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Pancoast tumour (superior sulcus tumour)
A Pancoast tumour is an apical lung cancer invading thoracic outlet structures — the upper ribs, the brachial plexus, the sympathetic chain and the subclavian vessels — and presents with shoulder and arm pain, Horner syndrome and wasting of the hand muscles; accepted treatment is neoadjuvant chemoradiotherapy followed by en bloc resection, provided there is no N2 nodal involvement.
Why it matters in the exam
The exam usually shows a smoker with shoulder pain radiating to the ulnar side of the hand, treated for a long time as an "orthopaedic problem", and on examination a small pupil, eyelid droop and absent sweating on one side (Horner — from invasion of the stellate ganglion). Pain and weakness of the hand muscles come from invasion of the C8–T1 roots. The tumour is classified at least as T3, and sometimes T4 when it invades vertebrae, vessels or the plexus above T1. Work-up includes CT, PET-CT, MRI of the thoracic apex (to assess the brachial plexus, vertebrae and vessels) and brain MRI, and invasive mediastinal staging is mandatory, because N2 involvement indicates a poor prognosis and usually removes the patient from a surgical plan.
Treatment based on the SWOG 9416 trial: platinum-based chemotherapy with concurrent radiotherapy, re-assessment, and then — in the absence of progression — en bloc resection of the upper lobe with the chest wall and involved structures, followed by completion chemotherapy. In this trial 5-year survival reached 44% across all patients and a higher rate after complete resection, a significant improvement compared with surgery alone. The surgical approach depends on location: a posterior approach (Paulson) for posterior tumours with rib and vertebral involvement, and an anterior transclavicular approach (Dartevelle) for anterior tumours invading the subclavian vessels. Contraindications to surgery: N2 or N3, distant metastases, and extensive involvement of the brachial plexus above the T1 root or of the vertebral body that cannot be resected.
A patient unfit for surgery receives definitive chemoradiotherapy followed by consolidation immunotherapy, as in unresectable stage III lung cancer.
Key points
- An apical tumour invading the thoracic outlet.
- Shoulder pain, Horner, wasting of the hand muscles.
- MRI of the apex and mediastinal staging.
- Chemoradiotherapy followed by en bloc resection.
- N2 — not for surgery.
Summary table
| Stage | Test or treatment | Note |
|---|---|---|
| Diagnosis | CT, PET-CT, MRI of the apex and brain | MRI defines invasion of the plexus and vertebrae |
| Mediastinal staging | EBUS or mediastinoscopy | N2 — usually not for surgery |
| Neoadjuvant treatment | Concurrent chemoradiotherapy | SWOG 9416 |
| Surgery | En bloc resection of lobe and wall | Posterior or anterior approach by location |
| Unfit for surgery | Definitive chemoradiotherapy and immunotherapy | As in unresectable stage III |
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Sources
- NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer, 2025 — Superior sulcus tumors
- Rusch et al., SWOG 9416 (Intergroup 0160), J Clin Oncol, 2007 — Induction chemoradiation and surgical resection for superior sulcus NSCLC
- Shields' General Thoracic Surgery, 8th edition (2019) — Superior sulcus tumors
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.