Respiratory · Year 1 · from Respiratory

Case 3: Pancoast Tumor - Superior Sulcus Syndrome

Clinical Image

Source: Wikimedia Commons - Pancoast tumor - CC BY-SA 3.0

Patient Presentation

A 55-year-old man presents with 3 months of progressively worsening right shoulder and arm pain radiating down the inner aspect of his arm to his fourth and fifth fingers. He has seen an orthopedist and physical therapist without improvement. He also noticed his right eyelid drooping and he sweats less on the right side of his face. He has smoked 2 packs per day for 35 years.

Demographics

  • Age: 55 years
  • Sex: Male
  • Past Medical History: None significant
  • Medications: NSAIDs for pain (ineffective)
  • Social History: 70 pack-year smoking history, current smoker

Chief Complaint

Right shoulder and arm pain, eyelid drooping, and facial changes

Physical Examination

  • Blood pressure: 136/84 mmHg
  • Heart rate: 82 bpm
  • General: Appears uncomfortable due to pain
  • HEENT: Right-sided ptosis, miosis, anhidrosis on right side of face (Horner syndrome)
  • Neck: No adenopathy
  • Respiratory: Decreased breath sounds at right apex
  • Neurological:
  • Weakness and atrophy of right intrinsic hand muscles (C8-T1)
  • Decreased sensation along ulnar distribution (C8-T1)
  • Triceps reflex diminished on right

Workup

  • Chest X-ray: Asymmetric apical opacity on right (initially interpreted as pleural thickening)
  • CT chest: 4.5 cm right apical mass extending into the thoracic inlet, adjacent rib destruction (first and second ribs), invasion of right brachial plexus
  • MRI chest/brachial plexus: Confirms invasion of lower brachial plexus (C8-T1 roots), involvement of subclavian vessels, no vertebral body invasion
  • PET-CT: FDG-avid apical mass, ipsilateral hilar node, no distant metastases
  • CT-guided biopsy: Squamous cell carcinoma
  • Brain MRI: No metastases

Diagnosis

Stage IIIA Pancoast Tumor (Superior Sulcus Tumor) - Squamous Cell Carcinoma with:

  • Brachial plexus invasion (C8-T1)
  • Horner syndrome (stellate ganglion involvement)
  • Chest wall invasion

Treatment

  1. Induction chemoradiation:
  • Concurrent cisplatin-based chemotherapy with radiation
  • 45-50 Gy over 5 weeks
  1. Restaging after induction
  2. Surgical resection (if responding):
  • En bloc resection including chest wall, involved ribs, lower brachial plexus roots
  • Goal: R0 resection (negative margins)
  1. Pain management (neuropathic pain regimen: gabapentin, opioids)
  2. Smoking cessation (though damage done, still beneficial)
  3. Long-term surveillance

Physiological Principles Demonstrated

  • Pancoast syndrome anatomy: Tumors at the lung apex (superior sulcus) invade adjacent structures: brachial plexus (C8-T1 causing arm pain and weakness), stellate ganglion (Horner syndrome), subclavian vessels, ribs, and vertebrae.
  • Horner syndrome triad: Ptosis (sympathetic innervation to Muller muscle), miosis (pupil dilator), anhidrosis (facial sweating) - caused by interruption of the sympathetic chain at the stellate ganglion.
  • Pain pattern: Lower brachial plexus involvement causes pain and weakness in the ulnar distribution (C8-T1), often misdiagnosed as musculoskeletal or cervical spine disease.
  • Multimodality treatment necessity: Pancoast tumors require combined modality therapy (chemoradiation followed by surgery) for best outcomes; surgery alone has high local recurrence rates.

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