26.8.

2016

Pancoasttumour&redflagsfortheupperlimb

Pancoasttumour&redflagsfortheupperlimb
"Medicineisnotandcannotbeanexactsciencebecauseofthecomplexityofthehumanelement
involved"(HenryPancoast,1932,p.1391).
Thetopicofredflagsintriguesme.Somepractitionerswouldsaythatthediagnosticutilityofredflagsisnot
verystrong,andtheyarenotentirelywronginmakingthisclaimbasedonourcurrentlyavailableevidence.
Nonetheless,weneedsomethingtousetohelpguideourclinicaldecisionmaking.Frommyexperience
usingspecialquestionstotryidentifyredflagshasbeenveryuseful,especiallywhenIknowwhatIam
lookingfor.Whenyouaskyourspecialquestionsyoureallyneedtohaveanideaofwhatcompeting
conditionshavemadetheirwayontoyourhypothesislist.Takingthisapproachismoreeffectivethansimply
askingoutofhabit.PreviouslyIhavewrittenbroadlyonthetopicofredflagsandthisblogisgoingtozoom
inontooneconditioninparticular,thePancoastTumour.
InarecentpodcastbyUntoldPhysioStories,JasonShaneandErsonReligiosodiscussacasewhereErson
identifiedseveralredflagsandhispatientultimatelywasdiagnosedwithcancer.WhenIlistenedtothe
podcastitremindedmeofafewunusualcasesthatIveexperienced.Youneverforgetthembecausethe
truefactisthatwhenyougutstartstochurnandyoutrulyrealisesomethingisntquiteright,thenwhat
remainstobedeterminedisnotalwaysfriendly.Norisiteasytotreat.

AcaseofasuspectedPancoastTumour
ThecaseIwanttoshareisofatimewhenIwashighlysuspiciousmypatienthadapancoasttumour.
Female,59yearsold,heavysmoker,stressfuljob,strugglingwithanlengthyworkcover(litigation)claimfor
hershoulderinjury,poorgeneralhealth,andIwastreatingherpostasupraspinatussurgicalrepairand
shoulderdecompression.Herrehabwasfairlyconsistentwiththeexpectedrecoveryuntiloneday,whenshe
cameinwiththissuddenswellingoverherleftsupraclavicularregion.Theswellingwasaccompaniedwith
severe,nonremitting,nonmechanicalpainshoulderpainandpainradiatinginherarmallthewayintothe
wristandhand.Therewerenoreflexormyotomalchangesbutherpainlookedverymuchasthougha
nerverootwasbeingentrapped(C6nerverootdermatomalpattern).Theswellingwassounusualand
givenhersmokinghistory,herageandthenatureofherpresentationIimmediatelythought"Ohdear,
haveIbeentreatingherforamusculoskeletalshoulderinjuryandwhatifI'veoverlookedaPancoast
tumour?"Thisgotmesoworried.Pancoasttumoursareafairlyrareandveryaggressivelungtumour
thatareassociatedwithapoorprognosisandhighmortalityrates.

WhatisaPancoasttumour?
Thefirstcaseofthisconditionwasreportedin1838byHare(Panagopoulos,etal.,2014).Itwasn'tuntil90
yearslaterthatthetumourbecomeaknownentity.In1924HenryPancoast,AmericanRadiology,wentto
theAmericanMedicalAssociationandpresentedhisfirstpaperonanewcaseofintrathoracictumours
(Pancoast,1932).Atthistimethetumourwastermed"superiorpulmonarysulcustumour"whichimplied
thelocationofthetumourbutnottheorigin.Aroundthesametime,Tobiasdiscoveredthatthetumourwas
brachiopulmonaryinorigin(Arcasoy&Jett,1997).Pancoastpresentedtwopapersin1924and1932and
thetumourbecameknownasPancoastTumour.

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Inhispapers,Pancoastdescribestheclinicalpresentationofthreecases.Ineachthetumourwas
associatedwithshoulderandarmpain,Horner'ssyndrome,andatrophyofthemusclesofthehand.On
radiographicimagingtherewasevidenceofashadowintheapexofthethoracicinlet,localdestructionof
thefirstthreeribsandonoccasion,infiltrationofthevertebralbodies(Pancoast,1932).Inadditiontothese
clinicalfeatures,patientswereoftenfoundtohaveasmall,hardandtendernoduleatthebaseoftheirneck,
distendedveinsintheneck,leftupperchest,shoulder,andupperthirdofthearm(Pancoast,1932).
Pancoasttumourscomeunderthesubsetofnonsmallcellcarcinomaofthelung(NSCLC).As
mentionedpreviously,itisatumourwithinthepulmonarysulcusandaccountsfor5%ofallcancers
(Manenti,etal.,2013Panagopoulis,etal.,2014).

Clinicalpresentation
ThemainclinicalfeaturesoriginallynotedbyPancoastaredescribedabove,andsomeauthorsreferredto
theseasPancoastTobiasSyndrome(Panagopoulos,etal.,2014).Differentialdiagnosisinvolvescervical
radiculopathy,rotatorcuffdiseaseandthoracicoutletsyndrome.Noneoftheseconditionshowever
wouldresultindistendedvein'sontheneck,chestandarm,Horner'ssyndrome,andanopaquemasson
chestXRAY.

Horner'sSyndrome.ImagecourtesyofGoogleImages
OneofthehallmarkfeaturesofPancoasttumoursisthedevelopmentofHorner'ssyndrome.Horner's
syndromeoccursontheipsilateralsidetothesymptomsandiscausedbytheinvasionofthetumourinto
thecervicalstellateganglionresultingin:
Miosis(constrictedpupil),
Ptosis(droopyeyelid),
Enophthalmos(inseteyeball),
Anhidrosis(decreasedsweating)(Arcasoy&jett,1997Manenti,etal.,2013).

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(Arcasoy&Jett,1997,p.1370)
Horner'ssyndromedoesn'toccurinallpresentations.Whenitdoesoccur,shoulderpainistheprimary
symptomformonthspriortoit'sdevelopment.Thiswouldexplainwhythisconditionsisoftenmistakenfor
musculoskeletalconditionsoftheshoulderorcervicalspine.

ImagecourtesyofGoogleImages
Toalargeextent,thesymptomsdependonthesurroundingstructuresthatthetumourencroachesonor
invades.Interestingly,Panagopoulos,etal(2014,p.S111)discusshowthelocationofthetumouraltersthe
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clinicalsymptoms:
Ifthetumourisbetweenthesternumandanteriorscalenethenthepainispredictedtoradiateintothe
anteriorchestwallandalsocausevenousthrombosis.
Ifthetumourisbetweentheanteriorandmiddlescaleneitcausespainandparaesthesisinthe
shoulder,anteriorupperlimb,andarterialthrombosisanddiaphragmparalysis.
Ifthetumourisbehindthemiddlescaleneitresultsinpainintheaxillaryregion,medialupperarmand
Horner'ssyndrome.
Noneofthearticlesdiscussthenatureorbehaviourofthepainaroundtheshoulder.Luckilyforus,
90yearslaterandwehavedevelopedalotmoreknowledgeaboutpainpresentationsofcommon
musculoskeletalconditionsandcanusethisknowledgeinourassessmenttodetermineinthepainis
mechanical,neurogenic,centrallydrivenetc.

Medicalimaging
Inmanycases,thefirstlineofreferralisforaplainchestXray.OnXrayadifferenceinapicalcapsof>5mm
isconsideredtobeclinicallysignificant(Arcasoy&Jett,1997,p.1371).

(Pancoast,1932,p.1393)
MRIandCTscansplayanimportantroleindiagnosticimaging.IfradioopacityisseenonXRAYthenPET
CTcanbeusedtoconfirmdiagnosis,whileMRIhelpstoprovideahighresolutionimageofallthe
surroundingtissues(Manenti,etal.,2013).
"MRimaginghasapivotalroleforstagingandtherapeuticmanagementinpatientswithPancoasttumour.
MRneurography,DiffusionWeighted(DW)imaging,andMRangiographyareactuallymandatoryimaging
techniquesinallpatientswithsuperiorpulmonarysulcustumours"(Manenti,etal.,2013,p.5).
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(Manenti,etal.,2013,p.3)

(Manenti,etal.,2013,p.3)

Treatment&prognosis
ManyofthecasestudiesI'vereadaroundthistopic,includingDartnelletal(2009)describethepancoast
tumourasrareandhighlyaggressive.AtthetimethatPancoastpublishedhispapers(over90yearsago)
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thetumourwastreatedprimarilywithradiationtherapy,notsurgicalresection,andknowntoberapidly
fatal,withmostpatientsdyeingwithin34monthsofdiagnosis.Sincethen,treatmenthaschanged.

(Dartnell,etal.,2009,p.137)
The1960'ssawthefirstattemptsofsurgicalresectioncombinedwithradiotherapyandthisapproach
remainedthemainstayforthenext30years.Itwasn'tuntilthe1990'swhencombinedchemotherapy,
radiotherapyandsurgicalresectionwasintroducedandsuddenlymortalityratesbegantochange
(Panagopoulos,etal.,2014).
"PrognosisdependsmainlyonTstageoftumour,responsetopreoperativechemoradiotherapyand
completenessofresection"(Formulas,etal.,2013,p.S342).
SurgeryforPancoasttumoursisassociatedwith5%mortalityrateandthecomplicationratevariesfrom
738%(Formulas,etal.,2013,p.S342).
Theoverallfiveyearsurvivalrateaftercombinedpreoperativeradiotherapyandextendedsurgical
resectionisgenerallyaround20to35percent,withamediansurvivalof7to31months(Arcasoy&
Jett,1997,p.1374).
Theoverall2yearsurvivalrateafterinductionchemoradiotherapyandresectionvariesfrom55%to
70%,whilethe5yearsurvivalforresectionsisquitegood(5477%)(Formulas,etal.,2013,p.S342).
Themainpatternofrecurrenceisthatofdistantmetastases,especiallyinthebrain(Formulas,etal.,
2013,p.S342).

Whatdidmytreatmentandassessmentinvolve?
Comingbacktothecaseabove...Iassessedherneck,thoracicspine,andshoulderthoroughlyandthen
wrotealettertothedoctorstatingmyphysicalfindings,clinicalpresentationsandconcernsaboutthe
suddenchangesinherclinicalpresentation.Thispatientdidn'thavesignsofHorner'ssyndromebutasthe
researchsuggests,thisdoesn'toccuruntillaterinthediseaseprogression.
Afterreferraltothedoctor,thepatientwasquicklyreferredforanXRAYandcervicalMRIasthedoctor
sharedthesameconcernsasIhad.LuckilytherewasnotumourbuttheMRIrevealedalargenerve
entrapment.Giventheseverityofherpain,shewasreferredforacortisoneinjectionasafirstlineof
treatmentandthankfullyhersymptomsresolvedquickly.
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Closingthoughts
Soallinall,itwasnastyandpainfulbutnotsinister.ItdidntlooklikeausualC6radiculopathyandthere
wereseveralredflagsinherpresentation.ImgladImadethedecisiontoreferheroutimmediatelyandshe
landedupquicklyonthebestcourseoftreatment.
WhatIhavefoundclinicallyisthatifyouperformathoroughphysiotherapyassessment,asktherelevant
specialquestionsandthenreferyourclienttotheirdoctorwithalettersupportingyoursuspicions,theywill
bemuchbettercaredforthansimplytellingsomeonetogoasktheirdoctorforasecondopinion.
Pancoasttumoursarearareconditionandrapidlyprogressing.Oftentherearedelaysindiagnosiswhen
aspectsofclinicalpresentationaresimilartocommoncomplaintssuchascervicalradiculopathy.Makethe
piecesfitandwhenindoubt,referoutforasecondopinion.
Sian:)

References:
Arcasoy,S.M.,&Jett,J.R.(1997).SuperiorpulmonarysulcustumorsandPancoast'ssyndrome.New
EnglandJournalofMedicine,337(19),13701376.
Dartnell,J.,Pilling,J.,Ferner,R.,Cane,P.,&LangLazdunski,L.(2009).Malignanttritontumorofthe
brachialplexusinvadingtheleftthoracicinlet:araredifferentialdiagnosisofpancoasttumor.Journalof
ThoracicOncology,4(1),135137.
Foroulis,C.N.,Zarogoulidis,P.,Darwiche,K.,Katsikogiannis,N.,Machairiotis,N.,Karapantzos,I.,...&
Zarogoulidis,K.(2013).Superiorsulcus(Pancoast)tumors:currentevidenceondiagnosisandradical
treatment.Journalofthoracicdisease,5(Suppl4),S342.
Manenti,G.,Raguso,M.,D'Onofrio,S.,Altobelli,S.,Scarano,A.L.,Vasili,E.,&Simonetti,G.(2013).
Pancoasttumor:theroleofmagneticresonanceimaging.Casereportsinradiology,2013.
Pancoast,H.K.(1932).SuperiorPulmonarySulcusTumor:Tumorcharacterizedbypain,Horner's
Syndrome,destructionofboneandatrophyofhandmusclesChairman'sAddress.JournaloftheAmerican
MedicalAssociation,99(17),13911396.
Panagopoulos,N.,Leivaditis,V.,Koletsis,E.,Prokakis,C.,Alexopoulos,P.,Baltayiannis,N.,...&
Katsikogiannis,N.(2014).Pancoasttumors:characteristicsandpreoperativeassessment.Journalof
thoracicdisease,6(1),S108S115.
Weber,D.J.,Okereke,I.C.,Birdas,T.J.,Ceppa,D.P.,Rieger,K.M.,&Kesler,K.A.(2014).Thecutin
patchouttechniqueforPancoasttumorresectionsresultsinpostoperativepainreduction:acasecontrol
study.Journalofcardiothoracicsurgery,9(1),163.

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