Hi, everybody.
It's Rishi Agrawal, and in this video, I want to take you back almost
a hundred years to talk about one of the seminal papers in radiology.
But let me set the stage a little bit.
The year 1892 and the son of a prominent Quaker family
just graduates from Friends Central High School.
I looked this place up in Google Maps, and it's still there.
It's a private high school in Philadelphia, Pennsylvania.
Now, he wants to go on to medical school, but both of his parents die unexpectedly
and he's forced to take a job as a bank teller for two years.
He then gets into the University of Pennsylvania med school.
And this is without doing any pre-med education in undergrad.
So basically, he goes straight from high school into med school.
Now, I'm not sure how common
that was back in the day, but today it's pretty unheard of.
So he must have been pretty smart.
After he
finished med school, he graduates and does his internship
at the same hospital, University Hospital in Philadelphia.
And then he gets a job as assistant professor
of surgery in the year 1900.
A couple of years later, the head of the Department of Radiology retires.
A guy named Dr. Leonard.
And the chief of surgery, Dr.
White, asks the young surgeon to take over the new job as the head of radiology.
So this young surgeon takes on the job of head of radiology in 1902
and he really flourishes.
In 1911 he becomes the first full professor
of radiology apparently in the whole country at the time.
He goes on to many more accolades.
He's the president of the American Board of Radiology.
He becomes the president of the American College of Radiology.
But none of those things are the reason why
most of you know his name today.
The reason why most of us know his name today is because of two papers
that he wrote in 1924 and 1932.
And in those papers he talks about an unusual tumor
at the apex of the chest
that causes symptoms in the arm and in the eye.
And of course this man's name was Henry Pancoast.
And we call these tumors Pancoast tumors.
So let's take a look at those two papers.
Here's the
first paper which was published in JAMA in 1924.
It's entitled Importance
of Careful Roentgen Ray Investigations of Apical Chest Tumors.
And he writes: "There is an unusual but apparently infrequent
type of intra thoracic growth occurring in the apical region.
The neoplastic condition is unusual for the reason
that it produces referred nerve phenomena in the upper extremity
and when to these manifestations are added certain cervical sympathetic phenomena.
The symptomatology of spinal cord tumor is closely simulated."
So in other words, these patients have tumors
of the upper chest that simulate tumors of the spine.
And it causes symptoms in the arm like pain and numbness and tingling.
And it also causes symptoms in the eye, specifically Horner's syndrome.
Now, Pancoast doesn't use the term Horner's syndrome in this paper,
but he does in the subsequent paper.
Remember, Horner's syndrome is due to involvement
of the sympathetic chain on one side, and it causes meiosis,
which is contraction of the pupil, ptosis, which is depression
of the superior eyelid,
and lack of sweating on one side of the face, that's called anhydrosis.
In this
paper, Pancoast goes over five patient cases.
Let's take a look at the first one.
This is a man age 52, and his chief complaint was "intense,
burning pain high in the left axilla, extending down the arm.
And on admission, there was a contracted left pupil, enophthalmos and a narrowing
of the palpebral fissure." Enophthalmos is when the eye sinks into the socket.
And it's something that you can also see in patients with Horner's syndrome,
although it's not as common as those three other things.
Narrowing of the palpebrail fissure is usually due
to depression of the eyelid.
"The patient brought with him some films of the spine
which were said to have been regarded as negative.
And in this we concurred." That's really interesting to me
because he's very candid about missing this finding on the initial study.
But then he also writes "It's important to note, however, that
the films were very dense." So already radiologists
back in the 1920s were hedging based on the quality of the films.
A little further down, it says "Roentgen-ray examination
was made five days later and we discovered a shadow in the extreme
left apex and destruction of the posterior portions of the left, second
and third ribs and adjacent corresponding transverse processes."
And then he says "a 50 mg radium tube was implanted in the growth
and seven needles around the periphery for 19 hours." So he made the diagnosis.
The patient had surgery and then he also implanted
radiation tubes in order to treat the tumor.
The pathology report says that it was an endothelial carcinoma
of the pleura, which is not really a term that we use today.
But I think he was talking about a hemangioendothelioma
of the pleura which is a pretty rare tumor.
Let's take a look at the patient images.
So unfortunately, the images are pretty bad.
And I think part of that has to do with it being reproduced in a journal.
But I would really like to see what these actually look like in real life.
So note that this is flipped.
This image is not how we normally look at images
with the right being on the left and the left being on the right.
In this case, the patient's right is over here and the patient's left is over here.
And you can see that in this area, there's an asymmetric opacity
and you lose the definition of the second and third ribs
because they're being eroded by tumor.
I want to draw your attention to another part
of this paper that I thought was really funny, and that's down
in case 4 where Pancoast writes about "a man, aged 61,
who was referred to me in April 1920 for examination for possible
cervical rib." "There was no cervical rib.
But I called attention incidentally to a circumscribed
area of increased density in the right apical region.
Evidently this portion of my report was not taken seriously."
So you can tell that Pancoast was salty about this interaction
and he doesn't write more about it.
But I would really love to know what actually happened there.
Did the primary care physician see the report
and just dismiss the findings, or did he not look at the report at all?
I don't know.
And that actually brings up a good point
which is a problem that happens to us even today in modern radiology.
We make recommendations and sometimes those recommendations aren't
carried out by the primary care physician.
But I thought that that was funny that he was dealing with that back in 1924.
Now let me show you a couple of aspects of the second paper.
So the second paper was published in 1932.
It was also in JAMA.
The title of the paper was "Superior Pulmonary
Sulcus Tumor.--tumor characterized by pain, Horner's syndrome,
destruction of bone and atrophy of hand muscles."
And in the third paragraph
he writes, "It has been found advisable to discard the name of apical chest tumor
as a designation for this growth because it has proved to be confusing
and has permitted the inclusion of other more common tumors
in the upper part of the thorax.
The name of superior pulmonary sulcus tumor has been given to it
because this term implies its approximate location
and a lack of origin from the lung, pleura, ribs or mediastinum.
It is possible that this new designation may be changed again
with a better knowledge of the histopathology of the growth."
Now, he was right about that second part because we don't really use the term
superior pulmonary sulcus tumor anymore.
That's sort of an out of date term.
And what he got wrong about this was he ascribed these tumors
to something outside of the lung, pleura, ribs or mediastinum.
He thought it was something separate from those areas
when in fact we know that most of the tumors that cause
these symptoms in the arm and in the eye are actually from primary lung tumors.
And the way
we describe these tumors now, instead of saying superior
pulmonary sulcus tumor, we talk about the origin of the tumor.
So a lung cancer at the lung apex or a plural tumor at the apex of the
right or left hemithorax, we don't really use that term.
superior pulmonary sulcus, tumor anymore.
In this second paper, Pancoast puts forth
a hypothesis that these tumors are coming from
embryonal epithelial rests which turns out to not be the case.
And actually, he was a little bit more accurate in his first paper
because in his first paper, one of the things he that he wrote
was, "I do not wish to imply that diffuse infiltrating
endothelioma of the pleura is the only growth in the apical region
that will produce the same symptom complex, including cervical sympathetic
paralysis, as in the first three cases reported.
The following case may serve to prove that such a contention is not correct."
So actually in the first paper he's leaving open the possibility
that tumors of multiple different origins can cause the same symptoms,
whereas in the second paper he ascribes them specifically
to these embryonal cell tumors, which is incorrect.
So that's probably the biggest thing that he got wrong with these two papers.
But he got a couple of huge things, right.
And the first is just a mode of thinking
about the diagnosis through the lens of anatomy and radiology.
So a patient comes with these symptoms, then he knows that
he should be looking at the apex because the tumor can invade the brachial
plexus causing arm symptoms, the tumor can invade the sympathetic chain
causing the ocular symptoms.
So he knows based on the patient's symptoms
and his knowledge of anatomy, where to look on the radiologic study.
And as radiologists, we use that mode of thinking
all the time.
So if a patient has a unilateral vocal cord paralysis, for example,
I know where the recurrent laryngeal nerve runs
and I'm going to be looking in those places to look for pathology.
So that is really elegantly described in these two papers.
The second big thing that Pancoast really got right here
was that you have to look at everything.
So in the conclusion section of his first paper,
he wrote that "Roentgen ray examinations of the shoulder alone
before the appearance of eye manifestations may fail to reveal
such a growth and a wider area should be included in obscure cases.
In Roentgen-ray examinations of the spine and for cervical ribs,
the film should be carefully studied for any increased density
in the apex of the lung or for erosion
of the upper ribs or adjacent vertebra."
So remember that these patients came for suspected tumors of the spine,
and he found that
the issue was not the spine, but these tumors in the apex of the chest.
So you have to really look at everything, not just the thing
that the clinician wants you to rule in or out.
And that's one of the things that we teach all residents when they first start
that you have to look at the corners of the film.
You have to look at the scout images on your CTs.
You have to look at the scout images on your MRIs so that you don't miss
anything that might be very, very important for the patient.
So I think he really
elaborated that well with these two papers.
All right. Well, that's it for this video.
If you have any questions about this topic or you have something you want to add,
leave them in the comments below.
Also, I'm going to link to the two papers in the description below,
so be sure to check those out. Thanks.