Pancoast’s Tumor Syndrome

THE CLINICAL SYNDROME

Pancoast’s tumor syndrome is the result of local growth of tumor from the apex of the lung directly into the brachial plexus. Such tumors usually involved the first and second thoracic nerves as well as the eighth cervical nerve, producing a classic clinical syndrome consisting of severe arm pain and, in some patients, Horner’s syndrome.

A smoking history should suggest the possibility of Pancoast's tumor in patients suffering from shoulder and upper extremity pain.

Destruction of the first and second ribs is also common. Diagnosis is usually delayed, and patients are often erroneously treated for cervical radiculopathy or primary shoulder pathology until the diagnosis becomes clear.

SIGNS AND SYMPTOMS

Patients suffering from Pancoast’s tumor syndrome will complain of pain radiating to the supraclavicular region and upper extremity. Initially, the lower portion of the brachial plexus is involved as the tumor growth is from below, causing pain in the upper thoracic and lower cervical dermatomes. The pain is neuritic in character and may take on a deep, boring quality with invasion of the brachial plexus by tumor. Movement of the neck and shoulder will exacerbate the pain, and patients suffering from brachial plexopathy will often avoid such movements in an effort to palliate the pain. Frozen shoulder often results and may confuse the diagnosis. As the disease progresses, Horner’s syndrome may occur.

Pancoast's tumor (adenocarcinoma) with infiltration of the brachial plexus. A 65-year-old man complained of servere pain in the shoulder radiating to the elbow, medial side of the forearm, and the fourth and fifth fingers in an ulnar nerve distribution. Screening coronal T1-weighted image shows the brachial plexus from the region of the roots (long arrows) to the region of the trunks and divisions, where there is tumor invasion (short arrow) and loss of fat planes on the left.

TREATMENT

The primary treatment of Pancoast’s tumor syndrome should be aimed at the tumor itself. Based on the cell type and extent of involvement, chemotherapy and radiation therapy may be indicated. Primary surgical treatment of tumors involving the brachial plexus is difficult, and the results are disappointing.

Drug Therapy

Opioid Analgesics

The mainstay of the treatment of pain associated with Pancoast’s tumor syndrome is the opioid analgesics. Although as a general rule neuropathic pain responds poorly to opioid analgesics, given the severity of pain and lack of options available to treat the pain of Pancoast’s tumor syndrome, a trial of opioid analgesics is warranted. The use of a short-acting potent opioid such as oxycodone is a reasonable starting point. Immediate-release morphine or methadone can also be considered. These drugs can be used in combination with nonsteroidal anti-inflammatory drugs and the adjuvant analgesics described here.

Invasive Therapy

Brachial Plexus Block

The use of brachial plexus block with local anesthetic and steroid serves as an excellent adjunct to drug treatment of Pancoast’s tumor syndrome. This technique rapidly relieves pain while medications are being titrated to effective levels. The initial block is carried out with preservative-free bupivacaine combined with methylprednisolone. Subsequent daily nerve blocks are carried out in a similar manner with the substitution of a lower dose of methylprednisolone. This approach may also be used to obtain control of breakthrough pain.

Radiofrequency Destruction of the Brachial Plexus

The destruction of the brachial plexus can be carried out by creating a radiofrequency lesion under biplanar fluoroscopic guidance. This procedure is reserved for patients for whom all of the aforementioned treatments for Pancoast’s tumor syndrome have failed.

Dorsal Root Entry Zone Lesioning (DREZ)

This technique, which is called DREZ lesioning, is the neurosurgical procedure of choice for intractable brachial plexopathy associated with Pancoast’s tumor in those patients in whom all other treatments for branchial plexopathy have failed. This is a major neurosurgical procedure and carries significant risks.

Physical Modalities

The use of physical and occupational therapy to maintain function and to help palliate pain is a crucial part of the treatment plan for patients suffering from Pancoast’s tumor syndrome. Shoulder abnormalities, including subluxation and adhesive capsulitis, must be aggressively searched for and treated. Occupational therapy to assist in activities of daily living is also important to avoid further deterioration of function.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.