An apical lung cancer that invades the chest wall: MRI shows the relation to the brachial plexus (first thoracic root), subclavian vessels, vertebral bodies and neural foramina — the anatomy that decides resectability.
Orient first
- Presents with shoulder and arm pain (C8 and first thoracic roots), Horner syndrome.
- Apical pleural thickening on a radiograph may be the only clue.
- Involvement of the brachial plexus above the first thoracic root, > 50% of a vertebral body, or the oesophagus/trachea limits resection (verify).
Acquire the study
- Coronal and sagittal T1, T2 fat-saturated, post-gadolinium fat-saturated T1 of the thoracic inlet.
The manoeuvre
- Sagittal T1: fat plane around the brachial plexus trunks and the subclavian artery.
- Coronal: first thoracic and C8 nerve roots; extension above the first rib.
- Vertebral body and neural foramen invasion on axial and sagittal images.
- Chest wall and rib invasion.
What confirms it
- Histology with the local extent mapped on MRI.
What licenses you to exclude it
- Symmetric smooth apical caps without a mass or bone destruction are benign.
The classic misread
- Calling apical pleural thickening from TB scarring a Pancoast tumour — look for a mass and enhancement.