Definition
Tumour of the superior pulmonary sulcus at the lung apex invading the chest wall and thoracic inlet. Pancoast syndrome is shoulder and arm pain, Horner syndrome and hand weakness from this invasion.
Pathology
- Non-small cell lung cancer in most, squamous cell carcinoma or adenocarcinoma
- Mesothelioma, lymphoma, metastases and infection are rare causes
- At least T3 by definition, with chest wall invasion
- Invades lower brachial plexus, stellate ganglion, upper ribs, subclavian vessels and vertebrae
Clinical Features
- Shoulder and periscapular pain, the earliest and most frequent symptom
- Pain radiating along the medial arm and forearm to the ring and little fingers
- Wasting and weakness of the intrinsic hand muscles from C8 and T1 involvement
- Horner syndrome with ptosis, miosis and anhidrosis
- Supraclavicular mass or lymphadenopathy
- Smoking history and weight loss, often with few chest symptoms
- Misdiagnosis as cervical radiculopathy, ulnar neuropathy or shoulder pathology delays treatment
Investigations
- Check the lung apex on every cervical spine and shoulder radiograph
- Apical opacity or pleural thickening, with destruction of upper ribs
- CT chest and PET CT for staging
- MRI for brachial plexus, subclavian vessel, foraminal and spinal canal invasion
- Mediastinal nodal staging before surgery
- CT guided or bronchoscopic biopsy
Differential Diagnosis
- C8 cervical radiculopathy
- Thoracic outlet syndrome
- Cubital tunnel syndrome
- Neuralgic amyotrophy
- Brachial plexus lesions
- Rotator cuff disease and other shoulder pathology
Management
- Induction chemoradiotherapy then resection. T3 to T4, N0 to N1 disease, 44% survival at 5 years in SWOG 9416
- Complete resection. Survival at 5 years rose to 54% after complete resection
- Definitive chemoradiotherapy. Unresectable or N2 disease
- Spinal reconstruction. Vertebral or foraminal invasion, with combined thoracic and spinal teams
- Palliative radiotherapy. Pain control in metastatic disease
References
- Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast’s syndrome. N Engl J Med. 1997, 337(19), 1370-6. PubMed
- Rusch VW, Giroux DJ, Kraut MJ, Crowley J, Hazuka M, Winton T, Johnson DH, Shulman L, Shepherd F, Deschamps C, Livingston RB, Gandara D. 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(3), 313-8. PubMed
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.