Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report

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However, Pancoast tumors, a rare subset of non-small cell lung cancer (NSCLC), represent an uncommon clinical presentation. While the liver, bones, brain, and adrenal glands are the most frequent metastatic sites of lung cancer, gastrointestinal involvement, particularly colonic metastasis, is exceedingly rare. Herein, we present the case of a 61-year-old man diagnosed with Pancoast-Tobias syndrome, initially manifesting through colonic metastasis." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-420/v1", "name": "Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias..." } } ] } Home Browse Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Mensi A, Nesrine K, Bel Hadj Mabrouk E et al. Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :420 ( https://doi.org/10.12688/f1000research.163018.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] Asma Mensi 1 , Krifa Nesrine https://orcid.org/0009-0007-5089-3598 1 , Emna Bel Hadj Mabrouk https://orcid.org/0000-0003-2990-1876 1 , [...] Linda Bel Hadj 2 , Rim Makhlouf 3 , Shema Ayadi 1 , Leila Mouelhi 1 , Radhouane Debbeche 1 Asma Mensi 1 , Krifa Nesrine https://orcid.org/0009-0007-5089-3598 1 , [...] Emna Bel Hadj Mabrouk https://orcid.org/0000-0003-2990-1876 1 , Linda Bel Hadj 2 , Rim Makhlouf 3 , Shema Ayadi 1 , Leila Mouelhi 1 , Radhouane Debbeche 1 PUBLISHED 09 Apr 2025 Author details Author details 1 Gastroenterology department, Hopital Charles Nicolle, Tunis, Tunis, Tunisia 2 Pathology department, Hopital Charles Nicolle, Tunis, Tunis, Tunisia 3 Radiology department, Hopital Charles Nicolle, Tunis, Tunis, Tunisia Asma Mensi Roles: Conceptualization, Data Curation, Investigation, Resources, Supervision, Validation, Writing – Review & Editing Krifa Nesrine Roles: Conceptualization, Data Curation, Resources, Writing – Original Draft Preparation Emna Bel Hadj Mabrouk Roles: Supervision, Validation, Writing – Review & Editing Linda Bel Hadj Roles: Data Curation, Resources, Visualization Rim Makhlouf Roles: Data Curation, Resources, Visualization Shema Ayadi Roles: Supervision, Validation, Writing – Review & Editing Leila Mouelhi Roles: Supervision, Validation, Writing – Review & Editing Radhouane Debbeche Roles: Supervision, Validation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Oncology gateway. This article is included in the Rare diseases collection. Abstract Lung cancer remains one of the most prevalent malignancies worldwide, with a high mortality rate. However, Pancoast tumors, a rare subset of non-small cell lung cancer (NSCLC), represent an uncommon clinical presentation. While the liver, bones, brain, and adrenal glands are the most frequent metastatic sites of lung cancer, gastrointestinal involvement, particularly colonic metastasis, is exceedingly rare. Herein, we present the case of a 61-year-old man diagnosed with Pancoast-Tobias syndrome, initially manifesting through colonic metastasis. READ ALL READ LESS Keywords Lung Cancer, Pancoast-Tobias Syndrome, Colonic Metastasis, Non-Small Cell Lung Cancer. Corresponding Author(s) Krifa Nesrine ( [email protected] ) Close Corresponding author: Krifa Nesrine Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Mensi A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Mensi A, Nesrine K, Bel Hadj Mabrouk E et al. Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :420 ( https://doi.org/10.12688/f1000research.163018.1 ) First published: 09 Apr 2025, 14 :420 ( https://doi.org/10.12688/f1000research.163018.1 ) Latest published: 09 Apr 2025, 14 :420 ( https://doi.org/10.12688/f1000research.163018.1 ) Introduction Lung cancer is a prevalent malignant tumor with a high mortality rate, ranging from 18% to 23%. 1 Approximately half of lung cancer cases present with distant metastases at diagnosis, with mortality rates exceeding 50% in these patients. 2 The most common metastatic sites include the lungs, liver, bones, brain, and adrenal glands. 3 , 4 In contrast, colonic metastasis from lung cancer is exceptionally rare, 3 with an incidence ranging from 0.2% to 1.7%. 5 Among lung cancer subtypes, squamous cell carcinoma is the most frequently reported histological type associated with colonic metastasis, whereas adenocarcinoma rarely spreads to the colon or rectum. 6 Given its rarity, distinguishing primary colonic neoplasms from metastatic lung cancer remains challenging. Herein, we present a case of Pancoast-Tobias syndrome (PTS) initially manifesting as colonic metastasis and anemia, highlighting an unusual metastatic presentation of lung cancer. Case presentation A 61-year-old man with a history of chronic alcoholism and heavy smoking (60 pack-years) presented to our hospital with asthenia, anorexia, and significant weight loss, accompanied by anemia-related symptoms such as dyspnea and palpitations. He denied any gastrointestinal bleeding, digestive symptoms, or respiratory complaints. However, he reported back and right shoulder pain. On examination, mucocutaneous pallor was the primary clinical finding. Abdominal, cardiovascular, and pulmonary examinations were unremarkable, and no lymphadenopathy was detected. Laboratory tests revealed severe iron deficiency anemia (hemoglobin: 2 g/dL), while renal and liver function tests were within normal limits. The patient received blood transfusion and intravenous iron supplementation, leading to an improvement in hemoglobin and ferritin levels. An upper gastrointestinal endoscopy revealed no abnormalities, whereas lower gastrointestinal endoscopy identified a large ulcerated mass in the sigmoid colon. Histopathological examination confirmed a poorly differentiated adenocarcinoma ( Figure 1 ). Figure 1. Histologic examination of sigmoid biopsy (high magnification x40): ovoid cells with a large atypical nucleus and a moderately abundant eosinophilic cytoplasm. For tumor staging, a contrast-enhanced computed tomography (CT) scan of the chest, abdomen, and pelvis was performed. Coronal and axial contrast-enhanced thoracic CT scans (parenchymal and bone windows) revealed mediastinal lymphadenopathy and a left apical mass with heterogeneous enhancement. The lesion invaded the posterior arch of the second rib with lytic destruction and extended into the D1-D2 lateral foramen, showing proximity to the ipsilateral subclavian and vertebral arteries ( Figure 2 ). These findings were consistent with PTS. Figure 2. Coronal and axial contrast-enhanced thoracic CT scan: Parenchymal and bone windows demonstrate a left apical tissue process exhibiting heterogeneous enhancement (yellow star). It invades the posterior arch of the second rib with lytic lesions and extends towards the lateral foramen D1-D2 (blue arrow). The process shows close association with the ipsilateral subclavian and vertebral arteries (red arrow). Abdominal and pelvic CT scans demonstrated an irregular circumferential thickening of the sigmoid colon wall, suspicious for malignancy, along with perilesional lymphadenopathy ( Figure 3 ), an irregular right retroperitoneal nodule suggestive of carcinoma, and bilateral adrenal nodules concerning for metastatic disease. Figure 3. Contrast-enhanced abdominal CT scan: Irregular circumferential thickening of the sigmoid colon wall suggestive for malignancy. A percutaneous biopsy of the lung mass was performed, and histopathological analysis confirmed pulmonary adenocarcinoma with positive thyroid transcription factor-1 (TTF-1) staining ( Figure 4 ). Given the suspicion of lung carcinoma with colonic metastasis, immunohistochemical analysis of the colonic biopsy for TTF-1 was conducted and returned positive, confirming colonic metastasis of pulmonary adenocarcinoma ( Figure 5 ). Figure 4. Immunohistochemical analysis of lung cells: Tumor cells show intense nuclear staining for TTF-1 positivity. Figure 5. Immunohistochemical Staining of Colonic Biopsy: Diffuse and Intense Nuclear Positivity for TTF-1. The patient was enrolled in oncologic care and initiated on systemic chemotherapy. Discussion Pancoast-Tobias syndrome is a rare presentation of lung cancer, accounting for 3% to 5% of all cases. 7 Smoking is the primary risk factor, and the disease predominantly affects men in their sixth decade of life, 7 which aligns with our case, as the patient was a 61-year-old smoker. Clinically, this tumor subtype is characterized by shoulder and arm pain, as observed in our patient. Radiological findings typically include an upper lobe mass with pleural invasion and rib infiltration. The histological type in our case was adenocarcinoma, which is consistent with the literature, as adenocarcinoma is the most commonly reported cause of PTS. 8 Lung cancer is one of the most prevalent malignancies worldwide, with nearly half of cases presenting with distant metastases at diagnosis, regardless of the primary histological type. The most common metastatic sites include the brain, lungs, bones, liver, adrenal glands, and lymph nodes. 1 Our patient had bone, peritoneal, adrenal gland, and lymph node metastases. However, less common metastatic sites have also been reported in the literature. In this case, we focused on colonic metastasis, a rare manifestation of lung cancer. The incidence of colonic metastases is estimated at 12% in autopsy studies, whereas symptomatic cases are exceedingly rare (0.1%). 9 , 10 The reported incidence varies depending on the diagnostic method used (digestive endoscopy, surgical specimens, or autopsy). 11 Gastrointestinal metastases from lung cancer can manifest with anemia, gastrointestinal bleeding, or bowel obstruction. 12 – 16 In our patient, metastatic lung adenocarcinoma was revealed by iron deficiency anemia, a presentation similar to that reported by Vasa Jevremovic et al. in a 71-year-old female patient who presented with iron deficiency anemia. Digestive endoscopy confirmed adenocarcinoma in the transverse colon, and chest CT revealed a left upper lobe mass. The histological subtype was also adenocarcinoma. 15 A literature review of 18 cases of lung cancer with gastrointestinal metastases identified intestinal obstruction (5 cases) and anemia (4 cases) as the most frequent clinical presentations. Other symptoms included abdominal pain, weight loss, and intestinal perforation. The most common metastatic sites were the small bowel (9 cases) and the stomach (5 cases), while colonic metastases were observed in only two patients. Histologically, 10 patients had large cell carcinoma, while 8 had adenocarcinoma. 13 A more recent review of 34 cases of lung cancer with colonic metastases found that squamous cell carcinoma was the most common histological type, identified in 15 cases. Adenocarcinoma, as in our patient, accounted for one-third of cases, while large cell carcinoma and small cell carcinoma were less frequently observed. 14 In contrast, colorectal cancer frequently metastasizes to the lungs, 17 making it challenging to differentiate primary pulmonary cancer from metastatic colorectal cancer. For instance, Ana Cunha et al. reported a case of metastatic colorectal cancer presenting as a Pancoast tumor. 18 Immunohistochemical staining plays a crucial role in distinguishing primary tumors in such cases. Typically, primary lung cancer is positive for TTF-1, CK7, and CK20 markers. 19 In our patient, both colonic and lung biopsies tested positive for TTF-1, confirming the diagnosis of primary lung cancer with colonic metastasis. Conclusion This case report highlights a rare presentation of colonic metastasis revealing a Pancoast tumor. In patients presenting with both pulmonary and colonic tumors, a thorough evaluation of radiological features and histopathological findings, particularly immunohistochemical markers, is essential to accurately determine the primary site of malignancy. Ethical approval Ethical approval was not required for this study. Consent to publish Written informed consent for the publication of clinical details and/or images was obtained from the patient. Data availability No data are associated with this article. Acknowledgements No acknowledgements to declare. References 1. Sung H, Ferlay J, Siegel RL, et al. : Global cancer statistics 2020. CA Cancer J. Clin. 2021; 71 : 209–249. PubMed Abstract | Publisher Full Text 2. Kosciuszek ND, Noel P, Takabe K, et al. : Intraluminal Small Bowel Metastasis From Primary Lung Cancer. World. J. Oncol. 2022; 13 (6): 409–416. PubMed Abstract | Publisher Full Text | Free Full Text 3. Chaitanya Thandra K, Barsouk A, Saginala K, et al. : Epidemiology of lung cancer. Współczesna Onkol. 2021; 25 (1): 45–52. PubMed Abstract | Publisher Full Text | Free Full Text 4. Hu Y, Feit N, Huang Y, et al. : Gastrointestinal metastasis of primary lung cancer: An analysis of 366 cases. Oncol. Lett. 2018; 15 : 9766–9776. PubMed Abstract | Publisher Full Text 5. Lin L, Wang X, Tang C, et al. : Clinical Characteristics and Prognosis of Gastrointestinal Metastases in Solid Tumor Patients: A Retrospective Study and Review of Literatures. Anal. Cell. Pathol. 2019; 2019 : 1–7. PubMed Abstract | Publisher Full Text | Free Full Text 6. Badipatla KR, Yadavalli N, Vakde T, et al. : Lung cancer metastasis to the gastrointestinal system: An enigmatic occurrence. World J Gastrointest Oncol. 2017; 9 (3): 129–134. PubMed Abstract | Publisher Full Text | Free Full Text 7. Panagopoulos N, Leivaditis V, Koletsis E, et al. : Pancoast tumors: characteristics and preoperative assessment. J. Thorac. Dis. 2014; 6 (S1): S108–S115. PubMed Abstract | Publisher Full Text | Free Full Text 8. Wright CD, Moncure AC, Shepard JAO, et al. : Superior sulcus lungtumors. J. Thorac. Cardiovasc. Surg. 1987; 94 (1): 69–74. Publisher Full Text 9. Hsing CT, Kim HY, Lee JH, et al. : Gastrointestinal metastasis from a primary adenocarcinoma of the lung presenting with acute abdominal pain. Korean J. Gastroenterol. 2012; 59 (5): 382–385. PubMed Abstract | Publisher Full Text 10. Tamura T, Kurishima K, Nakazawa K, et al. : Specific organ metastases and survival in metastatic non-small-cell lung cancer. Mol Clin Oncol. 2015; 3 (1): 217–221. PubMed Abstract | Publisher Full Text | Free Full Text 11. Leidich RB: Small Bowel Perforation Secondary to Metastatic Lung Carcinoma. Ann. Surg. 1981; 193 (1): 67–69. PubMed Abstract | Publisher Full Text | Free Full Text 12. Shih-Chun C, Shih-Chiang H, Chun-Yi T, et al. : Non-small cell lung cancer with gastric metastasis and repeated gastrointestinal bleeding: A rare case report and literature review. Thorac Cancer. 2021; 12 (4): 560–563. PubMed Abstract | Publisher Full Text 13. Rossi G, Marchioni A, Romagnani E, et al. : Primary lung cancer presenting with gastrointestinal tract involvement: clinicopathologic and immunohistochemical features in a series of 18 consecutive cases. J. Thorac. Oncol. 2007; 2 (2): 115–120. PubMed Abstract | Publisher Full Text 14. Parker NA, McBride C, Forge J, et al. : Bowel obstruction caused by colonic metastasis of lung adenocarcinoma: a case report and literature review. World J. Surg. Oncol. 2019; 17 (1): 63. PubMed Abstract | Publisher Full Text | Free Full Text 15. Jevremovic V, Abboud A, Krauss S: Colonic Metastasis with Anemia Leading to a Diagnosis of Primary Lung Adenocarcinoma. Case Rep. Oncol. Med. 2016; 2016 : 1–4. PubMed Abstract | Publisher Full Text | Free Full Text 16. Choi SJ, Hong SK, Chae G, et al. : Solitary colonic metastasis from primary lung adenocarcinoma first presenting as intestinal obstruction: A case report. Medicine (Baltimore). 2019; 98 (3): e14063. PubMed Abstract | Publisher Full Text | Free Full Text 17. Roshandel G, Gasemi-Kabria F, Malekzadeh R: Colorectal cancers: epidemiology, risk factors and prevention. Cancers. 2024; 16 : 1530. PubMed Abstract | Publisher Full Text | Free Full Text 18. Cunha A, Quintela M, Costa C, et al. : Pancoast Tumor as the Initial Presentation of a Metastatic Colon Adenocarcinoma. Cureus. 2021; 13 (2): e13371. PubMed Abstract | Publisher Full Text 19. Ishikawa E, Nakaguro M, Nakamura M, et al. : Gastrointestinal tract metastasis of lung cancer: The PD-L1 expression and correlated clinicopathological variables. Pathol. Int. 2021; 71 (1): 33–41. PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 09 Apr 2025 ADD YOUR COMMENT Comment Author details Author details 1 Gastroenterology department, Hopital Charles Nicolle, Tunis, Tunis, Tunisia 2 Pathology department, Hopital Charles Nicolle, Tunis, Tunis, Tunisia 3 Radiology department, Hopital Charles Nicolle, Tunis, Tunis, Tunisia Asma Mensi Roles: Conceptualization, Data Curation, Investigation, Resources, Supervision, Validation, Writing – Review & Editing Krifa Nesrine Roles: Conceptualization, Data Curation, Resources, Writing – Original Draft Preparation Emna Bel Hadj Mabrouk Roles: Supervision, Validation, Writing – Review & Editing Linda Bel Hadj Roles: Data Curation, Resources, Visualization Rim Makhlouf Roles: Data Curation, Resources, Visualization Shema Ayadi Roles: Supervision, Validation, Writing – Review & Editing Leila Mouelhi Roles: Supervision, Validation, Writing – Review & Editing Radhouane Debbeche Roles: Supervision, Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 09 Apr 2025, 14:420 https://doi.org/10.12688/f1000research.163018.1 Copyright © 2025 Mensi A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Mensi A, Nesrine K, Bel Hadj Mabrouk E et al. Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :420 ( https://doi.org/10.12688/f1000research.163018.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 09 Apr 2025 Views 0 Cite How to cite this report: Lannagan T. Reviewer Report For: Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :420 ( https://doi.org/10.5256/f1000research.179309.r385982 ) The direct URL for this report is: https://f1000research.com/articles/14-420/v1#referee-response-385982 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Jun 2025 Tamsin Lannagan , SAiGENCI, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, Australia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.179309.r385982 This case study describes the diagnosis of Pancoast-Tobias syndrome with rare presentation of metastasis to the colon. Positive immunohistochemical staining of both lung and colonic tumour biopsies for TTF-1 is the basis for the conclusion "colonic metastasis of pulmonary adenocarcinoma". ... Continue reading READ ALL This case study describes the diagnosis of Pancoast-Tobias syndrome with rare presentation of metastasis to the colon. Positive immunohistochemical staining of both lung and colonic tumour biopsies for TTF-1 is the basis for the conclusion "colonic metastasis of pulmonary adenocarcinoma". This conclusion provides the significance of the case report; however, they have not satisfactorily excluded the possibility that this could be a rare case of a primary colorectal cancer that aberrantly expressed TTF-1. Studies from the 2010s have described rare cases such as this and have described the immunohistochemical staining that should be included of intestinal specific markers such as MUC2 to exclude this possibility (Dettmer at al, 2011 and Belalcazar et al, 2016, citations below). Completion of a larger panel of stains beyond TTF-1 is required before they can safely make their conclusion. The authors themselves state that "a thorough evaluation of...immunohistochemical markers, is essential to accurately determine the primary site of malignancy." Further, the import of the diagnosis was not discussed in relation to the impact on treatment or patient outcome, or how practitioners in the future should handle such cases, it is currently presented as though staining for TTF-1 is sufficient when it is not. It would be of interest to know if their diagnosis influenced treatment. Minor comments relate to the quality and description of the images shown. In general, the quality of immunohistochemical images is low, higher quality images should be obtained. Figures 1, 4 and 5 are lacking a scale bar. Figures 4 and 5 need the magnification in the legend. It would be helpful if in Figure 3 the thickened colon wall could be indicated along with the enlarged lymph node they refer to in the text. Reference 19 describes PDL1 expression, not TTF-1, CK7 or CK20 as described in the text. Please cite the publication that describes these stains or update the text to reflect that it discusses PD-L1. Additional references: ( refer to 1 and 2 ) Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly References 1. Matthias Dettmer, Tae Eun Kim, Chan Kwon Jung, Eun Sun Jung, Kyo Young Lee, Chang Suk Kang, Thyroid transcription factor-1 expression in colorectal adenocarcinomas. Pathology - Research and Practice. 2011. Volume 207;11:686-690. 2. Belalcazar A, Krishnamurti U, Shaib W. TTF-1 Expression in Rectal Adenocarcinoma: A Case Report and Review of the Literature. Case Rep Oncol. 2016 Nov 18;9(3):747-751. doi: 10.1159/000450973. PMID: 27990111; PMCID: PMC5156892. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Lung cancer, colorectal cancer, histology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Lannagan T. Reviewer Report For: Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :420 ( https://doi.org/10.5256/f1000research.179309.r385982 ) The direct URL for this report is: https://f1000research.com/articles/14-420/v1#referee-response-385982 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 09 Apr 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 09 Apr 25 read Tamsin Lannagan , The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, Australia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Lannagan T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Jun 2025 | for Version 1 Tamsin Lannagan , SAiGENCI, The University of Adelaide Faculty of Health and Medical Sciences, Adelaide, Australia 0 Views copyright © 2025 Lannagan T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This case study describes the diagnosis of Pancoast-Tobias syndrome with rare presentation of metastasis to the colon. Positive immunohistochemical staining of both lung and colonic tumour biopsies for TTF-1 is the basis for the conclusion "colonic metastasis of pulmonary adenocarcinoma". This conclusion provides the significance of the case report; however, they have not satisfactorily excluded the possibility that this could be a rare case of a primary colorectal cancer that aberrantly expressed TTF-1. Studies from the 2010s have described rare cases such as this and have described the immunohistochemical staining that should be included of intestinal specific markers such as MUC2 to exclude this possibility (Dettmer at al, 2011 and Belalcazar et al, 2016, citations below). Completion of a larger panel of stains beyond TTF-1 is required before they can safely make their conclusion. The authors themselves state that "a thorough evaluation of...immunohistochemical markers, is essential to accurately determine the primary site of malignancy." Further, the import of the diagnosis was not discussed in relation to the impact on treatment or patient outcome, or how practitioners in the future should handle such cases, it is currently presented as though staining for TTF-1 is sufficient when it is not. It would be of interest to know if their diagnosis influenced treatment. Minor comments relate to the quality and description of the images shown. In general, the quality of immunohistochemical images is low, higher quality images should be obtained. Figures 1, 4 and 5 are lacking a scale bar. Figures 4 and 5 need the magnification in the legend. It would be helpful if in Figure 3 the thickened colon wall could be indicated along with the enlarged lymph node they refer to in the text. Reference 19 describes PDL1 expression, not TTF-1, CK7 or CK20 as described in the text. Please cite the publication that describes these stains or update the text to reflect that it discusses PD-L1. Additional references: ( refer to 1 and 2 ) Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Partly Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Partly References 1. Matthias Dettmer, Tae Eun Kim, Chan Kwon Jung, Eun Sun Jung, Kyo Young Lee, Chang Suk Kang, Thyroid transcription factor-1 expression in colorectal adenocarcinomas. Pathology - Research and Practice. 2011. Volume 207;11:686-690. 2. Belalcazar A, Krishnamurti U, Shaib W. TTF-1 Expression in Rectal Adenocarcinoma: A Case Report and Review of the Literature. Case Rep Oncol. 2016 Nov 18;9(3):747-751. doi: 10.1159/000450973. PMID: 27990111; PMCID: PMC5156892. Competing Interests No competing interests were disclosed. Reviewer Expertise Lung cancer, colorectal cancer, histology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Lannagan T. Peer Review Report For: Case Report: Colonic metastasis as the initial manifestation of Pancoast-Tobias syndrome: A rare case report [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :420 ( https://doi.org/10.5256/f1000research.179309.r385982) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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