Pancoast Tumors of the Lungs

Symptoms, diagnosis, treatments, and prognosis of this type of lung cancer

In This Article

Pancoast tumors are a type of lung cancer that begin at the top of the right or left lung and invade the chest wall. They are also called superior sulcus tumors. Pancoast tumors often have unique symptoms known as “Pancoast syndrome,” which consists of pain in the shoulder and the inside of the arm and hand. Accounting for roughly three to five percent of lung cancers, the tumors are often misdiagnosed for some time due to both their uncommon symptoms, and the difficulty seeing these tumors on X-rays. Many of these tumors are diagnosed at a stage when surgery can be done (often after chemotherapy and radiation), and the prognosis is often better than other types of lung cancer. Learn about other ways in which these types of tumors are unique, and how they are diagnosed and treated.


Symptoms of a Pancoast tumor are due to compression of structures (nerves) that lie near the upper part of the lung where the cancer is present. The classic symptoms are called the Pancoast-Tobias syndrome and include:

Arm and shoulder pain

Pain in the shoulder frequently radiates down the arm (especially the inside part of the arm and on the pinky side of the hand). This pain is often severe and unrelenting. Pain can also radiate into the armpit or into the shoulder blade. (Shoulder pain may be the first symptom of lung cancer, especially for those who have Pancoast tumors.)

Weakness in Hand Muscles

People may feel weakness in the muscles of the hand that can easily be dismissed as musculoskeletal in origin.

Tingling and Prickly Sensations in the Hand

A strange sensation like tingling may be noted, especially the ring and pinky fingers.

Horner's Syndrome

Horner's syndrome is a constellation of symptoms that includes ptosis (a droopy eyelid) hyphidrosis or anhidrosis (an eventual lack or absence of sweating on one side of the face that is often preceded by flushing and sweating on one side of the face) and miosis (a constricted pupil of the eye).

Swelling of the Upper Arm

Sometimes there is also swelling of the upper arm due to pressure on the subclavian vein (the vein that runs beneath the collarbone). 

If you have any symptoms suggestive of a Pancoast tumor, talk to your doctor or get a second opinion. Many of these tumors are missed at first due to both their unique symptoms and because they can be difficult to see on x-rays. 

Location and Anatomy

Pancoast tumors occur in the upper part of the right or left lung (the apical region) and invade structures near this area. These can include:

  • Ribs (often the 1st and 2nd ribs) and vertebrae.
  • The brachial plexus, a cluster of nerves located near the armpit.
  • Nerves or blood vessels near the top of the lungs (for example, the subclavian artery, the phrenic nerve, the recurrent laryngeal nerve, and the vagus nerve.)

Medical/Anatomic Definition of Pancoast Syndrome 

For those who want a more in-depth definition of Pancoast syndrome, the American College of Chest Physicians defines Pancoast syndrome as lung tumors which invade any of the structures of the apex (top of the lung) of the chest, including the first thoracic ribs, the lower nerve roots of the bronchial plexus, the sympathetic chain and stellate ganglion near the apex of the chest or the subclavian vessels (the subclavian vessels include the artery and vein that travel under the collarbone or clavicle.)


Smoking is responsible for many of these cancers, but it's important to note that the diagnosis of lung cancer is currently more common in non-smokers (either former smokers or those who have never smoked). Other risk factors for lung cancer include radon exposure, secondhand smoke, and occupational exposures to chemicals and substances known to cause lung cancer. While lung cancer has decreased overall as fewer people smoke, it is increasing in young adults, especially young women who have never smoked.


Diagnosis of Pancoast tumors is frequently delayed for two reasons. These tumors are less likely to have typical lung cancer symptoms, such as shortness of breath and coughing, and people often first see an orthopedic surgeon or neurologist for their symptoms. Pancoast tumors are also difficult to see on chest x-rays due to their location.

Up to 25 percent of lung cancers are missed on chest X-rays, but Pancoast tumors are even more likely to be missed.

A combination of CT scans and MRI's are often used—with MRI important before surgery to look for nerve involvement. (MRIs are used less often with other types of lung cancer). A lung biopsy of some form—whether an open chest biopsy (thoracotomy) or through biopsy of the lymph nodes above the collarbone (supraclavicular lymph node biopsy) is often done to make the diagnosis. Other tests, such as a bronchoscopy may be done as well.


Staging is often done with a combination PET scan/CT, and a PET scan can be very important in planning treatment as a 2015 study found that PET scans changed the staging (and consequently the best treatment choices) for 21 percent of people with these tumors.

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, meaning the tumor is often larger than 7 centimeters (or 3 1/2 inches) in diameter at the time of diagnosis.

Differential Diagnosis

Pancoast syndrome symptoms are most often associated with Pancoast tumors, but have been noted due to benign causes such as infections with viruses, bacteria, or fungi.

Type of Lung Cancer

Pancoast tumors are usually a form of non-small cell lung cancer. Of these, around 2/3 are lung adenocarcinoma and 1/3 are squamous cell carcinoma or large cell carcinoma. Since there are several targeted therapies now available for lung adenocarcinoma, and now for squamous cell carcinoma as well, it is very important to make sure you have gene profiling (molecular profiling) done on your tumor.


Treatment options for people with Pancoast tumors depend upon the extent of the tumor. Currently, for those with stage I to stage III tumors, the "ideal" treatment includes a combination of chemotherapy and radiation therapy followed by surgery. Options include:

Chemotherapy and Targeted Therapies

Treatment for a Pancoast tumor usually begins with lung cancer chemotherapy, whether or not surgery would be possible. Due to the location which can make surgery difficult, the goal is to reduce the tumor in size as much as possible before surgery. In addition, many of these tumors have "targetable mutations," genetic abnormalities found on gene testing for which targeted therapies are available. If you have not had gene testing, also called molecular profiling or gene profiling, talk to your doctor.


Surgery can often be done on Pancoast tumors, but is usually done after chemotherapy and/or targeted therapy plus radiation therapy to shrink the tumors. Chemotherapy before surgery is called "induction therapy." This surgery can be very difficult, and it's important to find a cancer center in which the surgeons are familiar with this type of tumor. Unlike some cancers which have spread to bones, some people with Pancoast tumors which have invaded the vertebrae can be successfully treated with surgery.

During surgery, lymph nodes in the chest between the lungs (called mediastinal lymph nodes) are often removed as well.

While surgery for Pancoast tumors has generally been via a thoracotomy (open chest surgery in which a rib is separated or removed), a 2014 study suggested that minimally invasive surgery with video-assisted thoracoscopic surgery (VATS) may be safe and effective. VATS involves making small incisions in the chest, and using instruments to remove a tumor.

Since Pancoast tumors often lie in close association to nerves, it's often recommended that both a thoracic surgeon and a neurosurgeon be present for these surgeries.

Radiation Therapy

If treatment aimed at a cure is not possible, radiation therapy can still be helpful as a palliative therapy, one used to relieve pain and other symptoms. Radiation therapy may also be used along with chemotherapy to "shrink" a tumor before surgery.

Targeted Therapy

As noted above, everyone with non-small cell lung cancer and especially lung adenocarcinoma should have molecular profiling done on their tumor. Medications are currently approved for those with EGFR mutations, ALK rearrangements, ROS1 rearrangements, BRAF mutations, and more, with further treatments being studied in clinical trials.


Immunotherapy is an exciting new way to treat lung cancer, with the first treatments approved in this category in 2015. While it does not work for everyone, some people—even those with advanced lung cancer—have had long-term control of their disease with these treatments.

Clinical Trials

Pancoast tumors are quite rare, and clinical trials are in progress to evaluate new treatments.


A significant improvement in survival from Pancoast tumors has been achieved in the past few decades. In general, Pancoast tumors have a better prognosis than tumors that are located more centrally in the lungs, and the survival rate may be better than other cancers at a similar stage

The 2-year survival rate was found to be between 55 percent and 70 percent—significantly higher than some other lung cancers, and of those who have Pancoast tumors which could be treated with surgery, the 5-year survival rate was between 50 and 77 percent.

It's important to note that these survival rates could very well be higher now, since newer targeted therapies, as well immunotherapy drugs, have been approved since these studies were completed.

If You Have Been Diagnosed

Since Pancoast tumors are fairly uncommon, and since surgery is tricky, it is very important to consider getting a second opinion if you've been diagnosed. Studies tell us that learning as much as possible about your cancer not only helps you feel more in control, but may help with your outcome as well. Check out these tips on what to do when you are newly diagnosed, as well as how to research your cancer online.

Being your own advocate for your cancer care has made a difference for many people, and according to the National Cancer Institute, people with lung cancer should consider the option of clinical trials.

You may have heard more about breast cancer and pink ribbons, but the lung cancer community is active and very supportive. Even if you aren't the type of person who likes support groups or social media, consider connecting with others living with the same disease.

And, if it is your loved one who has been diagnosed instead, you should learn about what you should do when your loved one has lung cancer.

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