Pancoast tumor - what an osteopath should remember

An osteopath always needs to be aware of medical conditions that mimic musculo-skeletal ones so as not to miss a problem that requires a referral to another discipline. Most osteopaths are familiar with treating musculo-skeletal pain conditions that cause pain starting in the lower cervical or upper dorsal spine with pain that radiates into the shoulder, scapula, down the arm and into the hand. These kind of symptoms could very easily be justified as compression of the lower cervical nerve roots C7-C8 due to narrowing of the zygo-apophyseal joints at the relative level. It could also be justified as thoracic outlet syndrome or a another shoulder condition.

It may however be worth the osteopath considering the possibility of a Pancoast tumor when faced with such a symptom picture. A Pancoast tumor is an extrathoracic tumor of the lung, plaquelike, located in the upper apex of either lung usually found in smokers. It is the location of the tumor and not the pathophysiological changes in the lung tissue that result in the symptom picture, and so one rarely sees lung symptoms in this condition. Rather, the symptoms are the result of the tumor invading adjoining tissue in the confines of the thoracic inlet such as the intercostal nerves, the lower roots of the brachial plexus, the stellate ganglion and the sympathetic chain.

The patient will most likely complain to the osteopath about pain felt locally in the shoulder and down the medial border of the scapula, not an uncommon complaint in any osteopathic clinic! Due to the invasion of the tumor into the lower roots of the brachial plexus (C8) and upper thoracic trunk (T1, T2), the patient may also complain of pain radiating down the ulnar distribution of arm to the elbow (T1) and ultimately to the ulnar surface of the forearm and to the small and ring fingers of the hand (C8). The osteopath should examine the patient's hand muscles checking for weakness and atrophy, reflexes may show a reduced or absent triceps reflex on the affected side. Since the tumor may also involve the cervical sympathetic ganglion and stellate ganglion, sympathetic involvement leads to ispilateral Horner's syndrome (hemianhydrosis, enophthalmos, ptosis and miosis) on the affected side of the face. If the tumor invades the recurrent laryngeal nerve there may be hoarsness and a bovine cough associated with the symptoms.

The patient is often in extreme pain with postural change creating little relief. The patient may tell the osteopath that other than supporting the elbow of the painful arm with the unaffected hand in order to take the tension off the painful area there are not many postural positions that help. The patient will most likely be taking narcotics for relief.
After reading this the osteopath should begin to see the overlap between a Pancoast tumor and any musculo-skeletal condition causing similar symtoms. However, unlike an ordinary neck-shoulder condition or nerve root irritation the osteopath may discover on questioning that the patient also experiences malaise, fever, weight loss and fatigue emphasising the importance of a comprehensive osteopathic case history.


A Pancoast tumor is just one example of a life-threatening pathalogical condition that mimics a musculo-skeletal one. The osteopath needs to be fully aware of these conditions in order not to make the mistake of treating the condition and potentially delaying the appropriate treatment
http://www.osteopath.co.il/
http://www.osteopath.co.il/home-eng.php