TENSION PNEUMOTHORAX COMPLICATING PANCOAST TUMOR A PRESENTATION AT THE CMDA NATIONAL CONFERENCE BY Dr R. BAYO

BACKGROUND Pancoast tumor, or superior sulcus tumor, is a tumor of the pulmonary apex. It is a bronchogenic cancer located at the top end of the lung. It accounts for less than 5% of bronchogenic carcinomas.

Chest wall is involved through tissue contiguity The underlying pathology usually does not result in pneumothorax

OBJECTIVES To draw attention to an uncommon presentation of lung cancers To highlight a rare complication of Pancoast tumour And management of the complication

CASE PRESENTATION We present a 43yr old man with right upper back pain with progressive wasting and pain of the right upper limb of 4months duration He had no cough, chest pain or haemoptysis, but had significant weight loss

Examination revealed a young man, not pale, anicteric, afebrile RR was 26/min Had right apical flattening of the chest wall Bronchial breath sounds posteriorly in the apex on the right Vesicular breath sounds in other lung zones

Pulse – 84/min BP – 110/70mmHg Chest X-ray – Showed right upper lobe apical opacity, with irregular outline with features of subcutaneous emphysema Chest CT Scan showed a right isodense lesion filling up the right apical space

He was worked up for a right posterolateral thoracotomy He was intubated (DLET) in a supine position, while preparing to place him in a posterolateral position

Patients was noticed to develop haemodynamic instability (Tachycardia + Hypotension) A suspicion of incorrect intubation was entertained initially ETCO₂ was suggestive of tracheal intubation

Saturation (SPO₂) dropped to 80% Pulse rate at induction of anaesthesia which was 104/min rose to 164/min Percussion notes on the Right hemi-thorax was hyper-resonant

A right closed thoracostomy tube drain was inserted immediately SPO₂ post procedure rose to 100% Pulse dropped to 110/min He had a right posterolateral thoracotomy and debulking of tumour (R2 resection)

Intraoperative findings were: A Right lung mass located in the apex with chest wall involvement & vertebral extension Mass involving C7 – T4 vertebrae Mass involving lower distribution of the brachial plexus

DISCUSSION These tumours have the same biology to other lung tumours They spread into contiguous structures Complication ranges from 8 – 38% and it is constituted by the sum of complications of pulmonary parenchyma resection, chest wall & vascular/vertebral resection

It includes Atelectasis Pneumonia Prolonged ventilator support SVT Bleeding or clotted hemothorax Prolonged air leak Wound infection and dehiscence Broncho-pleural fistula Chylothorax Thrombosis of subclavian vein Myatrophies & muscular weakness

Pneumothorax is an uncommon complication of Pancoast tumors A search of the literature yielded no reported case

Tension Pneumothorax develops with the creation of a one way valve mechanism (30 – 97%) Air escapes into the pleura and is trapped

The ipsilateral lung collapses The trachea and mediastinum deviates to the contralateral side This causes cardio-respiratory compromise

COMPARISON

Should always be CLINICAL Should never be a radiographic diagnosis Death is the inevitable result if this vicious cycle is not interrupted Diagnosis Should always be CLINICAL Should never be a radiographic diagnosis If suspected - TREAT IMMEDIATELY  

TREATMENT Immediate placement of a 14G catheter into the second intercostal space at the midclavicular line . All patients require subsequent chest tube placement.

CONCLUSION Pneumothorax is a rare presentation of Pancoast tumor which should be anticipated and treated accordingly

REFERENCES Superior Sulcus (Pancoast) tumors: Current evidence on diagnosis and radical treatment J Thorac Dis 2013 Superior Pulmonary Sulcus Tumors and Pancoast Syndrome: N Engl J Of Med 1997 Sabiston & Spencer’s Surgery of the Chest

THANK YOU FOR LISTENING