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Pancoast’s Tumor

Pancoast’s Tumor. Sallie Ruth Coleman December 15, 2008. Outline. What is it? What else could it be? Clinical Presentation Imaging Work-Up Treatment Prognosis What next?. Henry Pancoast: early 20 th century One region…Many names Location. Introduction. Malignant Tumor

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Pancoast’s Tumor

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  1. Pancoast’s Tumor Sallie Ruth Coleman December 15, 2008

  2. Outline • What is it? • What else could it be? • Clinical Presentation • Imaging Work-Up • Treatment • Prognosis • What next?

  3. Henry Pancoast: early 20th century One region…Many names Location Introduction

  4. Malignant Tumor Pancoast’s Tumor Mesothelioma Lymphoma Metastatic Disease Benign Tumor (most commonly Neurofibroma Pleural Thickening Status post radiation Infection (i.e. TB, fungi, hydatid cysts) Pleural effusion (loculated at apex) Hematoma Extrapleural from aortic rupture Vascular aneurysms Iatrogenic (i.e. after attempted CVC placement) Associated with rib or vertebral fracture Differential Diagnosis

  5. Clinical Presentation • Arm/shoulder pain • Horner’s syndrome • Weakness/atrophy or hand muscles Pancoast’s Syndrome

  6. Radiographic findings • X-Ray • Unilateral cap > 5mm • Asymmetry of bilateral caps > 5 mm • Apical mass • Bone destruction

  7. X-Ray Unilateral cap > 5mm Asymmetry of bilateral caps > 5 mm Apical mass Bone destruction CT Presence of satellite nodules, parenchymal disease, mediastinal lymphadenopathy Radiographic findings

  8. X-Ray Unilateral cap > 5mm Asymmetry of bilateral caps > 5 mm Apical mass Bone destruction CT Presence of satellite nodules, parenchymal disease, mediastinal lymphadenopathy MRI Evaluation of brachial plexus, subclavian vessels, vertebral bodies, spinal canal, and chest wall involvement Radiographic findings

  9. Diagnostic Work-Up • Bronchoscopy and sputum cytology? • Percutaneous needle biopsy • VATS • Thoracotomy

  10. Pathology • Mostly non-small cell lung cancer • Mainly squamous cell carcinoma • Small cell carcinoma: 5% of cases

  11. Staging/Preoperative Assessment • Staging same as with NSCLC’s (TMN staging) • PET scan • Mediastinoscopy • Brain Imaging

  12. Treatment • Multimodality therapy • Radiation therapy followed by en bloc extended surgical resection • Chemotherapy/chemoradiotherapy

  13. Prognosis • Overall 5-year survival rates with preoperative RT and surgical resection: 30% • Patients with uninvolved lymph nodes: 30-40% • Patients with incomplete resection, mediastinal nodal involvement, or T4 vertebral body invasions: <10% • 2/3 patients will have recurrent disease • Poor prognostic factors: • Presence of Horner’s syndrome • Extension of tumor into the base of the neck, great vessels, or vertebral bodies • Involvement of mediastinal lymph nodes

  14. Post-Therapy Surveillance • Little data to support evidence-based guidelines for routine surveillance following therapy

  15. Further Recommendations • Whenever possible, patients with superior sulcus tumors should be enrolled in prospective clinical trials so that the optimal therapy may be determined.

  16. The End

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