Pancoast’s Tumor Syndrome




Abstract


Pancoast’s tumor syndrome is the result of local growth of tumor from the apex of the lung directly into the brachial plexus. Such tumors usually involve the first and second thoracic nerves, as well as the eighth cervical nerve, and produce a classic clinical syndrome consisting of severe arm pain and, in some patients, Horner’s syndrome. Destruction of the first and second ribs is also common. Diagnosis is usually delayed, and patients are often erroneously treated for cervical radiculopathy or primary shoulder disease until the diagnosis becomes clear.


Patients suffering from Pancoast’s tumor syndrome complain of pain radiating to the supraclavicular region and upper extremity. Initially, the lower portion of the brachial plexus is involved because the tumor growth is from below, causing pain in the upper thoracic and lower cervical dermatomes. The pain is neuritic and may take on a deep, boring quality as the tumor invades the brachial plexus. Movement of the neck and shoulder exacerbates the pain, so patients often try to avoid such movement. Frozen shoulder often results and may confuse the diagnosis. As the disease progresses, Horner’s syndrome may occur.




Keywords

brachial plexopathy, Pancoast’s tumor syndrome, Parsonage-Turner syndrome, herpes zoster, shoulder pain, cervical radiculopathy, carcinoma, brachial plexus block

 


ICD-10 CODE C34.10




The Clinical Syndrome


Pancoast’s tumor syndrome is the result of local growth of tumor from the apex of the lung directly into the brachial plexus. Such tumors usually involve the first and second thoracic nerves, as well as the eighth cervical nerve, and produce a classic clinical syndrome consisting of severe arm pain and, in some patients, Horner’s syndrome ( Fig. 23.1 ). Destruction of the first and second ribs is also common. Diagnosis is usually delayed, and patients are often erroneously treated for cervical radiculopathy or primary shoulder disease until the diagnosis becomes clear.




FIG 23.1


Magnetic resonance imaging of normal coronal anatomy. A, Most posterior image with the horizontal course of the T1 nerve root (long arrow), very close to the lung apex. The short arrow points to the stellate ganglion. B, Image just anterior to A with the C8 nerve roots (arrows). C, T2-weighted short tau inversion recovery image at the same level as B shows the slightly increased signal intensity of the normal C8 nerve roots (arrows). D, Arrow points to the C7 nerve root. MSM, Middle scalene muscle. E, The cords (white arrow) are seen as linear structures above the axillary artery (AA). The dorsal scapular artery (DSA) courses between the trunks of the brachial plexus; the black arrow points to the superior trunk. ASM, Anterior scalene muscle.

(From Van Es HW, Bollen TL, van Heesewijk HP. MRI of the brachial plexus: a pictorial review. Eur J Radiol. 2010;74(2):391–402.)




Signs and Symptoms


Patients suffering from Pancoast’s tumor syndrome complain of pain radiating to the supraclavicular region and upper extremity ( Fig. 23.2 ). Initially, the lower portion of the brachial plexus is involved because the tumor growth is from below, causing pain in the upper thoracic and lower cervical dermatomes. The pain is neuritic and may take on a deep, boring quality as the tumor invades the brachial plexus. Movement of the neck and shoulder exacerbates the pain, so patients often try to avoid such movement. Frozen shoulder often results and may confuse the diagnosis. As the disease progresses, Horner’s syndrome may occur ( Fig. 23.3 ).




FIG 23.2


Horner’s syndrome in patient suffering from Pancoast’s tumor syndrome. A , This 58-year-old man presented with chronic left arm and shoulder pain along with progressive weakness of his lower arm and hand. Physical examination showed clinical findings of a superior sulcus (Pancoast’s) tumor, ptosis of the left eyelid, miosis of the pupil, decreased sweating of the left face, arm, and upper chest (Horner’s syndrome), and a tumor mass in the lung apex that involved the brachial plexus and adjacent rib. B , After radiation therapy the manifestations of Horner’s syndrome have resolved. Also his pain and neurologic symptoms were reduced. Survival is poor with Pancoast’s tumors (under 30% at 5 years) as a result of progressive regional disease but also distant metastases.

(From: Salgia R, Blanco R, Skarin AT. Lung cancer and tumors of the heart and mediastinum. In: Atlas of diagnostic oncology. 4th ed. Philadelphia; 2010:98–159.)



FIG 23.3


Pancoast’s tumor should be suspected in patients suffering from shoulder and upper extremity pain who have a history of smoking.




Testing


All patients presenting with brachial plexopathy, especially those without a clear history of antecedent trauma, must undergo magnetic resonance imaging (MRI) of the cervical spine and the brachial plexus ( Figs. 23.4 and 23.5 ). Computed tomography (CT) and/or ultrasound imaging is a reasonable alternative if MRI is contraindicated ( Fig. 23.6 ). Positron emission tomography may help clarify the nature of suspicious masses in this regions ( Fig. 23.7 ). Electromyography (EMG) and nerve conduction velocity testing are extremely sensitive, and a skilled electromyographer can determine which portion of the plexus is abnormal. All patients with a significant smoking history and suspected Pancoast’s tumor or other tumor of the brachial plexus should undergo chest radiography with apical lordotic views or CT scanning through the apex of the lung. If the diagnosis is in question, screening laboratory tests consisting of a complete blood count, erythrocyte sedimentation rate, antinuclear antibody testing, and automated blood chemistry should be performed to rule out other causes of the patient’s pain.


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Sep 9, 2019 | Posted by in PAIN MEDICINE | Comments Off on Pancoast’s Tumor Syndrome

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