Durable complete response to PET-CT driven stereotactic radiation therapy plus pembrolizumab for pleomorphic Pancoast cancer: Case report and literature review.

PET-driven SBRT plus pembrolizumab as first-line therapy against pleomorphic Pancoast cancer appears beneficial, probably due to high equivalent doses of SBRT on photopenic necrotic core and synergic immune system stimulation of immunoradiotherapy.

Chest wall resection with robotic-assisted thoracoscopic surgery for a Pancoast tumour: a case report.

We describe a rare procedure involving near-total robotic-assisted thoracoscopic surgery resection of a right posterior Pancoast tumour. Four ports and an assistant port were used. The DaVinci X system was used. The lobectomy was performed first to allow for adequate exposure to the apex and spine. The lateral aspect of ribs 1 to 4 was resected next, and the extrathoracic space was entered. Dissection proceeded through this space superiorly up to the level of the scapula and then posteriorly towards the spine. The second to the fifth ribs were dissected off the chest wall and resected medially off the spine at the rib heads. Further postero-superior exploration revealed the tumour to be invading the transverse process of the second rib, with ill-defined margins. Because of this development, and with the support of the spinal surgeons, a small high posterior thoracotomy was performed to complete the procedure and remove the specimen en bloc. The postoperative recovery was uneventful, and the patient was discharged on post-operative day 5. The final histological report confirmed a squamous non-small-cell lung cancer (pT3N0M0) with negative margins (R0). Asymptomatic recurrence was noted near the margin of the second rib resection posteriorly 1 year postoperatively and was successfully treated with radiotherapy.

Chest wall resections for sulcus superior tumors.

Chemoradiotherapy followed by surgical resection (trimodality therapy) is a guideline recommended treatment for sulcus superior tumors (SST). By definition, SSTs invade the chest wall and therefore require en-bloc chest wall resection with the upper lung lobe or segments. The addition of a chest wall resection, potentially results in higher morbidity and mortality rates when compared to standard anatomical pulmonary resection. This, together with their anatomical location in the thoracic outlet, and varying grades of fibrosis and adhesions resulting from induction chemoradiotherapy in the operation field, make surgery challenging. Depending on the exact location of the tumor and extent to which it invades the surrounding structures, the preferred surgical approach may vary, e.g., anterior, posterolateral, hemi-clamshell, or combined approach; all with their own potential advantages and morbidities. Careful patient selection, adequate staging and discussion in a multidisciplinary tumor board in a center experienced in complex thoracic oncology leads to the best long-term survival outcomes with the least morbidity and mortality. Enhanced recovery guidelines are now available for thoracic surgery, promoting faster recovery and helping to minimize complications and morbidity, including infections and thoracotomy pain. Although minimally invasive surgery can enhance recovery and reduce chest wall morbidity, and is in widespread use in thoracic oncology, its use for SST has been limited. However, this is an evolving area and hybrid surgical approaches (including use of the robot) are being reported. Chest wall reconstruction is rarely necessary, but if so, the prosthetic materials are preferably radiolucent/non-scattering, rigid enough while still being somewhat flexible, and inert, providing structural support, allowing chest wall movement, and closing defects, while inciting a limited inflammatory response. New techniques such as 3D image reconstructions/volume rendering, 3D-printing, and virtual reality modules may help pre-operative planning and informed patient consent.

Deciphering the enigmatic symptoms of Pancoast tumors: Navigating the complex landscape of pain management-A case report.

Pancoast tumors, also known as superior sulcus tumors, encompass a diverse spectrum of neoplasms that infiltrate the apex of the chest wall, yielding distinctive clinical presentations. One of the earliest signs of tumor growth is pain radiating to the upper limb, stemming from peripheral nerve involvement, which can mimic joint pain or spinal radicular irritation. In this case report, we present the clinical history of a 64-year-old female smoker who had previously been recommended for orthopedic elbow surgery due to epicondylitis. Subsequent to the development of additional symptoms and rigorous investigation, a Pancoast tumor was diagnosed. Furthermore, we discuss the characteristic treatment modalities available for Pancoast tumors, including pharmacological pain management and interventional strategies such as spinal cordotomy and spinal alcoholysis. This case underscores the significance of recognizing atypical presentations and emphasizes the importance of comprehensive evaluation in the diagnosis and management of Pancoast tumors.

Superior Sulcus Tumors Invading the Spine: Multimodal Treatment Outcomes From the Preimmunotherapy Era.

Introduction: Curative-intent treatment of superior sulcus tumors (SSTs) of the lung invading the spine presents considerable challenges. We retrospectively studied outcomes in a single center, uniformly staged patient cohort treated with induction concurrent chemoradiotherapy followed by surgical resection (trimodality therapy). Methods: An institutional surgical database from the period between 2002 and 2021 was accessed to identify SSTs in which the resection included removal of at least part of the vertebral body. All patients were staged using fluorodeoxyglucose positron emission tomography (/computed tomography), computed tomography scan of the chest/upper abdomen, and brain imaging. Surgical morbidity was assessed using the Clavien-Dindo classification. Overall and disease-free survival were calculated using the Kaplan-Meier method. Results: A total of 18 patients were included: 8 complete and 10 partial vertebrectomies were performed, with six of the eight complete vertebrectomies involving two vertebral levels, resulting in Complete surgical resection (R0) in 94%. Nine patients had a 1-day procedure, and nine were staged over 2 days. The median follow-up was 30 months (interquartile range 11-57). The 90-day postoperative morbidity was 44% (grade III/IV), with no 90-day surgery-related mortality. There were 83% who had a major pathologic response, associated with improved survival (p = 0.044). The 5-year overall and disease-free survival were 55% and 40%, respectively. Disease progression occurred in 10 patients, comprising locoregional recurrences in two and distant metastases in eight patients. Conclusions: Multimodality treatment in selected patients with a superior sulcus tumor invading the spine is safe and results in good survival. Such patients should be referred to expert centers. Future research should focus on improving distant control (e.g. [neo]adjuvant immunotherapy).

Completely portal robotic Pancoast tumour resection with en bloc resection of the left upper lobe and chest wall.

The current gold standard for the treatment of Pancoast tumours is considered to be neoadjuvant chemoradiation followed by radical resection of the affected upper lobe en bloc with resection of the chest wall. Shaw and Paulson first described the most commonly used approach in 1961 via an extended posterolateral thoracotomy. However, because this approach comes with significant soft tissue damage and occasionally provides only suboptimal exposure, especially for anterior superior sulcus tumours, other approaches have been published in recent years, including open anterior approaches (Dartevelle and Gruenenwald) in addition to rare case reports of minimally invasive assisted hybrid procedures. Because we routinely perform robotic anatomical lung resections as well as three-port robotic first rib resections for thoracic inlet/outlet syndrome in our department, combining both techniques with our accumulated experience seemed to be the next logical step. We describe step-by-step what is (to our knowledge) one of the first reported cases of a fully portal robotic-assisted Pancoast tumour resection consisting of a left upper lobe resection en bloc with the first rib after neoadjuvant chemoradiation therapy. This approach proved to be safe and allowed for excellent exposure, especially of the thoracic outlet.

Erector Spinae Plane Block for the Treatment of Intractable Pain in a Patient with Pancoast Tumor: A Case Report.

Introduction: The erector spinae plane (ESP) block is a regional anesthetic technique that involves injecting a local anesthetic below the erector spinae muscle in an interfascial plane. Case Presentation: We report a case of a 66-year-old man with cervicothoracic junction pain caused by an advanced Pancoast tumor. The administration of ESP block at the T2-T3 level led to pain relief of more than 50% in this patient after two sessions. Conclusions: Therefore, the application of this method of regional analgesia is both convenient and safe and reduces opioid consumption. Further studies are needed to evaluate the safety and effectiveness of continuous blocks in outpatient settings.

Genomic profile of Pancoast syndrome due to hepatocellular carcinoma: A case report.

Hepatocellular carcinoma (HCC) is a common cancer and is frequently diagnosed at a late and unresectable stage with limited effective treatment options. Here, we present the fifth reported case of a 77 year-old male with metastatic HCC presenting as a symptomatic superior sulcus lung tumor and discuss the genomic profile of this rare presentation of HCC for the first time, which included multiple classic mutations in HCC such as TERT, TP53, and WNT/ß-catenin signaling as well as in the DNA repair gene ATM. The patient was treated with palliative radiotherapy to the Pancoast tumor followed by atezolizumab plus bevacizumab and passed away 6 months after diagnosis. This rare case highlights the need for effective treatment in aggressive and unresectable HCC and the utility of early genomic studies to allow for targeted therapy such as poly (ADP-ribose) polymerase (PARP)-inhibitors.

Long-Term Outcomes After Chemoradiotherapy and Surgery for Superior Sulcus Tumors.

Introduction: Superior sulcus tumors (SSTs) are uncommon, and their anatomical location can make treatment challenging. We analyzed late outcomes of patients with SST treated with concurrent chemoradiotherapy followed by surgical resection (trimodality) in a single tertiary institution. Methods: Patients with non-small cell SSTs, who underwent trimodality therapy between 2002 and 2017, were selected from a prospective institutional surgical database. Patients were uniformly staged with 18F-fluorodeoxyglucose-positron emission tomography, computed tomography scan of the chest and upper abdomen, and brain imaging. Patients undergoing resection of the lung plus chest wall were grouped as limited SST and those needing extensive resections (e.g., including the vertebral body) as extended SST. Kaplan-Meier survival analysis was performed to determine difference in survival. Multivariate Cox regression was used to identify prognostic factors. Results: A total of 123 patients were identified with a median follow-up of 4.9 years (interquartile range: 1.6-8.9 y). The 90-day postoperative mortality and morbidity (Clavien-Dindo grades III-V) were 6.5% and 21.1%, respectively. Patients with a radical resection (R0: 92.7%) had better survival (p = 0.002), as did those who had major pathologic response (73%) (p = 0.001). Ten-year overall survival (OS) and disease-free survival were 48.1% and 42.6%, respectively. There were no differences in 90-day mortality (p = 0.31) and OS (p = 0.79) between extended SST and limited SST patients. Conclusions: In patients with SST, trimodality resulted in a 10-year estimated OS and disease-free survival of 48.1% and 42.6%, respectively, which were improved after radical resection (R0) and major pathologic response. Survival for limited and extended resections was comparable, and distant relapse was the main pattern of failure. Better systemic treatments are therefore needed.

Pancoast tumor mimicking lung tuberculosis, a case report.

It is well-recognized that tuberculosis (TB) can mimic several clinical diseases, particularly cancer. On several occasions, lung TB can be misdiagnosed as cancer, particularly in developed countries with a rare case of TB and high incidence of lung cancer, and vice versa- in which Indonesia, with a high incidence of TB, lung cancer may be mistakenly identified as TB, delaying the initiation of definitive therapy and causing unnecessary diagnostic and treatment procedures. We reported a 59-year-old male who complained of right upper chest pain, accompanied by chronic cough and weight loss, with a history of 6-month treatment with a TB regimen without resolution of his symptoms. Core biopsy CT guiding pathology anatomy revealed atypical adenocarcinoma. All patients seeking medical attention must be treated carefully, avoiding diagnostic procedures that can result in a delay in definitive therapy.

Treatment patterns and outcomes in patients with Pancoast tumors: a national cancer database analysis.

Background: Pancoast tumors represent 5% of non-small cell lung cancers. Complete surgical resection and no lymph node involvement are important positive prognostic factors. Previous literature has identified neoadjuvant chemoradiation treatment, followed by surgical resection, as the standard of care. But many institutions choose upfront surgery. Our goal was to identify the treatment patterns and outcomes in patients with node-negative Pancoast tumors using the National Cancer Database (NCDB). Methods: The NCDB was queried from 2004 through 2017 to identify all patients who had undergone surgery for a Pancoast tumor. Treatment patterns, including the percentage of patients who received neoadjuvant treatment, were recorded. Logistic regression and survival analyses were used to determine outcomes based on different treatment patterns. Secondary analyses were performed on the cohort who received upfront surgery. Results: A total of 2,910 patients were included in the study. Overall 30- and 90-day mortality were 3% and 7% respectively. Only 25% (717/2,910) of the group received neoadjuvant chemoradiation treatment prior to surgery. Patients who received neoadjuvant chemoradiation treatment experienced significantly improved 90-day survival (P<0.01) and overall survival (P<0.01). When analyzing the cohort who received upfront surgery, there was a statistically significant difference in survival based on adjuvant treatment pattern (P<0.01). Patients in this group who received adjuvant chemoradiation had the best survival, whereas patients who received adjuvant radiation only or no treatment had the worst outcomes. Conclusions: Patients with Pancoast tumors receive neoadjuvant chemoradiation treatment in only a quarter of cases nationally. Patients who received neoadjuvant chemoradiation treatment had improved survival compared to patients who had upfront surgery. Similarly, when surgery is performed first, adjuvant chemoradiation treatment improved survival compared to other adjuvant strategies. These results suggest underutilization of neoadjuvant treatment for patients with node-negative Pancoast tumors. Future studies with a more clearly defined cohort are needed to assess the treatment patterns being utilized on patients with node-negative Pancoast tumors. It will be beneficial to see whether neoadjuvant treatment for Pancoast tumors has increased in recent years.

Pancoast Tumor With Cardiac Metastases and Intracardiac Thrombosis.

Pancoast tumor is a rare and aggressive form of lung cancer; cardiac metastasis is very uncommon. We present a case of advanced Pancoast tumor, with extensive cardiac metastases and intracardiac thrombosis in a woman presenting with dyspnea, shoulder pain, and weight loss. A contrast-enhanced chest computed tomographic scan revealed an apical mass, metastatic thoracic nodes, and filling defects within both ventricles. Further imaging with cardiac magnetic resonance imaging revealed 2 left ventricular masses infiltrating into the myocardium suggestive of metastatic disease, and a multilobulated mass within the right ventricle suggestive of intracardiac thrombus. She was initiated on anticoagulation for intracardiac thrombosis. Surgical pathology of biopsied tissue samples was consistent with advanced metastatic lung adenocarcinoma. She was a poor candidate for surgical intervention. Given the patient's goals of care, she was ultimately transitioned to comfort care.

Complex Regional Pain Syndrome-like Pattern in a Case of Pancoast Tumor.

We present the case of a 52-year-old male who was recently diagnosed case of a Pancoast tumor and presented to the pulmonary outpatient department with a complaint of pain in the shoulder and chest region which was burning type, associated with shoulder abduction weakness and poor hand grip. Subsequently, he was referred for a 99m-Tc bone scan for metastatic workup, which showed increased uptake in all the joints and long bones of the ipsilateral upper limb. This case highlights the importance of considering nontraumatic cause of pattern similar to complex regional pain syndrome.

Apical lung mass-A rare presentation of multiple myeloma.

Multiple myeloma is a neoplastic proliferation of immunoglobulin-producing plasma cells with clinical features resulting from infiltration of plasma cells into bones and other organs. Multiple myeloma manifesting as an apical lung mass is less common and very few cases have been reported. We report the case of a 50-year-old female who presented with an apical lung mass which happened to be multiple myeloma arising from the upper ribs into the lung. At the time of diagnosis, patient had axillary lymph node metastasis with extensive bony involvement. This case report and literature review provides insight to a rare but significant presentation of multiple myeloma and highlights the need to consider multiple myeloma as a possible differential for Pancoast tumor in the appropriate clinical setting as this could potentially affect management options and patient outcome.

Pancoast tumor presenting with multiple joint pains: a case report.

BACKGROUND: Pancoast tumors represent a unique subset of lung cancers wherein a primary neoplasm arises in the lung's apex and invades the surrounding soft tissues. One of the main challenges in the diagnosis and treatment of these apical lung cancers is that they are usually not visualized on initial chest x-ray and, by the time the patient presents with symptoms, the tumor has almost always invaded nearby structures. CASE PRESENTATION: Herein we report a case of a 58-year-old nonsmoking African American male who presented to the neurology clinic with a history of multiple chronic joint pains. The patient complained of shoulder pain that traveled into his right arm and right finger and had worsened over the past 9 months. The patient also reported decreased right proximal strength and swelling of his right hand. Magnetic resonance imaging of the shoulder and cervical region showed mild cervical spondylosis and a questionable right apical mass. A subsequent high-resolution computed tomography scan of the chest revealed a large right apical lung mass, with chest wall invasion and erosion of the adjacent ribs. Biopsy of the mass confirmed poorly differentiated non-small cell lung cancer. Radiation therapy was initiated, and the patient's pain improved significantly. Given the size of the tumor, chemotherapy was recommended by the oncology team. The patient decided against chemotherapy. CONCLUSION: This case highlights the importance of early diagnosis by expanding the differential diagnosis in patients presenting with weakness, sensory loss, and shoulder pain beyond radiculopathy or joint-related diseases. A comprehensive history and careful examination may lead to an earlier diagnosis, more appropriate treatment, and better outcome in cases of Pancoast tumor presenting with neuropathic or musculoskeletal pain.

Surgical resection of superior pulmonary sulcus tumor after neoadjuvant chemoradiation via the anterior transmanubrial approach: a case report.

Superior pulmonary sulcus tumor is a cancer arising in the apex of the lung that with potential invasion of the brachial plexus, upper ribs, vertebrae, subclavian vessels, and stellate ganglion. Induction concurrent chemoradiotherapy followed by radical surgical resection with lobectomy combined with any structures in the thoracic inlet invaded by tumor and thorough mediastinal lymph node dissection is the preferred treatment. Both anterior and posterior approaches are applied for resection. Here, we report a 61-year-old man with an 8.6 cm × 5.1 cm mass arising from the right upper lobe invading the apex of the chest wall. Brachial plexus magnetic resonance imaging suggested tumor invasion of the inferior trunk of the brachial plexus, anterior portion of the first 2 ribs, and suspicious involvement of the subclavian artery. Biopsy of the mass showed stage cT4N2M0, IIIB, poorly differentiated adenocarcinoma. The patient was treated by induction concurrent chemoradiotherapy, which was followed by surgical resection of the right upper lobe and the affected chest wall via the transmanubrial approach. The patient suffered prolonged postoperative air leak and empyema. After continuous chest tube drainage and intrapleural fibrinolytic therapy, he recovered well and was discharged safely. Final pathology showed no viable residue tumor, pathologic complete response of the tumor to induction treatment, a tumor size of 4.1 cm, and no lymph nodes; therefore, the final stage was ypT0N0M0. The transmanubrial approach is feasible for resection of tumor invading the branches of the subclavian artery; however, postoperative empyema which might have resulted from prolonged air leak should be carefully treated by meticulous air leak management.

Cardiopulmonary bypass for resection of pancoast tumor with mediastinal extension and involvement of right bronchial branch: A case report.

INTRODUCTION: and importance: Pneumonectomy is commonly associated with cardiopulmonary complications. Pneumonectomy in Pancoast tumor with mediastinal extension and no metastasis could be successful and efficient. CASE PRESENTATION: Herein, we report a successful pneumonectomy of a 54-year-old man with pancoast tumor along with the involvement of mediastinal space including right hilum of the lung, right bronchial, inferior vena cava vein and pericardium. CLINICAL DISCUSSION: Based on the bronchoscopy and biopsy, the complete involvement of right bronchial tree was reported and non-small cell carcinoma was diagnosed in pathology. CONCLUSION: To reduce the complications of the surgery, the cardiopulmonary pump machine was used during the operation.

A rare case of chordoma presenting as a Pancoast tumor.

The notochord is the defining structure of all chordate embryos. It is a midline structure ventral to the ectoderm, neural plates, and neural arch. Remnants of the notochord ultimately give rise to the nucleus pulposus. The function of the notochord is to organize the surrounding structures. Chordoma is a rare malignant bone tumor arising from remnants of the notochord. These tumors are indolent and can present as incidental or locally advanced involving adjacent structures. These tumors typically present at the skull base and sacral spine but more rarely can be seen on the cervical and thoracic spine. Rare cases of chordoma invading the brachial plexus have been recorded. Surgical resection is the mainstay of treatment for chordomas. We would like to discuss a novel presentation of a chordoma as a Pancoast tumor, and aim to highlight the clinical importance of accurate diagnosis and planning therapy along with poor prognosis of incomplete surgical resection.

Pathologic complete response after neoadjuvant tislelizumab and chemotherapy for Pancoast tumor: A case report.

A 60-year-old man was hospitalized because of numbness and weakness in the right upper limb. Magnetic resonance imaging revealed a large mass in the right upper lobe invading the right eighth cervical and first thoracic nerve root. Biopsy pathology confirmed primary lung adenocarcinoma with a clinical stage of cT4N0M0 IIIA, negative for anaplastic lymphoma kinase fusion gene and epidermal growth factor receptor mutations but positive for programmed death ligand 1 (3%). Neoadjuvant tislelizumab and chemotherapy were offered to this patient with Pancoast tumor, and tumor shrinkage of 71% was achieved. After the operation, surgical pathology indicated pathologic complete response (pCR). Circulating tumor cells testing was negative after the first adjuvant treatment. In this case, we provide real-world evidence of encouraging pCR with neoadjuvant tislelizumab and chemotherapy for a patient with Pancoast tumor.

Pancoast Tumor as the Initial Presentation of a Metastatic Colon Adenocarcinoma.

A Pancoast tumor is a rare condition, representing 3% to 5% of all lung cancers. The particular location of these lesions leads to the invasion of structures in the thoracic inlet, causing a constellation of symptoms known as Pancoast-Tobias syndrome. Diagnosis can be challenging due to their low prevalence and the possibility of being asymptomatic. Most of these tumors are non-small cell lung cancers. However, rare conditions might arise at the same location, and histologic confirmation is relevant. We report the case of a 45-year-old man admitted to the internal medicine department with a one-month history of night sweats. A full-body computed tomography (CT) scan revealed a mass on the upper lobe of the left lung, with soft tissue invasion. Histopathologic examination revealed an adenocarcinoma pattern originating from the colon. Colonoscopy showed two synchronous lesions. Hitherto, this is the second case ever described of a Pancoast tumor as metastasis of colon adenocarcinoma.