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Superior pulmonary sulcus (Pancoast) tumors

Selim M Arcasoy, MD
James R Jett, MD
Steven E Schild, MD
Section Editors
Rogerio C Lilenbaum, MD, FACP
Joseph S Friedberg, MD
Deputy Editors
Sadhna R Vora, MD
Helen Hollingsworth, MD


Superior sulcus tumors were first described in 1838, but they were an obscure entity until the reports of Henry Pancoast in the first third of the 20th century [1]. Pancoast mistakenly believed that these neoplasms arose from embryonal rests of the fifth branchial cleft; other investigators subsequently recognized the pulmonary origin of the vast majority of these malignancies.

Since Pancoast original reports, the terms “Pancoast tumors,” “superior sulcus tumors,” or “superior pulmonary sulcus tumors” have been applied to neoplasms located at the apical pleuropulmonary groove, adjacent to the subclavian vessels (figure 1) [2-4]. The actual pulmonary sulcus comprises the thoracic costovertebral gutter on either side of the vertebral column and is limited by the arch of the first rib superiorly and the diaphragmatic insertion inferiorly. Tumors located at the upper part of the pulmonary sulcus near the thoracic inlet may correctly be regarded as superior sulcus tumors, although the inferior margins of the superior sulcus are not well defined.

The diagnosis and management of tumors arising within the superior sulcus are reviewed here. General issues regarding lung cancer and management of stage II and stage III non-small cell lung cancer (NSCLC) are reviewed separately. (See "Overview of the risk factors, pathology, and clinical manifestations of lung cancer" and "Management of stage I and stage II non-small cell lung cancer" and "Management of stage III non-small cell lung cancer".)


Lesions in the superior sulcus may result in shoulder and arm pain (in the distribution of the C8, T1, and T2 dermatomes), Horner's syndrome, and weakness and atrophy of the muscles of the hand, a constellation of symptoms referred to as Pancoast syndrome [4] (figure 2). The majority of patients with superior sulcus tumors present with one or more of these complaints. Due to the peripheral location of the tumor, pulmonary symptoms such as cough, hemoptysis, and dyspnea are uncommon until late in the disease.

Shoulder pain — The most common initial symptom of superior sulcus tumors is shoulder pain, present in 44 to 96 percent of patients [5-11]. Pain is produced by invasion of the brachial plexus and/or extension of the tumor into the parietal pleura, endothoracic fascia, first and second ribs, or vertebral bodies. Pain can progress and radiate up to the head and neck, or down to the medial aspect of the scapula, axilla, anterior chest, or ipsilateral arm in the distribution of the ulnar nerve [10].


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Literature review current through: Sep 2016. | This topic last updated: Oct 16, 2013.
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