Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office (2023)

Published Tuesday 04 October 2022

Pancoast tumors, also called superior sulcus tumors, are a rare type of cancer affecting the lung apex. These tumors can spread to the brachial plexus and spine and present with symptoms that appear to be of musculoskeletal origin. Patients with an advanced Pancoast tumor may thus feel intense, constant, or radiating pain in their arms, around their chest wall, between their shoulder blades, or traveling into their upper back or armpit. In addition, a Pancoast tumor may cause the following symptoms:

  • Swelling in the upper arm
  • Chest tightness
  • Weakness or loss of coordination in the hand muscles
  • Numbness or tingling sensations in the hand
  • Loss of muscle tissue in the arm or hand
  • Fatigue
  • Unexplained weight loss

This case report details the story of a 59-year-old Asian man who presented to a chiropractor in Hong Kong with a 1-month history of neck and shoulder pain and numbness. His symptoms had been treated unsuccessfully with exercise, medications, and acupuncture. He had a history of tuberculosis currently treated with antibiotics and a 50-pack-year history of smoking.

Cervical magnetic resonance imaging (MRI) revealed a small cervical disc herniation thought to correspond with radicular symptoms. However, when the patient did not respond to a brief trial of chiropractic treatment, the chiropractor referred the patient back to the chest hospital for further testing, which confirmed the diagnosis of a Pancoast tumor. The patient was then referred for medical care and received radiotherapy and chemotherapy. At 2 months’ follow-up, the patient noted feeling lighter with less severe neck and shoulder pain and numbness. He also reported that he could sleep longer but still had severe pain upon waking for 2–3 hours, which subsided through the day.

A literature review identified six previously published cases in which a patient presented to a chiropractor with an undiagnosed Pancoast tumor. All patients had shoulder, spine, and/or upper extremity pain.

The authors concluded that patients with a previously undiagnosed Pancoast tumor can present to chiropractors given that these tumors may invade the brachial plexus and spine, causing shoulder, spine, and/or upper extremity pain. Chiropractors should be aware of the clinical features and risk factors of Pancoast tumors to readily identify them and refer such patients for medical care.

This is an important case report, in my view. It demonstrates that symptoms treated by chiropractors, osteopaths, and physiotherapists on a daily basis can easily be diagnosed wrongly. It also shows how vital it is that the therapist reacts responsibly to the fact that his/her treatments are unsuccessful. Far too often, the therapist has an undeniable conflict of interest and will say: “Give it more time, and, in my experience, symptoms will respond.”

The chiropractor in this story was brilliant and did the unusual thing of not continuing to treat his patient. However, I do wonder: might he be the exception rather than the rule?

Posted in alternative therapist, Cancer, case report, chiropractic, conflict of interest, education, experience, gullible consumer, malpractice, medical ethics, neck-pain, neglect, pain, prevention, risk, symptom-relief

9 Responses to Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office

  • Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office (1)

    Dr. Guy Almog, DC on Tuesday 04 October 2022 at 15:08

    In general a patient not responding significantly within 4-6 tx should be re-evaluated.

    Reply

  • Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office (4)

    David Nette on Tuesday 04 October 2022 at 16:03

    When time and early detection is so very critical in assessing the root cause of any serious pain, why not err on the side of caution?

    it’s time to please break away from the status quo and immediately refer the patient presenting to a qualified Doctor. Period.

    Or it is the money that guides the Chiropractors principles?

    (Video) Radicular pain of Pancost syndrome

    Reply

  • Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office (5)

    DN: When time and early detection is so very critical in assessing the root cause of any serious pain, why not err on the side of caution?

    Is that what was done prior to seeing the chiropractor?

    “Previous treatment for his neck pain directed by his primary care provider included prescription pain medications (nonsteroidal anti-inflammatory drugs and acetaminophen) and rehabilitation exercises provided by a physical therapist.”

    Reply

  • Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office (6)

    Dr Julian Money-Kyrle on Thursday 06 October 2022 at 13:02

    (Video) Lung Pancoast Tumor (Superior Sulcus Tumor) | Pancoast Syndrome | Pancoast-Tobias syndrome

    Pancoast’s tumours aren’t all that rare – I have seen quite a few of them over my career.

    In the case of the patient in your account, there were several missed opportunities to diagnose it:

    1. The pain and numbness indicates a significant neurological problem, and careful assessment of the distribution of the sensory loss could well point to a brachial plexus lesion rather than one arising from the nerve roots.

    2. The tumour, and possibly erosion of the ribs, was probably visible on one of the chest x-rays that he would have had to assess how his TB treatment was going.

    3. The tumour was quite possibly visible on the initial MRI if anybody had looked at the paraspinal area at the edge of the images. I have often found tumours on scans of various kinds that have been missed because they were slightly away from the anatomical site that the scan was concentrating on (e.g. para-aortic lymph node masses on a lumbar spine MRI).

    When I was preparing for my MRCP exam I was taught always to look beyond the obvious when trying to diagnose a problem. Later in my career I would always look carefully at the existing imaging (not just the reports) before ordering further studies.

    Unfortunately Pancoast’s tumours are often highly malignant small cell carcinomas, so although they generally respond well to chemotherapy initially, they do very badly in the long term. The histology isn’t mentioned in the abstract in this case study, nor the interval between the two MRI scans, and I can’t find a link to the full paper.

    Case reports are often written as a lesson to other doctors not to get caught out by something that they have never heard of before (although often well-known to other specialists). I wonder who reads the American Journal of Case Reports, therefore. Most doctors tend to concentrate on the literature concerning their own area of specialism, and would otherwise only look at major journals such as The Lancet and the Journal of the American Medical Association.

    Reply

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(Video) Lung cancer symptoms - shoulder pain

FAQs

Which of the following is the most common early symptom of Pancoast tumor? ›

Sharp shoulder or scapula (shoulder blade) pain are some of the most common symptoms of a Pancoast tumor, particularly in its early stages.

Can a Pancoast tumor be misdiagnosed? ›

Three cases were misdiagnosed as "pulmonary tuberculosis" according to the images of X-ray, and another 3 went unnoticed. Conclusions: Painful shoulder and back were the most common symptoms of pancoast cancer. pancoast cancer was often diagnosed at an advanced stage, and misdiagnosis was common.

What mimics a Pancoast tumor? ›

Extraosseous spread of multiple myeloma is seen in less than 10% of cases and can mimic Pancoast tumor when in the upper thoracic region. However, laboratory findings, bone marrow examination, and biopsy from the lesion can confirm the diagnosis of multiple myeloma.

What nerve does Pancoast tumor affect? ›

Because the cancer is at the top of the lungs, it might put pressure on or damage a group of nerves that runs from the upper chest into your neck and arms. The group of nerves is called the brachial plexus.

Can a tumor cause neck pain? ›

Neck pain is the most common presenting symptom of patients with a cervical spine tumor. Patients often have unrelenting pain, as well as night pain, that is not relieved by rest or traditional measures. Patients may have neck stiffness and decreased range-of-motion.

What cancers cause neck pain? ›

Sometimes persistent, continuing neck pain is a warning sign of head or neck cancer. Although it could also be a sign of another less serious condition, head and neck cancers might include a lump, swelling or a sore that doesn't heal.

What are the first signs of a Pancoast tumor? ›

Pancoast tumor symptoms
  • Pain is the most common symptom of a Pancoast tumor, occurring in 44 to 96% of patients. ...
  • Numbness or weakness of the hand and arm and tingling in the fingers can occur on the affected side of the body. ...
  • Droopy eyelid and pupil constriction may occur in up to 40% of patients with Pancoast tumors.

Is Pancoast tumor pain constant? ›

Pancoast Tumor Symptoms

The associated pain is severe and constant, often requiring narcotic pain medications for relief. The affected person usually needs to support the elbow of the affected arm in the opposite hand to ease the tension on the shoulder and upper arm.

How did you find out you had Pancoast tumor? ›

Doctors often first see a tumor in a chest X-ray after the cancer has spread to other parts of your lungs. Once your doctor finds a Pancoast tumor, you may get other imaging scans, such as CT, MRI, or PET scans, which can help your doctor know the size of the tumor and whether it has spread to other areas of your body.

How fast do Pancoast tumors grow? ›

Most often, Pancoast tumor grows slowly. In some cases, it can grow and spread quickly and cause rapid death. The cancer may spread to other parts of the body, including the bone, liver, small intestine, and brain.

Can non smokers get Pancoast tumor? ›

They may also spread into the ribs at the top of the chest and affect important areas at the base of the neck, like nerves and blood vessels. It's not clear why tumors develop here, though cigarette smoking is often a factor. Exposure to certain harmful chemicals, radon gas and asbestos may also cause these tumors.

Does Pancoast tumor show up in blood work? ›

The blood exam for persons with Pancoast tumor is not specific, and the results are not diagnostic. Chest X-ray film: In the early stages, Pancoast tumors are difficult to detect on chest X-ray films because the top of the lung is located in an area of the body that is difficult to visualize clearly on an X-ray film.

What is Pancoast tumor associated with? ›

Primary tumors in superior sulcus/apex of the lung are generally considered Pancoast tumors, which account for 3% to 5% of lung cancers. The vast majority being bronchogenic cancers. Non-small cell lung cancer account for more than 95% of all the cases of Pancoast tumors.

What is the prognosis of Pancoast tumor? ›

Surgery for Pancoast tumors is associated with 5% mortality rate and the complication rate varies from 7-38%. The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%).

What is the treatment of choice for Pancoast tumors? ›

Pancoast tumor treatment options often include surgery, chemotherapy and radiation therapy. Nutritional therapy and mind-body medicine can also be used as forms of supportive care treatments.

What are the symptoms of a Tumour in the neck? ›

Head and neck cancer symptoms may include a lump in the neck or a sore in the mouth or the throat that does not heal and may be painful, a sore throat that does not go away, difficulty in swallowing, and a change or hoarseness in the voice. These symptoms may also be caused by other, less serious conditions.

What causes shoulder pain that radiates to the neck? ›

Nerve compression or inflammation.

Similarly, a nerve compressed or inflamed in the shoulder may radiate pain up to the neck. The brachial plexus, which is the group of nerves that run from the lower neck and upper back across the shoulder, can be involved in various types of neck and shoulder pain.

Can a tumor cause a stiff neck? ›

Tumor. A brain tumor, especially if it is located in the cerebellum, can cause a stiff neck. A tumor in the cervical spine, such as from cancer, could also cause the neck to become sore and/or stiff.

What are the red flags for neck pain? ›

Red flag symptoms
  • Significant preceding trauma or neck surgery.
  • Systemic upset (unintentional weight loss, night sweats, fevers)
  • Severe pain.
  • Nocturnal pain.
  • Relatively young (<20 years) or old (>55 years)
  • Signs of spinal cord compression.
  • Significant vertebral body tenderness.
16 Aug 2021

What underlying conditions cause neck pain? ›

Neck pain may be caused by arthritis, disc degeneration, narrowing of the spinal canal, muscle inflammation, strain or trauma. In rare cases, it may be a sign of cancer or meningitis.

What is the most common cause of neck pain? ›

Neck pain is common. Poor posture — whether from leaning over a computer or hunching over a workbench — strains neck muscles. Osteoarthritis also is a common cause of neck pain. Rarely, neck pain can be a symptom of a more serious problem.

Does Pancoast tumor pain start suddenly? ›

As with most cancer pain, it is unlikely to come and go or vary in intensity. Rather, it is more likely to be constant and increase in severity over time. It's important to note that a pancoast tumor usually shows up on a chest x-ray, and certainly on a chest CT.

What stage is Pancoast tumor? ›

Roughly three-quarters of Pancoast tumors are stage III tumors as they involve the parietal pleura, and the rest are regularly stage IIB and stage IV with the involvement of brachial plexus, mediastinum, great vessels, vertebral body, or with distant metastases.

How do you know if shoulder pain is lung related? ›

People who have shoulder pain from lung cancer often describe it as a radiating pain from the shoulder down their arms to their hands. There may also be numbness or tingling. At other times, it can feel like a deep ache. Lung cancer frequently causes chest pain as well.

Can shoulder xray show Pancoast tumor? ›

Pancoast's tumours are often challenging to diagnose as they are difficult to detect on plain chest x-ray. Radioisotope bone scanning is used primarily to detect bone abnormalities and involves the injection of a radioactive tracer which is taken up by bone during new bone formation.

Can Pancoast tumor be missed on CT scan? ›

Most of the time pancoast tumors are mistaken for hugely more common orthopedic issues before being picked up by a CT scan.

Do Pancoast tumors cause headaches? ›

Conclusions. Pneumocephalus related to spontaneous bronchopleurodurosubarachnoid fistula from a necrotic Pancoast tumor after chemoradiation is a rare cause of acute headache associated with back pain.

Who is at risk for Pancoast tumor? ›

A number of risk factors can increase the likelihood of developing a Pancoast tumor, including: Tobacco use – Smoking or being exposed to secondhand smoke. Exposure to certain occupational hazards – Being exposed to asbestos, diesel exhaust, gold or nickel. Advanced age – Being older than 50.

Will shoulder MRI show Pancoast tumor? ›

MR imaging has a pivotal role for staging and therapeutic management in patients with Pancoast tumor. MR neurography, DW imaging, and MR angiography are actually mandatory imaging techniques in all patients with superior pulmonary sulcus tumors.

How common is Pancoast tumor? ›

A Pancoast tumor is a rare condition, representing 3% to 5% of all lung cancers. The particular location of these lesions leads to the invasion of structures in the thoracic inlet, causing a constellation of symptoms known as Pancoast-Tobias syndrome.

What is Pancoast-Tobias syndrome? ›

The combination of severe and unrelenting shoulder and arm pain along the distribution of the eighth cervical and first and second thoracic nerve trunks, Horner's syndrome (ptosis, miosis, and anhidrosis) and atrophy of the intrinsic hand muscles comprises a clinical entity named as “Pancoast-Tobias syndrome”.

How big is a Pancoast tumor? ›

Many of these cancers are stage IIB non-small cell lung cancer. Based on TNM lung cancer staging, most of them are T3 or T4. 4 This means that the tumor is often larger than 7 centimeters (or 3.5 inches) in diameter at the time of diagnosis.

Do Pancoast tumors cause weight loss? ›

Aside from constitutional symptoms of cancer such as malaise, fever, weight loss and fatigue, Pancoast tumor can include a complete Horner's syndrome in severe cases: miosis (constriction of the pupils), anhidrosis (lack of sweating), ptosis (drooping of the eyelid), and pseudoenophthalmos (as a result of the ptosis).

Can a Pancoast tumor be benign? ›

Benign causes of Pancoast's syndrome are rarely reported in the literature. Here, we report a case of fungal abscess located in the apex of lung causing Pancoast's syndrome in an immunocompetent housewife of thirty-five years of age.

Why does Pancoast tumor cause shoulder pain? ›

When a Pancoast tumor spreads outside your lung, it can grow into and press against nerves nearby. This squeezing causes the shoulder pain, but also nerve-related symptoms like these on one side of your face: Drooping eyelid.

Can you remove a Pancoast tumor? ›

Surgery. Surgical treatment for a Pancoast tumor typically involves the removal of the entire tumor, the affected lung's upper lobe and possibly a portion of the chest wall.

What are the criteria for characterizing a tumor as Pancoast tumor? ›

The following criteria must be met for characterizing a lesion as a Pancoast tumor; the tumor must invade the parietal pleura and cause pain, paresthesias or other neurological dysfunction; it is not sufficient only to have an apical lung tumor.

Can you feel a Pancoast tumor? ›

Pancoast tumors have unique symptoms.

Patients may feel neck, back, arm or chest pain on the affected side. In some cases, these tumors may involve the nerves of the brachial plexus, which provide sensory and motor supply to the arm and hand.

How fast does a Pancoast tumor grow? ›

Most often, Pancoast tumor grows slowly. In some cases, it can grow and spread quickly and cause rapid death. The cancer may spread to other parts of the body, including the bone, liver, small intestine, and brain.

What is the life expectancy with a Pancoast tumor? ›

For patients with early-stage, surgically-treatable cancer, the five-year survival rate is generally considered to be between 30 and 50 percent, although rates as high as 90 percent have been more reported in patient groups with very favorable characteristics.

Will neck MRI show Pancoast tumor? ›

MR imaging has a pivotal role for staging and therapeutic management in patients with Pancoast tumor. MR neurography, DW imaging, and MR angiography are actually mandatory imaging techniques in all patients with superior pulmonary sulcus tumors.

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