From the Guidelines
A lung tumor in the apices that radiates pain to the shoulder is likely a Pancoast tumor, and management typically involves a multidisciplinary approach with combined chemoradiation therapy followed by surgical resection when possible, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.
Diagnosis and Management
The diagnosis of a Pancoast tumor is typically made through a combination of imaging studies, including CT scans and MRI, as well as a tissue diagnosis obtained through transcutaneous needle biopsy or other invasive procedures 1.
- The patient's case should be discussed within a multidisciplinary team to provide an individualized diagnostic and therapeutic plan 1.
- Pain management is essential and may include NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), along with opioid medications such as morphine (starting at 5-15mg every 4 hours as needed) or oxycodone (5-10mg every 4-6 hours as needed) 1.
- Adjuvant medications like gabapentin (starting at 300mg daily and titrating up) or pregabalin (75mg twice daily) may help with neuropathic pain components 1.
Treatment Approach
The treatment approach for Pancoast tumors should prioritize a multidisciplinary approach with combined chemoradiation therapy followed by surgical resection when possible, as this has been shown to improve outcomes in these challenging tumors 1.
- Invasive mediastinal staging should be performed in all patients being considered for curative resection, regardless of whether the CT or PET scan suggests involvement of the mediastinal lymph nodes 1.
- Both a chest CT scan and an MRI are indicated to assess the resectability of a Pancoast tumor, as they provide complementary information about the tumor's extent and involvement of nearby structures 1.
From the Research
Lung Tumor in Apices that Radiates Pain to Shoulder
- The symptoms described are characteristic of Pancoast tumors, which are located in the apex of the lung and involve the apical chest wall and/or the structures of the thoracic inlet 2.
- Pancoast tumors account for less than 5% of all bronchogenic carcinomas and are often associated with severe pain in the shoulder radiating toward the axilla and/or scapula 2, 3.
- The diagnosis of Pancoast tumors is typically made by a combination of characteristic clinical symptoms and radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1st and/or 2nd ribs 2.
- Treatment options for Pancoast tumors include induction chemo-radiotherapy followed by surgical resection, with the goal of achieving a complete tumor resection 2, 4, 5, 6.
- The prognosis for Pancoast tumors depends on several factors, including the T stage of the tumor, response to preoperative chemo-radiotherapy, and completeness of resection 2, 6.
Treatment Options
- Induction chemo-radiotherapy is the standard of care for potentially resectable Pancoast tumors, followed by an attempt to achieve a complete tumor resection 2, 4, 5, 6.
- Surgical resection can be performed through a variety of anterior and posterior approaches to the thoracic inlet, depending on the location and extent of the tumor 2, 3.
- Adjuvant chemoradiation treatment may improve local and systemic control by addressing individual adverse findings 4, 6.
- Palliative surgical resection may be considered for inoperable patients with severe pain after irradiation therapy 3.
Outcomes
- The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%) 2, 6.
- Complete surgical resection with negative margins can be achieved after induction chemoradiotherapy, and curative-intent trimodality treatment can lead to long-term survival in some patients 6.
- The main pattern of recurrence is that of distant metastases, especially in the brain 2.