Pancoast (superior sulcus) tumour — when shoulder pain is the first sign

A Pancoast tumour, also called a superior sulcus tumour, is a lung cancer that grows at the very top (apex) of the lung. Because of where it sits, it tends to involve nearby structures — the chest wall, ribs, the nerves of the brachial plexus and sometimes the sympathetic nerves — rather than causing the usual lung symptoms. Most Pancoast tumours are non-small cell lung cancers. They are uncommon, but recognising them early matters because shoulder and arm pain, not cough, is often the first sign.

The most common early symptom is pain in the shoulder, shoulder blade or upper back, which can spread down the inner arm and into the hand. As the tumour grows it may cause weakness, numbness or wasting of the hand muscles. If it affects the sympathetic nerves it can cause Horner's syndrome — a drooping eyelid, a small pupil and reduced sweating on one side of the face. Typical lung symptoms like cough or breathlessness are often absent early on, which is why these tumours can be missed.

Pancoast syndrome is the cluster of symptoms caused by a tumour at the lung apex pressing on nearby nerves and tissues. It classically includes shoulder and arm pain, weakness or wasting of the hand, and Horner's syndrome (drooping eyelid, small pupil, reduced facial sweating on one side). The same syndrome can occasionally be caused by other conditions, so a scan and, where needed, a biopsy are used to confirm the cause before any treatment is planned.

Because the first symptom is usually shoulder or arm pain rather than a cough, a Pancoast tumour is frequently treated at first as a frozen shoulder, muscle strain or trapped nerve. People may have physiotherapy or painkillers for weeks before a chest scan is done. Pain that does not settle with rest or physiotherapy — especially in someone who smokes or used to smoke, or when it comes with hand weakness or a drooping eyelid — should prompt a chest X-ray or CT.

Diagnosis usually begins with a chest X-ray and then a CT scan, which shows the tumour at the lung apex and how far it reaches into the chest wall. An MRI is often added because it shows the nerves, blood vessels and spine more clearly, which is important for planning treatment. A biopsy confirms the type of cancer, and the sample is tested for gene changes that guide therapy. A PET-CT checks whether the cancer has spread. At CION, all findings are reviewed by a multidisciplinary tumour board.

Treatment depends on the stage and whether the tumour can be removed. For many patients with disease that has not spread, the standard approach is chemotherapy and radiation given together first, followed by surgery to remove the tumour and affected chest wall. When surgery is not suitable, chemoradiation, targeted therapy or immunotherapy may be used, guided by molecular testing. Because the area is anatomically complex, a Pancoast tumour is best managed by a team of medical, surgical and radiation oncologists working together.

A Pancoast tumour that is found before it has spread can often be treated with the aim of long-term control, usually through chemoradiation followed by surgery. The outlook depends on the stage at diagnosis, how completely the tumour can be removed and the patient's overall health. This is why early recognition of shoulder and arm pain matters. We cannot promise an outcome for any individual, but a tumour-board plan gives each patient the most appropriate, evidence-based treatment for their situation.

Yes. CION Cancer Clinics evaluates and treats Pancoast (superior sulcus) tumours with a multidisciplinary team of medical, surgical and radiation oncologists. We offer a free first consultation and a written second opinion. You can bring existing scans and reports, and every case is discussed by a tumour board before a plan is agreed, so decisions are made by a team rather than a single doctor — with transparent costs and no unnecessary tests.