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
- 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?
In general a patient not responding significantly within 4-6 tx should be re-evaluated.
1) Patient got better –> “my treatment is effective”
2) No Change –> “without my treatment, it would be much worse; my treatment is effective; we must continue”
3) Patient got worse –> “without my treatment, you’d be dead; my treatment is effective; we must continue”
Four to six weeks is the general rule, of course that is depending on the case. Personally, I give it two weeks and expect to see some improvement on every visit.
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?
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.”
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.
Full case report
Thank-you for the link.
So it seems it was an adenocarcinoma; they generally do better and these days can be treated with immunotherapy as well.
He initially presented with pain which was disturbing his sleep. This is a very sinister symptom. Cancer pain is always worse at night, whereas pain due to benign causes generally eases somewhat when you settle down to sleep, and is often at its worst first thing in the morning. Surprisingly few doctors know this but I have found it to be a very reliable pointer to what is going on.
Yes, pain worse at night always gets my upmost attention as possible pathology. Covered in my chiropractic classes.