Pancoast Tumors

A Pancoast tumor, also called a superior sulcus tumor, is a tumor that arises in the very apex of the chest, in the upper portion of either the right or the left lung. These are usually found to be non-small cell lung cancer (NSCLC). While NSCLC is the most common lung cancer type, this location in the chest (an area called the superior sulcus) is rare, accounting for only 3 to 5% of all lung cancers.

This unusual presentation means the tumor often interferes with surrounding structures — the ribs, spine, nerves, blood vessels and the lining of the chest cavity, making treatment difficult. These tumors were previously thought to be inoperable, but advances in radiation therapy and surgical techniques have greatly improved outcomes for patients.

Treatment for a Pancoast tumor is complex and requires a multidisciplinary approach from various physicians specializing in thoracic surgery, medical oncology and radiation medicine. At Roswell Park, we are proud to offer the excellence in multidisciplinary thoracic cancer care necessary for treating these tumors.

Pancoast Tumor Symptoms

Lung cancer, in general, is usually asymptomatic in its earliest stages. When a Pancoast tumor grows to the point where it involves surrounding structures, these symptoms typically arise:

  • Pain is the most common symptom of a Pancoast tumor, occurring in 44 to 96% of patients. A classic syndrome called Pancoast-Tobias syndrome causes severe pain in the neck, arm, wrist, armpit, shoulder and chest wall. Chest pain and shoulder pain are common and occur when the tumor invades the lining of the chest wall overlying the ribs or spine, which contains many nerves.
  • Numbness or weakness of the hand and arm and tingling in the fingers can occur on the affected side of the body. Numbness of the hand or inner arm indicates the tumor is compressing the brachial plexus, a network of nerves that run from the spine to the chest, shoulder, arm and hand, and not necessarily invading a nerve. Weakness or atrophy of the hand muscles occurs when the tumor invades the ulnar nerve.
  • Droopy eyelid and pupil constriction may occur in up to 40% of patients with Pancoast tumors. These symptoms indicate a condition called Horner’s syndrome and involve the sympathetic nervous system. 
  • Excessive sweating or flushing of the face on the affected side.

What Causes a Pancoast Tumor?

The overwhelming majority of superior sulcus tumors are non-small cell lung cancers, but the presence of a tumor in this location does not guarantee a diagnosis of lung cancer. Lymphoma, tuberculosis, and tumors originating from tissues of the chest wall can create a Pancoast tumor, too.

The term Pancoast tumor refers to the tumor’s location, symptoms and appearance (as seen on X-ray or CT scans) rather than the specific disease pathology. 

How is a Pancoast Tumor Diagnosed?

The diagnosis process for Pancoast tumor has multiple steps. If initial imaging — chest x-ray or CT scan — shows suspicion of a Pancoast tumor, a PET/CT scan or an MRI is performed. An MRI is the most sensitive test for assessing the neurological and vascular structures surrounding the tumor.

Once imaging is obtained, an interventional radiologist performs a percutaneous (through the skin) biopsy. First, the skin is numbed with a local anesthetic. Then, using CT scan imaging as guidance, the physician directs the biopsy needle into the tumor to take a tissue sample. In some cases, a biopsy of the tumor and surrounding lymph nodes is obtained with a technique called flexible bronchoscopy, which uses an instrument (bronchoscope) inserted in the airways.  

Treatment for Pancoast Tumor

Treatment of this rare tumor type is complex and requires a well-coordinated combination of therapies including chemotherapy, radiation therapy and surgery.

  • Chemotherapy and radiation therapy for Pancoast tumor are performed simultaneously before surgery with the goal of shrinking the tumor and improving the chances that the tumor can be successfully removed. Typically, patients receive two or three cycles of chemotherapy and approximately six weeks of external beam radiation therapy. About 75% of patients who initiate treatment with chemotherapy and radiation are then able to undergo surgery.
  • Surgery for Pancoast tumor typically includes removing the lung’s upper lobe as well as any portion of the chest wall and other structures that the tumor involves. Roswell Park is a high-volume thoracic surgery center with expertise in the complex surgical management of these tumors. In many cases, surgeons from multiple specialties may be involved in the procedure. In selected situations, a minimally invasive approach may be possible.