Pancoast tumour (Cancer)

🧾 About

• 🌄 Pancoast tumour (superior sulcus tumour) = apical lung cancer with local invasion.
• Most linked to NSCLC (squamous cell, adenocarcinoma).
• Classically presents with ipsilateral Horner’s syndrome + severe shoulder pain.

🧠 Key Structures Invaded

• 🫁 Lung Apex → starting point.
• 💪 Brachial Plexus (C8–T1) → arm/hand pain, weakness, wasting.
• 👁️ Sympathetic Chain → Horner’s syndrome: ptosis, miosis, anhidrosis, enophthalmos.
• 🦴 Chest Wall / Ribs / Vertebrae → pain + destruction.
• 🗣️ Recurrent Laryngeal Nerve → hoarseness, “bovine cough.”

👩‍⚕️ Clinical Features

• 🎯 Shoulder pain → often misdiagnosed as MSK issue.
• 💨 Cough, haemoptysis, weight loss.
• 👁️ Horner’s syndrome (triad: ptosis, miosis, anhidrosis ± enophthalmos).
• 🗣️ Hoarseness / weak cough (recurrent laryngeal nerve).
• 🖐️ Systemic signs: digital clubbing, cachexia, nicotine stains, metastatic features.

📸 Example: Left Pancoast Tumour + Horner’s Syndrome

Ptosis often mild, but miosis + anhidrosis usually evident.

🔎 Investigations

• 📷 CXR: apical opacity, subtle → scrutinise carefully.
• 🧪 U&E: check for SIADH / hyponatraemia (ectopic ADH).
• 🦴 Bone profile: hypercalcaemia = mets/paraneoplastic.
• 🧪 LFTs: raised ALP = liver/bone involvement.
• 🖥️ CT chest: staging + invasion extent.
• 🔬 Biopsy: via bronchoscopy or CT-guided.
• 🧫 Sputum cytology: less sensitive but may show malignant cells.

🩺 Management

• 🩹 Pain & Palliation: opioids, nerve blocks, radiotherapy for pain control.
• ☢️ Radiotherapy: shrink tumour, symptom relief.
• 💉 Chemotherapy: systemic control (esp. NSCLC subtypes).
• 🔪 Surgery: rare (due to invasion); some centres attempt combined surgery + RT if limited spread.
• 🤝 MDT care: oncology, respiratory, radiology, palliative care.

📊 Prognosis

• ⚠️ Often late presentation → poor outcomes.
• 📈 5-yr survival ~20–30% if unresectable; better with trimodal therapy (chemo + RT + surgery in select cases).
• Improving survival with modern chemo-radiotherapy + immunotherapy.

📌 Exam Pearls

• 🎯 Shoulder pain + Horner’s = Pancoast until proven otherwise.
• 🧠 Don’t forget: recurrent laryngeal nerve → hoarseness.
• ⚠️ Apical lung lesions → scrutinise CXR apex carefully.
• 🔎 Paraneoplastic syndromes (SIADH, hypercalcaemia) may coexist.

Cases - Pancoast Tumour (Apical Lung Cancer)

• Case 1 - Shoulder pain & arm weakness 💪: A 62-year-old man with a 40-pack-year smoking history presents with severe right shoulder pain radiating down the arm. Exam: wasting of small hand muscles and reduced grip strength. CXR: right apical lung mass. MRI: invasion of brachial plexus. Diagnosis: Pancoast tumour with brachial plexus involvement. Managed with combined chemo-radiotherapy and surgical resection if operable.
• Case 2 - Horner’s syndrome 👁️: A 58-year-old man presents with ptosis, miosis, and anhidrosis of the left face, along with chronic shoulder pain. CXR: apical opacity. CT chest: apical NSCLC compressing sympathetic chain. Diagnosis: Pancoast tumour with Horner’s syndrome. Managed with oncological staging and definitive chemoradiation ± surgery.
• Case 3 - Vascular compression 🩸: A 65-year-old man complains of swelling of his right arm and distended chest wall veins. Exam: engorged right upper limb, venous congestion. CT chest: apical mass compressing subclavian vein. Diagnosis: Pancoast tumour with subclavian vein obstruction. Managed with chemo-radiotherapy and possible surgical resection.
• Case 4 - Advanced disease with metastases 🌍: A 60-year-old woman presents with chronic cough, weight loss, and right shoulder pain. She has Horner’s syndrome and palpable supraclavicular lymph nodes. CT: apical mass with mediastinal lymphadenopathy and bone metastases. Diagnosis: metastatic Pancoast tumour. Managed with palliative chemo-radiation and supportive care.

Teaching Point 🩺: Pancoast tumours are apical lung cancers, often non-small cell (usually squamous or adenocarcinoma), presenting with: - Shoulder/arm pain (brachial plexus invasion) - Horner’s syndrome (ptosis, miosis, anhidrosis from sympathetic chain involvement) - Upper limb swelling (vascular compression) Management: chemo-radiotherapy ± surgical resection, prognosis depends on staging. Always consider in a smoker with shoulder pain + neurological or autonomic signs.