Pancoast syndrome is an important clinical presentation of several disorders with different etiologies that develop in the apex of the lungs [1] [2] [3] [4]. Bronchogenic carcinoma, however, is by far the most common cause of this clinical syndrome characterized by one or more of the following symptoms [5]:

• Shoulder pain - Proliferation of a mass from the lung apex eventually compresses the brachial plexus, parietal pleura, and the surrounding blood vessels, leading to severe ipsilateral and progressive pain in the shoulder [2] [3]. The pain can spread to the neck, anterior chest wall, and axilla, or progress down to the arm and hand, simultaneously producing weakness and atrophy of the muscles innervated by nerves stemming from C8-T1 roots of the brachial plexus (the ulnar nerve being predominantly affected) [2] [3] [4]. In some cases, blood vessel occlusion may lead to unilateral edema that further contributes to muscle atrophy [2] [6].
• Horner syndrome - Enophthalmos, anhidrosis, ipsilateral miosis and ptosis comprise this neurological syndrome, which is encountered in up to 50% of patients with superior sulcus tumors, and the pathogenesis stems from a mechanical damage of the sympathetic plexus by a growing mass [2].

Although bronchogenic carcinomas are responsible for the development of Pancoast syndrome in the majority of cases (hence the terms Pancoast tumors or superior sulcus tumors), other conditions are neoplastic diseases (non-Hodgkin lymphomas, multiple myelomas, metastatic cancers of the liver and uterus), fungal infections (hydatid cysts as a result of Echinococcosis, histoplasmosis, aspergillosis, and mucormycosis) and pulmonary tuberculosis, whereas bacterial infections and other benign pathologies rarely induce Pancoast syndrome [1] [3] [6].

• Arm Pain

  Shoulder and arm pain (from the brachial plexus invasion C8-T1) with wasting of the intrinsic hand muscles and paraesthesiae in the medial side of the arm. [patient.info]

  Pancoast syndrome is a term used to describe unilateral shoulder and arm pain, weakness, and atrophy of hand muscles and Horner's syndrome as a result of a mass in the lung apex compressing blood vessels and nerve trunks. [symptoma.com]

  Pancoast's syndrome is a constellation of characteristic symptoms and signs that includes shoulder and arm pain along the distribution of the eighth cervical nerve trunk and first and second thoracic nerve trunks, Horner's syndrome, and weakness and atrophy [nejm.org]

  Reference work entry DOI: 10.1007/978-3-540-85516-3_525 Definition The classic Pancoast syndrome presents symptoms and signs that include shoulder and arm pain along the distribution of the eighth cervical nerve trunk and first and second thoracic nerve [link.springer.com]

  They typically involve the brachial plexus first and cause shoulder and arm pain in almost all patients. They can also involve the parietal pleura, ribs, or vertebral bodies and cause pain. [ncbi.nlm.nih.gov]

• Enophthalmos

  Horner syndrome - Enophthalmos, anhidrosis, ipsilateral miosis and ptosis comprise this neurological syndrome, which is encountered in up to 50% of patients with superior sulcus tumors, and the pathogenesis stems from a mechanical damage of the sympathetic [symptoma.com]

  •Horner’s Syndrome: miosis, ptosis, enophthalmos and anhidrosis. •Lower brachial plexus injury (C8-T1): Klumpke’s palsy. •Paresthesia of the upper extremity due to compression of subclavian artery & vein. [abcradiology.blogspot.com]

  Clinical This is accompanied by: 1) severe pain in the shoulder region radiating toward the axilla and scapula along the ulnar aspect of the muscles of the hand; 2) atrophy of hand and arm muscles; 3) Horner syndrome (ptosis, miosis, hemianhidrosis, enophthalmos [pallipedia.org]

  Presentation This syndrome results from the invasion of a number of structures and tissues around the thoracic inlet and may be characterised by: Ipsilateral invasion of the cervical sympathetic plexus, leading to Horner's syndrome (miosis, enophthalmos [patient.info]

  Horner’s syndrome Horner’s syndrome, comprised of • ipsilateral partial ptosis, • meiosis, • enophthalmos, • anhydrosis, and • loss of ciliospinal reflex, results from invasion of the stellate ganglion and paravertebral cervical sympathetic chain. 42. [slideshare.net]

• Blurred Vision

  When asked about other ‘abnormal’ symptoms, he reported blurred vision in his right eye and felt his right eyelid was ‘drooping’. [casereports.bmj.com]

• Shoulder Pain

  A 61-year-old patient had the clinical findings of Pancoast syndrome with shoulder pain, weakness and atrophy of band muscles, and an opacified area in the apical lung field. [ncbi.nlm.nih.gov]

  Unusual association of diseases/symptoms Pancoast tumour presenting as shoulder pain with Horner’s syndrome Nimlan Shanmugathas1, Kapil Mohan Rajwani2 and Shumontha Dev3 1 Emergency Department, Guy’s & St Thomas’ Hospitals, London, UK 2 Department of [casereports.bmj.com]

  •Shoulder pain: due to involvement of upper ribs and intercostal nerves. [abcradiology.blogspot.com]

  Bronchogenic carcinoma, however, is by far the most common cause of this clinical syndrome characterized by one or more of the following symptoms: Shoulder pain - Proliferation of a mass from the lung apex eventually compresses the brachial plexus, parietal [symptoma.com]

  Clinical presentation The syndrome consists of: shoulder pain C8-T2 radicular pain Horner syndrome The classical syndrome is uncommon, with Horner syndrome present in only 25%. [radiopaedia.org]

• Neck Pain

  Cancer is an uncommon cause of radicular neck pain but should be considered in the differential, particularly when constitutional complaints are also present. [ncbi.nlm.nih.gov]

  […] ulnar aspect of the muscles of the hand, (2) atrophy of hand and arm muscles, (3) Horner syndrome (ptosis, miosis, hemianhidrosis, enophthalmos), and (4) compression of the blood vessels with edema." [6] Common presentations include: Pancoast syndrome Neck [physio-pedia.com]

• Upper Back Pain

  Learning points Persistent shoulder and upper back pain should always be investigated, particularly with an atypical history and absence of trauma, as it is often the presenting feature in Pancoast tumours.7 A systemic review will often help to bring [casereports.bmj.com]

  National Institutes of Health, National Cancer Institute, Lung Cancer Pancoast Tumor Pictures A 53-year-old man with a 50-pack-per-year history of smoking began experiencing upper back pain for several weeks. [emedicinehealth.com]

• Edema of the Upper Extremity

  […] of the upper extremity if the subclavian vein has to be ligated; Persistent post-thoracotomy intercostal neuralgia; Myatrophies and muscular weakness of the upper extremity if the ulnar nerve has to be sacrificed; Damage of the dura resulting in cerebrospinal [jtd.amegroups.com]

• Left Shoulder Pain

  Case report A 59‐year‐old man was admitted to the hospital because of left shoulder pain, low‐grade temperature, a productive cough and an abnormal chest radiograph. [ncbi.nlm.nih.gov]

• Hyperactivity

  This happens due to a hyperactive contralateral sympathetic reaction called Harlequin syndrome.[7][8] Histopathology Squamous cell carcinoma historically has been the most common subtype associated with Pancoast tumors. [ncbi.nlm.nih.gov]

As Pancoast syndrome is the likely manifestation of a malignant disease, its early recognition is vital for ensuring optimal patient outcomes. Unfortunately, tumors are already at an advanced stage when Pancoast syndrome appears (T3 or T4 stage is observed in the majority of cases) [4]. Nevertheless, the immediate workup should start with a patient history that will note the timeline of complaints and their progression, whereas a properly conducted physical examination could identify unilateral pain of the shoulder and weakness of the ipsilateral arm, as well as constitutive features of Horner's syndrome. There should be a clinical suspicion regardless of the severity of symptoms, and imaging studies should be performed promptly, as they are the cornerstone in determining the etiology. Plain chest X-rays often reveal a homogeneous shadow or opacity in the lung apex and asymmetry of the apical caps of > 5 mm, but computed tomography (CT) is the gold standard [2] [3] [4] [5]. CT is able to confirm the state of the surrounding tissues and determine whether the mass has invaded the ribs, vertebral bodies, the mediastinum, the brachial plexus, but also if blood vessel occlusion has occurred [2] [4] [5]. Furthermore, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) can be employed to obtain an even better view of the tissues [2] [4]. Even though bronchoscopy and subsequent biopsy of the lesion yields a definite diagnosis, the hardly accessible location of the lung apex does not allow for appropriate sampling [4] [5]. For this reason, transthoracic image-guided needle aspiration biopsy has established itself as the main technique for obtaining a viable sample for histopathological examination [1] [5].

• Normal Chest X-Ray

  Chest Radiograph • CXR FINDINGS FREQUENCY • Mediastinal Mass • or Widening 59-84% • Hilar LAD 19-50% • Pleural Effusions 25% • Normal chest X-ray does not exclude SVCO 21. [slideshare.net]

• Abnormal Bone Scan

  Bone Scan : An occasional case where abnormal bone scan is the presenting abnormality. [angelfire.com]

• Staphylococcus Aureus

  We report the unusual occurrence of a case of Pancoast syndrome caused by a destructive sclerosing fibrosis after pulmonary Staphylococcus aureus infection. [ncbi.nlm.nih.gov]

  Pancoast syndrome: an unusual complication of pulmonary infection by Staphylococcus aureus. Ann Thorac Surg. 1992 May. 53(5):903-4. [Medline]. Simpson FG, Morgan M, Cooke NJ. Pancoast's syndrome associated with invasive aspergillosis. [emedicine.medscape.com]

• Hepatocellular Carcinoma

  Abstract Hepatocellular carcinoma (HCC) is common in Taiwan. Recently, extrahepatic metastases have developed more frequently in patients due to prolonged survival rates to which improved diagnostic and treatment methods have contributed. [ncbi.nlm.nih.gov]

  Hepatocellular carcinoma with Pancoast's syndrome as an initial symptom: a case report. Jpn J Clin Oncol 2001;31:119-21. [ PubMed ] White HD, White BA, Boethel C, et al. [jtd.amegroups.com]

1. Sarkar A, Das A, Basuthakur S, Pandit S, Das SK, Choudhury S. Pancoast syndrome: A rare presentation of non-Hodgkin’s lymphoma. Lung India. 2013;30(3):209-211.
2. Foroulis CN, Zarogoulidis P, Darwiche K, et al. Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment. J Thorac Dis. 2013;5(Suppl 4):S342-S358.
3. Dao I, El Mostarchid B, Onen J, Mandour C, El Asri CA, Boucetta M. Pancaost syndrome related to hydatid cyst. Pan Afr Med J. 2013;14:118.
4. Panagopoulos N, Leivaditis V, Koletsis E, et al. Pancoast tumors: characteristics and preoperative assessment. J Thorac Dis. 2014;6(Suppl 1):S108-S115.
5. Fontenele e Silva J, Barbosa Mde P, Viegas CL. Small cell carcinoma in Pancoast syndrome. J Bras Pneumol. 2009;35(2):190-193.
6. Bansal M, Martin SR, Rudnicki SA, Hiatt KM, Mireles-Cabodevila E. A rapidly progressing Pancoast syndrome due to pulmonary mucormycosis: a case report. J Med Case Reports. 2011;5:388.