Superior sulcus tumor with vertebral invasion following initial diagnosis of cavitary lung disease: a case report

Introduction

Pancoast tumors, or superior sulcus tumors, are a distinct subset of non-small cell lung cancer characterized by early invasion of critical structures at the thoracic inlet. Although they account for less than 5% of bronchogenic carcinomas, they are, by definition, locally advanced T3 or T4 lesions (1). Their anatomic location places the brachial plexus, subclavian vessels, stellate ganglion, vertebral bodies, and upper ribs at significant risk of involvement (2). Extensive brachial plexus invasion remains a contraindication to surgical resection due to poor outcomes and high rates of incomplete resection. While sacrifice of the T1 nerve root is generally tolerated, involvement of the C8 root or the lower trunk of the brachial plexus results in substantial functional impairment and must be carefully considered (3).

Advances in multimodality therapy have improved outcomes, with induction chemoradiotherapy followed by surgical resection representing the standard approach in appropriately selected patients (3). Complete resection remains the most important determinant of long-term survival (4,5). Vertebral and major vascular involvement, once considered unresectable, can now be managed surgically with acceptable outcomes when an R0 resection is achieved (3). Multidisciplinary approaches incorporating thoracic and spine surgery have enabled R0 resection rates approaching 85% to 94% in selected patients (6). Despite this progress, perioperative morbidity remains high, exceeding 50%, with early mortality ranging from 3% to 7% (4,5,7).

Cavitary lung lesions often prompt evaluation for infectious etiologies such as tuberculosis, pulmonary abscess, or nontuberculous mycobacterial disease. However, necrotic lung malignancies may present with similar imaging features, creating diagnostic uncertainty, particularly when infection and malignancy coexist (8). Consequently, infectious and inflammatory processes may obscure or delay recognition of underlying malignancy. Both infectious cavitary lung disease and superior sulcus tumors may present with constitutional symptoms, chronic cough, chest or shoulder pain, weight loss, and nonspecific inflammatory imaging findings, creating substantial diagnostic overlap.

We present a complex case of right upper lobe (RUL) adenocarcinoma initially managed as a cavitary infectious process with documented nontuberculous mycobacterial infection, ultimately diagnosed as a locally advanced superior sulcus tumor with vertebral and foraminal invasion. This case underscores the importance of maintaining diagnostic vigilance and multidisciplinary evaluation when persistent cavitary apical lesions evolve despite antimicrobial therapy. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0121/rc).

Case presentation

A 48-year-old woman with a 15.5-pack-year smoking history presented with a presumed RUL pulmonary abscess after several months of progressive respiratory symptoms, including persistent cough, fatigue, anorexia, and 20-pound weight loss, followed by acute onset of right upper back pain radiating to the chest and neck. Computed tomography (CT) demonstrated an 8.9 cm × 6.2 cm × 5.6 cm complex cavitary lesion in the RUL with air-fluid levels, associated satellite cavitation, and hilar lymphadenopathy (Figure 1). Given the combination of constitutional symptoms, smoking history, and interval growth, both infectious and malignant etiologies were considered. Differential diagnoses included pulmonary abscess, tuberculosis, fungal infection, and less likely cavitary malignancy. Broad-spectrum intravenous antibiotics were initiated. Infectious evaluation demonstrated a positive pneumococcal urinary antigen, while blood cultures remained negative, QuantiFERON-TB Gold and Mycobacterium tuberculosis polymerase chain reaction testing were negative, and no evidence of active tuberculosis was identified. The patient improved clinically with antimicrobial therapy. Subsequent microbiologic workup identified Mycobacterium chimaera, and the patient was treated with multidrug antimycobacterial therapy including azithromycin, ethambutol, and rifampin. Although imaging demonstrated partial interval improvement, the lesion persisted with ongoing cavitation, progressive constitutional symptoms, and limited overall radiographic resolution over several months, prompting repeat diagnostic evaluation and tissue sampling. Endobronchial ultrasound-guided biopsy demonstrated adenocarcinoma of the RUL, with negative mediastinal lymph nodes. Staging positron emission tomography (PET)-CT demonstrated a fluorodeoxyglucose (FDG)-avid necrotic right apical mass with a maximum standardized uptake value (SUV) of approximately 30 and a suspicious right lower paratracheal lymph node (Figure 2). Brain magnetic resonance imaging (MRI) showed no metastases. Additional MRI demonstrated invasion of the T3 and T4 vertebral bodies with extension into the T3 to T4 neural foramen, without spinal canal involvement (Figure 3). The tumor was in close proximity to the right T1 nerve root and inferior trunk of the brachial plexus without evidence of spinal canal invasion or distant metastatic disease. Despite negative cytopathology, the FDG-avid 4R nodal station was considered suspicious, and the case was managed as a locally advanced superior sulcus tumor, clinically staged as cT4N0M0 (stage IIIA), with initial concern for possible N2 disease based on PET-CT findings.

Figure 1 Initial chest computed tomography demonstrating a complex cavitary lesion in the right upper lobe. (A,B) Axial, (C) sagittal, and (D) coronal views show an 8.9 cm × 6.2 cm × 5.6 cm thick-walled cavitary mass with internal air-fluid levels in the right upper lobe, with an adjacent smaller cavitary lesion laterally and surrounding reticular opacities. Prominent right hilar lymph nodes are also noted.

Figure 2 Subsequent staging CT and PET obtained following initial antimicrobial therapy, demonstrating interval evolution of the previously cavitary right upper lobe lesion into a malignant superior sulcus tumor. Axial (A) and coronal (B) contrast-enhanced CT images demonstrate interval transformation of the previously cavitary right upper lobe lesion into a large, centrally necrotic mass with irregular margins and loss of normal parenchymal architecture, concerning for malignancy. Axial (C) and coronal (D) PET-CT images show a large right upper lobe centrally necrotic mass measuring approximately 7 cm × 5 cm × 7.3 cm with intense peripheral fluorodeoxyglucose uptake (SUVmax ~30) and central photopenia consistent with necrosis. An enlarged FDG-avid right lower paratracheal (station 4R) lymph node is present (SUVmax ~14.8), while an additional right upper paratracheal lymph node demonstrates no abnormal FDG uptake. No other FDG-avid intraparenchymal lesions or nodal disease are identified. CT, computed tomography; FDG, fluorodeoxyglucose; PET, positron emission tomography; SUVmax, maximum standardized uptake value.

Figure 3 Magnetic resonance imaging demonstrating vertebral involvement by the right apical lesion. (A,B) Sagittal images show involvement of the anterior and right lateral aspects of the T3 and T4 vertebral bodies (yellow arrowheads) with cortical irregularity and erosion adjacent to the right upper lobe lesion.

The patient underwent induction chemoradiotherapy with carboplatin, pemetrexed, and 60 Gy of radiation. Repeat cultures prior to induction chemoradiotherapy were negative, although antimycobacterial therapy was continued throughout oncologic treatment. Restaging demonstrated a partial response. MRI of the thoracic spine showed a decrease in tumor size but persistent mediastinal invasion, osseous involvement of T3 and T4, and extension into the right T3 to T4 neural foramen and anterior epidural space without high-grade spinal canal stenosis or cord compression. PET-CT demonstrated a marked metabolic response, with reduction in SUVmax to 8.4, decrease in tumor size from 7.5 to 5.8 cm, and resolution of the previously FDG-avid lymph node (Figure 4). No new locoregional or distant disease was identified. Pulmonary function testing demonstrated a forced expiratory volume in one second (FEV1) of 2.27 L and FEV1/forced vital capacity (FVC) ratio of 71%, and stress echocardiography showed no inducible ischemia.

Figure 4 Radiographic and metabolic response following induction chemoradiotherapy. (A) Axial CT image demonstrates an interval decrease in the size of the right upper lobe mass, with a reduction in overall tumor bulk and persistence of central necrosis. (B) Axial, (C) sagittal, and (D) coronal PET-CT images show a marked reduction in FDG uptake within the lesion, with SUVmax decreasing from approximately 30 to 8.4, consistent with significant metabolic response. The mass measures approximately 5.8 cm × 3.6 cm, decreased from 7.5 cm on prior imaging. Resolution of the previously FDG-avid right lower paratracheal (station 4R) lymph node is noted, with no evidence of new locoregional or distant FDG-avid disease. CT, computed tomography; FDG, fluorodeoxyglucose; PET, positron emission tomography; SUVmax, maximum standardized uptake value.

Given the favorable response to induction therapy, absence of distant disease, and persistent but potentially resectable locally advanced tumor, the patient was reevaluated in a multidisciplinary setting including thoracic surgery and neurosurgery. A coordinated operative strategy was established for potential en bloc thoracic and spinal resection. Because of suspected mediastinal and airway proximity, perioperative airway contingency planning was performed in collaboration with the anesthesia team. High-frequency jet ventilation was prepared and readily available for potential airway management or cross-field ventilation. The operative approach was selected to optimize both oncologic exposure and access to the posterior thoracic spine, with readiness to extend the incision or modify the strategy intraoperatively based on resectability. Multidisciplinary coordination was essential for operative planning and management of potential airway, mediastinal, and spine-related challenges.

Flexible bronchoscopy demonstrated no endobronchial lesions or evidence of tracheal invasion. Esophagogastroduodenoscopy revealed external compression of the esophagus without mucosal invasion. The patient was then positioned in the left lateral decubitus position, and a right video-assisted thoracoscopic exploration was initially performed. Exploration of the pleural cavity revealed no pleural dissemination, and parietal pleural biopsies were negative for malignancy on frozen section, permitting continuation to definitive resection. A right posterolateral muscle-sparing thoracotomy was performed through the fourth intercostal space (Figure 5A,5B). Due to dense postradiation fibrosis and extensive apical adhesions, meticulous adhesiolysis was required (Figure 5C). Partial resection of the fourth and fifth ribs was performed to optimize exposure, and a vascularized fourth intercostal muscle flap was harvested for later bronchial stump reinforcement. Right upper lobectomy with en bloc wedge resection of the superior segment of the right lower lobe was performed, followed by mediastinal lymphadenectomy (Figure 5D). The tumor demonstrated direct invasion of the azygos vein and vagus nerve, both of which were divided to achieve oncologic resection. Because of vertebral involvement, the procedure proceeded to en bloc spinal resection with partial T3 corpectomy following T2–T3 and T3–T4 discectomies. The corpectomy defect was reconstructed with a structural cage packed with allograft, and lateral plate fixation was performed spanning T2 to T4 to achieve stabilization and arthrodesis (Figure 6). The involved thoracic nerve roots at T2, T3, and T4 were ligated to facilitate complete oncologic resection. Continuous intraoperative neuromonitoring remained stable throughout the procedure, confirming preserved neural pathway conductivity during spinal resection.

Figure 5 Intraoperative images demonstrating key steps of combined thoracic resection. (A) Skin incision for right posterolateral thoracotomy. (B) Right posterolateral thoracotomy performed through the fourth intercostal space with elevation of the scapula to optimize exposure of the right hemithorax. (C) Mobilized right upper lobe after adhesiolysis (yellow star), demonstrating dense posterior adherence to the thoracic spine (purple arrow). (D) Completion of right upper lobectomy (yellow star marks right upper lobe). The blue arrow indicates the right upper pulmonary vein stump, and the green arrow indicates the divided right upper lobe pulmonary arterial branches following sequential hilar dissection and vascular stapling. RLL, right lower lobe; RML, right middle lobe.

Figure 6 Intraoperative and postoperative imaging demonstrating spinal reconstruction following en bloc resection. (A) Intraoperative view of spinal reconstruction following partial T3 corpectomy, demonstrating placement of a structural vertebral body cage packed with allograft and lateral plate fixation spanning T2 to T4 (purple arrow). Instrumentation includes screw fixation at T2 and T4 to achieve stabilization and arthrodesis. (B,C) Intraoperative fluoroscopic images [anteroposterior (B) and lateral (C) views] confirming appropriate positioning and alignment of the vertebral body cage and lateral plate construct across T2 to T4 following corpectomy, with restoration of spinal alignment and adequate hardware placement. (D) Postoperative chest radiograph demonstrating expected postsurgical changes following corpectomy with T2 to T4 posterior fusion. The lungs are well expanded. Right apical and basilar chest tubes are in place. Small bilateral pleural effusions with adjacent atelectatic changes are noted.

Frozen section analysis confirmed negative margins. Total operative time was 614 minutes with estimated blood loss of 2 L. The patient remained hemodynamically stable throughout the procedure. She was extubated on postoperative day one and discharged on postoperative day six without complications. Final pathology demonstrated complete pathologic response with negative margins and no nodal involvement (ypT0N0) (Figure 7).

Figure 7 Pathologic evaluation of the resected specimen. (A) Gross specimen demonstrating a centrally necrotic mass (yellow star) within the right upper lobe. (B) Hematoxylin and eosin stain at 5× magnification showing a necrotic nodule on the left with adjacent viable lung parenchyma on the right. (C) TTF-1 immunohistochemical staining at 20× magnification demonstrating nuclear positivity in malignant cells. (D) CK7 immunohistochemical staining at 20× magnification demonstrating cytoplasmic positivity in malignant cells. CK7, cytokeratin 7; TTF-1, thyroid transcription factor 1.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Superior sulcus tumors represent a uniquely challenging subset of non-small cell lung cancer due to their apical location and propensity for early invasion into adjacent osseous, vascular, and neural structures (9). Despite advances in multimodality therapy, diagnosis and management remain complex, particularly in cases with atypical clinical and radiographic presentations that obscure the underlying malignancy (10).

This case illustrates several diagnostic and management challenges encountered during evaluation of cavitary apical lung lesions. The tumor initially presented as a cavitary pulmonary process with microbiologically confirmed nontuberculous mycobacterial infection, obscuring recognition of the underlying malignancy, ultimately contributing to delayed definitive diagnosis. Subsequent evaluation revealed a locally advanced superior sulcus adenocarcinoma with vertebral and foraminal invasion, requiring multidisciplinary assessment of resectability. Following a favorable response to induction chemoradiotherapy, the patient underwent successful en bloc resection incorporating both thoracic and spinal components, demonstrating the feasibility of aggressive surgical management in selected patients with complex locally advanced disease.

Cavitary pulmonary lesions pose a persistent diagnostic challenge. Although certain imaging features may raise suspicion for malignancy, substantial overlap exists between infectious abscesses and cavitating carcinomas (11). Cavity wall characteristics alone are insufficient to reliably distinguish benign from malignant etiologies, and partial radiographic improvement with antimicrobial therapy does not exclude an underlying neoplasm (10). Superior sulcus tumors typically present with symptoms related to invasion of the thoracic inlet rather than primary pulmonary complaints (3,6,9). Patients often develop shoulder and arm pain radiating along the ulnar distribution due to lower brachial plexus involvement and may exhibit neurologic deficits such as weakness or paresthesia (12). Involvement of sympathetic structures may produce Horner syndrome, while extension into vertebral bodies or ribs can cause persistent localized pain (5). However, our patient lacked many of the classic neurologic manifestations of Pancoast syndrome at presentation. This contributed to the atypical clinical picture and initial diagnostic uncertainty. Instead, the presentation was dominated by constitutional symptoms, chronic cough, cavitary pulmonary findings, and progressive weight loss, features that substantially overlapped with chronic infectious lung disease. Radiographically, these tumors appear as apical masses with adjacent bone destruction or soft tissue invasion (10). In contrast, this case initially mimicked an infectious pulmonary process. Cavitary and cystic pulmonary lesions remain diagnostically challenging because infectious etiologies such as abscesses, fungal disease, and nontuberculous mycobacterial infection may closely mimic primary or metastatic malignancy radiographically (11). Similarly, cavitary lung adenocarcinoma and cystic metastatic disease have been reported to present with nonspecific inflammatory and infectious-appearing radiographic findings, often delaying tissue diagnosis and definitive oncologic management (13). In this patient, isolation of nontuberculous mycobacteria supported an infectious diagnosis and guided initial management toward antimicrobial therapy. This presentation underscores how overlapping imaging findings and microbiologic confirmation can obscure an underlying malignancy. Only with further imaging and staging was the lesion recognized as a locally advanced superior sulcus tumor with vertebral and foraminal invasion.

This diagnostic complexity is amplified by the increasing prevalence of nontuberculous mycobacterial pulmonary disease, particularly among smokers and patients with structural lung disease (14). While prior reports describe coexistence of lung cancer and nontuberculous mycobacterial infection, malignancy is typically identified incidentally rather than being masked by infection (8,15). Additionally, the possibility of concomitant colonization rather than direct causative overlap should be considered, particularly in patients with structural lung abnormalities and smoking-related lung disease. In this case, microbiologic confirmation and initial radiographic improvement reinforced an infectious etiology and delayed tissue diagnosis. Progressive symptoms and evolving imaging findings ultimately prompted reevaluation and biopsy, illustrating a key cognitive pitfall in thoracic oncology: early diagnostic anchoring may delay recognition of malignancy in high-risk patients.

The management of superior sulcus tumors has evolved with induction chemoradiotherapy followed by surgical resection now representing the standard approach in selected patients (Table 1) (3,4,9). In the present case, induction chemoradiotherapy produced a marked metabolic and radiographic response, permitting successful en bloc thoracic and spinal resection despite vertebral involvement. Modern multidisciplinary approaches incorporating thoracic and spine surgery have expanded surgical candidacy in carefully selected patients with locally advanced disease (3,6,19,22,28-31). Unlike most previously reported superior sulcus tumor series summarized in Table 1, the present case was additionally characterized by an initial infection-mimicking cavitary presentation with microbiologically confirmed nontuberculous mycobacterial disease, contributing to diagnostic complexity.

Retrospective review of serial imaging suggested progressive local evolution of the cavitary lesion over time; however, the extent of vertebral and neural foraminal involvement became most clearly apparent on dedicated staging imaging and MRI. From a thoracic surgical perspective, persistent or progressively evolving apical cavitary lesions warrant careful reassessment even when an infectious etiology has been identified, particularly in patients with a smoking history, constitutional symptoms, persistent pain, or incomplete radiographic response to antimicrobial therapy. Dedicated evaluation of adjacent chest wall, vertebral, and neural foraminal structures on cross-sectional imaging may help identify occult locally advanced disease earlier in the diagnostic course. This case also highlights the importance of multidisciplinary reassessment when clinical progression appears disproportionate to the presumed infectious process.

Combined thoracic and spinal resections also present unique anesthetic challenges. Lung isolation is essential, yet difficult airway anatomy may complicate double-lumen tube placement. In this case, a markedly anterior glottis required multiple airway strategies before successful placement. Although rarely emphasized, airway complexity represents a meaningful contributor to perioperative risk in prolonged multidisciplinary procedures. Stable intraoperative neuromonitoring further reflects the technical coordination required for safe resection. Together, these considerations emphasize that successful management extends beyond surgical technique and relies on meticulous perioperative planning and interdisciplinary collaboration.

Conclusions

This case highlights the diagnostic and therapeutic complexity of superior sulcus tumors, particularly when presentation is confounded by coexisting infectious disease. Cavitary pulmonary lesions in high-risk patients require sustained diagnostic vigilance, as microbiologic confirmation may obscure an underlying malignancy. Multimodality therapy remains the cornerstone of management, with induction chemoradiotherapy enabling tumor downstaging and facilitating surgical resection in selected patients. Advances in combined thoracic and spinal surgical techniques have expanded resectability criteria, demonstrating that even tumors with vertebral involvement can be managed with curative intent when complete resection is achievable. Successful management requires careful preoperative staging, multidisciplinary coordination, and adaptability during perioperative planning. Persistent or progressively evolving cavitary apical lesions should prompt reassessment for underlying malignancy and careful evaluation for adjacent chest wall or vertebral invasion, even when an infectious etiology has been identified.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0121/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0121/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0121/coif). A.I.G. serves as an unpaid editorial board member of AME Case Reports from February 2025 to January 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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