PBL 1 - Pancoast's Tumour

Question 1

What structures are found in the thoracic outlet? Draw a diagram.

Answer 1

1. Apex of lung
3. Inferior trunk of brachial plexus
4. Stellate ganglion of cervical sympathetic trunk
5. Subclavian vessels

Question 2

Draw a diagram of the cervical sympathetic trunk. What is its spinal origins?

Answer 2

Spinal origins: T1-T2

See Stewart McDonald’s diagrams

Question 3

Describe the myotomes of the upper limb.

Answer 3

Musculocutaneous n. – Flexor muscles of arm
Axillary n. – Deltoid m, terres minor m.
Median n. – Flexor muscles of forearm/hand
Radial n. – Extensor muscles
Ulnar n. – Intrinsic hand muscles

Question 4

In the eyelid, which muscle has sympathetic innervation?

Answer 4

Superior tarsal muscle

Question 5

Describe Horner’s syndrome. What is it caused by?

Answer 5

1. Pupil constriction
2. Ptosis (drooping eyelid)
3. Absence of sweating on the ipsilateral face/neck

Caused by: loss of sympathetic innervation via cervical sympathetic trunk

Question 6

What is a Pancoast’s tumour?

Answer 6

A tumour of the apical region of the lung, which may involve nearby structures including the brachial plexus, subclavian vein and subclavian artery

Question 7

Describe the clinical features of a Pancoast’s tumour.

Answer 7

1. Swelling of arm
2. Discolouration of arm
3. Grip weakness in hand
4. Loss of sensation on arm
5. Horner’s syndrome

Question 8

Describe the pathophysiology of Pancoast’s tumour.

Answer 8

1. Compression of the cervical sympathetic trunk.
2. Compression of the subclavian vein.
3. Compression of the inferior trunk of the brachial plexus (C8 and T1).

Question 9

What investigations would you do to diagnose Pancoast’s tumour?

Answer 9

1. Chest x-ray
2. MRI of thoracic inlet
3. CT

Question 10

How is Pancoast’s tumour treated?

Answer 10

1. Surgical removal
2. Radiotherapy
3. Chemotherapy
4. Supportive care