References for this review were identified by searches of MEDLINE and PubMed with the terms “Pancoast tumours”, “superior sulcus tumours”, “adjuvant therapy”, and “surgery”, and by looking through reference lists from relevant articles. Reports published between 1996 and 2006 were included, as well as historical material.
ReviewManagement of Pancoast tumours
Introduction
Non-small-cell lung carcinomas (NSCLC) of the superior sulcus, frequently termed Pancoast tumours, are some of the most challenging thoracic malignant diseases to treat because they generally invade adjacent vital structures, including the brachial plexus, subclavian vessels, and spine (figure 1).1 Originally described by a radiologist, Henry Pancoast, in 1932,2 superior sulcus NSCLC were deemed universally fatal until the 1950s, when the strategy of induction radiotherapy and en-bloc resection was shown to be potentially curative.3, 4 During the next 40 years, this approach remained standard care, with advances restricted to development of surgical techniques for T4 tumours infiltrating the subclavian vessels and spine.5, 6, 7 However, complete resection was usually achieved in only 60% of patients, and overall survival at 5 years generally did not exceed 30%, indicating a clear need for innovative treatments.8 During the 1990s, concurrent cisplatin-based chemotherapy and radiotherapy followed by resection was shown to be safe and effective for some stage III NSCLC.9 Findings of small studies10 suggested that this treatment strategy was appropriate for Pancoast tumours, which led to a large North American trial of induction chemoradiotherapy followed by resection, establishing this treatment as standard care. In this review, I discuss initial assessment and multimodality management of Pancoast tumours and the technical aspects of resection.
Section snippets
Anatomical definition
The original description by Pancoast of a superior pulmonary sulcus tumour was that of a carcinoma (of uncertain origin) arising in the extreme apex of the chest, associated with shoulder and arm pain, atrophy of the hand muscles, and Horner's syndrome. Anatomically, the pulmonary sulcus is synonymous with the costovertebral gutter, which extends from the first rib to the diaphragm. The superior pulmonary sulcus describes the uppermost extent of this recess.11, 12 Unknown to Pancoast, the most
Initial assessment
The clinical diagnosis of a Pancoast tumour does not invariably mean that the lesion is NSCLC. Patients with other diagnoses such as lymphoma, tuberculosis, or primary chest-wall tumours can present with an apical mass and chest-wall involvement. Lesions in this location are readily accessible for biopsy procedures via transthoracic fine-needle aspiration, and this technique should be done to confirm NSCLC.
Thorough preoperative assessment is needed before embarking on treatment that could lead
Evolution of multimodality management
Developments in the management of NSCLC of the superior sulcus during the past 70 years can be classified into four eras. At the onset of the first era, Pancoast described these tumours as “a peculiar neoplastic entity found in the upper portion of the pulmonary sulcus of the thorax…evidently epithelial in its histopathology, but its exact origin is uncertain”.2 During the ensuing 20 years, these tumours became recognised as primary lung carcinomas but were thought to be inoperable and
Future directions for multimodality treatment
Accrual to the phase II trial described above was completed successfully within the planned time frame, but needed the efforts of 76 surgeons from all North American cooperative groups to enrol 110 eligible patients. Thus, in future, randomised phase III trials that include resection are unlikely to complete accrual within an acceptable length of time for this uncommon NSCLC subset. However, the results highlight several issues that could be investigated in future trials of either single-group
Posterior approach
Figure 4 shows a patient positioned in the lateral decubitus position, rotated slightly anteriorly. With a posterior surgical approach, the chest is entered at the estimated level of chest-wall involvement via a posterolateral thoracotomy. The pleural cavity is examined to ascertain resectability, then an incision is made superiorly midway between the scapula and the spinous processes to the seventh cervical vertebra, dividing the trapezius and rhomboid muscles. This technique allows the
Conclusion
Superior sulcus NSCLC pose a formidable therapeutic challenge because of their proximity to several vital structures in the body. During the past 40 years, the development of effective combined modality treatments and of new surgical approaches has greatly increased local control and overall survival for patients with these tumours. Future studies are needed to address the continuing difficulties of systemic relapse after surgery, especially in the brain.
Search strategy and selection criteria
References (55)
- et al.
Pancoast tumor: five year survival without recurrence or metastases following radical resection and postoperative irradiation
J Thorac Surg
(1956) - et al.
Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet
J Thorac Cardiovasc Surg
(1993) - et al.
Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus
J Thorac Cardiovasc Surg
(2000) Carcinomas in the superior pulmonary sulcus
J Thorac Cardiovasc Surg
(1975)Concerning the Pancoast tumor: what is the superior pulmonary sulcus?
Ann Thorac Surg
(1983)Changes in the treatment of Pancoast tumors
Ann Thorac Surg
(2003)- et al.
Superior sulcus (Pancoast) tumor: experience with 105 patients
Ann Thorac Surg
(1998) Pancoast's tumor
Ann Thorac Surg
(1984)- et al.
Combined radiosurgical treatment of Pancoast tumor
Ann Thorac Surg
(1994) - et al.
Superior sulcus lung tumors: impact of local control on survival
J Thorac Cardiovasc Surg
(1999)
Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas MD Anderson Cancer Center
Int J Radiat Oncol Biol Phys
Influence of surgical resection and brachytherapy in the management of superior sulcus tumor
Ann Thorac Surg
Pancoast's tumor: irradiation or surgery?
Ann Thorac Surg
Resection of superior sulcus tumours (posterior approach)
Thorac Surg Clin
Treatment of superior sulcus tumor (Pancoast tumor)
Surg Clin North Am
Carcinoma of the superior pulmonary sulcus: results of irradiation and radical resection
J Thorac Cardiovasc Surg
High relapse-free survival after preoperative and intraoperative radiotherapy and resection for sulcus superior tumors
Chest
Surgical treatment of superior sulcus tumors: results and prognostic factors
Chest
Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor
Ann Thorac Surg
En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina
J Thorac Cardiovasc Surg
Induction chemoradiation and surgical resection for rnon-small cell lung carcinomas of the superior sulcus: initial results of Southwest Oncology Group trial 9416 (intergroup trial 0160)
J Thorac Cardiovasc Surg
Induction chemoradiotherapy and surgical resection for non-small cell lung carcinomas of the superior sulcus: prediction and impact of pathologic complete response
Lung Cancer
Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus
Ann Thorac Surg
High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival
J Thorac Cardiovasc Surg
Anterior approach for tumor of the superior sulcus
J Thorac Cardiovasc Surg
Surgical therapy for apical invasive lung cancer: different approaches according to tumor location
Lung Cancer
Technique for resecting primary and metastatic nonbronchogenic tumors of the thoracic outlet
Ann Thorac Surg
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2017, Thoracic Surgery ClinicsCitation Excerpt :In the decades that followed, Pancoast and Tobias’ original description of superior sulcus tumors, treatments were limited and largely ineffective. Although surgical resection was occasionally attempted, the associated morbidity and mortality were high.5,10,13 Radiation therapy was the mainstay of early treatment and effective in palliating pain; however, outcomes were poor.5,13
Surgical Treatment of Superior Sulcus Tumors: A 15-Year Single-center Experience
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