Microsurgical DREZotomy for pain related to Pancoast-Tobias syndrome: how I do it?

BACKGROUND: Neuralgic pain related to Pancoast-Tobias syndrome can be difficult to treat. An invasive but effective option for management is open cervical DREZotomy. METHOD: This procedure involves the interruption of the dorsal root entry zone (A delta and C fibers) that sustains the nociceptive pathways. After dura opening, the microsurgical steps are micro incisions of the pia mater under each dorsolateral rootlets and contiguous microcoagulations in the posterolateral sulcus downward to the posterior horn. CONCLUSION: When properly performed in a well-selected patient, DREZotomy is a safe and effective procedure for treating devastating pain related to Pancoast-Tobias syndrome.

Can MRI differentiate surrounding vertebral invasion from reactive inflammatory changes in superior sulcus tumor?

OBJECTIVES: Vertebral invasion is a key prognostic factor and a critical aspect of surgical planning for superior sulcus tumors. This study aims to further evaluate MRI features of vertebral invasion in order to distinguish it from reactive inflammatory changes. METHODS: Between 2000 and 2016, a retrospective study was performed at a single institution. All patients with superior sulcus tumors undergoing surgery, including at least two partial vertebrectomies, were included. An expert radiologist evaluated qualitative and quantitative MRI signal intensity characteristics (contrast-to-noise ratio [CNR]) of suspected involved and non-involved vertebrae. A comparison of CNR of invaded and sane vertebrae was performed using non-parametric tests. Imaging data were correlated with pathological findings. RESULTS: A total of 92 surgical samples of vertebrectomy were analyzed. The most specific sequences for invasion were T1 and T2 weighted (92% and 97%, respectively). The most sensitive sequences were contrast enhanced T1 weighted fat suppressed and T2 weighted fat suppressed (100% and 80%). Loss of extrapleural paravertebral fat on the T1-weighted sequence was highly sensitive (100%) but not specific (63%). Using quantitative analysis, the optimum cut-off (p < 0.05) to distinguish invasion from reactive inflammatory changes was CNR > 11 for the T2-weighted fat-sat sequence (sensitivity 100%), CNR > 9 for contrast-enhanced T1-weighted fat-suppressed sequence (sensitivity 100%), and CNR < - 30 for the T1-weighted sequence (specificity 97%). Combining these criteria, 23 partial vertebrectomies could have been avoided in our cohort. CONCLUSION: Qualitative and quantitative MRI analyses are useful to discriminate vertebral invasion from reactive inflammatory changes. KEY POINTS: • Abnormal signal intensity in a vertebral body adjacent to a superior sulcus tumor may be secondary to direct invasion or reactive inflammatory changes. • Accurate differentiation between invasion and reactive inflammatory changes significantly impacts surgical planning. T1w and T2w are the best sequences to differentiate malignant versus benign bone marrow changes. The use of quantitative analysis improves MRI specificity. • Using contrast media improves the sensitivity for the detection of tumor invasion.

Recurrent Diffuse Large B-Cell Lymphoma Presenting with Pancoast Syndrome: A Rare Cause of Radicular Neck Pain in the Emergency Department.

BACKGROUND: Pancoast syndrome is an uncommon complication of apical lung tumors. Symptoms include pain, brachial plexopathy, and Horner's syndrome, and are the result of extrinsic compression of tissues within the thoracic inlet. Lymphoma is a very rare etiology. CASE REPORT: We describe the presentation of a 59-year-old male with recurrent diffuse large B-cell lymphoma presenting with Pancoast syndrome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cancer is an uncommon cause of radicular neck pain but should be considered in the differential, particularly when constitutional complaints are also present. Symptoms and physical examination findings associated with Pancoast syndrome are the consequence of compression of the C7-T2 vertebral roots and sympathetic chain. Computed tomography is usually required to definitively visualize the mass.

A Patient With Pancoast Tumor Presenting With Cervical Radiculopathy: A Case Report.

Objective: The purpose of this report was to describe a patient with a Pancoast tumor who presented for chiropractic care with neck and arm pain. Clinical Features: A 52-year-old male patient with right-sided cervicothoracic pain and numbness in the right upper extremity presented to a chiropractic office for care. The patient reported an occupational history of repetitive lifting motions and overuse injuries. The patient denied history of smoking at the time of presentation. Intervention and Outcome: Radiographic imaging revealed tracheal deviation. A chest computed tomography image demonstrated a large lesion in the apex of the right lung, suggestive of bronchogenic carcinoma. The patient was referred to an oncology clinic, where he admitted to having a 20-year history of smoking. The diagnosis of adenocarcinoma was made via biopsy, and the oncologist's evaluation confirmed the cancer to be stage IIIC. The patient received palliative care treatments, as the advanced state of his condition determined that he was not a candidate for surgical intervention. Conclusion: Chiropractors and other first-contact health care providers must keep in mind unusual presentations masquerading as common conditions. This case demonstrates the importance of including apical lung tumors in the differential diagnosis of unilateral arm and neck pain and neurologic deficits of the upper extremity. This case demonstrates the importance of thorough follow-up on images ordered, including the ordering clinicians viewing the images themselves.

Single-Stage Posterior Approach for the En Bloc Resection and Spinal Reconstruction of T4 Pancoast Tumors Invading the Spine.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aimed to evaluate the outcomes of patients who had T4 Pancoast tumors invading the spine and underwent en bloc resection and spinal stabilization through a single-stage posterior approach. OVERVIEW OF LITERATURE: Surgical resection for Pancoast tumors affecting the spine has been successfully performed in two stages involving spinal reconstruction and tumor resection. However, reports have rarely presented the results of en bloc resection combined with spinal stabilization for T4 Pancoast tumors invading the spine through a single-stage posterior approach. METHODS: Patients who had T4N0M0 Pancoast tumors invading the spine and underwent a single-stage posterior approach were retrospectively recruited. The following data were obtained and examined: demographics, tumor histology, preoperative and postoperative therapy, complications, spinal reconstruction technique, tumor resection extent, survival time, and disease recurrence. RESULTS: Eighteen patients were included. The mean population age was 61±17 years, and the most common pathological type was adenocarcinoma (61.1%). Complete resection (R0) was obtained in 15 patients (83.3%), positive surgical margins (R1) were found in three patients (16.7%), and the 90-day mortality rate was 0%. Postoperative major complications were detected in 12 patients (66.7%), who required reoperation. The mean survival time was 67±24 months, but the median survival time was not reached. Among the patients, 10 (55.6%) are still alive at the end of the study. The 2- and 5-year actual survival rates were 59% (95% confidence interval [CI], 35.7%-82.3%) and 52.5% (95% CI, 28.4%-76.6%), respectively. CONCLUSIONS: En bloc resection and spinal stabilization through a single-stage posterior approach might be effective for T4 Pancoast tumors invading the spine.

Small Cell Lung Carcinoma with Pancoast Syndrome: A Case Report.

Small cell lung cancer mostly arises centrally in the large bronchi. The literature search revealed very limited cases of small cell lung cancer arising at the upper part of the pulmonary sulcus near the thoracic inlet as superior sulcus tumor and also manifesting with typical Pancoast syndrome. We report a case of a 71 years old male patient, presenting with features of Pancoast syndrome including Horner's syndrome with completed three cycles of chemotherapy resulting in partial response which concludes that small cell lung carcinoma has to be considered despite the clinical findings like pancoast syndrome.

Apical pleural aspergillosis with pancoast's syndrome and posterior circulation stroke: a case report.

Pancoast's syndrome and subclavian arteritis are rarely caused by Aspergillus sp. . Here we report a case of a 22-yr-old, immunocompetent male who presented with fever, weight loss, right-sided facial anhidrosis and hand weakness of six months duration. Neurological examination confirmed right Horner's syndrome and weakness of small muscles of right hand. Contrast MRI of neck and chest revealed a pleural-based right apical mass abutting subclavian artery and C8-T1 root and multiple enlarged lymph nodes. He developed right hemiataxia due to cerebellar infarct before the planned excision of mass. Surgical exploration showed abscess encasing subclavian artery. Biopsy of the mass resulted in accidental injury of subclavian artery which was repaired. He developed bleeding from suture site postoperatively due pseudo-aneurysm of the subclavian artery which was stented. Histopathology of mass was suggestive of Aspergillus sp. . He was successfully treated with voriconazole. This is probably the first report of Pancoast's syndrome and large vessel angiitis caused by Aspergillus fumigatus which has been successfully managed.

Pancoast Syndrome Due to High Grade Anaplastic Tumor.

Description The 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 is a known complication that includes shoulder and arm musculoskeletal pain, Horner's syndrome and neurological complications of the upper extremities, including weakness and atrophy. Even though adenocarcinoma is the most common cause of Pancoast syndrome among lung cancers, other malignancies can be responsible as well. Treatment is similar to that of other standard NSCLC treatments that include chemotherapy, radiation, immunotherapy and surgery. Here we report a patient with Pancoast syndrome secondary to a poorly differentiated malignant neoplasm composed of anaplastic cells.

A case of pulmonary mucormycosis presented as Pancoast syndrome and bone destruction in an immunocompetent adult mimicking lung carcinoma.

Pulmonary mucormycosis is a rare opportunistic infection caused by Mucormycosis. This fungal infection is uncommon in immunocompetent individuals. Because of its various clinical and imaging manifestations, it is a diagnostic challenge to distinguish pulmonary mucormycosis from other pulmonary diseases, such as carcinoma. Herein, we report a case of pulmonary mucormycosis presenting as Pancoast syndrome and bone destruction of ribs. A 46-year-old Chinese woman was admitted due to pain in chest, right neck and arm for four months and hoarseness for one week. The pre-admission diagnosis via chest CT was pulmonary carcinoma. The subsequent bronchoalveolar lavage fluid analysis and bronchoscopic biopsy were negative for malignant cells, except chronic inflammation. Imaging-guided percutaneous biopsies were carried out after admission and the final pathological diagnosis was pulmonary mucormycosis. Although the patient was started on oral posaconazole of 400mg bid, the disease condition continued to deteriorate. She finally died of respiratory failure.

A rare presentation of myxofibrosarcoma as a Pancoast tumor: a case report.

BACKGROUND: Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor. CASE PRESENTATION: A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable. Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma. CONCLUSIONS: Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner's syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature.

["Pancoast Tobias tumor"]. / Tumeur de Pancoast-Tobias.

"Dépistage des troubles visuels chez l'enfant. Le dépistage visuel chez l'enfant représente un objectif de santé publique en raison de l'impact social, scolaire et financier d'une anomalie de la vision, potentiellement irréversible en l'absence de prise en charge précoce. De plus, la plupart de ces troubles sont corrigibles, c'est le cas notamment des anomalies de la réfraction et du strabisme. Un groupe d'experts de l'Association francophone de strabologie et d'ophtalmologie pédiatrique (AFSOP) a récemment mis à jour des recommandations consensuelles pour l'optimisation de ce dépistage. Ce travail souligne l'importance d'un examen ophtalmologique rapide dans la première semaine ou première année de vie respectivement pour les enfants à risque d'amblyopie organique et fonctionnelle, ainsi que d'un dépistage systématique de tous les enfants à l'âge de 3 ans à l'aide de trois examens visant à détecter respectivement un trouble de la réfraction, un strabisme ou une amblyopie. Par ailleurs, certains signes d'appel, comme la présence d'une leucocorie ou d'une buphtalmie, conduisant à un examen ophtalmologique sans délai, doivent être reconnus par tout professionnel en charge de l'examen global de l'enfant."

Single Posterior Approach for En-Bloc Resection and Stabilization for Locally Advanced Pancoast Tumors Involving the Spine: Single Centre Experience.

STUDY DESIGN: Monocentric prospective study. PURPOSE: To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors. OVERVIEW OF LITERATURE: In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach. METHODS: We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation. RESULTS: Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment. CONCLUSIONS: The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Diagnosing and treating pancoast tumors.

INTRODUCTION: According to the American College of Chest Physician definition, a Pancoast tumor is a tumor which invades any of the structures of the apex of the chest including the first thoracic ribs or periosteum, the lower nerve roots of the bronchial plexus, the sympathetic chain and stellate gaglion near the apex of the chest or the subclavian vessels. Pancoast tumors account for less than 3-5 % of lung tumors. Areas covered: We searched the libraries scopus and pub med and found 124 related manuscripts. From those we chose 18 to include in our short commentary based on the most up-date information included. Expert commentary: The present status of the recommended treatment of Pancoast tumors for patients medically fit for surgical resection is trimodality (chemoradiation followed by radical surgery excersion) as state of the art. Patients with unresectable Pancoast tumors and poor PS 4 or distant metastasis are candidate for radiation therapy for palliation of symptoms and best supportive care. In this mini review we will present up to date information regarding diagnosis and treatment management.

Pancaost syndrome related to hydatid cyst.

Pancoast syndrome remains a rare presentation of pulmonary diseases. Even in endemic area of echinococcosis, lung's hydatid cyst is seldomly revealed by this syndrome. We report a case of a 38 year old male patient who presented to our department with neck and left superior limb pain associated with palmar muscle atrophy and Horner's syndrome. Radiological investigations suggested the diagnosis of hydatid cyst of the left lung apex which was confirmed by surgical excision and pathological examination of the lesion. This case highlights an uncommon etiology of Pancoast syndrome which might mislead physicians in their practice.

Pancoast syndrome: A rare presentation of non-Hodgkin's lymphoma.

Pancoast syndrome is a common presentation of bronchogenic carcinoma, but other malignancies are rarely cited as its cause. Pancoast syndrome due to non-Hodgkin's lymphoma is rarely described in the literature. Here, we report a case of Pancoast syndrome due to non-Hodgkin's lymphoma to increase the awareness of the clinicians regarding essentiality of tissue diagnosis of Pancoast tumor before starting the treatment.

Síndrome de Pancoast - perdendo o melhor momento de diagnosticar / Pancoast Syndrome - losing the best time to diagnose

Os autores descrevem um caso de Síndrome de Pancoastcom desfecho desfavorável por atraso no diagnóstico.Enfatiza-se a necessidade de alto índice de suspeiçãopara esta síndrome, a fim de oportunizar a sua detecçãoprecoce e, consequentemente, a possibilidade de tratamentocurativo ou maior sobrevida.

The authors describe a case of Pancoast Syndrome withunfavorable outcome because of delay on diagnosing.It?s emphasized the need of high suspicion index to thesyndrome, in order to nurture it?s early detection and,consequently, the possibility of curative treatment or increasedsurvival.

Bronquiolite obliterante com pneumonia organizada simulando síndrome de Pancoast / Bronchiolitis obliterans organizing pneumonia mimicking Pancoast syndrome

É descrito o caso de um paciente de 52 anos, tabagista, que procurou atendimento médico queixando-se de dor em região interescápulo vertebral direita acompanhada de parestesia distal de metacarpos ipsilateral, febre, tosse produtiva e perda ponderal. Ao exame físico, havia presença de murmúrio vesicular diminuído em ápice pulmonar direito. A radiografia de tórax evidenciava opacidade neste mesmo local e na tomografia computadorizada, havia presença de massa encapsulada lobo superior direito, com mediastino superior desviado para esquerda e presença de linfadenomegalias. Com a hipótese de neoplasia pulmonar e síndrome de Pancoast, foi solicitado uma mediastinoscopia com biópsia cujo resultado foi inconclusivo. Logo, optou-se pela toracotomia para retirada da massa e realização de biópsia cujo resultado foi confirmatório para BOOP. Para o tratamento, optou-se por prednisona, cuja resposta foi efetiva.

Bone single photon emission computed tomography (SPECT) in a patient with Pancoast tumor: a case report / Tomografia óssea computadorizada por emissão de fóton único (SPECT) em paciente com tumor de Pancoast: um relato de caso

CONTEXT: Non-small cell lung carcinomas (NSCLCs) of the superior sulcus are considered to be the most challenging type of malignant thoracic disease. In this disease, neoplasms originating mostly from the extreme apex of the lung expand to the chest wall and thoracic inlet structures. Multiple imaging procedures have been applied to identify tumors and to stage and predict tumor resectability in surgical operations. Clinical examinations to localize pain complaints in shoulders and down the arms, and to screen for Horner's syndrome and abnormalities seen in paraclinical assessments, have been applied extensively for differential diagnosis of superior sulcus tumors. Although several types of imaging have been utilized for diagnosing and staging Pancoast tumors, there have been almost no reports on the efficiency of whole-body bone scans (WBBS) for detecting the level of abnormality in cases of superior sulcus tumors. CASE REPORT: We describe a case of Pancoast tumor in which technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs. In describing this case, we stress the clinical and diagnostic points, in the hope of stimulating a higher degree of suspicion and thereby facilitating appropriate diagnosis and treatment. From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended.

CONTEXTO: Carcinomas pulmonares de células não pequenas (NSCLCs) do sulco superior são considerados como o maior desafio nos tumores malignos torácicos. Nesta doença, as neoplasias se originam principalmente do ápice do pulmão e se expandem pela parede e pelas estruturas torácicas. Diversas técnicas de imagem têm sido utilizadas para identificar e estagiar os tumores, permitindo um prognóstico para a sua ressecção em procedimentos cirúrgicos. O exame clínico tem sido bastante usado para diagnóstico diferencial de tumores do sulco superior nas queixas de dores no ombro, síndrome de Horner e anormalidades observadas em exames paraclínicos. Embora diversos tipos de exames de imagem sejam utilizados para diagnóstico e estadiamento de tumores de Pancoast, praticamente não existem relatos sobre a eficácia do exame ósseo do corpo todo (WBBS) na detecção do nível de anormalidade em casos de tumores do sulco superior. RELATO DE CASO: Descrevemos um caso de tumor de Pancoast, em que foi realizada a tomografia computadorizada óssea por emissão de fóton único (SPECT) com metileno difosfonato de tecnécio-99 (Tc-99m MDP). Este exame foi capaz de detectar com acurácia as múltiplas áreas de anormalidade em vértebras e costelas. Ao descrever este caso, os autores ressaltam os pontos clínicos e diagnósticos, esperando estimular maior grau de suspeita, facilitando assim o diagnóstico e tratamento apropriados. A partir dos resultados deste trabalho, outros estudos clínicos podem avaliar o potencial do SPECT como uma ferramenta eficiente de imagem a ser recomendada na investigação de casos de tumor de Pancoast.

Carcinoma de pequenas células na síndrome de Pancoast / Small cell carcinoma in Pancoast syndrome

A síndrome de Pancoast consiste de sinais e sintomas decorrentes do acometimento do ápice pulmonar e estruturas adjacentes por um tumor. Na maioria das vezes, o processo causal é uma neoplasia. O carcinoma broncogênico é a principal neoplasia causadora da síndrome. Os subtipos histológicos mais encontrados são o adenocarcinoma e o carcinoma epidermoide. A ocorrência de carcinoma de pequenas células de pulmão como gênese da síndrome de Pancoast é rara, com poucos relatos na literatura. Descrevemos o caso de um doente com síndrome de Pancoast causado por um carcinoma de pequenas células de pulmão, discutindo aspectos referentes ao diagnóstico e à terapêutica.

Pancoast syndrome consists of signs and symptoms resulting from a tumor affecting the pulmonary apex and adjacent structures. The process is typically caused by a neoplasm. The majority of cases of Pancoast syndrome are caused by bronchogenic carcinoma. The most commonly found histologic subtypes are adenocarcinoma and epidermoid carcinoma. There have been very few reports of small cell lung carcinoma in the genesis of Pancoast syndrome. We describe the case of a patient with Pancoast syndrome caused by small cell lung carcinoma and discuss the aspects related to the diagnosis and treatment.