What are the symptoms and signs of a Pancoast tumor?

Symptoms and Signs of Pancoast Tumor

Pancoast tumors typically present with a characteristic syndrome of shoulder and arm pain, Horner syndrome, and weakness/paresthesias in the distribution of the C8 and T1-T2 nerve roots due to invasion of the brachial plexus and adjacent structures at the thoracic inlet. 1

Classic Clinical Manifestations

Pain Patterns

• Severe and unrelenting shoulder pain radiating toward the axilla and/or scapula
• Pain along the ulnar distribution of the upper arm (C8, T1, T2 nerve roots)
• Localized chest wall pain due to invasion of the chest wall and ribs
• Pain may be the initial and predominant symptom, often preceding diagnosis by months

Neurological Manifestations

• Horner syndrome (complete or partial):
  • Ptosis (drooping eyelid)
  • Miosis (constricted pupil)
  • Anhidrosis (lack of facial sweating)
  • Caused by invasion of sympathetic chain and stellate ganglion 2, 1
• Weakness and atrophy of intrinsic hand muscles
• Paresthesias in the ulnar nerve distribution of the arm and hand

Vascular Symptoms

• Hand swelling due to subclavian or brachiocephalic vein compression
• Dilated neck veins
• Prominent venous pattern on the chest in advanced cases

Other Manifestations

• Hoarseness from recurrent laryngeal nerve involvement (more common on left side) 2
• Elevated hemidiaphragm from phrenic nerve dysfunction
• Dysphagia if there is esophageal compression

Radiographic Findings

• Chest radiographs may show:

  • Apical pleural thickening
  • Opacity in the apex of the lung
  • Rib destruction (1st and/or 2nd ribs)
  • Tumors may be hidden behind the first rib on standard views 1

• CT scan findings:

  • Detects small lesions with excellent anatomic detail
  • Shows extent of chest wall invasion
  • May reveal nodal involvement

• MRI findings (particularly valuable for Pancoast tumors):

  • Superior to CT for demonstrating invasion of apical chest wall structures
  • Best for evaluating brachial plexus involvement
  • Shows invasion of subclavian vessels and extradural space 1

Important Clinical Considerations

Diagnostic Pitfalls

• Respiratory symptoms are often completely absent due to the peripheral location of the tumor 2
• The distribution of symptoms outside the chest (shoulder/arm pain) may delay consideration of lung cancer as the primary etiology 2
• Patients may initially present to providers like chiropractors with what appears to be musculoskeletal pain 3
• Diagnosis is often delayed by 5-10 months from symptom onset

Risk Factors to Consider

• Smoking history (major risk factor)
• Age typically >50 years
• Male predominance

Anatomical Classification

Pancoast tumors are now divided into:

• Anterior compartment tumors
• Middle compartment tumors
• Posterior compartment tumors Based on the location of chest wall involvement in relation to the insertions of the anterior and middle scalene muscles on the first rib 2

Staging Considerations

• By definition, Pancoast tumors are at least T3 (involvement of T1 or T2 nerve roots or first rib)
• Classified as T4 if there is involvement of C8 or higher nerve roots, cords of the brachial plexus, subclavian vessels, vertebral bodies, or lamina 2, 1
• Mediastinal nodal involvement is a significant negative prognostic factor

Early recognition of these characteristic signs and symptoms is crucial for timely diagnosis and treatment, as Pancoast tumors have historically poor outcomes without treatment, with patients typically surviving only about 10 months after diagnosis 2.