Multidisciplinary Approach to Superior Sulcus Tumors (original) (raw)
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Posterior and anterior sulcus tumors
Current Challenges in Thoracic Surgery
Pancoast or superior sulcus tumors are rare lung lesions arising from the apex of the lung located above the level of the second rib invading vital structures such as first rib, lower roots of the brachial plexus, subclavian vessels, stellate ganglion, sympathetic trunk, and adjacent vertebral bodies. They may be responsible for characteristic symptoms such as pain from the shoulder to anterior chest wall, arm pain and weakness and atrophy of the hand, Claude-Bernard-Horner Syndrome and upper arm oedema. Pancoast tumors are frequently caused by non-small cell lung cancer and for many years they were considered fatal for their malignity and not amenable for surgery until 1950s when Chardack and MacCallum described a successful bimodal treatment including surgical resection followed by postoperative irradiation. In 1966 Paulson proposed a combined preoperative radiation therapy followed by en bloc resection of lung and chest wall through a postero-lateral approach. In the late 90s, some authors began to study a new trimodality approach based on the combination of chemo-radiotherapy followed by surgery obtaining an improvement of systemic and local control of the disease. However, a remarkable variability still exists between in terms of chemiotherapic medications, number and timing of administration, modality and dose of radiotherapy and eligibility criteria. Different surgical approaches have been described based on location of the tumor and invaded structures: anterior approach for superior sulcus tumors invading subclavian vessels and first rib; posterior approach for the management of tumors invading the posterior thoracic inlet, particularly the vertebrae; combined approaches according to the degree of inlet involvement.
Carcinoma of the Superior Pulmonary Sulcus
The Annals of Thoracic Surgery, 1979
26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoast's syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at Ieast 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.
Lung Cancer, 1997
During the 14-year period under study, 48 patients with SST were treated at the Institute of Oncology in Ljubljana, Slovenia. There were 46 males and two females, aged 29-88 years (median, 60 years). Of 37 cytologically or histologically confirmed tumors, 12 were squamous, eight large-cell, one small-cell, eight adeno, and eight unclassified carcinomas. Performance status (Karnofsky) was assessed as > 90 in eight, 70-90 in 31 and < 70 in nine patients. The duration of symptoms before diagnosis ranged from 1 to 36 months (median, 5 months). All patients had pain, while six also had hemophthysis, 14 Horner's syndrome. and four Horner's syndrome and upper limb paresis. Before the first chest X-ray, 19 patients were treated for shoulder pain by different specialists. Apical tumor infiltration only on the chest X-ray was found in 13, destruction of the ribs in 31, and destruction of the ribs and vertebral bodies in four patients. Treatment was as follows: radiotherapy in 39 patients (22 with radical, 17 with palliative dose), a combination of surgery and radiotherapy in seven. radiotherapy and chemotherapy in one, and symptomatic therapy alone in one patient. Oneand four-year survival of all treated patients was 27% and ll%, respectively. One of the seven patients operated on survived for 44 months, and 2/39 irradiated ones survived for 37 and 56 months, respectively, while others died within 24 months from diagnosis. In 81% of patients the pain was subdued after radiotherapy. The disease-specific survival of all patients included in the follow-up correlated with performance status and M stage, while that of those treated by irradiation alone correlated with tumor dose (P < 0.05). 0 1997 Elsevier Science Ireland Ltd.
European Journal of Cardio-Thoracic Surgery, 2009
Objective: Superior sulcus tumours (SSTs) or Pancoast tumours are preferably treated with chemoradiotherapy (CRT) followed by surgical resection. However, when followed by surgery, it is associated with an increased complication rate. This study aims to evaluate the efficacy and safety of a concurrent induction protocol of 66 Gy radiotherapy with cisplatinum and evaluate the rationale for subsequent surgery. Methods: Patients with SST treated in our institute from 1994 to 2006 were identified. The preferred induction treatment consisted of accelerated radiation (66 Gy in fractions of 2.75 Gy) with concurrent daily cisplatinum 6 mg m À2. Surgical resection was planned 4-6 weeks thereafter. Performance status, co-morbidity, clinical and pathological tumour stage, (response to) treatment and survival were reviewed. Survival analysis was performed using the Kaplan-Meier method. Results: Over these 12 years, 85 patients with Pancoast tumours, 57 men and 28 women, were referred. Mean follow-up was 42 months (range: 2-120 months). Twenty-five patients had stage IIB (29%), seven had stage IIIA (8%), 32 had stage IIIB (38%) and 21 had stage IV (25%). Of the 64 patients presenting with stage II or III disease, 38 medically operable patients with potentially resectable tumours received induction therapy. After restaging, 22 patients underwent resection. All resections were complete and local recurrences were not observed. In 13 patients (62%) a pathologic complete response was found. In most cases, pathologic response was not evident from radiological imaging. The morbidity of surgery after induction treatment was acceptable. There was no fatal toxicity or treatmentrelated mortality. The 2-and 5-year overall survival of this selected group was 70% and 37%, respectively. Conclusion: This schedule of induction therapy with high-dose radiation and concurrent cisplatinum was safe and highly effective in fit patients. At this time, pathologic complete response cannot be reliably recognised preoperatively, and better tools for response assessment are critical for more tailored treatment of patients with SST.
CHEST Journal, 2009
A 49-year-old, white man with a l00-pack-year smoking history presented with progressive scapular paresthesias and pain radiating down his right ann for 6 weeks. His medical history was significant for low-grade transitional cell bladder cancer status post transurethral bladder resection. He had multiple chemical exposures as a military aviator. He presented to another institution, where a CT chest scan demonstrated a 4.5 X 2.5-cm right apical lobulated and necrotic mass, bilateral hilar and subcarinal adenopathy, and tree-in-bud interstitial markings (Fig 1). He underwent fiberoptic bronchoscopy (FOB) with transbronchial biopsy (TBBx) of the right upper lobe (RUL) and transbronchial needle aspiration (TBNA) of a subcarinallymph node. The TBBx demonstrated noncaseating granulomas, and subcarinal biopsy specimens showed lymphoid tissue without malignancy. He then presented to our institution for evaluation of increasing back and right ann pain. Physical examination was normal except for point tenderness over the suprascapular region of the right upper back with no palpable adenopathy. Laboratory Findings and Imaging Laboratory results were all within normal limits. Full pulmonary function tests demonstrated moder
Cancer, 1992
Several studies suggest that patients with non-small cell lung carcinoma (NSCLC) of the superior sulcus fare better after radiation therapy than those patients with comparable tumors at other thoracic sites. There is limited data on stage-by-stage comparisons between patients with superior sulcus tumors (SST) and non-SST (NSST). Thirty patients had SST among 656 patients with American Joint Committee on Cancer clinically staged IIIA (n = 389) and IIB (n = 267) primary NSCLC who received definitive once-daily radiation therapy. The median patient age, sex ratio, histologic findings, grade, weight loss, and performance status were similar for SST and NSST. Minimum follow-up was 24 months, with 88% of patients followed until death.