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Pancoast Tumor

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Pancoast Tumor

  1. 1. Pancoast’s Tumor Sallie Ruth Coleman December 15, 2008
  2. 3. Outline <ul><li>What is it? </li></ul><ul><li>What else could it be? </li></ul><ul><li>Clinical Presentation </li></ul><ul><li>Imaging Work-Up </li></ul><ul><li>Treatment </li></ul><ul><li>Prognosis </li></ul><ul><li>What next? </li></ul>
  3. 4. Introduction <ul><li>Henry Pancoast: early 20 th century </li></ul><ul><li>One region…Many names </li></ul><ul><li>Location </li></ul>
  4. 5. Differential Diagnosis <ul><li>Malignant Tumor </li></ul><ul><ul><li>Pancoast’s Tumor </li></ul></ul><ul><ul><li>Mesothelioma </li></ul></ul><ul><ul><li>Lymphoma </li></ul></ul><ul><ul><li>Metastatic Disease </li></ul></ul><ul><li>Benign Tumor (most commonly Neurofibroma </li></ul><ul><li>Pleural Thickening </li></ul><ul><ul><li>Status post radiation </li></ul></ul><ul><ul><li>Infection (i.e. TB, fungi, hydatid cysts) </li></ul></ul><ul><li>Pleural effusion (loculated at apex) </li></ul><ul><li>Hematoma </li></ul><ul><ul><li>Extrapleural from aortic rupture </li></ul></ul><ul><ul><li>Vascular aneurysms </li></ul></ul><ul><ul><li>Iatrogenic (i.e. after attempted CVC placement) </li></ul></ul><ul><ul><li>Associated with rib or vertebral fracture </li></ul></ul>
  5. 6. Clinical Presentation <ul><li>Arm/shoulder pain </li></ul><ul><li>Horner’s syndrome </li></ul><ul><li>Weakness/atrophy or hand muscles </li></ul>Pancoast’s Syndrome
  6. 7. Radiographic findings <ul><li>X-Ray </li></ul><ul><ul><li>Unilateral cap > 5mm </li></ul></ul><ul><ul><li>Asymmetry of bilateral caps > 5 mm </li></ul></ul><ul><ul><li>Apical mass </li></ul></ul><ul><ul><li>Bone destruction </li></ul></ul>
  7. 11. Radiographic findings <ul><li>X-Ray </li></ul><ul><ul><li>Unilateral cap > 5mm </li></ul></ul><ul><ul><li>Asymmetry of bilateral caps > 5 mm </li></ul></ul><ul><ul><li>Apical mass </li></ul></ul><ul><ul><li>Bone destruction </li></ul></ul><ul><li>CT </li></ul><ul><ul><li>Presence of satellite nodules, parenchymal disease, mediastinal lymphadenopathy </li></ul></ul>
  8. 14. Radiographic findings <ul><li>X-Ray </li></ul><ul><ul><li>Unilateral cap > 5mm </li></ul></ul><ul><ul><li>Asymmetry of bilateral caps > 5 mm </li></ul></ul><ul><ul><li>Apical mass </li></ul></ul><ul><ul><li>Bone destruction </li></ul></ul><ul><li>CT </li></ul><ul><ul><li>Presence of satellite nodules, parenchymal disease, mediastinal lymphadenopathy </li></ul></ul><ul><li>MRI </li></ul><ul><ul><li>Evaluation of brachial plexus, subclavian vessels, vertebral bodies, spinal canal, and chest wall involvement </li></ul></ul>
  9. 18. Diagnostic Work-Up <ul><li>Bronchoscopy and sputum cytology? </li></ul><ul><li>Percutaneous needle biopsy </li></ul><ul><li>VATS </li></ul><ul><li>Thoracotomy </li></ul>
  10. 19. Pathology <ul><li>Mostly non-small cell lung cancer </li></ul><ul><ul><li>Mainly squamous cell carcinoma </li></ul></ul><ul><li>Small cell carcinoma: 5% of cases </li></ul>
  11. 21. Staging/Preoperative Assessment <ul><li>Staging same as with NSCLC’s (TMN staging) </li></ul><ul><li>PET scan </li></ul><ul><li>Mediastinoscopy </li></ul><ul><li>Brain Imaging </li></ul>
  12. 22. Treatment <ul><li>Multimodality therapy </li></ul><ul><li>Radiation therapy followed by en bloc extended surgical resection </li></ul><ul><li>Chemotherapy/chemoradiotherapy </li></ul>
  13. 23. Prognosis <ul><li>Overall 5-year survival rates with preoperative RT and surgical resection: 30% </li></ul><ul><ul><li>Patients with uninvolved lymph nodes: 30-40% </li></ul></ul><ul><ul><li>Patients with incomplete resection, mediastinal nodal involvement, or T4 vertebral body invasions: <10% </li></ul></ul><ul><li>2/3 patients will have recurrent disease </li></ul><ul><li>Poor prognostic factors: </li></ul><ul><ul><li>Presence of Horner’s syndrome </li></ul></ul><ul><ul><li>Extension of tumor into the base of the neck, great vessels, or vertebral bodies </li></ul></ul><ul><ul><li>Involvement of mediastinal lymph nodes </li></ul></ul>
  14. 24. Post-Therapy Surveillance <ul><li>Little data to support evidence-based guidelines for routine surveillance following therapy </li></ul>
  15. 25. Further Recommendations <ul><li>Whenever possible, patients with superior sulcus tumors should be enrolled in prospective clinical trials so that the optimal therapy may be determined. </li></ul>
  16. 26. The End

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