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

2. 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.

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

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

5. 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

6. 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

7. 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

9. 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

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

11. 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

12. 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)

13. 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

14. 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

15. 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

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

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

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

20. COMPARISON

21. 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  

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

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

24. 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

25. THANK YOU FOR
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