Pancoast Tumor

What is a Pancoast tumor?

A Pancoast tumor is a rare type of lung cancer. It begins in the upper part of your lung (the apex), above your first rib.

Unlike most lung cancers, Pancoast tumors don’t usually cause coughing or chest pain. Instead, people with Pancoast tumors almost always develop shoulder pain accompanied by arm weakness and other symptoms. Healthcare providers call this collection of symptoms “Pancoast syndrome.”

Because Pancoast syndrome doesn’t cause classic lung cancer symptoms, there may be a delay in the detection of these tumors. In many cases, a clear diagnosis doesn’t occur until the cancer has spread to nearby nerves and blood vessels.

Pancoast tumors get their name from the radiologist who first described them in the early 20th century. Another name for a Pancoast tumor is a superior sulcus tumor.

Types of Pancoast tumors

Subtypes of Pancoast tumors include:

• Non-small cell lung cancers, such as adenocarcinomas and squamous cell carcinomas.
• Small cell lung cancers.

The majority of Pancoast tumors are adenocarcinomas. These cancers begin in the lining of your airways and alveoli (the air sacs in your lungs) — specifically in your mucus-making gland cells.

How common are Pancoast tumors?

Pancoast tumors are rare, making up less than 5% of all lung tumors.

What are the symptoms of a Pancoast tumor?

A Pancoast tumor may place pressure on your brachial plexus — a group of nerves that runs from your upper chest into your neck and arms. When this happens, it causes a specific group of symptoms. Healthcare providers call this collection of symptoms Pancoast syndrome or Pancoast-Tobias syndrome.

Pancoast tumor symptoms appear on the affected side of your body. For example, if the tumor is in your right lung, then you’ll develop symptoms that affect the right side of your body.

Pancoast tumor symptoms may include:

• Severe shoulder pain, which may include pain in your shoulder blade.
• Pain that radiates down your arm and stops at your wrist, just above your pinky finger.
• Arm and hand weakness.
• Neck pain.
• Pain in your upper ribs.
• Upper arm swelling.
• Loss of dexterity in your hand and fingers.
• Tingling or numbness in your hand.
• Tiredness (fatigue).
• Tightness in your chest.
• Unexplained weight loss.

Up to 50% of people who have Pancoast tumors may also develop Horner’s syndrome, which may cause:

• Facial flushing.
• A droopy eyelid (ptosis).
• Displaced eyeball (enophthalmos).
• Lack of sweat (anhidrosis).

What causes Pancoast tumors?

Causes and risk factors of Pancoast tumors are similar to other lung cancer tumors. Common risk factors include:

• Smoking.
• Secondary smoke exposure.
• Long-term exposure to certain substances, including asbestos, radon gas and heavy metals.

How do Pancoast tumors spread?

When cancer spreads, cancer cells break away from the original tumor, travel through your blood or lymph system and form new tumors in other parts of your body.

Most commonly, Pancoast tumors can spread from your upper lung into your:

• Upper chest.
• Upper back.
• Thoracic ribs (in your chest).
• Nearby blood vessels in your arms.

How are Pancoast tumors diagnosed?

In the early stages, Pancoast tumors don’t show up easily on two-dimensional chest X-rays. For this reason, they can be difficult to diagnose.

If your healthcare provider suspects a Pancoast tumor based on your symptoms, they may recommend other diagnostic tests, which may include:

• Additional imaging tests.
• Needle biopsy.
• Video-assisted thoracoscopy surgery (VATS).
• Thoracotomy.

Imaging tests

Advanced imaging can give your healthcare provider a clearer view of your lungs. They may order:

• CT (computed tomography) scans.
• PET (positron emission tomography) scans.
• MRI (magnetic resonance imaging).

Needle biopsy

During a needle biopsy, a healthcare provider will extract fluid, tissue or cells from any abnormal lumps. Then, they’ll send the sample to a pathology lab for further testing.

VATS (video-assisted thoracoscopy surgery)

During video-assisted thoracic surgery (VATS), a healthcare provider makes an incision (cut) in your chest and inserts a thoracoscope (a thin tube with a tiny camera on the end). This allows them to see inside your chest cavity and detect any tumors or other abnormalities. If they see anything, they’ll take a sample of the tissue and send it to a lab for testing.

Thoracotomy

In some cases, a healthcare provider may need to perform a thoracotomy. During this procedure, they’ll make an incision (cut) on the right or left side of your chest, between your ribs. This allows them to clearly see the affected lung and take a biopsy of any abnormal tissue.

In most cases, they’ll go ahead and remove the tumor, too. This helps you avoid multiple surgical procedures.

What should I know about Pancoast tumor staging?

As with other types of lung cancer, healthcare provider categorize Pancoast tumors using the cancer staging system. They use numerals (I, II, III, IV) and subtypes (A, B) to describe how advanced the tumor is and how far it has spread.

For Pancoast tumors, providers also use letters (T, N, M) and numbers (1, 2, 3, 4) to indicate the severity of the condition:

• T indicates the size of your tumor and how far it has spread.
• N tells you whether cancer has spread to your lymph nodes.
• M indicates whether the cancer has spread to distant sites in your body (metastasis).

What stage are most Pancoast tumors?

Because Pancoast tumors are difficult to detect in the early stages, most are T3 or T4 at the time of diagnosis. T3 means the cancer has invaded your chest wall or your sympathetic nerves. T4 means the cancer has spread to other structures like your brachial nerves or spinal cord.

How are Pancoast tumors treated?

It depends on the location of the tumor and how far the cancer has spread. Treatment options include:

• Chemoradiation and surgery.
• Chemoimmunotherapy and surgery.
• Chemoradiation and immunotherapy.
• Radiation therapy.
• Targeted treatment.

Chemoradiation and surgery

Surgery is the preferred treatment, when possible. However, before surgery, providers use chemoradiation (chemotherapy and radiation therapy) to shrink the tumor.

Pancoast tumor surgery can be difficult. Generally, a surgeon must remove your top two ribs. They may also need to remove a major artery and replace it with a vascular graft (an artificial tube to carry blood flow). Your surgeon will let you know what to expect before your procedure.

Chemoimmunotherapy and surgery

In some cases, healthcare providers use a combination of surgery and chemoimmunotherapy (a combination of chemotherapy and immunotherapy). While chemotherapy kills cancer cells to slow the growth of a tumor, immunotherapy stimulates your own immune system so it can fight cancer.

Chemoradiation and immunotherapy

Sometimes, surgery isn’t an option. In these cases, your medical team may recommend a combination of chemoradiation and immunotherapy.

Radiation therapy

If surgery isn’t possible and the cancer has spread to other areas of your body, your provider may recommend stand-alone radiation therapy to slow cancer growth. This supportive care approach shrinks the cancer and eases your symptoms.

Targeted therapy

Some people benefit from targeted therapy. This treatment targets the genetic mutations (changes) that turn healthy cells into cancer cells.

To find out if you’re eligible for targeted therapy, a healthcare provider will test your cancer cells for specific receptors of particular proteins. If you have questions about targeted therapy, talk to your healthcare provider.

Can I prevent Pancoast tumors?

While you can’t totally prevent Pancoast tumors, there are things you can do to reduce your risk for this type of cancer:

• Avoid smoking and other tobacco products. If you smoke, talk to your healthcare provider about quitting smoking.
• Avoid secondhand smoke when possible.
• Make sure your environment is free from harmful chemicals or substances, like asbestos.

In addition, if you have a family history of lung cancer, or you’re predisposed to lung cancer, you may want to ask your healthcare provider about preventive cancer screenings.

What can I expect if I have a Pancoast tumor?

If you receive a Pancoast tumor diagnosis, your healthcare provider will assemble a treatment team that’s tailored to your specific needs. Your treatment team will include:

• Thoracic surgeons.
• Neurosurgeons.
• Oncologists, including medical oncologists, surgical oncologists and radiation oncologists.

Your medical team will recommend treatment based on the size and location of the Pancoast tumor, as well as whether the cancer has spread to other areas.

How quickly do Pancoast tumors grow?

In most cases, Pancoast tumors grow slowly. But there are rare instances in which a tumor can grow very rapidly. Your healthcare provider will routinely monitor the growth of the tumor before, during and after treatment.

What is the life expectancy with a Pancoast tumor?

Pancoast tumor survival rates have gradually improved over the last several years, due to advances in technology. But there’s still a lot to learn.

For people with early-stage, surgically treatable Pancoast tumors, the five-year survival rate is around 30% to 50%. That means that up to half of all people diagnosed with early-stage Pancoast tumors are still alive five years after their diagnosis.

It’s important to know that Pancoast tumor survival rates are just estimates. They can’t tell you how long you’ll live or how well a particular treatment will work for you. For a better understanding of how this cancer affects you, talk with your healthcare provider.

When should I seek care?

You should see a healthcare provider immediately if you start to have severe shoulder pain, arm pain, hand weakness or other Pancoast tumor symptoms. Early detection is key.

What questions should I ask my healthcare provider?

If you or a loved one received a Pancoast tumor diagnosis, here are some questions you may want to ask your healthcare provider:

• Where’s the tumor located?
• Has it spread into surrounding tissues?
• Has it spread to distant areas of my body?
• What stage of cancer do I have?
• What are my treatment options?
• Will I be able to work during treatment?
• How long does treatment usually take?
• What’s my outlook?

Do I have a Pancoast tumor or a pinched nerve?

Some people with Pancoast tumors report that symptoms began with a “pinched nerve” sensation. If you develop this type of pain and it lingers for more than a couple of weeks, let a healthcare provider know.

A note from Cleveland Clinic

Pancoast tumors start in the upper portion of your lung. They differ from other types of lung tumors because they’re difficult to detect in the early stages. A Pancoast tumor diagnosis can bring up a lot of complex emotions. Planning your next steps can feel overwhelming. Your healthcare provider is there to help you. Ask them for additional resources or information about your specific situation. You may also want to join a local or online support group. Talking with others who are going through the same thing can be beneficial for your mental, emotional and spiritual health.