What is a Pancoast tumor? How does it differ from other lung cancers? What are the symptoms and treatment options? Get answers to your questions about this rare but serious condition.

Understanding Pancoast Tumors

Pancoast tumors are a unique type of lung cancer that originate in the upper portion of the lung, also known as the lung apex. These cancers were first described by American physician Henry Pancoast in 1932, and are therefore often referred to as “Pancoast tumors” or “superior pulmonary sulcus tumors.” Pancoast tumors account for less than 5% of all lung cancer cases, making them a relatively rare form of this disease.

Anatomy and Spread of Pancoast Tumors

Pancoast tumors are characterized by their location at the top of the lung. Due to this positioning, these cancers can spread and invade surrounding structures, including the:

• First ribs in the chest (thoracic ribs)
• Upper part of the back
• Bundle of nerves that send signals from the spinal cord to the shoulder, arm, and hand (brachial plexus)
• Blood vessels supplying the arms

This ability to infiltrate nearby anatomical structures sets Pancoast tumors apart from other lung cancers, which typically grow and spread within the lung tissue itself.

Histological Subtypes of Pancoast Tumors

The majority of Pancoast tumors are a type of non-small cell lung cancer, most commonly adenocarcinomas. Adenocarcinomas originate from the mucus-producing gland cells lining the airways. Other less common subtypes include squamous cell carcinoma and small cell lung cancer.

Symptoms of Pancoast Tumors

What are the typical symptoms associated with Pancoast tumors? Due to their location at the lung apex, these cancers can put pressure on or damage the brachial plexus – the bundle of nerves running from the upper chest into the neck and arms. This can lead to a characteristic set of symptoms, including:

• Severe shoulder or arm pain
• Muscle weakness or atrophy in the hand and arm
• Numbness or tingling sensations in the hand and arm
• Drooping eyelid and constricted pupil on the affected side (Horner’s syndrome)

In addition, Pancoast tumor patients may also experience more general lung cancer symptoms such as cough, shortness of breath, and weight loss.

Diagnosis and Imaging of Pancoast Tumors

How are Pancoast tumors detected and diagnosed? Initial imaging with a chest X-ray may show subtle changes, such as a non-homogenous opacity in the upper lung zone or tracheal deviation. However, in up to 1.7% of cases, the chest X-ray may appear normal despite the presence of a Pancoast tumor. Therefore, if there is a high clinical suspicion, further imaging with a CT scan of the chest is warranted. CT scans can clearly demonstrate the soft tissue mass in the lung apex and assess for invasion of surrounding structures.

Treatment Approaches for Pancoast Tumors

The treatment of Pancoast tumors typically involves a multimodal approach, often combining surgery, radiation therapy, and chemotherapy. The specific treatment plan depends on the stage and extent of the tumor, as well as the patient’s overall health and preferences. In early-stage Pancoast tumors, surgical resection may be the primary treatment, potentially followed by adjuvant (additional) therapies. For more advanced or inoperable tumors, neoadjuvant (pre-surgical) chemotherapy and radiation therapy may be used to try to shrink the tumor prior to surgery. In some cases, definitive chemoradiation therapy without surgery may be the most appropriate approach.

Prognosis and Outcomes

The prognosis for patients with Pancoast tumors can vary widely, depending on factors such as the stage at diagnosis, the tumor’s resectability, and the patient’s response to treatment. In general, early-stage Pancoast tumors that are surgically resectable tend to have a better prognosis, with 5-year survival rates around 30-40%. However, more advanced or inoperable Pancoast tumors have a poorer prognosis, with 5-year survival rates often less than 10%. Continuous advancements in treatment approaches and the use of multimodal therapy have helped to improve outcomes for some patients with Pancoast tumors in recent years.

Images in…: Pancoast tumour – PMC

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BMJ Case Rep. 2012; 2012: bcr2012006285.

Published online 2012 Jun 12. doi: 10.1136/bcr-2012-006285

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A 61-year-old man was referred to our rheumatology unit with a 3-month history of worsening left-sided neck and shoulder pain. His general practitioner (GP) suspected Giant cell arteritis and a temporal artery biopsy was performed which was negative. Shoulder and neck x-rays were also normal. He had a 40-pack-year smoking history and a chest radiograph was organised by his GP. On questioning, he admitted to significant weight loss and hoarseness of voice.

On examination, shoulder movements did not exacerbate his pain and he had a full range of shoulder and upper-limb movements. He had a left Horner’s syndrome, a cyanosed left forearm with feebly palpable left upper-limb pulses. The temporal arteries were non-tender. Chest examination was unremarkable. His erythrocyte sedimentation rate and C-reactive protein level were raised at 30 mm/h and 60 mg/l, respectively. Other blood tests were unremarkable.

A chest radiograph () showed slight right-sided tracheal deviation and subtle non-homogenous left upper-lobe opacity. The history and clinical features along with radiological findings were highly suggestive of a left apical lung lesion. An urgent enhanced CT scan of the thorax ( and ) was arranged and demonstrated a soft-tissue mass (6. 9 cm × 5.4 cm × 7.7 cm) in the left lung apex encasing the left subclavian artery.

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Chest radiograph with slight right tracheal deviation and subtle non-homogenous opacity in left upper zone (black arrows).

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Coronal enhanced CT scan image of the thorax demonstrates a soft-tissue mass (6.9 cm × 5.4 cm × 7.7 cm), in left lung apex encasing the subclavian artery (white arrows).

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Sagittal enhanced CT scan image of the thorax shows encased subclavian artery by a Pancoast tumour (white arrows).

Of the patients presenting with a Pancoast tumour, 1.7% have a normal plain chest radiograph.¹ Our case illustrates that when there is a high index of clinical suspicion, CT imaging should be undertaken to exclude a Pancoast tumour even when the plain radiograph changes are subtle.

Shoulder pain has been reported as being the first presenting feature of a Pancoast tumour in 90% of cases. ² It is of interest that the original description of a Pancoast tumour in 1932 by Henry Pancoast³ was of shoulder pain due to an apical mass.

Competing interests: None.

Patient consent: Obtained.

1. Fletcher F, Johnston RN, Stradling P.
The normal chest radiograph in bronchial carcinoma. BMJ
1976;2:403.1. [PMC free article] [PubMed] [Google Scholar]

2. Yacoub M, Hupert C.
Shoulder pain as an early symptom of Pancoast tumour. J Med Soc N J
1980;77:583–6. [PubMed] [Google Scholar]

3. Pancoast H.
Superior pulmonary sulcus tumour. JAMA
1932;99:1391–6. [Google Scholar]

Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group

Pancoast tumours | Lung cancer

Pancoast tumours are cancers that start in the top part of the lung (the apex). 

These cancers were named after an American doctor called Professor Henry Pancoast in 1932.  They are also called superior pulmonary sulcus tumours.

Cancers in the top part of the lung are rare. Fewer than 5 in every 100 cases of lung cancer (5%) are Pancoast tumours.

A Pancoast tumour can spread into one or more structures in the top part of the chest, which include:

• the first ribs in the chest (thoracic ribs)
• upper part of the back
• the bundle of nerves that sends signals from the spinal cord to the shoulder, arm and hand (the brachial plexus)
• blood vessels that supply blood to the arms

Types of Pancoast tumour

Most Pancoast tumours are a type called non small cell cancer and most commonly adenocarcinomas. These are cancers that start in the mucus making gland cells in the lining of your airways.

Symptoms

Because the cancer is at the top of the lungs, it might put pressure on or damage a group of nerves that runs from the upper chest into your neck and arms. The group of nerves is called the brachial plexus.

Pressure on the brachial plexus can cause several very specific symptoms:

• severe pain in the shoulder or the shoulder blade (scapula)
• pain in the arm and weakness of the hand on the affected side
• Horner syndrome

Horner syndrome is the medical name for a group of symptoms. They include:

• flushing on one side of the face
• not sweating in the face
• the eye on the same side has a smaller (constricted) pupil with a drooping or weak eyelid

Diagnosing Pancoast tumours

Pancoast tumours can be difficult to diagnose. This is because, in the early stages, they often don’t show up easily on x-ray. To help diagnose a Pancoast tumour, you might have a:

• needle biopsy
• biopsy through a video assisted thoracoscopy surgery (VATS)
• biopsy through a small cut in the chest wall (small thoracotomy)
• scans such as a CT, MRI or PET-CT

The symptoms are unusual, and this might lead your doctor to suspect other conditions before lung cancer.

Treatment

Treatment for a Pancoast tumour depends on the stage of the cancer, it’s exact position in the lung and your general health. The stage means the size of the cancer and whether it has spread to other areas of the body.

Chemoradiotherapy and surgery

If you are fit enough to have surgery, you usually have a combination of chemotherapy and radiotherapy (chemoradiotherapy) first. This helps to shrink the cancer. 

Surgery for Pancoast tumours is often difficult. It needs to be carried out by a team of specialist surgeons at a specialist cancer hospital. The surgery involves removing the top two ribs or sometimes more.

Sometimes the surgeon also needs to remove a major artery behind the collar bone. They replace it with an artificial tube (graft). This keeps a good blood supply to the arm on the affected side. They might carry out the surgery through a cut in the back or the front of the chest.

Chemoradiotherapy and immunotherapy

If you can’t have surgery, you might have chemoradiotherapy (chemotherapy with radiotherapy).

You might then have immunotherapy after chemoradiotherapy. Immunotherapy uses our immune system to fight cancer. It works by helping the immune system recognise and attack cancer cells.

Radiotherapy or supportive care

You usually have radiotherapy if:

• the cancer can’t be removed with surgery
• has spread to other areas of the body

This treatment shrinks the cancer and reduces symptoms. You can also have other medicines or treatments to control symptoms.

Targeted treatment

Your doctor will test your cancer cells for certain receptors of particular proteins. The receptors make them sensitive to targeted cancer drugs. If these receptors are present, your doctor might offer you treatment with a targeted cancer drug.

More information and support

You can phone the Cancer Research UK nurses on freephone 0808 800 4040, from 9am to 5pm, Monday to Friday. They can help with questions on cancer.

• Lung cancer: diagnosis and management

  National Institute for Health and Care Excellence, March 2019 (updated September 2022)

• Management of lung cancer
  Scottish Intercollegiate Guideline Network, February 2014

• Diagnosing and treating pancoast tumors
  K Zarogoulidis and others
  Expert Review of Respiratory Medicine, 2016

  Volume 10, Issue 12

• Pancoast tumour: current therapeutic options

  VD Palumbo and others

  Clinica Terapeutica, 2019

  Volume 170, Issue 4

• Superior pulmonary sulcus (Pancoast) tumors

  UpToDate website

  Accessed January 2023

• Cancer: Principles and Practice of Oncology (11th edition)

  VT DeVita, TS Lawrence, SA Rosenberg

  Wolters Kluwer, 2019

• The information on this page is based on literature searches and specialist checking. We used many references and there are too many to list here. If you need additional references for this information please contact [email protected] with details of the particular risk or cause you are interested in.

Last reviewed: 

03 Jan 2023

Next review due: 

03 Jan 2026

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Pancreatic cancer: symptoms, treatment, stages

Chemotherapy

Levikin

Evgeny Alexandrovich

Experience 22 years

Oncologist

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Pancreatic cancer is not in vain called one of the most insidious and severe oncological diseases. For a long time, it is asymptomatic and reveals itself already at a late stage, when surgical treatment becomes extremely difficult. The tumor develops from malignantly modified glandular cells or epithelial tissue lining the ducts. As a result of mutation, cells lose their main function and become capable only of active uncontrolled division. The neoplasm rapidly increases in size and grows into neighboring organs. In terms of incidence, oncology of the pancreas is approximately in tenth place among all cancer pathologies, and in terms of mortality, it is in fourth place.

Species

According to localization, they distinguish:

• tumors of the head of the pancreas, accounting for 50-60% of all cases;
• tumors of the body of the gland – up to 10% of cases;
• tail tumors – about 6-8%.

In about 25-30% of patients, oncopathology affects the entire organ.

According to histological features, they are distinguished:

• adenocarcinomas – neoplasms consisting of mutated glandular cells, occur in 85-95% of patients;
• neuroendocrine tumors;
• malignant cystic tumors.

Symptoms

The initial symptoms of pancreatic cancer are non-specific and can easily be attributed to poor health, but they should never be neglected. In the early stages, the disease manifests itself:

• upper abdominal discomfort;
• intense thirst, frequent urination and other signs of diabetes;
• weakening of the stool up to liquefaction, frequent urge to defecate;
• fatigue, decreased performance, loss of appetite.

With the growth of the tumor and the progression of the disease, more serious symptoms develop:

• pain in the upper abdomen, often radiating to the back;
• yellowing of the sclera of the eyes and skin due to disturbances in the outflow of bile;
• nausea, occasional vomiting;
• digestive disorders due to decreased production of digestive enzymes;
• weight loss.

Causes and risk factors

The only reason why pancreatic oncology occurs is a malignant mutation of cells and their uncontrolled growth, which is not prevented by the immune system in time. However, there are a number of factors that have a negative effect on the body and contribute to the appearance of a tumor:

• chronic pancreatitis, which increases the risk of morbidity by about 20 times;
• tobacco smoking;
• the presence of diabetes mellitus;
• obesity;
• malnutrition with excessive consumption of meat, animal fats, fried foods;
• inherited predisposition to oncopathologies.

Men get sick one and a half to two times more often than women. The main proportion of patients are people of the older age group (from 60 to 80 years).

Stages

Oncologists distinguish four stages of pancreatic cancer.

1. A small neoplasm that does not spread outside the organ, without metastases.
2. Malignant cells extend beyond the gland, but large vessels are not involved in the process. Metastases in regional lymph nodes are possible.
3. The tumor invades large vessels, affects most of the regional lymph nodes, but does not metastasize to other organs.
4. The size of the tumor does not matter, the tumor actively metastasizes through large blood arteries to the lungs, liver, spine and bones, through the lymph flow to distant lymph nodes, as well as to the intestines, stomach and other organs of the peritoneum.

Diagnostics

It is difficult to diagnose a pancreatic tumor in time: there are practically no symptoms in the early stages, and routine tests do not show serious abnormalities. It is necessary to perform a number of instrumental and laboratory studies to identify pathology.

• A biochemical blood test reveals an increased level of bilirubin, a number of digestive enzymes and bile acids, and a decrease in the level of proteins.

• Coagulogram determines the ability of blood to clot.

• Ultrasound of the abdominal cavity allows you to detect a neoplasm in the tissue of the gland, to assess its size and spread to other organs.

• Esophagogastroduodenoscopy, i.e. the introduction of a probe with a video camera into the intestine through the mouth is prescribed to detect metastases of pancreatic cancer in the digestive tract.

• A chest x-ray is done to look for lung metastases.

• MRI of the pancreas and surrounding tissues makes it possible to assess the prevalence of the tumor process.

• A biopsy of the tumor tissue followed by histological examination is necessary to confirm the diagnosis and establish the type of tumor cells.

Treatment

Treatment for pancreatic cancer depends on the stage of the disease.

• Surgery is the main method in the first or second stage, after which chemotherapy drugs are prescribed to destroy residual malignant cells. Depending on the degree of damage, the organ is removed completely or partially.

• Chemotherapy is the first step in a long-term treatment regimen in the third stage. If it helps to reduce the spread of the tumor, surgery is performed to remove the gland. Together with the pancreas, the duodenum, part of the small intestine and / or stomach, and the gallbladder with ducts can be removed.

• Radiation therapy is prescribed to the patient if chemotherapy has failed, and the operation is considered impossible.

• In the fourth stage, the tumor is usually inoperable, so the patient is prescribed only chemotherapy drugs to reduce the growth rate of malignant cells and prolong the patient’s life.
• Patients with neuroendocrine tumors are operated on at any stage, after which courses of chemotherapy are prescribed.

Forecasts

Despite the achievements of modern oncology, the prognosis for the treatment of pancreatic cancer leaves much to be desired. After a radical operation to remove an organ at the first or second stage, the five-year survival rate does not exceed 25-30%, at the second or third stage – up to 15%. With the fourth stage, no more than 3% of patients can live for more than five years. Much depends on the skill of the surgeon and the quality of postoperative care, since interventions on the pancreas are classified as the most difficult, and postoperative complications are the main cause of death.

Prevention

To reduce the risk of developing a tumor in the pancreas, you must:

• give up alcohol and smoking;
• eat less red meat, fried and fatty foods, fast food and smoked meats;
• carefully treat chronic pancreatitis when the disease occurs;
• regularly undergo preventive examinations.

Rehab

Recovery after surgery is an important step in the treatment of pancreatic cancer, including:

• analgesic therapy, elimination of pain curvature of the body;
• expansion of bile ducts narrowed after surgery, treatment of inflammation;
• meticulous care of surgical sutures;
• sparing diet;
• regular administration of insulin, other hormones and enzymes;
• physiotherapy treatments, etc.

Hormone and enzyme replacement therapy after radical surgery is necessary for the patient for the rest of his life.

Diagnosis and treatment of pancreatic cancer in Moscow

After the signs of pancreatic cancer are detected, it is important to choose the right treatment facility where you can receive high-quality care. Contact the clinic “Medicine” to undergo a diagnostic examination and receive high-quality treatment. At your service:

• the most modern, unique medical equipment;
• any chemotherapy drugs used in accordance with Russian and Western protocols;
• high professionalism of oncologists, surgeons, endocrinologists, chemotherapists and other specialists;
• comfortable hospital, where patients are provided with care in accordance with international standards.

Call us to sign up for an initial consultation, undergo an examination and confirm or refute the suspicion of oncopathology.

Questions and answers

How long do people live with pancreatic cancer?

After the appearance of distant metastases in pancreatic cancer, most patients live for one to two years. Therefore, it is extremely important to detect the disease in time at the stages preceding metastasis, when the chances of successful treatment remain quite high.

What does pancreatic cancer look like?

At the initial stage, the tumor develops asymptomatically. Since the pancreas is a small organ located deep in the abdominal cavity, it is impossible to notice the presence of a neoplasm outwardly. With liver damage, many patients develop a yellowish tint to the skin and eye proteins, people noticeably lose weight due to digestive disorders and general intoxication.

Is there a cure for pancreatic cancer?

With early detection of the tumor and high qualification of the operating surgeon, as well as with careful professional care after the operation, the chances of a cure are quite high. Therefore, when symptoms resembling pancreatitis or diabetes appear, it is necessary to undergo a preventive examination by an oncologist. This is especially important for older people who are at risk.

Attention!
You can cure this disease free of charge and receive medical care at JSC “Medicina” (Academician Roitberg’s clinic) under the program of State guarantees of compulsory medical insurance (Compulsory medical insurance) and VMP (high-tech medical care).
To find out more, please call +7(495) 775-73-60, or visit the VMP CHI page

List of sources

• Davydov, M.I. Oncology / M.I. Davydov. – M.: Publishing group RONTS, 2015
• Bazin I. Place of chemotherapy in the treatment of localized pancreatic cancer/I. Bazin, I. Pokataev. – 2016
• Malyarchuk V.I., Klimov A.E., Pautkin Yu.F. Biliopancreatoduodenal cancer: Monograph. – M .: Publishing house of RUDN University, 2006
• V.A. Kubyshkin, V.A. Vishnevsky. Pancreas cancer. – M .: ID Medpraktika – M, 2003

Pancreatic cancer – symptoms, treatment, causes.

Pancreatic cancer is a common malignant disease that affects an important human organ responsible for the secretion of necessary enzymes.

The pancreas is an organ of the gastrointestinal tract that produces a special secret. Its main function is the production of pancreatic juice, which helps control the balance of fats, carbohydrates and proteins in the body. Another important function is the production of insulin, which helps control blood glucose levels.

The tumor develops without visible symptoms, which leads to late detection of pancreatic cancer, which is difficult to diagnose. This disease has a high mortality and manifests itself in men and women who, on average, have reached the age of 65 years.

Pancreatic cancer – causes

The causes of a tumor in the pancreas are multifactorial.

The most common cause of a tumor is an unhealthy lifestyle. Drinking alcohol and smoking negatively affect the functioning of the organs, which leads to depressing consequences. Signs of a malignant neoplasm appear as consequences in the later stages, which leaves little chance for a normal life.

Also, eating junk food, fried and fatty, adversely affects the internal organs. The gland works “for wear and tear”, which weakens its functions and increases the chance of pancreatic cancer.

The causes of the disease can be harmless obesity and a sedentary lifestyle, as a result of a decrease in immunity, as well as depression. All these signs worsen the condition of a person and aggravate health.

The tumor develops in people with genetic inheritance. Unfortunately, this is a common cause of pancreatic cancer.

Chronic diseases such as pancreatitis can develop into cancer. It is important to monitor the condition of the disease and treat it in order to rid yourself of the cause of pancreatic cancer.

Pancreatic cancer – symptoms

Cancer symptoms have a general picture, and they include: malaise, rapid fatigue, decreased appetite and, as a result, rapid weight loss.

With the development of the tumor, intense pain appears in the epigastric part. Such pain can be accompanied by a deterioration in the general condition and a violation of the normal functions of the body. Vomiting, diarrhea or, conversely, constipation is added to the malaise and pain.

The development of pancreatic cancer affects the functions of the internal system of the body. The level of bilirubin in the blood rises, the appearance of jaundice, with characteristic signs arising from it.

Pancreatic cancer – diagnosis

Diagnosis of a pancreatic tumor begins with a visit to a gastroenterologist and an oncologist. The development of the disease can occur without pronounced symptoms, which complicates the ability to determine the disease.

Diagnostic procedures for pancreatic cancer begin with a doctor’s consultation. The attending physician refers the patient to certain examinations

To determine the localization of pancreatic cancer, the size of the tumor and the nature of its growth, doctors use magnetic resonance imaging and ultrasound, laboratory blood tests, as well as urine and histology.

As the diagnosis shows, contrasting with tomography can successfully determine the development of the tumor and the possibility of its metastasis.

Pancreatic cancer – stages

The staging of pancreatic cancer is calculated according to the formula, which has the name – Classification of malignant tumors. The development of a neoplasm and its spread in the body has certain stages, depending on the signs, symptoms and course of the growth process, and a treatment program is being developed.

Stage 1 – size of the neoplasm is small and localized in the tissue of the organ,

Stage 2 – the size and growth of the tumor increases,

Stage 3 – cancer cells get into the lymphatic vessels,

Stage 4 – metastasis to other organs and lymph nodes.

Pancreatic cancer – treatment

Treatment of pancreatic cancer is carried out by several or complex types of procedures.

Depending on the signs of growth, symptoms, and stages of the tumor, resection, radiation therapy, chemotherapy and the use of a modern type of treatment such as HIFU therapy are possible.

The main and most radical method of treatment is the surgical removal of the entire organ or part of it, in which the tumor grows. This application of treatment occurs mainly in the 3 stages of the disease. The consequences of recovery depend on the state of the body and possible metastases. Symptoms of the disease may persist for a certain period, after which it is time for recovery and struggle. Lethal outcomes are minimized.

Radiation therapy is used as a method of postoperative treatment. To relieve symptoms and risks of metastasis of cancer cells to other organs and lymph nodes.

Chemotherapy is also an important maintenance therapy. Such therapy helps to avoid relapse and relieve the symptoms of the disease.

HIFU therapy is a new advanced way to treat pancreatic cancer using high frequency ultrasound. The technique helps to get rid of the symptoms and not bring the treatment to the surgical removal of the tumor. The effectiveness of the treatment, as practice shows, works very well in the best possible way.