4N2-3.
  Therefore, even the earliest of these lesions are staged at least IIB. Invasion of the ipsilateral supraclavicular nodes in the setting of lung cancer is classified as N3 disease. In superior sulcus carcinomas the importance of supraclavicular node involvement is quite different because it is considered to represent a locoregional lymph node extension.

  References
  1] Pancoast H.K. Superior pulmonary sulcus tumor. JAMA. 1932;99:1391.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top