Cloward’s approach for Pancoast neurogenic tumors: illustrative cases

BACKGROUND Pancoast tumors are a wide range of tumors located in the apex of the lung. Traditional surgery for Pancoast neurogenic tumors frequently involves extensive approaches, whether anterior or posterior or a combination, in which osteotomies are sometimes required. In this study, the authors proposed a less invasive surgical strategy using the standard Cloward’s approach for complete resection of a schwannoma arising from the T1 nerve root. OBSERVATIONS Two patients, each harboring a large T1 tumor, one on each side, underwent Cloward’s approach with and without thoracoscopic surgery. Both patients had complete resection of the tumor. Considering the benign and encapsulated nature of neurogenic tumors, Cloward’s approach under neuromonitoring, which is a common procedure for anterior cervical discectomy for most neurosurgeons, is a safe and less invasive alternative for Pancoast neurogenic tumors. For patients whose tumor cannot be removed completely via Cloward’s approach, video-assisted thoracoscopic surgery is a viable backup plan with minimal invasiveness. LESSONS Cloward’s approach is a viable option for Pancoast neurogenic tumors.

Percutaneous Peripheral Nerve Stimulation for Treatment of Brachial Plexopathy Secondary to Pancoast Tumor: A Case Report

Background: Pancoast tumors can result in significant arm and shoulder pain due to invasion of the lower brachial plexus (BP). They are usually treated by chemoradiotherapy followed by surgical resection, which may alleviate the pain. When patients respond poorly to chemoradiation and the tumor is not surgically resectable, options to treat the pain are limited. We report here successful use of percutaneous peripheral nerve stimulation (PNS) with leads inserted under ultrasound (US)-guidance for treatment of brachial plexopathy in a patient with an unresectable Pancoast tumor unresponsive to chemoradiation. Case Report: The patient was a 70-year-old woman with an unresectable poorly differentiated squamous cell carcinoma of the left lung status post chemoradiation with poor response and recently started on immune therapy who presented to her oncologist with refractory left upper extremity (LUE) pain and weakness. She was admitted for pain control, and pain management was consulted. Physical examination findings were concerning for involvement of the lower trunk of the BP, findings confirmed in imaging. Patient elected to proceed with placement of a PNS. Device was successfully placed under US guidance. Patient responded well for the first 2 weeks with significant improvement in allodynia and hyperesthesia, however, at week 3, physical examination was significantly changed and further growth of the tumor was seen on imaging. The PNS was removed at this time. Conclusion: This case demonstrates successful use of PNS to treat refractory neuropathic pain in a patient with a locally advanced Pancoast tumor. US imaging made it possible to identify the interscalene BP and accurately place the leads. The PNS achieved its desired outcome of providing pain relief in the lower trunk distribution for the full 3 weeks it was in place. Pain from Pancoast tumors can be severe, and neural blockade via PNS to interrupt pain is an option for patients with intractable pain. Additional prospective study is warranted to determine the efficacy of this technique. Key words: Brachial plexus, upper extremity, cancer pain, interventional pain management, neuromodulation, peripheral nerve stimulation

Modernes Management des Pancoast-Tumors

ZusammenfassungDer Pancoast-Tumor (Sulcus-superior-Tumor) ist eine Sonderform des Lungenkarzinoms mit Infiltration der oberen Thoraxapertur, die durch Schulterschmerz und eventuell Horner-Syndrom klinisch auffällig wird. Die häufig verspätete Diagnose und die komplexe Anatomie der Region stellen eine Herausforderung für die Therapeuten dar. Dieser Beitrag schildert, wie moderne Diagnostik und multimodale Behandlung die Prognose der Erkrankung positiv beeinflussen können.

Modernes Management des Pancoast-Tumors

ZusammenfassungDer Pancoast-Tumor (Sulcus-superior-Tumor) ist eine Sonderform des Lungenkarzinoms mit Infiltration der oberen Thoraxapertur, die durch Schulterschmerz und eventuell Horner-Syndrom klinisch auffällig wird. Die häufig verspätete Diagnose und die komplexe Anatomie der Region stellen eine Herausforderung für die Therapeuten dar. Dieser Beitrag schildert, wie moderne Diagnostik und multimodale Behandlung die Prognose der Erkrankung positiv beeinflussen können.