A Case of Pancoast's tumour

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A Case of Pancoast's tumour

  1. 1. AN INTERESTING CASE OF LUNG MASS Dr. NAMITHA NARAYANAN Prof.DHANDAPANI’S UNIT
  2. 2. CASE SUMMARY <ul><li>CHIEF COMPLAIN TS: </li></ul><ul><li>51 years old male admitted with complaints of pain right side of the chest -45 days. </li></ul><ul><li>Loss of appetite – one month. </li></ul><ul><li>HISTORY OF PRESENTING COMPLAINTS : </li></ul><ul><li>Apparently normal 45 days back. Developed pain right upper chest wall and right shoulder. pain radiating to right arm . </li></ul><ul><li>Pain aggravated by deep inspiration, coughing and on movement of right upper limb. </li></ul>
  3. 3. Case summary <ul><li>Associated with breathlessness. </li></ul><ul><li>History of loss of appetite and loss of weight present. </li></ul><ul><li>No left sided chest pain, palpitation or giddiness. </li></ul><ul><li>PAST HISTORY : </li></ul><ul><li>Pulmonary TB 5 years back. completed treatment. Not a known case of DM, SHT, CAD or BA. </li></ul>
  4. 4. CASE SUMMARY <ul><li>PERSONAL HISTORY : </li></ul><ul><li>Chronic smoker and alcoholic. </li></ul><ul><li>ON EXAMINATION : </li></ul><ul><li>Conscious, oriented and afebrile. </li></ul><ul><li>Thin built and poorly nourished. </li></ul><ul><li>Generalized muscle wasting present. </li></ul><ul><li>Mild pallor + </li></ul><ul><li>Clubbing + </li></ul><ul><li>Muddy conjunctiva </li></ul><ul><li>No cyanosis or lymphadenopathy. </li></ul>
  5. 5. CASE SUMMARY <ul><li>Difficulty in getting up + </li></ul><ul><li>Painful movements of right upper limb + </li></ul><ul><li>Vitals stable. </li></ul><ul><li>SYSTEMIC EXAMINATION : </li></ul><ul><li>Trachea deviated to right. </li></ul><ul><li>Drooping of right shoulder and hollowing of right supra and infraclavicular region present. </li></ul><ul><li>Chest movements and expansion decreased on right side. </li></ul><ul><li>Scoliosis with concavity to right side present. </li></ul>
  6. 6. CASE SUMMARY <ul><li>Tenderness present in right upper thoracic region, right supraclavicular and infraclavicular region. </li></ul><ul><li>On percussion dull note on the above areas+ </li></ul><ul><li>On auscultation: bilateral NVBS + </li></ul><ul><li>CVS and per abdominal examination- normal. </li></ul><ul><li>CNS - pain and touch sensation decreased on T1-3 dermatomal areas. </li></ul><ul><li>PROVISIONAL DIAGNOSIS: </li></ul><ul><li>? PT SEQULAE. To rule out MALIGNANCY </li></ul>
  7. 7. INVESTIGATIONS <ul><li>Hb-11G% </li></ul><ul><li>TC-6200 cells/mm3 </li></ul><ul><li>ESR-2/5 mm(30 mts and </li></ul><ul><li>60mts) </li></ul><ul><li>PCV- 33% </li></ul><ul><li>PLATELETS- 100000/mm3 </li></ul><ul><li>Blood Sugar- 88 mg% </li></ul><ul><li>Blood Urea- 21mg% </li></ul><ul><li>Serum Creatinine- 0.6mg% </li></ul><ul><li>Serum Electrolytes: </li></ul><ul><li>Na- 135Meq/L </li></ul><ul><li>K- 3.3 Meq/L </li></ul><ul><li>HIV- non-reactive </li></ul><ul><li>VDRL- non-reactive </li></ul><ul><li>Urine routine- normal </li></ul><ul><li>CT- 5 minutes </li></ul><ul><li>BT- 1 minute and 45 sec </li></ul>
  8. 11. INVESTIGATIONS <ul><li>CT Scan Chest : </li></ul><ul><li>Hetero -dense contrast enhancing lesion with central non-enhancing areas noted occupying the upper lobe of right lung. </li></ul><ul><li>Lesion causes encasement of mediastinal vessels. </li></ul><ul><li>Erosion of the ribs and vertebrae noted on right side. </li></ul><ul><li>Chest wall invasion noted. </li></ul><ul><li>Left side normal. </li></ul><ul><li>S/O PANCOAST TUMOR (R) UPPER LOBE </li></ul>
  9. 27. <ul><li>Chest Physician’s Opinion : </li></ul><ul><li>Scar Ca right upper lobe. </li></ul><ul><li>Suggested Bronchoscopy and sputum cytology. </li></ul><ul><li>Bronchoscopy : </li></ul><ul><li>Trans nasal route under LA </li></ul><ul><li>Vocal cords, trachea and larynx normal. </li></ul><ul><li>Left bronchial systems normal. </li></ul><ul><li>Right upper lobe bronchus- segmented lesion, extrinsic compression and no intraluminal lesion. </li></ul><ul><li>Suggested CT guided biopsy </li></ul>
  10. 28. <ul><li>USG guided FNAC of the right upper lobe mass </li></ul><ul><li>Moderately cellular smear showing numerous groups and clusters of malignant epithelial cells on a hemorrhagic and keratinous background. </li></ul><ul><li>IMP: SQUAMOUS CELL CARCINOMA. </li></ul><ul><li>ONCOLOGIST’S OPINION- suggested Radiotherapy </li></ul>
  11. 29. <ul><li>FINAL DIAGNOSIS </li></ul><ul><li>PANCOAST TUMOR </li></ul>
  12. 30. INTRODUCTION <ul><li>In 1932 Henry Pancoast defined - superior pulmonary sulcus tumor. </li></ul><ul><li>A mass growing at the thoracic inlet that produces a constant and characteristic presentation of pain in C-7 or T-1 thoracic trunk distribution. </li></ul><ul><li>Are subset of lung cancer that invades the apical chest wall. </li></ul>
  13. 31. <ul><li>Various other tumors produces a similar clinical presentation because of their location at thoracic inlet as they invade the adjoining structures. </li></ul><ul><li>Bronchogenic Carcinoma arising in or near the superior sulcus and invading the adjacent extra thoracic structures –most common. </li></ul><ul><li>Invade the lymphatics in the endothoracic fascia, the intercostal nerves, lower roots of brachial plexus, stellate ganglion, sympathetic chain, adjacent ribs and vertebrae. </li></ul>
  14. 32. <ul><li>FREQUENCY: </li></ul><ul><li>Much less common than other lung tumors. </li></ul><ul><li>1-3% of all lung cancers. </li></ul><ul><li>May not be visualized in on an initial chest radiograph. </li></ul><ul><li>Usually present as advanced stage disease. </li></ul><ul><li>ETILOGY: </li></ul><ul><li>Risk factors same as that of lung cancer. </li></ul><ul><li>includes smoking, secondary smoke exposure, exposure to asbestos and industrial chemicals. </li></ul>
  15. 33. PATHOPHYSIOLOGY <ul><li>The mass is an extension of lung cancer. </li></ul><ul><li>Mostly squamous cell carcinomas or adeno carcinomas. </li></ul><ul><li>3-5% are small cell carcinomas. </li></ul><ul><li>Involvement of the phrenic or recurrent laryngeal nerve or SVC obstruction is not representative of the classic Pancoast tumor. </li></ul>
  16. 34. PRESENTATION <ul><li>SYMPTOMS: </li></ul><ul><li>Symptoms are typical of the location of the tumor. </li></ul><ul><li>Neuralgic pain due to involvement of the C-7, T-1& 2 Nerve roots. </li></ul><ul><li>Symptoms due to involvement of the stellate ganglion and sympathetic chain- Ipsilateral Horner’s syndrome. </li></ul><ul><li>Pt. usually supports the elbow of the affected side. </li></ul>
  17. 35. <ul><li>Wasting of the hand muscles, absent triceps reflex. </li></ul><ul><li>Symptoms of spinal canal tumor or cervical disc disease if the spinal cord is invaded or compressed. </li></ul><ul><li>Paraneoplastic syndrome- ( Cushing syndrome, hypercalcemia, excessive ADH secretion, myopathies, hematological problems, HOCM). </li></ul><ul><li>Brain metastasis is frequent. </li></ul>
  18. 36. DIFFERENTIAL DIAGNOSIS <ul><li>Primary tumors of the Thyroid, Larynx and Pleura. </li></ul><ul><li>Infectious disorders of the lung, </li></ul><ul><li>Aneurysms of the subclavian vessels </li></ul><ul><li>Amyloid of pleura </li></ul><ul><li>Multiple myeloma. </li></ul><ul><li>Thoracic outlet syndrome </li></ul><ul><li>Cervical disc disease. </li></ul>
  19. 37. DIAGNOSIS <ul><li>Diagnosis - based on clinical and radiological findings(90% of cases) </li></ul><ul><li>Transthoracic needle biopsy. </li></ul><ul><li>Bronchoscopy is less useful as tumors are peripherally located. </li></ul><ul><li>Liver, bone and brain scans- to rule out metastasis. </li></ul><ul><li>Open biopsy - through a supraclavicular incision. </li></ul>
  20. 38. STAGING <ul><li>Staging is based on the location of the lesion and its metastasis. </li></ul><ul><li>True pancoast tumor is T-3 disease .(extension through the visceral pleura to the parietal pleura and chest wall). </li></ul><ul><li>T-4 when mediastinal invasion, cervical invasion or both have occurred. </li></ul><ul><li>Mediastinoscopy- to delineate the metastasis to mediastinal lymph nodes.(performed if lymph nodes appear > 1 cm on a CT scan). </li></ul>
  21. 39. <ul><li>If mediastinal lymph nodes are present– poor prognosis. </li></ul><ul><li>If CT does not reveal LN –patient is deemed operable. </li></ul>
  22. 40. WORKUP <ul><li>LABORATORY STUDIES : </li></ul><ul><li>CBC </li></ul><ul><li>BUN/ creatinine levels. </li></ul><ul><li>WBC count </li></ul><ul><li>Urine analysis. </li></ul><ul><li>Coagulation profile(PT, aPTT and platelet count). </li></ul><ul><li>Cross matching. </li></ul><ul><li>Tumor markers are non-specific (CEA, beta-2 micro globulin, bombesin, neuron specific enolase, tumor oncogenes). </li></ul>
  23. 41. WORKUP <ul><li>Chest radiographs .(small homogenous apical cap, or pleural thickening, plaque, or mass). </li></ul><ul><li>Apical lordotic views (better visualization). </li></ul><ul><li>Bony erosion of posterior 1-3 ribs. </li></ul><ul><li>Vertebral body erosion. </li></ul><ul><li>Mediastinal involvement. </li></ul><ul><li>CT scanning and MRI :(of neck, chest and upper abdomen) </li></ul><ul><li>MRI is useful for evaluating the resectability . </li></ul><ul><li>CT scan- helps to identify the invasion of the brachial plexus, chest wall and mediastinum CECT –to assess the subclavian vessel involvement. </li></ul>
  24. 42. WORKUP <ul><li>MRI findings more accurate than CT findings for assessing the involvement of the cervical structures and vertebral bodies. </li></ul><ul><li>ARTERIOGRAM or VENOGRAM. </li></ul><ul><li>ECG. </li></ul><ul><li>Bronchoscopy- diagnostic yield is low. </li></ul><ul><li>Tissue diagnosis – by percutaneous biopsy. </li></ul><ul><li>Mediastinoscopy and scalene node biopsy. </li></ul>
  25. 43. TREATMENT <ul><li>SURGERY: (Curative vs palliative) </li></ul><ul><li>Should be considered for surgery after the appropriate diagnostic evaluation is completed. </li></ul><ul><li>Perfect candidate is one with lesion restricted to chest(T3N0M0). </li></ul><ul><li>Right upper lobe lesion with intranodal metastasis and T3N2M0.( RARE EXCEPTION) </li></ul>
  26. 44. SURGERY <ul><li>CONTRAINDICATIONS : </li></ul><ul><li>Distant metastasis </li></ul><ul><li>Extensive involvement of brachial plexus. </li></ul><ul><li>Involvement of paraspinal region. </li></ul><ul><li>Involvement of lamina of vertebrae body </li></ul><ul><li>Involvement of mediastinal lymph node </li></ul><ul><li>Subclavian venous obstruction </li></ul><ul><li>Co-morbid conditions like heart failure, recent MI and unstable angina. </li></ul>
  27. 45. SURGERY <ul><li>PREOPERATIVE DETAILS: </li></ul><ul><li>Evaluation of pulmonary function, high risk patients benefit from supervised pulmonary rehabilitation. </li></ul><ul><li>Prophylactic heparin and antiembolic stockings. </li></ul><ul><li>Encouragement to stop smoking at least 2 weeks prior to surgery. </li></ul><ul><li>Assessment of the cardiac status </li></ul>
  28. 46. SURGERY <ul><li>IRRADIATION: </li></ul><ul><li>purpose of pre-operative irradiation: to shrink the tumor and to temporarily block lymphatic spread. </li></ul><ul><li>30-40 Gy of radiation administered over 2-3 weeks. </li></ul><ul><li>After 4 weeks all patients are reassessed for surgery. </li></ul>
  29. 47. <ul><li>CHEMOTHERAPY: </li></ul><ul><li>Induction chemotherapy combined with hyper fractionated accelerated radiotherapy prior to surgery may be effective in improving the long term survival and local recurrence rates. </li></ul><ul><li>SURGICAL PRINCIPLES OF CURATIVE RESECTION : </li></ul><ul><li>Excise the entire first rib and posterior segments of the second and third ribs. </li></ul><ul><li>excise the corresponding thoracic nerve roots up to the intervertebral foramen. </li></ul><ul><li>Excise portion of the upper thoracic vertebrae, including the transverse process if necessary. </li></ul>
  30. 48. SURGERY <ul><li>Excise the lower trunk of brachial plexus. </li></ul><ul><li>Excise part of the stellate ganglion and the thoracic sympathetic chain. </li></ul><ul><li>Lung resection can be either wedge or lobectomy. </li></ul><ul><li>Radical mediastinal lymph node resection can be performed. </li></ul><ul><li>POSTOPERATIVE COMPLICATIONS : </li></ul><ul><li>Atelectasis </li></ul><ul><li>Severe chest pain </li></ul>
  31. 49. Surgical complications <ul><li>Air leaks </li></ul><ul><li>Spinal fluid leaks </li></ul><ul><li>Horner’s syndrome. </li></ul><ul><li>Pain </li></ul><ul><li>POST-OP RADIOTHERAPY </li></ul><ul><li>not indicated for patients who undergo complete resection and have no nodal metastasis. </li></ul><ul><li>Benefit for post op RT for patients with nodal disease. </li></ul>
  32. 50. PRIMARY RADIATION THERAPY <ul><li>For patients with unresectable tumors and for those who are not surgical candidates. </li></ul><ul><li>It provides excellent pain relief. </li></ul><ul><li>No long term survival occurs if the primary tumor is not controlled. </li></ul>
  33. 51. THANK YOU

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