Pancoast tumor differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]

Overview

Pancoast tumor must be differentiated from other causes of mass located in the apical region of the chest which may present with pain in the shoulder region. Differential diagnosis includes most common other conditions that cause hemoptysis, cough, dyspnea, wheeze, chest pain, shoulder pain, unexplained weight loss, unexplained loss of appetite, and fatigue such as superior vena cava syndrome, thoracic outlet syndrome, cervical disk disease, pneumonia/bronchitis, carcinoid tumor, infectious granuloma and thyroid mass.

Differential Diagnosis

Pancoast tumor must be differentiated from other causes of mass located in the apical region of the chest which may present with pain in the shoulder region.The table below summarizes the findings that differentiate apical mass in the chest from the most common other conditions that cause hemoptysis, cough, dyspnea, wheeze, chest pain, shoulder pain, unexplained weight loss, unexplained loss of appetite, and fatigue


The following table summarizes the differentiation of various lung tumors based on histological and topographical features:[1][2][3][4][5][6][7][8][9][10][11][12][13]

Abrevations:

HPV: human papillomavirus; CEA: Carcino embryogenic antigen; TTF1: Thyroid transcription factor-1; EMA: Epithelial membrane antigen; CK: Cyto keratin; CD: Cluster differentiation; NCAM: Neural Cell Differentiation Molecule;

MMP's: Mettaloprotineases matrix ; GFAP: Glial fibrocilliary acid protein

Risk/Epidemiology Pleuripotent cells Topography Gross Histology Immunohistochemistry Imaging Metastasis
Pancoast Tumor Squamous cell carcinoma (SCC)
  • Central
  • Exophytic
  • Intra-epithelial
  • Without invasion
  • Cells with clear cytoplasm
  • Peripheral palisading of nuclei.
  • Poor differentiation

Chest x-ray: Lordotic view on chest x-ray is helpful in visualizing Pancoast tumor because of its characteristic location in the apical portion of the lung.

Small cell carcinoma
  • Bronchial precursor cell
  • Peripheral
  • White-tan, soft, friable perihilar masses
  • Extensive necrosis
  • 5% peripheral coin lesions
  • Sheet-like growth
  • Nesting
  • Trabeculae
  • Peripheral palisading
  • Rosette formation
  • High mitotic rate
  • Bone marrow
  • Liver
Adenocarcinoma
  • Columnar cells of bronchioles
  • Peripheral
  • Single or multiple lesions
  • Different in size
  • Peripheral distribution
  • Gray-white central fibrosis
  • Pleural puckering
  • Anthracotic pigmentation
  • Lobulated or ill defined edges
  • Nuclear atypia
  • Eccentrically placed nuclei
  • Abundant cytoplasm with mucin vacuoles
  • Often conspicuous nucleoli
  • Lack of intercellular bridges.
  • Different patterns, include: acinar, lepidic, micropapillary, papillary, and solid.
Aerogenous spread is characteristic
Benign Lung Tumors[14]
Papilloma[15] Squamous cell papilloma
  • HPV 6 and 11
  • Men
  • Median age of diagnosis is 54 years
  • Endobronchial
  • Cauliflower-like lesions
  • Tan-white soft to semifirm protrutions
  • Loose fibrovascular core
  • Stratified squamous epithelium
  • Acanthosis
  • Binucleate forms and perinuclear halos
  • Koilocytosis
  • N/A
  • Well circumscribed
  • Homogenous
  • Non-calcified
  • Solitary mass
  • N/A
Glandular papilloma
  • Rare
  • Mean age of diagnosis is 68 years
  • Endobronchial
  • White to tan endobronchial polyps that measure from 0.7-1.5 cm
  • N/A
  • Well circumscribed
  • Homogenous
  • Non-calcified
  • Solitary mass
  • N/A
Adenoma[16] Alveolar adenoma
  • Mean age of diagnosis is 53 years
  • Female predominance
  • All lung lobes
  • Lower lobes
  • Hilar
  • 0.7-6.0 cm
  • Well demarcated smooth
  • Lobulated, multicystic
  • Soft to firm
  • Pale yellow to tan cut surfaces
  • Well circumscribed
  • Homogenous
  • Non-calcified
  • Solitary mass
  • N/A
Papillary adenoma[17]
  • Mean age of diagnosis is 32 years
  • Male predominance
  • Bronchioloalveolar cell
  • No lobar predilection
  • Involves alveolar parenchyma
  • Well defined
  • Encapsulated
  • Soft, spongy to firm mass
  • Granular gray white/ brown
  • 1.0- 4.0 cm
  • Incidental finding
  • N/A
Mucinous cystadenoma
  • No sex predilection
  • Mean age of diagnosis is 52 years
  • Central
  • White-pink to tan
  • Smooth and shiny tumors
  • Gelatinous mucoid solid core
  • 0.7-7.5 cm
  • Numerous mucin-filled cystic spaces
  • Non-dilated microacini, glands, tubules and papillae
  • Coin lesion
  • Air-meniscus sign
  • N/A
Malignant Lung Tumors[18]
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Squamous cell carcinoma (SCC)[19] Papillary
  • Epithelial cells
  • Central
  • Exophytic
  • Intra-epithelial
  • Without invasion
Clear cell
Basaloid
  • Peripheral palisading of nuclei.
  • Poor differentiation
Small cell carcinoma[20]
  • Bronchial precursor cell
  • Peripheral
  • White-tan, soft, friable perihilar masses
  • Extensive necrosis
  • 5% peripheral coin lesions
  • Sheet-like growth
  • Nesting
  • Trabeculae
  • Peripheral palisading
  • Rosette formation
  • High mitotic rate
  • Bone marrow
  • Liver
Adenocarcinoma[21][22][23] Acinar adenocarcinoma
  • Columnar cells of bronchioles
  • Peripheral
  • Single or multiple lesions
  • Different in size
  • Peripheral distribution
  • Gray-white central fibrosis
  • Pleural puckering
  • Anthracotic pigmentation
  • Lobulated or ill defined edges
  • Irregular-shaped glands
  • Malignant cells:
    • Hyperchromatic nuclei
    • Fibroblastic stroma
  • Peripheral nodules under 4.0 cm in size
  • Central location as a hilar or perihilar mass
  • Rarely show cavitations.
  • Hilar adenopathy
  • Adenocarcinomas account for the majority of small peripheral cancers identified radiologically.
Aerogenous spread is characteristic
  • Brain
  • Bone
  • Adrenal glands
  • Liver
  • Kidney
  • Gastrointestinal Tract
Papillary adenocarcinoma
Bronchio-alveolar carcinoma Non-mucinous
Mucinous
  • Low grade differentiation
  • Composed of:
    • Tall columnar cells
    • Basal nuclei
    • Pale cytoplasm resembling goblet cells
    • Varying amounts of cytoplasmic mucin
  • Cytologic atypia
Mixed non-mucinous and mucinous or indeterminate
  • Mixed type of cells
  • Low to high grade differentiated cells.
Solid adenocarcinoma with mucin production Fetal adenocarcinoma
Mucinous (“colloid”) carcinoma
Mucinous cystadenocarcinoma
Signet ring adenocarcinoma
  • Focal
  • Cells with nuclei displaced to sides
  • Components of other cells are present.
Clear cell adenocarcinoma
  • Clear cells with no nuclei
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Large cell carcinoma[24] Basaloid large cell carcinoma of the lung
  • Approximately 10% of lung cancers
  • Smoking
  • Soft, pink-tan tumor
  • Invasive growth pattern
  • Peripheral palisading
  • Small, monomorphic, cuboidal fusiform
  • Large, peripheral masses
Clear cell carcinoma of the lung
Lymphoepithelioma-like carcinoma of the lung
Large-cell lung carcinoma with rhabdoid phenotype
Mixed type
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Sarcomatoid carcinoma[25] Carcinosarcoma
  • Central or peripheral
  • Upper lobes
  • No specific imaging features 
Spindle cell carcinoma
  • Only spindle shaped tumor cells
  • Lymphoplasmacytic infiltrates
Giant cell carcinoma
Pleomorphic carcinoma
Pulmonary blastoma
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Carcinoid tumor[26] Typical carcinoid

Atypical carcinoid

  • Most common in males
  • Mean age of diagnosis 45
  • Atypical carcinoid is more commonly peripheral
  • Firm, well demarcated, tan to yellow tumors
  • Uniform polygonal cells
  • Nuclear atypia
  • Pleomorphism
  • The most common patterns are the organoid and trabecular
  • Highly vascularized fibrovascular stroma
  • Focal necrosis
Salivary gland tumors[27] Mucoepidermoid carcinoma
  • Most patients presents in the third and fourth decade
  • Constitutes of less than 1% tumor
  • No association with cigarette smoking or other risk factors
  • Primitive cells of tracheobronchial origin
  • Bronchial glands
  • Ranging in size from 0.5-6 cm
  • Soft, polypoid, and pink-tan in colour
  • High-grade lesions are infiltrative
  • Well-circumscribed oval or lobulated mass
  • Calcifications
  • Post-obstructive pneumonic infiltrates
Adenoid cystic carcinoma
  • Constitutes less than 1% of all lung tumors
  • Most commonly seen in fourth and fifth decades of life
  • Primitive cells of tracheobronchial origin
  • Gray-white or tan polypoid lesions
  • Size ranges from 1–4 cm
  • Infiltrative margins
  • Invades other cell layers
  • Heterogeneous cellularity
  • Cribriform pattern
  • Perineural invasion
  • Well circumscribed
  • Nodule
Epithelial-myoepithelial carcinoma
  • Age ranges from 33 to 71 years
  • No association with smoking
  • Endobronchial
  • Solid to gelatinous in texture
  • White to gray in colour
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Preinvasive lesions[28] Squamous carcinoma in situ
  • Most commonly seen in fifth or sixth decades
  • Mostly seen in women
  • Basal cells of squamous epithelium
  • Focal or multi-focal plaque-like greyish lesions
  • Nonspecific erythema
  • Even nodular or polypoid lesions
  • Micropapillomatosis
  • Cauliflower like
  • Mosaic pattern
Atypical adenomatous hyperplasia
  • Multiple grey to yellow foci
  • 1mm to 10mm in size
  • Typically not visualized on radiographs
  • Small non-solid nodules
  • Ground-glass opacity
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
  • Endobronchial
  • Early lesions are:
    • Small, gray-white nodules
    • Resembling ‘miliary bodies’
  • Larger carcinoid tumors are:
    • Firm
    • Homogeneous
    • Well-defined
    • Grey or yellow-white masses
  • Mosaic pattern of air trapping
  • Sometimes with nodules
  • Thickened bronchial and bronchiolar walls
Variants of lung carcinoma Risk Factors/Epidemiology Pleuripotent cell Topography Gross Histology Immunohistochemistry Imaging Metastasis
Mesenchymal tumors[29] Epithelioid haemangioendothelioma / Angiosarcoma
  • Caucasian
  • 80% are women
  • Endothelial cells
  • 0.3-2.0 cm circumscribed mass
  • Gray-white or gray-tan firm tissue
  • Yellow flecks
  • Central calcifications
  • Cut surface has a cartilaginous consistency
Pleuropulmonary blastoma
  • Most common in children
  • Median age of diagnosis is 2 years
  • Purely cystic
  • Thin-walled
  • Rarely solid
  • Firm to gelatinous
  • Upto 15 cm
  • Unilateral
  • Localized airfilled cysts
  • Septal thickening or an intracystic mass
Chondroma
  • Young women
  • Capsulated lobules
  • Hypocellular
  • Features of malignancy are absent
  • N/A
  • Multiple
  • Well circumscribed lesions
  • “Pop-corn” calcifications
Congenital peribronchial myofibroblastic tumor
  • Along the bronchi
  • 5-10 cm
  • Well-circumscribed
  • Non-encapsulated
  • Smooth or multinodular surface
  • The cut surface has a tann-grey to yellow-tan fleshy appearance
  • Hemorrhage
  • Necrosis
  • Well circumscribed
  • Opaque hemithorax
  • Heterogeneous mass
  • Rare
Diffuse pulmonary lymphangiomatosis
  • Children
  • Young adults of both sexes
  • Prominence of the bronchovascular bundles along
  • Anastomosing endothelial-lined cells along lymphatic routes
  • Increased interstitial markings
  • Skin
  • Bone
Inflammatory myofibroblastic tumor
  • Localized to bronchi
  • Solitary
  • Round rubbery masses
  • Yellowish-gray discoloration
  • Average size of 3.0 cm
  • Non-encapculated
  • Calcifications
  • No local invasion
  • Solitary mass
  • Regular borders
  • Spiculated appearance
  • Accompanied by
  • Rare
Pulmonary artery sarcoma
  • Mucoid or gelatinous clots filling vascular lumens
  • The cut surface may show
    • Firm fibrotic areas
    • Bony/gritty or chondromyxoid foci
    • Hemorrhage and necrosis are common in high-grade tumors
  • Spindle cells in
    • A myxoid background
    • Collagenized stroma
    • Recanalized thrombi
Pulmonary vein sarcoma
  • Most common in women
  • Mean age of diagnosis is 49
  • Fleshy-tan tumor
  • Can occlude the lumen of the involved vessel
  • 3.0- 20.0 cm
  • Invasion of wall of the vein
  • N/A

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