Superior sulcus tumors (Pancoast tumors)

Lung cancer involving structures of apical chest wall.


Henry Khunrath Pancoast (1875 – 1939) was an American radiologist after whom a type of lung tumor is named (Pancoast tumor).

In 1838, Hare described the first recorded case of “tumor involving certain nerves”, producing constant and characteristic pain in the shoulder and the arm. However, it was Henry K. Pancoast in 1924, studying radiographic findings of several cases, who first described this clinical entity of “apical chest tumors”, characterized by “small homogeneous shadows at the extreme apex”, “more or less” rib destruction and often vertebral infiltration. These tumors were described as associated with a clinical syndrome of pain in the distribution of the eighth cervical, first and second thoracic nerve trunks and Horner’s syndrome. In 1932, Pancoast published a second report, in which he defined them as “superior pulmonary sulcus tumors” and stated that they probably arose from epithelial rest cells from the fifth brachial cleft. The first to propose a pulmonary origin for these tumors was Tobías, who better defined the anatomical and clinical aspects of this syndrome.

A wide variety of diseases can cause Pancoast-Tobías syndrome: primary neoplasms of lung and pleura, metastases from other organs, hematologic malignancies, inflammatory and infectious diseases. The term Pancoast Tumor includes, however, only patients with a primary lung cancer in the typical location of the apex of the lung, regardless of whether any symptoms of the syndrome are present.


Bronchogenic carcinomas:

< 5% of all bronchogenic carcinomas evolve into Pancoast tumors
  • Adenocarcinoma (M/C histologic type)


The unique feature of Pancoast tumours appears not to lie in the tumour biology, but rather in the anatomy of the region in which these tumours occur.

The Pancoast tumor can invade the thoracic inlet in a posterior (A), middle (B) or anterior (C) site. | Marulli, G., Battistella, L., Mammana, M., Calabrese, F., & Rea, F. (2016). Superior sulcus tumors (Pancoast tumors). Annals of Translational Medicine, 4(12), 239.

Clinical features

Pancoast-Tobias syndrome:

  • Severe and unrelenting shoulder and arm pain along with the distribution of the C8, T1 & T2 nerve trunks
  • Horner’s syndrome (15-50%) (ptosis, miosis, and anhidrosis)
  • Atrophy of the intrinsic hand muscles
  • Upper arm oedema


Regional spread:

  • Tracheal obstruction
  • Oesophagal compression with dysphagia
  • Recurrent laryngeal paralysis with hoarseness
  • Phrenic nerve palsy with the elevation of the hemidiaphragm and dyspnea
  • Sympathetic nerve paralysis with Horner’s syndrome (enophthalmos, ptosis, miosis, and anhydrosis).




Surgical resection:

Complex anatomy of the thoracic inlet led to the development of various surgical approaches to properly expose the tumor and the involved structures.
The variety of approaches used for the surgical treatment of superior sulcus tumors: A. the Shaw-Paulson approach; B. the Tatsamura approach; C. the trans-clavicular (Dartevelle) approach; D. the trans-manubrial (Grunenwald) approach; E. the trapdoor (hemi-Clamshell) approach; F. the Masaoka approach. | Foroulis, C. N., Zarogoulidis, P., Darwiche, K., Katsikogiannis, N., Machairiotis, N., Karapantzos, I., … Zarogoulidis, K. (2013). Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment. Journal of thoracic disease, 5 Suppl 4(Suppl 4), S342–S358. doi:10.3978/j.issn.2072-1439.2013.04.08

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