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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 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: Nov 2017. | This topic last updated: Jan 16, 2017.
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  1. Pancoast, HK. Superior pulmonary sulcus tumor. JAMA 1932; 99:1391.
  2. Paulson DL. Carcinomas in the superior pulmonary sulcus. J Thorac Cardiovasc Surg 1975; 70:1095.
  3. Teixeira JP. Concerning the Pancoast tumor: what is the superior pulmonary sulcus? Ann Thorac Surg 1983; 35:577.
  4. Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome. N Engl J Med 1997; 337:1370.
  5. Van Houtte P, MacLennan I, Poulter C, Rubin P. External radiation in the management of superior sulcus tumor. Cancer 1984; 54:223.
  6. Urschel HC Jr. Superior pulmonary sulcus carcinoma. Surg Clin North Am 1988; 68:497.
  7. Shahian DM, Neptune WB, Ellis FH Jr. Pancoast tumors: improved survival with preoperative and postoperative radiotherapy. Ann Thorac Surg 1987; 43:32.
  8. Miller JI, Mansour KA, Hatcher CR Jr. Carcinoma of the superior pulmonary sulcus. Ann Thorac Surg 1979; 28:44.
  9. Komaki R, Roh J, Cox JD, Lopes da Conceicao A. Superior sulcus tumors: results of irradiation of 36 patients. Cancer 1981; 48:1563.
  10. Komaki, R. Preoperative radiation therapy for superior sulcus lesions. Chest Surg Clin North Am 1991; 1:13.
  11. Grover FL, Komaki R. Superior sulcus tumors. In: Thoracic Oncology, 2nd, Roth JA, Ruckdeschel JC, Weisenburger TH (Eds), WB Saunders, Philadelphia 1995. p.225.
  12. Hepper NG, Herskovic T, Witten DM, et al. Thoracic inlet tumors. Ann Intern Med 1966; 64:979.
  13. Ziporyn T. Upper body pain: possible tipoff to Pancoast tumor. JAMA 1981; 246:1759, 1763.
  14. Anderson TM, Moy PM, Holmes EC. Factors affecting survival in superior sulcus tumors. J Clin Oncol 1986; 4:1598.
  15. Walls WJ, Thornbury JR, Naylor B. Pulmonary needle aspiration biopsy in the diagnosis of Pancoast tumors. Radiology 1974; 111:99.
  16. Sundaresan N, Hilaris BS, Martini N. The combined neurosurgical-thoracic management of superior sulcus tumors. J Clin Oncol 1987; 5:1739.
  17. Derbekyan V, Novales-Diaz J, Lisbona R. Pancoast tumor as a cause of reflex sympathetic dystrophy. J Nucl Med 1993; 34:1992.
  18. Delreux V, Kevers L, Callewaert A. [Paroxysmal hemicrania preceding Pancoast's syndrome]. Rev Neurol (Paris) 1989; 145:151.
  19. Umeki S, Tamai H, Yagi S, et al. [Harlequin syndrome (unilateral flushing and sweating attack) due to a spinal invasion of the left apical lung cancer]. Rinsho Shinkeigaku 1990; 30:94.
  20. Marangoni C, Lacerenza M, Formaglio F, et al. Sensory disorder of the chest as presenting symptom of lung cancer. J Neurol Neurosurg Psychiatry 1993; 56:1033.
  21. Paulson DL, Weed TE, Rian RL. Cervical approach for percutaneous needle biopsy of Pancoast tumors. Ann Thorac Surg 1985; 39:586.
  22. Yang PC, Lee LN, Luh KT, et al. Ultrasonography of Pancoast tumor. Chest 1988; 94:124.
  23. Maxfield RA, Aranda CP. The role of fiberoptic bronchoscopy and transbronchial biopsy in the diagnosis of Pancoast's tumor. N Y State J Med 1987; 87:326.
  24. Ginsberg RJ, Payne DG, Shamji F. Superior sulcus tumors. In: Comprehensive Textbook of Thoracic Oncology, Aisner J (Ed), Williams & Wilkins, Baltimore 1996. p.375.
  25. Fuller DB, Chambers JS. Superior sulcus tumors: combined modality. Ann Thorac Surg 1994; 57:1133.
  26. Hilaris BS, Martini N, Wong GY, Nori D. Treatment of superior sulcus tumor (Pancoast tumor). Surg Clin North Am 1987; 67:965.
  27. Devine JW, Mendenhall WM, Million RR, Carmichael MJ. Carcinoma of the superior pulmonary sulcus treated with surgery and/or radiation therapy. Cancer 1986; 57:941.
  28. Komaki R, Mountain CF, Holbert JM, et al. Superior sulcus tumors: treatment selection and results for 85 patients without metastasis (Mo) at presentation. Int J Radiat Oncol Biol Phys 1990; 19:31.
  29. Jones DR, Detterbeck FC. Pancoast tumors of the lung. Curr Opin Pulm Med 1998; 4:191.
  30. Gomez DR, Cox JD, Roth JA, et al. A prospective phase 2 study of surgery followed by chemotherapy and radiation for superior sulcus tumors. Cancer 2012; 118:444.
  31. Maggi G, Casadio C, Pischedda F, et al. Combined radiosurgical treatment of Pancoast tumor. Ann Thorac Surg 1994; 57:198.
  32. Johnson DH, Hainsworth JD, Greco FA. Pancoast's syndrome and small cell lung cancer. Chest 1982; 82:602.
  33. http://www.iaslc.org/assets/News-Releases/CAP-IASLC-AMP-Summary-of-Recommendations.pdf (Accessed on May 22, 2013).
  34. Hatton MQ, Allen MB, Cooke NJ. Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma. Eur Respir J 1993; 6:271.
  35. Chong KM, Hennox SC, Sheppard MN. Primary hemangiopericytoma presenting as a Pancoast tumor. Ann Thorac Surg 1993; 55:9.
  36. Amin R. Bilateral Pancoast's syndrome in a patient with carcinoma of the cervix. Gynecol Oncol 1986; 24:126.
  37. Chang CF, Su WJ, Chou TY, Perng RP. Hepatocellular carcinoma with Pancoast's syndrome as an initial symptom: a case report. Jpn J Clin Oncol 2001; 31:119.
  38. Rabano A, La Sala M, Hernandez P, Barros JL. Thyroid carcinoma presenting as Pancoast's syndrome. Thorax 1991; 46:270.
  39. Brenner B, Carter A, Freidin N, et al. Pancoast's syndrome in multiple myeloma. Acta Haematol 1984; 71:353.
  40. Chen KT, Padmanabhan A. Pancoast syndrome caused by extramedullary plasmacytoma. J Surg Oncol 1983; 24:117.
  41. Mills PR, Han LY, Dick R, Clarke SW. Pancoast syndrome caused by a high grade B cell lymphoma. Thorax 1994; 49:92.
  42. Arcasoy SM, Bajwa MK, Jett JR. Non-Hodgkin's lymphoma presenting as Pancoast's syndrome. Respir Med 1997; 91:571.
  43. White HD, White BA, Boethel C, Arroliga AC. Pancoast's syndrome secondary to infectious etiologies: a not so uncommon occurrence. Am J Med Sci 2011; 341:333.
  44. Dolan G, Smith J, Reilly JT. Extrapulmonary lymphomatoid granulomatosis presenting as Pancoast's syndrome. Postgrad Med J 1991; 67:914.
  45. Vandenplas O, Mercenier C, Trigaux JP, Delaunois L. Pancoast's syndrome due to Pseudomonas aeruginosa infection of the lung apex. Thorax 1991; 46:683.
  46. Gallagher KJ, Jeffrey RR, Kerr KM, Steven MM. Pancoast syndrome: an unusual complication of pulmonary infection by Staphylococcus aureus. Ann Thorac Surg 1992; 53:903.
  47. VAMOS G, PAPP A. [Pancoast's syndrome and pulmonary tuberculosis]. Schweiz Z Tuberc Pneumonol 1960; 17:423.
  48. Stanley SL Jr, Lusk RH. Thoracic actinomycosis presenting as a brachial plexus syndrome. Thorax 1985; 40:74.
  49. Collins PW, de Lord C, Newland AC. Pancoast's tumour due to aspergilloma. Lancet 1990; 336:1595.
  50. Simpson FG, Morgan M, Cooke NJ. Pancoast's syndrome associated with invasive aspergillosis. Thorax 1986; 41:156.
  51. Mitchell DH, Sorrell TC. Pancoast's syndrome due to pulmonary infection with Cryptococcus neoformans variety gattii. Clin Infect Dis 1992; 14:1142.
  52. Ziomek S, Weinstein W, Margulies M, Braun RA. Primary pulmonary cryptococcosis presenting as a superior sulcus tumor. Ann Thorac Surg 1992; 53:892.
  53. Gotterer N, Lossos I, Breuer R. Pancoast's syndrome caused by primary pulmonary hydatid cyst. Respir Med 1990; 84:169.
  54. Aletras H, Papaconstantinou C. Pancoast's syndrome following an intrapleural rupture of a hepatic echinococcus cyst. Scand J Thorac Cardiovasc Surg 1982; 16:283.
  55. Rong SH. Carotid pseudoaneurysm simulating Pancoast tumor. AJR Am J Roentgenol 1984; 142:495.
  56. Gibney RT, Connolly TP. Pulmonary amyloid nodule simulating pancoast tumor. J Can Assoc Radiol 1984; 35:90.
  57. Urschel JD, Hameed SM, Grewal RP. Neurogenic thoracic outlet syndromes. Postgrad Med J 1994; 70:785.
  58. Takasugi JE, Rapoport S, Shaw C. Superior sulcus tumors: the role of imaging. J Thorac Imaging 1989; 4:41.
  59. Hamlin DJ, Burgener FA. CT, including sagittal and coronal reconstruction, in the evaluation of pancoast tumors. J Comput Tomogr 1982; 6:43.
  60. Heelan RT, Demas BE, Caravelli JF, et al. Superior sulcus tumors: CT and MR imaging. Radiology 1989; 170:637.
  61. Pennes DR, Glazer GM, Wimbish KJ, et al. Chest wall invasion by lung cancer: limitations of CT evaluation. AJR Am J Roentgenol 1985; 144:507.
  62. Webb WR, Gatsonis C, Zerhouni EA, et al. CT and MR imaging in staging non-small cell bronchogenic carcinoma: report of the Radiologic Diagnostic Oncology Group. Radiology 1991; 178:705.
  63. Webb WR, Sostman HD. MR imaging of thoracic disease: clinical uses. Radiology 1992; 182:621.
  64. Musset D, Grenier P, Carette MF, et al. Primary lung cancer staging: prospective comparative study of MR imaging with CT. Radiology 1986; 160:607.
  65. McLoud TC, Filion RB, Edelman RR, Shepard JA. MR imaging of superior sulcus carcinoma. J Comput Assist Tomogr 1989; 13:233.
  66. Webb WR. The role of magnetic resonance imaging in the assessment of patients with lung cancer: a comparison with computed tomography. J Thorac Imaging 1989; 4:65.
  67. Rapoport S, Blair DN, McCarthy SM, et al. Brachial plexus: correlation of MR imaging with CT and pathologic findings. Radiology 1988; 167:161.
  68. Laissy JP, Soyer P, Sekkal SR, et al. Assessment of vascular involvement with magnetic resonance angiography (MRA) in Pancoast syndrome. Magn Reson Imaging 1995; 13:523.
  69. Martini N, Heelan R, Westcott J, et al. Comparative merits of conventional, computed tomographic, and magnetic resonance imaging in assessing mediastinal involvement in surgically confirmed lung carcinoma. J Thorac Cardiovasc Surg 1985; 90:639.
  70. Heelan RT, Martini N, Westcott JW, et al. Carcinomatous involvement of the hilum and mediastinum: computed tomographic and magnetic resonance evaluation. Radiology 1985; 156:111.
  71. Remmen HJ, Lacquet LK, Van Son JA, et al. Surgical treatment of Pancoast tumor. J Cardiovasc Surg (Torino) 1993; 34:157.
  72. Stanford W, Barnes RP, Tucker AR. Influence of staging in superior sulcus (Pancoast) tumors of the lung. Ann Thorac Surg 1980; 29:406.
  73. Wright CD, Moncure AC, Shepard JA, et al. Superior sulcus lung tumors. Results of combined treatment (irradiation and radical resection). J Thorac Cardiovasc Surg 1987; 94:69.
  74. Komaki R, Derus SB, Perez-Tamayo C, et al. Brain metastasis in patients with superior sulcus tumors. Cancer 1987; 59:1649.
  75. Buderi SI, Shackcloth M, Woolley S. Does induction chemoradiotherapy increase survival in patients with Pancoast tumour? Interact Cardiovasc Thorac Surg 2016; 23:821.
  76. Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for non-small cell lung carcinomas of the superior sulcus: Initial results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Thorac Cardiovasc Surg 2001; 121:472.
  77. Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol 2007; 25:313.
  78. Kunitoh H, Kato H, Tsuboi M, et al. Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806. J Clin Oncol 2008; 26:644.
  79. Pourel N, Santelmo N, Naafa N, et al. Concurrent cisplatin/etoposide plus 3D-conformal radiotherapy followed by surgery for stage IIB (superior sulcus T3N0)/III non-small cell lung cancer yields a high rate of pathological complete response. Eur J Cardiothorac Surg 2008; 33:829.
  80. Wright CD, Menard MT, Wain JC, et al. Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus. Ann Thorac Surg 2002; 73:1541.
  81. Kwong KF, Edelman MJ, Suntharalingam M, et al. High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival. J Thorac Cardiovasc Surg 2005; 129:1250.
  82. MJ Kraut, J Moon, CR Thomas, et al. Docetaxel is not feasible as consolidation therapy after cisplatin/etoposide/concurrent radiotherapy followed by surgical resection for pancoast tumors: preliminary results of SWOG 0220. Poster presentation, IASLC, 13th World Conference of Lung Cancer (July 31-August 4, 2009).
  83. Ginsberg RJ. Resection of a superior sulcus tumor. Chest Surg Clin N Am 1995; 5:315.
  84. Kent MS, Bilsky MH, Rusch VW. Resection of superior sulcus tumors (posterior approach). Thorac Surg Clin 2004; 14:217.
  85. Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993; 105:1025.
  86. Macchiarini P. Resection of superior sulcus carcinomas (anterior approach). Thorac Surg Clin 2004; 14:229.
  87. Masaoka A, Ito Y, Yasumitsu T. Anterior approach for tumor of the superior sulcus. J Thorac Cardiovasc Surg 1979; 78:413.
  88. Korst RJ, Burt ME. Cervicothoracic tumors: results of resection by the "hemi-clamshell" approach. J Thorac Cardiovasc Surg 1998; 115:286.
  89. Rusca M, Carbognani P, Bobbio P. The modified "hemi-clamshell" approach for tumors of the cervicothoracic junction. Ann Thorac Surg 2000; 69:1961.
  90. Ginsberg RJ, Martini N, Zaman M, et al. Influence of surgical resection and brachytherapy in the management of superior sulcus tumor. Ann Thorac Surg 1994; 57:1440.
  91. Martinod E, D'Audiffret A, Thomas P, et al. Management of superior sulcus tumors: experience with 139 cases treated by surgical resection. Ann Thorac Surg 2002; 73:1534.
  92. Gandhi S, Walsh GL, Komaki R, et al. A multidisciplinary surgical approach to superior sulcus tumors with vertebral invasion. Ann Thorac Surg 1999; 68:1778.
  93. York JE, Walsh GL, Lang FF, et al. Combined chest wall resection with vertebrectomy and spinal reconstruction for the treatment of Pancoast tumors. J Neurosurg 1999; 91:74.
  94. Bilsky MH, Vitaz TW, Boland PJ, et al. Surgical treatment of superior sulcus tumors with spinal and brachial plexus involvement. J Neurosurg 2002; 97:301.
  95. Shaw RR. Pancoast's tumor. Ann Thorac Surg 1984; 37:343.
  96. Rusch VW. Management of Pancoast tumours. Lancet Oncol 2006; 7:997.
  97. Narayan S, Thomas CR Jr. Multimodality therapy for Pancoast tumor. Nat Clin Pract Oncol 2006; 3:484.
  98. Hagan MP, Choi NC, Mathisen DJ, et al. Superior sulcus lung tumors: impact of local control on survival. J Thorac Cardiovasc Surg 1999; 117:1086.
  99. Neal CR, Amdur RJ, Mendenhall WM, et al. Pancoast tumor: radiation therapy alone versus preoperative radiation therapy and surgery. Int J Radiat Oncol Biol Phys 1991; 21:651.
  100. Attar S, Krasna MJ, Sonett JR, et al. Superior sulcus (Pancoast) tumor: experience with 105 patients. Ann Thorac Surg 1998; 66:193.
  101. Albain KS, Swann RS, Rusch VW, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet 2009; 374:379.
  102. Temeck BK, Okunieff PG, Pass HI. Chest wall disease including superior sulcus tumors. In: Lung Cancer: Principles and Practice, Pass HI, Mitchell JB, Johnson DH, Turrisi AT (Eds), Lippincott-Raven Publishers, Philadelphia 1996. p.585.
  103. Rusch VW, Parekh KR, Leon L, et al. Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus. J Thorac Cardiovasc Surg 2000; 119:1147.
  104. Bahce I, Vos CG, Dickhoff C, et al. Metabolic activity measured by FDG PET predicts pathological response in locally advanced superior sulcus NSCLC. Lung Cancer 2014; 85:205.
  105. Pfister DG, Johnson DH, Azzoli CG, et al. American Society of Clinical Oncology treatment of unresectable non-small-cell lung cancer guideline: update 2003. J Clin Oncol 2004; 22:330.
  106. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).