Superior Sulcus Tumors Research Articles

PANCOAST SYNDROME DUE TO A HIGH GRADE ANAPLASTIC TUMOR

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pancoast tumor is an uncommon type of lung cancer that arises from within the superior sulcus, with most clinical manifestations occurring due to mass effect. Pancoast syndrome describes symptoms that accompany such tumors. Symptoms include shoulder and arm musculoskeletal pain, Horner’s syndrome, and neurological complications of the upper extremities. Non-small cell lung cancers (NSCLC), most commonly adenocarcinoma is a predominant cause of Pancoast syndrome (1). CASE PRESENTATION: A 39-year-old male with a medical history of left-sided pneumothorax secondary to a stab wound and chronic cigar use presented to the hospital complaining of a right neck mass and right arm pain. Physical exam was notable for right supraclavicular lymphadenopathy. Initial labs were remarkable for leukocytosis of 13,200 cells/m3, hemoglobin 11 g/dl, lactate dehydrogenase 1590 IU/L, and ESR 92 mm/h. Neck CT with contrast showed a right side supraclavicular mass with right internal jugular vein thrombosis. Heparin infusion was initiated. Chest CT with contrast showed diffuse emphysematous changes, and a large bulky mass involving the medial right upper lobe and anterior mediastinum, with a mass-effect upon the brachiocephalic vein and superior vena cava consistent with Pancoast syndrome (image 1). Alpha 1 antitrypsin levels were normal. Ultrasound-guided biopsy of the right supraclavicular mass demonstrated a poorly differentiated malignant neoplasm composed of anaplastic cell sheets with extensive areas of necrosis. Immunohistochemical analysis was positive for CD34 and Vimentin (image 2). CT abdomen and pelvis showed multiple retroperitoneal nodal metastases and a right upper quadrant mass abutting the liver and posterior diaphragm. His tumor was inoperable, and palliative chemotherapy was elected. DISCUSSION: Most Pancoast tumors are caused by NSCLC(1), however, other malignancies can be responsible as well. In our patient, this occurred due to a poorly differentiated tumor with immunohistochemistry suggesting a possible mesenchymal origin. Surgery was contraindicated due to extensive local progression and distant metastases. In such patients, Site-specific chemotherapy can be selected based upon molecular testing and identification of the primary site (2). CONCLUSIONS: This case is notable for its rarity due to a poorly differentiated tumor of unknown primary site invaded the lung parenchyma and adjacent structures resulting in Pancoast’s syndrome. In such Cancer of Unknown Primary Site (CUP), empiric chemotherapy is the best treatment option available until further advancements in molecular targeted therapies are achieved (2). Reference #1: Marulli G, Battistella L, Mammana M, Calabrese F, Rea F.Superior sulcus tumors (Pancoast tumors). Ann Transl Med. 2016;4(12):239. doi:10.21037/atm.2016.06.16. Reference #2: Greco FA, Lennington WJ, Spigel DR, Hainsworth JD. Poorly differentiated neoplasms of unknown primary site: diagnostic usefulness of a molecular cancer classifier assay. Mol Diagn Ther 2015; 19:91. DISCLOSURES: No relevant relationships by christian ALMANZAR ZORRILLA, source=Web Response No relevant relationships by Omar Ansari, source=Web Response No relevant relationships by Mauricio Gomez, source=Web Response No relevant relationships by Seth Maxwell, source=Web Response No relevant relationships by Kishankumar Patel, source=Web Response No relevant relationships by Luis Silva, source=Web Response

THAT NAGGING COUGH: INTRATHORACIC SCHWANNOMA WITH HORNERS SYNDROME

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Malignant tumors in the mediastinum are unusual, accounting for less than 1% of mediastinal tumors. Of those, neural origin are usually benign in the mediastinum [1]. The most common tumors are located in the posterior mediastinum and are neurogenic such as schwannomas but also may be pleural fibromas. Definitive diagnosis requires tissue sampling [2]. Incidence is extremely rare, with 6% of giant schwannomas originating from the vagus nerve. Currently there are not enough cases to have a prevalence. Horner Syndrome is associated with mediastinal tumors, which is characterized by obstruction of the sympathetic pathway to the eye and face consisting of ipsilateral myosis, partial proptosis and anhidrosis [3]. CASE PRESENTATION: Thirty one-year-old female with a past medical history of two miscarriages was seen in the office for an upper respiratory infection and prescribed antibiotics and ordered a two view chest x-ray which showed a 6 cm round mass in the right upper lobe suspicious for pancoast tumor [Figure 1A, B]. She had been complaining of headaches, right eyelid dropping, dizziness and uneven pupils as her right side was smaller than left. Subsequently had computed tomography (CT) chest showing small right apical mass with fibrous tumor of the pleura with involvement possibly of the nerve sheath measuring 6 cm x 4.8 cm x 5.7 cm [Figure 2A, B]. Patient had CT guided lung biopsy which demonstrated S100, BCL-2 and CD 99+ compatible with schwannoma [Figure 3A-D]. She had positron emission tomography (PET) scan performed which showed intense fluorodeoxyglucose (FDG) uptake in the right apical region with standardized uptake values (SUV) max of 6.7 with no FDG avid thoracic lymphadenopathy, extensive FDG uptake within hypermetabolic fat in the left neck, supraclavicular fossa, and superior right suprarenal fat. Focal FDG uptake localizing to the posterior left neck with SUV max of 3.8. Patient was referred to surgery where she had brachial plexus exploration and dissection of thoracic inlet tumor resected through VATS. DISCUSSION: Neurogenic tumors are the most common type of neoplasia the posterior mediastinum. This consists of schwannomas and neurofibromas along with ganglion neuroblastomas. Recognition of adjacent nerves as well are well-defined margins in the presence of split fat sign may suggest benign tumor [4]. This patient developed a rare association of intrathoracic schwannoma that presented itself as Horner syndrome. Although Horner syndrome is a well-known association of sympathetic chain schwannomas of the neck and malignant lung tumors, it is uncommon for it to be presented as a benign intrathoracic lesion. Treatment is surgical resection. CONCLUSIONS: Our patient had a successful brachial plexus exploration and dissection of thoracic inlet tumor resected through VATS. Afterwards she had no more signs of Horner's syndrome. Reference #1: Angelopoulos, E., Eleftheriou, K., Kyriakopoulos, G., Athanassiadi, K., Rontogianni, D. and Routsi, C. (2016). A Giant Intrathoracic Malignant Schwannoma Causing Respiratory Failure in a Patient without von Recklinghausen’s Disease. Case Reports in Medicine, 2016, pp.1-3. Reference #2: Ritz, R., Pehl, A., Bartsch, D. and Kirschbaum, A. (2013). Giant Intrathoracic Left-Sided Vagal Schwannoma. The Thoracic and Cardiovascular Surgeon Reports, 02(01), pp.019-022. doi: 10.1055/s-0033-1337368 Reference #3: Torpiano, P., Borg, E., Cassar, P. and Manche', A. (2013). Intrathoracic schwannoma with Horner syndrome. Case Reports, 2013(dec06 1), doi: bcr2013201247. DISCLOSURES: No relevant relationships by Apurwa Karki, source=Web Response No relevant relationships by Salman Khan, source=Web Response No relevant relationships by Nathaniel McElhaney, source=Web Response No relevant relationships by Mahin Rehman, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response

Osteolysis of the Carpus as a Presentation of Pancoast's Tumor

Lung cancer is most often located in the right upper lobe and is called a Pancoast tumor. On many occasions, the Pancoast tumor begins with osteomyoarticular manifestations. A 72-year-old white male patient of peasant origin is presented who attends the Guard Corps because for a few weeks an increase in volume has been noted on the back of the right hand accompanied by pain in the absence of trauma. An X-ray of the hand was performed, observing osteolysis of the carpal bones, in the preoperative preparation a chest X-ray was performed where an image of condensation of the upper lobe of the right lung was observed. An excisional biopsy of the carpal lesion was performed, the result of which was metastasis of highly undifferentiated lung adenocarcinoma.

Percutaneous Peripheral Nerve Stimulation for Treatment of Brachial Plexopathy Secondary to Pancoast Tumor: A Case Report

Background: Pancoast tumors can result in significant arm and shoulder pain due to invasion of the lower brachial plexus (BP). They are usually treated by chemoradiotherapy followed by surgical resection, which may alleviate the pain. When patients respond poorly to chemoradiation and the tumor is not surgically resectable, options to treat the pain are limited. We report here successful use of percutaneous peripheral nerve stimulation (PNS) with leads inserted under ultrasound (US)-guidance for treatment of brachial plexopathy in a patient with an unresectable Pancoast tumor unresponsive to chemoradiation. Case Report: The patient was a 70-year-old woman with an unresectable poorly differentiated squamous cell carcinoma of the left lung status post chemoradiation with poor response and recently started on immune therapy who presented to her oncologist with refractory left upper extremity (LUE) pain and weakness. She was admitted for pain control, and pain management was consulted. Physical examination findings were concerning for involvement of the lower trunk of the BP, findings confirmed in imaging. Patient elected to proceed with placement of a PNS. Device was successfully placed under US guidance. Patient responded well for the first 2 weeks with significant improvement in allodynia and hyperesthesia, however, at week 3, physical examination was significantly changed and further growth of the tumor was seen on imaging. The PNS was removed at this time. Conclusion: This case demonstrates successful use of PNS to treat refractory neuropathic pain in a patient with a locally advanced Pancoast tumor. US imaging made it possible to identify the interscalene BP and accurately place the leads. The PNS achieved its desired outcome of providing pain relief in the lower trunk distribution for the full 3 weeks it was in place. Pain from Pancoast tumors can be severe, and neural blockade via PNS to interrupt pain is an option for patients with intractable pain. Additional prospective study is warranted to determine the efficacy of this technique. Key words: Brachial plexus, upper extremity, cancer pain, interventional pain management, neuromodulation, peripheral nerve stimulation

Estimated direct costs of non-small-cell lung cancer by stage and care phase: a whole disease model

Abstract Background Non-small-cell lung cancer (NSCLC) is the first cause of cancer-related death among men and the second among women worldwide. It also poses an economic threat to the sustainability of healthcare services. This study estimates the direct costs of care for patients with NSCLC by stage at diagnosis and management phase of pathway recommended in local and international guidelines. Methods Based on the most up-to-date guidelines we developed a detailed “whole-disease” model that lists the probabilities of all potentially necessary diagnostic and therapeutic actions involved in the management of each stage of NSCLC. Then we assigned the cost sustained by the public authorities to each procedure, obtaining an estimate of the total and average per-patient costs of each stage of the disease and management phase in Veneto Region, Italy. Results The mean expected cost of a patient with NSCLC is 22,968 € in the first year: 20,222 € in stage I, 23,935 € in stage II, 23,027 € in stage III, 22,915 € in stage IV and 31,749 € for Pancoast's tumors. In the second year the mean per patient-costs patient ranged from 2,722 €, for a patient with stage I disease, to 13,396 € for a patient with stage IV, with an overall average cost of 8,307 €. In the early stages, the main cost was due to surgery, whereas in the more advanced stages radiotherapy, medical therapy, treatment for progressions and supportive care become variously more important. Conclusions Our study enabled a prediction of the direct costs and outcomes for patients diagnosed with NSCLC on a two-year timeline after the diagnosis. An estimation of the direct costs of NSCLC, and in general for cancer, appears fundamental to predict the burden of new oncological therapies and treatments on healthcare services, and, in our opinion, our model could represent a useful tool for policy-makers in the optimization of resources allocation. Key messages Whole disease model allows an economic evaluation of a clinical pathway. The model is able to estimate direct costs of NSCLC by disease stage and management phase within a time horizon of two years. High cost-surgery makes the early stages no less expensive than advanced stages during the first year. In the second year, an advanced stage case costs almost five times more than an early stage case.

Retrospective Planning Study of Patients with Superior Sulcus Tumours Comparing Pencil Beam Scanning Protons to Volumetric-Modulated Arc Therapy

AimsTwenty per cent of patients with non-small cell lung cancer present with stage III locally advanced disease. Precision radiotherapy with pencil beam scanning (PBS) protons may improve outcomes. However, stage III is a heterogeneous group and accounting for complex tumour motion is challenging. As yet, it remains unclear as to whom will benefit. In our retrospective planning study, we explored if patients with superior sulcus tumours (SSTs) are a select cohort who might benefit from this treatment. Materials and methodsPatients with SSTs treated with radical radiotherapy using four-dimensional planning computed tomography between 2010 and 2015 were identified. Tumour motion was assessed and excluded if greater than 5 mm. Photon volumetric-modulated arc therapy (VMAT) and PBS proton single-field optimisation plans, with and without inhomogeneity corrections, were generated retrospectively. Robustness analysis was assessed for VMAT and PBS plans involving: (i) 5 mm geometric uncertainty, with an additional 3.5% range uncertainty for proton plans; (ii) verification plans at maximal inhalation and exhalation. Comparative dosimetric and robustness analyses were carried out. ResultsTen patients were suitable. The mean clinical target volume D95 was 98.1% ± 0.4 (97.5–98.8) and 98.4% ± 0.2 (98.1–98.9) for PBS and VMAT plans, respectively. All normal tissue tolerances were achieved. The same four PBS and VMAT plans failed robustness assessment. Inhomogeneity corrections minimally impacted proton plan robustness and made it worse in one case. The most important factor affecting target coverage and robustness was the clinical target volume entering the spinal canal. Proton plans significantly reduced the mean lung dose (by 21.9%), lung V5, V10, V20 (by 47.9%, 36.4%, 12.1%, respectively), mean heart dose (by 21.4%) and thoracic vertebra dose (by 29.2%) (P < 0.05). ConclusionsIn this planning study, robust PBS plans were achievable in carefully selected patients. Considerable dose reductions to the lung, heart and thoracic vertebra were possible without compromising target coverage. Sparing these lymphopenia-related organs may be particularly important in this era of immunotherapy.

Right Arm Numbness In An Adolescent

HISTORY: A 14-year-old high school student presented to Orthopedics Urgent Care for right arm numbness and discoloration. Four days prior had noticed that her right arm would turn a dusky purple or blue color from the shoulder to her fingers with associated numbness and tingling in the entire arm. Episodes lasted only a few seconds to a minute. She would have multiple episodes a day. No specific pattern or time of day, however she thinks it may occur more frequently while wearing a backpack or if her arm is in an elevated position. Episodes resolve on their own. ROS otherwise negative. PHYSICAL EXAMINATION: Right upper extremity without dusky appearance, appears similar to left upper extremity. Full ROM and strength at the shoulder, elbow, wrist, and fingers. Decreased sensation in the ulnar distribution of the right hand compared to the left. Strong radial pulse when right hand is lowered. Positive Adson for loss of radial pulse, positive Roos for numbness and tingling. DIFFERENTIAL DIAGNOSIS: 1. Right upper extremity DVT 2. Thoracic outlet syndrome 3. Pancoast tumor TEST AND RESULTS: Right upper extremity venous ultrasound normal. Right upper extremity arterial ultrasound with normal triphasic arterial waveforms with arm at patient’s side and at 90 degrees abducted in the subclavian, axial, brachial, radial, and ulnar arteries. With arm raised above patient’s head, abnormal monophasic waveform in the right subclavian artery. FINAL WORKING DIAGNOSIS: Arterial thoracic outlet syndrome. TREATMENT AND OUTCOMES: 1. Referred to pediatric vascular surgery. 2. Was referred to physical therapy, will follow up in 6 months.

What's Important: It's a Privilege.

What's Important: It's a Privilege.

The transmanubrial osteomuscular-sparing approach: a valuable adjunct to the head and neck surgical armamentarium.

To describe and popularize the transmanubrial osteomuscular-sparing approach (TOSA) outside its original thoracic surgical field of application, based on the consideration that it could be of interest for the management of a number of head and neck cases in both elective and emergent scenarios. The main advantages of TOSA compared with transclavicular techniques are its superb exposure of anatomic structures located at the level of the cervicothoracic junction, and superior postoperative aesthetic and functional outcomes. Recently, a number of studies have described the association of TOSA with other minimally invasive approaches, such as video-assisted thoracoscopic surgery and robotic hybrid approaches, with the aim of avoiding association of the transmanubrial route with anterior/posterior thoracotomies, or more extended surgeries, such as the trapdoor or hemiclamshell procedures. TOSA, even though originally conceived to reduce the morbidity ensuing from classic transclavicular approaches for management of Pancoast tumors, may well play an important role in a number of head and neck surgical conditions, including those related to mediastinal goiter and thyroid cancer, management of stenosis and lesions of the thoracic trachea and esophagus, treatment of the junction between innominate, internal jugular, and subclavian veins, epiaortic arteries, thoracic duct, brachial plexus, and low sympathetic chain. Whenever comprehensive control of vascular and nonvascular structures of the upper mediastinal inlet is required, TOSA should be planned and performed by combining the expertise of cooperating professionals.

Significant prognostic determinants in lung cancers of the superior sulcus: comparable analysis of resected and unresected cases

In this study, we aimed to identify prognostic determinants and to comparably analyze clinical features of patients with both resected and unresected superior sulcus tumors (SSTs). The data of 56 patients who underwent any treatment for an SST from 2004 through 2016 in our hospital were reviewed. Overall survival (OS) rates were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to determine independent prognostic factors for patients with resected and unresected SST separately. The number of patients with resected and unresected SSTs was 24 (43%) and 32 (57%), respectively. Of the 24 patients who underwent surgery, 20 received induction therapy, with 32% achieving pathological complete response. Complete resection (R0) was performed in 22 patients (92%). On multivariate survival analysis, preoperative serum carcinoembryonic antigen (CEA) level (median 8.3ng/ml, p = 0.021) was identified as the independent determinant of OS in surgical patients; whereas, initial treatment response (complete response or partial response, p = 0.032) was the independent OS indicator in non-surgical patients. The 5-year OS of the patient with resected and unresected SST was 68.8% and 29.1% (p = 0.008), respectively. Significant prognostic factors differ among patients stratified by the presence of surgical resection for SSTs. Preoperative CEA level in surgical candidates and initial treatment response in non-surgical patients were the independent factors associated with OS. Surgical candidates are expected to have more favorable survival than patients with unresectable SSTs.

Prognostic factors following complete resection of non-superior sulcus lung cancer invading the chest wall.

Locally advanced non-small-cell lung cancer (NSCLC) with chest wall invasion carries a high risk of recurrence and portends poor survival (30-40% and 20-50%, respectively). No studies have identified prognostic factors in patients who underwent R0 resection for non-superior sulcus NSCLC. A retrospective review was conducted for all chest wall resections for NSCLC from 2004 to 2018. Patients with superior sulcus tumours, partial (<1 rib) or incomplete (R1/R2) resection or distant metastasis were excluded. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazards modelling was used to determine factors associated with DFS and OS. A total of 100 patients met inclusion criteria. Seventy-three (73%) patients underwent induction therapy, and all but 12 (16%) patients experienced a partial radiological response. A median of 3 ribs was resected (range 1-7), and 67 (67%) patients underwent chest wall reconstruction. The 5-year DFS and OS were 36% and 45%, respectively. Pathological N2 status [hazard ratio (HR) 3.12, confidence interval (CI) 1.56-6.25; P = 0.001], intraoperative blood transfusion (HR 2.24, CI 1.28-3.92; P = 0.005) and preoperative forced vital capacity (per % forced vital capacity, HR 0.97, CI 0.96-0.99; P = 0.013) were associated with DFS. Increasing pathological stage, lack of radiological response to induction therapy (HR 7.35, CI 2.35-22.99; P = 0.001) and cardiovascular comorbidity (HR 2.43, CI 1.36-4.36; P = 0.003) were associated with OS. We demonstrate that blood transfusion and forced vital capacity are associated with DFS after R0 resection for non-superior sulcus NSCLC, while radiological response to induction therapy greatly influences OS. We confirm that pathological nodal status and pathological stage are reproducible determinants of DFS and OS, respectively.

Surgery for Pancoast tumors—the role of combined approaches

Background: The surgical techniques for Pancoast tumors are as variable as the clinical pictures. Involved structures and location/size of the tumor deeply affect the choice of technique and surgical approaches. Methods: Results of the surgical therapy in 23 consecutive patients with Pancoast tumor over an eighteen-year period was reviewed. Disease free survival (DFS) and overall survival (OS) were calculated by the Kaplan-Meier method. Results: Clinical stage was cT3N0M0 in 17 patients, cT3N1M0 in 2 and cT4N0M0 in 4. No cN2 patients were considered for surgery. Eighteen patients underwent induction chemoradiotherapy. The posterior approach was performed in 61%, the transmanubrial approach in 22% and an original “double step” approach in 17% of patients. A combined approach was performed in 39.1% of patients, mostly through an additional thoracotomy; a combined VATS approach was chosen just in one patient. The prosthetic stabilization of the chest wall was performed in 5 cases. No postoperative mortality was observed with a total complication rate of 48%. The type of approach did not influence the complication rate. Median follow-up was 52.24 months with IQR 13.16–85.39 months (range, 1.48–164.7 months). Median OS was 62.3 months (95% CI, 18.39–104.21 months). The 5-year OS was 55.6% (95% CI, 31.7–74.1%). Median DFS was 65.9 months (95% CI, 12.1–104.2 months); 5-year DFS was 51.5% (95% CI, 28.2–70.7%). Patients with R1 resection had a median OS of 13.1 months (95% CI, 12.2–18.4 months). Conclusions: Complete resection of the tumor represents one of the strongest prognostic factors of OS and DFS, along with T status and complete pathological response to therapy. Every effort should be made to obtain pathologic negative margin and combined approaches may facilitate this goal in anterior Pancoast tumors.

A clinico-epidemiological, pathological, and molecular study of lung cancer in Northwestern India.

Lung cancer is the most common malignant disease and is the topmost cause of cancer deaths in the world across all age groups and in both sexes. It is the most common cause of cancer deaths in developed countries and is also rising at an alarming rate in the developing countries. The present study was undertaken to explore the clinicopathological and molecular profile of bronchogenic carcinoma in northwestern population of India. A total of 136 consecutive patients with histologically proven bronchogenic carcinoma, registered between May 2014 and April 2016 at a tertiary care hospital in New Delhi, India, were analyzed. Out of a total of 136 diagnosed cases, 6% were in the third to fourth decade of life, 49% in the fifth to sixth decade, and 45% in the seventh decade and above. Seventy-one percent of patients were male. Smoking was the major risk factor in 65.40% of patients. About 33% of female patients were smokers with a significant overlap in the use of smoking objects. Twenty-one percent of patients had been initially empirically treated with antitubercular therapy. Most common symptoms at presentation were cough, dyspnea, weight loss, and chest pain. Pleural effusion, paraneoplastic phenomenon, clubbing, peripheral lymphadenopathy, and Pancoast syndrome were the major signs at presentation. Twenty-one percent of nonsmokers and 40% of smoker patients presented with ECOG Performance Status 3 or 4. Ninety-three percent of patients presented in stage III or IV. Metastases to skeleton, brain, liver, pleura, adrenals, lung, and distant lymph nodes were present in 30.8%, 16.9%, 15.4%, 15.4%, 14.7%, 13.2%, and 11.8%, respectively. Fiberoptic bronchoscopy was found to be the most efficient diagnostic procedure as compared to transthoracic and thoracoscopic methods. Histologically, squamous cell carcinoma, adenocarcinoma, and small cell carcinoma and its variants were seen in 35.30%, 44.9%, and 15.40% cases, respectively. Nearly 4.4% of patients were diagnosed as poorly differentiated carcinoma. Driver mutations (epidermal growth factor receptor or anaplastic lymphoma kinase) were detected in 48% (25 of 52 tested) of adenocarcinomas and 55.55% (5 of 9 tested) of young, nonsmoker, female squamous cell carcinoma patients. This study highlights that the adenocarcinoma incidence is surpassing squamous cell carcinoma in Indian lung cancer patients also, as observed in Western population. Mean age at diagnosis is about one decade earlier than in the Western population. Driver mutations are more common in India than in the West as also reported in other Asian studies.

What you don’t want to see after a superior sulcus tumor resection?: a tension pneumocephalus

What you don’t want to see after a superior sulcus tumor resection?: a tension pneumocephalus

Once again about difficulties of early diagnosis of Pancoast tumor (case studies)

Once again about difficulties of early diagnosis of Pancoast tumor (case studies)

A CASE OF PANCOAST SYNDROME IN TB

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Tuberculosis is one of the most common systemic infectious disease, and a major public health problem all over the world. It has several forms of presentation and clinical manifestations. Here we present an interesting clinical manifestation of Tuberculosis as Pancoast Syndrome. CASE PRESENTATION: A 55 year old male, smoker for past 30 years, presented with cough with expectoration, left shoulder pain and weakness of left upper limb of 6 months duration. He had irregular treatment for pulmonary tuberculosis two years ago. On examination he had partial ptosis of left eye, enophthalmos, miosis, ipsilateral anhydrosis, and tenderness in left supraclavicular region, wasting of left upper limb muscles. Sputum examination was positive for Acid fast bacilli. Cartridge based Nucleic Acid Amplification Test (CBNAAT) of sputum confirmed Rifampicin sensitive Mycobacterium Tuberculosis. Chest radiograph and CT Chest showed fibrocavitary changes, Cavitary consolidations predominantly involving right lung and mass like lesion in left apical lobe with erosion of left first rib. Histopathological examination with CT guided biopsy of the mass like lesion was negative for malignancy but showed caseous granulomatous inflammation. DISCUSSION: Pancoast syndrome1 refers to a constellation of symptoms of Brachial Neuralgia, Horner’s syndrome and atrophy of muscles of ipsilateral upper limb. Pancoast syndrome is commonly associated with Pancoast tumor of Squamous cell carcinoma , recently adenocarcinoma has emerged as commonest. Other conditions that may result in Pancoast syndrome are (1) Other tumors - primary chest wall and metastatic tumors, pleural mesothelioma, hematologic malignancies, (2) infectious and inflammatory lung diseases – tuberculosis, aspergillosis, echinococcosis, actinomyces and lung abscesses, inflammatory pseudotumor, amyloid nodules and (3) vascular lesions - carotid pseudoaneurysm, hemangioma.These conditions can invade and destruct the apical bony skeleton of the thorax, producing similar clinical and radiographic picture. CONCLUSIONS: We conclude that clinicians need to be aware of the variable manifestations of Tuberculosis. Reference #1: Pancoast HK. Superior pulmonary sulcus tumor: tumor characterized by pain Horner’s syndrome, destruction of bone and atrophy of hand muscles. JAMA 1932;19:1391-6. Reference #2: White HD, White BA, Boethel C, et al. Pancoast’s syndrome secondary to infectious etiologies: a not so uncommon occurrence. Am J Med Sci 2011;341:333-6 Reference #3: Beshay M, Roth T, Stein RM, et al. Tuberculosis presenting as Pancoast tumor. Ann Thorac Surg 2003;76:1733-5 DISCLOSURES: No relevant relationships by ALLWYN VIJAY GOWRI SHANKAR, source=Web Response No relevant relationships by Sagindar Samaraj, source=Web Response

Neuralgic Amyotrophy: Clinical and Epidemiological Features From a Spine Neurosurgeon's Perspective

Abstract INTRODUCTION Neuralgic amyotrophy (NA) is a rare but serious condition characterized by the acute onset of shoulder and arm pain, weakness, and sensory loss. NA may therefore be misdiagnosed as a cervical spine disease, or as a shoulder disorder. With little literature on the behavior of NA from a spine surgeon's perspective, accurate diagnosis and subsequent counseling of patients with NA can be challenging. METHODS Data were collected from 30 patients during an 11-yr period. Neurophysiologic studies were performed in all patients. A total of 19 patients were evaluated by magnetic resonance neurography (MRN) using a 1.5-T or 3.0-T scanner. RESULTS A total of 30 patients were diagnosed with NA based on positive neurophysiologic findings. The most common clinical presentation was severe shoulder pain and weakness in 22 patients (73%). A total of 15 patients (50%) were misdiagnosed with cervical disc herniations (12 patients), a pancoast syndrome (1 patient), a cubital tunnel syndrome (1 patient), and a posterior interosseous syndrome (1 patient). In neurophysiologic studies, the most commonly involved trunk of the brachial plexus was the upper trunk in 24 patients. MRN was taken at the acute phase in all patients and showed a thickened and hyperintense trunk of the affected brachial plexus, consistent with plexitis. The prognosis was good with a functional recovery (of up to 80%) in 28 patients (93%) at final follow-up period. Among them, however, 6 patients still had mild weakness (Grade IV). Two patients did not achieve their functional motor recovery (Grade 3) at 18 mo after onset. CONCLUSION Because NA is misdiagnosed in many cases, awareness and accurate diagnosis of this disorder can help neurosurgeons determine the most appropriate treatment. To prevent unnecessary surgical procedures or studies, it is important to distinguish NA from other alternative diseases. Neurophysiologic studies are critical for diagnosis of NA, and MRN is very helpful for early diagnosis.

The new 8th TNM staging system of lung cancer and its potential imaging interpretation pitfalls and limitations with CT image demonstrations.

The tumor, node, metastasis (TNM) staging system approved by International Association for the Study of Lung Cancer (IASLC) and the American Joint Committee on Cancer (AJCC) to stage lung cancer was recently revised. The latest revision is the 8th edition published in January, 2017. This new edition made some important changes to the previous edition, including modification of the T classification based on 1 cm increment, downstage of T descriptor including endobronchial tumor disregarding its distance from carina (T2), merging total and partial atelectasis/pneumonitis into the same T category (T2), upstage diaphragmatic invasion to T4, new classification concept of adenocarcinoma in situ and minimally invasive adenocarcinoma for pure and part-solid ground-glass nodules, and further division of extrathoracic metastasis into M1b and M1c based on the number and sites of extrathoracic metastases. Consensus is reached for debating situations not covered in the previous edition of staging system, such as the classification of pancoast tumor based on its invasion depth and staging tumors that extend directly across the fissure as T2a. Classification of multiple sites of pulmonary involvement, including multiple primary lung cancer, separate lung cancer nodules, multiple ground-glass or lepidic lesions, and consolidation, is also discussed. Even though the 8th edition of the TNM lung staging system provides us with more precise classification based on prognostic analysis of each TNM descriptors, there are still some potential limitations and clinical situations that have not yet been clarified in terms of clinical staging by imaging. It is important for radiologists to understand the major changes introduced in the 8th edition of TNM staging and to recognize the potential pitfalls and limitations of imaging interpretation to precisely classify the clinical stage of lung cancer.

Modernes Management des Pancoast-Tumors

ZusammenfassungDer Pancoast-Tumor (Sulcus-superior-Tumor) ist eine Sonderform des Lungenkarzinoms mit Infiltration der oberen Thoraxapertur, die durch Schulterschmerz und eventuell Horner-Syndrom klinisch auffällig wird. Die häufig verspätete Diagnose und die komplexe Anatomie der Region stellen eine Herausforderung für die Therapeuten dar. Dieser Beitrag schildert, wie moderne Diagnostik und multimodale Behandlung die Prognose der Erkrankung positiv beeinflussen können.

Evaluation of intra-tumoral blood feeding to predict the effect of induction therapy in patients with locally advanced lung cancer.

ABSTRACTThere is little known about predictors of the effects of induction therapy in locally advanced lung cancer, including superior sulcus tumors. We analyzed whether intra-tumoral blood feeding could predict a pathologic complete response (pCR). Patients who underwent induction therapy followed by surgery for locally advanced lung cancer were retrospectively reviewed. The intra-tumoral blood feeding was defined by the CT value (HU, Hounsfield unit), which was calculated by subtracting the non-enhanced value from the contrast-enhanced value (divided into the early and delayed phase) at the maximum diameter of the tumor on dynamic CT. The cases were classified, according to the efficacy of induction therapy, into the pCR and residual tumor (pRT) group. There were 38 cases of T3 and 12 of T4; the induction therapy consisted of chemoradiotherapy in 39 patients, chemotherapy in 6, and radiotherapy in 5. A pCR was obtained in 15 (30%) patients. The mean CT values of the early and delayed phases in the pCR group were 14.8 and 30.7 HU, while those in the pRT were 15.3 and 32.2 HU, respectively. A logistic regression analysis revealed that a smaller tumor size (< 42 mm) was a non-significant predictor of a pCR (p = 0.09); the maximum standardized uptake value on FDG-PET and the CT values on the early and delayed phases of dynamic CT were not associated with the achievement of a pCR. In conclusion, intra-tumoral blood feeding of the locally advanced lung cancer did not predict the effects of induction therapy, whereas smaller sized tumors tended to show a better response.