Pancoast tumors are a distinct entity seen mostly in non-small cell carcinoma of the lung. We present a case of a Pancoast tumor in newly diagnosed squamous cell carcinoma of the lung. A 56-year old female with a 40-pack year smoking history, presented with several weeks duration of right shoulder pain, radiating down her arm. Symptoms were aggravated with movement and slightly improved with rest and non-steroidal analgesics She had no other known medical history. Physical therapy provided little relief. Subsequently, magnetic resonance imaging (MRI) of the cervical spine from an outside facility revealed a large right apical lung mass, involving the T2 thoracic spine and sternum. She denied chest pain, shortness of breath, weight loss, or edema of the face or neck. Range of motion of right upper extremity was limited due to pain. Ptosis and miosis of the right eye were detected. Days after the MRI, the patient presented to the hospital for intractable right upper extremity pain. Comprehensive imaging including positron emission tomography scan and MRI of the brain were done. The right apical lung mass was suggestive of a Pancoast tumor, measuring 5.3 x 5.5 x 6.9 cm in size, extending into the medial portion of the upper mediastinum. The tumor abutted the apical pleura and partially encased the right subclavian artery. There was destruction of the first and second ribs and portions of the right T1 and T2 vertebral bodies along with right hilar and lower paratracheal adenopathy. Biopsy of the mass confirmed moderately differentiated, invasive squamous cell carcinoma of the lung, assessed to be Stage IIIB and unresectable. Pain control was achieved, and the patient was discharged. Treatment was initiated with concurrent radiation and chemotherapy with cisplatin and etoposide. Pancoast tumors, also known as superior sulcus tumors, were first noted in 1838 but not well defined at the time. In 1924 and 1932, American radiologist, Henry Pancoast, further described them as carcinomas of unknown origin of the chest apex. They occur in 3-5% of lung cancers, most commonly in non-small cell carcinoma. By definition, a Pancoast tumor must invade parietal pleura and cause pain, paresthesia, or neurologic dysfunction. Less than 50% of these tumors are resectable. They may involve the lower cervical and/or upper thoracic spines, first and second ribs, brachial plexus, and subclavian vessels. Involvement of paravertebral sympathetic chains can lead to Horner syndrome with a prevalence up to 40%. Neurologic compromise may cause upper extremity weakness, muscular atrophy, and paresthesia. In 5% of cases, they can cause spinal cord compression and paraplegia. Five-year survival is reported to be less than 10% if there is vertebral body invasion. In locally advanced lung cancers including Pancoast tumors, treatment can include neoadjuvant chemoradiation with subsequent resection. However due to the extensiveness and complexity of this patient’s tumors, resection was not amenable. Evaluation for Pancoast tumor may be warranted in those with lung cancer risk with acute musculoskeletal/neurologic complaints. Treatment is initiated promptly, based on stage and histology.

O câncer de pulmão tem alto grau de letalidade. O tabagismo é considerado o principal fator de risco associado ao carcinoma de pulmão não pequenas células. O tratamento que oferece as maiores possibilidades de cura é a cirurgia. A ressecção pulmonar associada atoracectomia é a cirurgia preconizada nos tumores T3 invadindo a parede torácica. A ressecção em Gaiola de Passarinho pode ser considerada uma técnica alternativa. Foram analisados retrospectivamente, de janeiro de 1990 à dezembro de 2009, 13 pacientes portadores de câncer de pulmão aderidos a parede torácica. Eles foram submetidos à ressecção extramusculoperiostal em Gaiola de Passarinho no Hospital Universitário Pedro Ernesto. A avaliação do grau de invasão à parede torácica foi feita no pré-operatório por métodos de imagem; e sua comprovação baseada nos achados histopatológicos dos fragmentos de tecidos enviados para a biópsia de congelação, assim como nos laudos definitivos das peças ressecadas. Os pacientes com tumores de Pancoast ou que abandonaram o acompanhamento foram excluídos do estudo. A avaliação da sobrevida global foi feita a partir dos dados de seguimento pós operatório a nível ambulatorial. A análise estatística foi composta pela curva de sobrevida ou livre de eventos ajustada pelo método de Kaplan-Meier. Complicações pós operatórias, intervalo livre de doença, recidiva local, e uso de terapia complementar também foram incluídos na análise. A idade média em anos foi de 59,6. Todos os pacientes eram tabagistas. O tipo histológico mais encontrado foi o carcinoma escamoso. A média de intervalo livre de doença foi de 44,7 meses. A sobrevida global em cinco anos foi de 60% e o índice de complicações pós-operatórias foi de 69,2%. Não houve mortalidade operatória. O estágio Ib foi encontrado em 80 %. A ressecção extramusculoperiostal demonstrou ser uma alternativa segura de tratamento cirúrgico dos tumores que não invadiram efetivamente o gradil costal. Porém novos estudos tornam-se necessários. Esta dissertação pode servir de base para futuras pesquisas sobre o tratamento cirúrgico do câncer de pulmão. / Lung cancer has high level of lethality. Smoking is considered the main risk factor associated with non small-cell lung cancer. The treatment that offers better opportunity for cure is surgery. Lung resection with thoracectomy is the procedure performed in T3 tumours invading chest wall. The bird cage resection can be considered an alternative approach. Between january 1990 and december 2009, 13 pacients with non-small cell lung cancer invading chest wall were retrospectively analyzed. They underwent resection in bird cage in Pedro Ernesto Hospital of State of Rio de Janeiro University. Preoperative evaluation of chest wall invasion was performed with imaging methods and based on histopathological findings of tissue fragments sent for frozen biopsy, as well as the final reports of surgical specimens. Pacients with Pancoasttumours and whose abandoned treatment was excluded. Overall survival evaluation was done from follow-up outpacients. Statistics analysis was performed using cumulative survival and cumulative metastasis-free survival curves, adjusted by Kaplan-Meier method. Postoperative complications, disease-free interval, local disease recurrence and complementary therapy were also included in the study. Median age was 56,9 years. Median free-disease interval was 44,7 months. All pacients were smokers. Carcinoma squamous cell was the main histological type founded. Overall long-term survival was 60% in five years and the rate of postoperative complications was 69,2%. There was no operative mortality. Stage Ib was present in 80%. The extramusculoperiosteal in bird cage resection has demonstrated to be a safe alternative in surgical treatment of tumours that effectively doesnt violate the chest wall. However, new studies are necessary. This dissertation can be used as basis for future researches in surgical treatment of lung cancer.

O câncer de pulmão tem alto grau de letalidade. O tabagismo é considerado o principal fator de risco associado ao carcinoma de pulmão não pequenas células. O tratamento que oferece as maiores possibilidades de cura é a cirurgia. A ressecção pulmonar associada atoracectomia é a cirurgia preconizada nos tumores T3 invadindo a parede torácica. A ressecção em Gaiola de Passarinho pode ser considerada uma técnica alternativa. Foram analisados retrospectivamente, de janeiro de 1990 à dezembro de 2009, 13 pacientes portadores de câncer de pulmão aderidos a parede torácica. Eles foram submetidos à ressecção extramusculoperiostal em Gaiola de Passarinho no Hospital Universitário Pedro Ernesto. A avaliação do grau de invasão à parede torácica foi feita no pré-operatório por métodos de imagem; e sua comprovação baseada nos achados histopatológicos dos fragmentos de tecidos enviados para a biópsia de congelação, assim como nos laudos definitivos das peças ressecadas. Os pacientes com tumores de Pancoast ou que abandonaram o acompanhamento foram excluídos do estudo. A avaliação da sobrevida global foi feita a partir dos dados de seguimento pós operatório a nível ambulatorial. A análise estatística foi composta pela curva de sobrevida ou livre de eventos ajustada pelo método de Kaplan-Meier. Complicações pós operatórias, intervalo livre de doença, recidiva local, e uso de terapia complementar também foram incluídos na análise. A idade média em anos foi de 59,6. Todos os pacientes eram tabagistas. O tipo histológico mais encontrado foi o carcinoma escamoso. A média de intervalo livre de doença foi de 44,7 meses. A sobrevida global em cinco anos foi de 60% e o índice de complicações pós-operatórias foi de 69,2%. Não houve mortalidade operatória. O estágio Ib foi encontrado em 80 %. A ressecção extramusculoperiostal demonstrou ser uma alternativa segura de tratamento cirúrgico dos tumores que não invadiram efetivamente o gradil costal. Porém novos estudos tornam-se necessários. Esta dissertação pode servir de base para futuras pesquisas sobre o tratamento cirúrgico do câncer de pulmão. / Lung cancer has high level of lethality. Smoking is considered the main risk factor associated with non small-cell lung cancer. The treatment that offers better opportunity for cure is surgery. Lung resection with thoracectomy is the procedure performed in T3 tumours invading chest wall. The bird cage resection can be considered an alternative approach. Between january 1990 and december 2009, 13 pacients with non-small cell lung cancer invading chest wall were retrospectively analyzed. They underwent resection in bird cage in Pedro Ernesto Hospital of State of Rio de Janeiro University. Preoperative evaluation of chest wall invasion was performed with imaging methods and based on histopathological findings of tissue fragments sent for frozen biopsy, as well as the final reports of surgical specimens. Pacients with Pancoasttumours and whose abandoned treatment was excluded. Overall survival evaluation was done from follow-up outpacients. Statistics analysis was performed using cumulative survival and cumulative metastasis-free survival curves, adjusted by Kaplan-Meier method. Postoperative complications, disease-free interval, local disease recurrence and complementary therapy were also included in the study. Median age was 56,9 years. Median free-disease interval was 44,7 months. All pacients were smokers. Carcinoma squamous cell was the main histological type founded. Overall long-term survival was 60% in five years and the rate of postoperative complications was 69,2%. There was no operative mortality. Stage Ib was present in 80%. The extramusculoperiosteal in bird cage resection has demonstrated to be a safe alternative in surgical treatment of tumours that effectively doesnt violate the chest wall. However, new studies are necessary. This dissertation can be used as basis for future researches in surgical treatment of lung cancer.

Les tumeurs de Pancoast-Tobias ont été clairement décrites pour la première fois en 1932. Leur fréquence reste faible, 3% des cancers bronchiques. Le premier traitement efficace est rapporté en 1956 depuis, malgré le développement des traitements combinés il reste controversé. Cette étude rétrospective de 1992 à 2004 a évalué les traitements reçus par 71 patients porteurs de tumeur de Pancoast-Tobias dans le cadre du groupe d'oncologie thoracique clermontois. La comparaison des différents traitements permet de conclure que la chirurgie quand elle est possible reste le meilleur traitement à condition que l'exérèse soit complète. La radio-chimiothérapie concomitante d'induction par cisplatine, 5 fluoro-uracile et vinorelbine semble le meilleur traitement en induction ou chez les non opérés en comparaison à la radiochimiothérapie séquentielle ou à d'autres protocoles de chimiothérapie concomitante. A l'exception des patients métastatiques qui tirent plus de bénéfice en terme de survie et de tolérance d'un traitement séquentiel. La survie médiane tous stades confondus a été calculée à 9 mois avec une survie pour les stades IIb de 33 mois et 14 mois pour les stade IIIA et IIIB. Les principaux facteurs pronostics retrouvés ont été : l'age, le performans statu, le stade, le statu T, le taux de cyfra 21 initial, la présence d'une résection complète et le statu pN post opératoire. Le problème reste la fréquence élevée de rechutes cérébrales pour lesquelles des essais sont en cours pour savoir s'il faut s'orienter vers une chimiothérapie d'induction, une irradiation cérébrale prophylactique ou une chimiothérapie de consolidation.