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McLaughlin K, Tan KS, Dycoco J, Chen MF, Chaft JE, Mankuzhy NP, Rimner A, Aly RG, Fanaroff RE, Travis WD, Bilsky M, Bains M, Downey R, Huang J, Isbell JM, Molena D, Park BJ, Jones DR, Rusch VW. Superior sulcus non-small cell lung cancers (Pancoast tumors): Current outcomes after multidisciplinary management. J Thorac Cardiovasc Surg 2023; 166:1477-1487.e8. [PMID: 37611845 PMCID: PMC11229055 DOI: 10.1016/j.jtcvs.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Despite neoadjuvant chemoradiotherapy, Pancoast tumors still present surgical and oncologic challenges. To optimize outcomes, we used a multidisciplinary care paradigm with medical and radiation oncology, and involvement of spine neurosurgery for most T3 and all T4 tumors. Spine neurosurgery permitted resection of transverse process for T3 and vertebral body resection for T4 tumors. METHODS Retrospective analysis of single institution, prospective database of patients undergoing resection for cT3 4M0 Pancoast tumors. Patients were grouped as cT3 with combined resection with spine neurosurgery (T3 Neuro), cT3 without spine neurosurgery (T3 NoNeuro), and cT4. Overall survival, progression-free survival were analyzed by Kaplan-Meier and compared between groups using log-rank test. Cumulative incidence of local-regional and distant recurrence were compared using Gray test. P value <.05 was considered significant. RESULTS From 2000 to 2021, 155 patients underwent surgery: median age was 58 years, and 81 were (52%) men. Most patients received neoadjuvant platinum-based neoadjuvant chemoradiotherapy (n = 127 [82%]). Operations were 48 cT3 Neuro, 41 cT3 NoNeuro, 66 cT4. R0 resection was achieved in 49 (94%) cT3 NoNeuro, 35 (85%) cT3 Neuro, and 57 (86%) cT4 patients (P = .4). Complete or major pathologic response occurred in 71 (55%) patients. Lower local-regional cumulative incidence was seen in cT3 Neuro versus cT3 NoNeuro (P = .05) and after major pathologic response. Overall survival and progression-free survival were associated with complete response, pathologic stage, and nodal status but not cT category. CONCLUSIONS This treatment paradigm was associated with a high frequency of R0 resection, complete response, and major pathologic response. cT3 and cT4 tumors had similar outcomes. Novel therapies are needed to improve complete response.
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Affiliation(s)
- Kaitlin McLaughlin
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joe Dycoco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Monica F Chen
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jamie E Chaft
- Thoracic Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nikhil P Mankuzhy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rania G Aly
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rachel E Fanaroff
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Manjit Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard J Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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Abstract
Horner syndrome is an uncommon but important clinical entity, representing interruption of the sympathetic pathway to the eye and face. Horner syndrome is almost always diagnosed clinically, though pharmacological testing can be used to confirm the diagnosis. Imaging modalities such as PET, CT and MRI are important components of work-up for patients presenting with acquired Horner syndrome. Our patient's presentation with Horner syndrome unmasked the causative superior sulcus squamous cell carcinoma and a coincidental lower lobe adenocarcinoma. Successful radical treatment of these cancers resulted in complete resolution of the syndrome and disease-free survival at 18 months. We review the anatomy and pathophysiology underlying this and other causes of Horner syndrome.
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Affiliation(s)
- Yu X Kong
- Cardiothoracic Care Centre, Fitzroy, Victoria, Australia
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Treatment of clinical T4 stage superior sulcus non-small cell lung cancer: a propensity-matched analysis of the surveillance, epidemiology, and end results database. Biosci Rep 2019; 39:BSR20181545. [PMID: 30647107 PMCID: PMC6356038 DOI: 10.1042/bsr20181545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/06/2018] [Accepted: 01/13/2019] [Indexed: 02/02/2023] Open
Abstract
Purpose/Objective(s): Treatments for superior sulcus non-small cell lung cancer (SS-NSCLC) have evolved, but adequate treatments of T4 disease have not been found. The aim of our study was to evaluate the prognostic factors and optimal treatment strategy for patients with T4 SS-NSCLC. Materials/Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) database (1973–2015) to identify patients diagnosed with T4 stage SS-NSCLC (according to the 7th edition American Joint Committee on Cancer (AJCC) staging system) from 2004 to 2015; those with M1 disease were excluded. Propensity score matching (PSM) with Kaplan–Meier and Cox proportional hazards’ models was performed to estimate prognosis. Results: A total of 384 patients were included. The majority was male (59.4%) at stage IIIB (56.6%), with N2 accounting for 45.3%. A total of 47 patients underwent cancer-directed surgery, while radiotherapy alone was received by 60.2% of patients. Median overall survival (OS) and lung cancer-specific survival (LCSS) were 12 and 17 months, respectively, and the 5-year OS and LCSS rates were 15.8 and 25.4%, respectively. In the matched population, the median survival outcomes were better following surgery (OS: 25 compared with 9.0 months, P<0.001; LCSS: not available (NA) compared with 11.0 months, P<0.001). Multivariate Cox analysis showed that ages ≥ 66 years (hazard ratio (HR) = 1.639, P=0.001), unmarried status (HR = 1.356, P=0.034), and tumor size ≥ 6.0 cm (HR = 1.694, P<0.001) were associated with inferior OS. Cancer-directed surgery (HR = 0.537, P=0.009) and radiotherapy (HR = 0.644, P=0.006) were independent prognostic factors for patients with T4 SS-NSCLC. Conversely, in the subgroup analysis, favorable impacts of radiotherapy were observed for nonsurgical patients (OS: HR = 0.58, P<0.001; LCSS: HR = 0.55, P<0.001). Conclusion: Our study showed that T4 stage SS-NSCLC patients had a poor prognosis. Surgical resection remains the best option for those with resectable disease. For nonsurgical T4 SS-NSCLC patients, radiotherapy should be actively considered.
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El Madi A, Irtan S, Sauvat F, Zérah M, Schleiermacher G, Galmiche-Roland L, Minard-Colin V, Brisse H, Sarnacki S. Long-term results of the transmanubrial osteomuscular-sparing approach for pediatric tumors. Pediatr Blood Cancer 2017; 64. [PMID: 28409885 DOI: 10.1002/pbc.26527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/28/2017] [Accepted: 02/20/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The complete and safe resection of pediatric cervicothoracic tumors, mostly represented by neurogenic tumors, remains a surgical challenge because of the complex anatomy of this region. The transmanubrial osteomuscular-sparing approach (TOSA) is an alternative to isolated or combined cervical and thoracic approaches enabling the control of supra-aortic vessels and nerves through the thoracic inlet. METHODS We retrospectively reviewed the tumor characteristics, completeness of resection, morbidity, and long-term outcome of patients with cervicothoracic tumors removed by TOSA between 2000 and 2012 in our institution. RESULTS Thirteen patients (7 males, 6 females) underwent surgery at a median age of 72 months (4-188) for neuroblastoma (n = 6), ganglioneuroblastoma (n = 3), rhabdoid tumor (n = 1), melanotic schwannoma (n = 1), chordoma (n = 1), and malignant peripheral nerve sheath tumor in one patient with type 1 neurofibromatosis. The median duration of the procedure was 215 minutes (110-315). Two children presented with postoperative chylothorax that resolved spontaneously. The median duration of hospitalization was 7 days (4-22). At a median follow-up of 39 months (2-159), four patients had died of metastatic relapse (n = 2), locoregional progression (n = 1), and chemotoxicity (n = 1). The patient with melanotic schwannoma was lost to follow-up after a local relapse at 5 months. Long-term morbidity revealed homolateral Claude-Bernard Horner sign and upper limb vasomotor dysfunction in disease-free patients due to mandatory resection of the stellate ganglia. CONCLUSIONS TOSA is a valuable surgical approach for all cervicothoracic tumors with acceptable long-term morbidity when compared with its complexity. We can therefore recommend TOSA for tumors involving the thoracic inlet.
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Affiliation(s)
- Aziz El Madi
- Department of Pediatric Surgery, Fez University Hospital, Fez, Morocco
| | - Sabine Irtan
- Department of Pediatric Surgery, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | - Frédérique Sauvat
- Department of Pediatric Surgery, Hôpital Felix Guyon, Saint Denis de la Reunion, France
| | - Michel Zérah
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | | | - Louise Galmiche-Roland
- Department of Pathology, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
| | | | - Hervé Brisse
- Department of Imaging, Institut Curie, Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery, Hôpital Necker-Enfants Malades, Paris Descartes University, Paris, France
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Abstract
Superior sulcus tumors have posed a formidable therapeutic challenge since their original description by Pancoast and Tobias in the early twentieth century. Initial therapeutic efforts with radiotherapy were associated with high rates of relapse and mortality. Bimodality therapy with complete surgical resection in the 1960s paved the way for trimodality therapy as the current standard of care in the treatment of superior sulcus tumors. The evolution of treatment approaches over time has provided outcomes that come increasingly closer to rivaling those of similarly staged nonapical lung cancer.
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Affiliation(s)
- Johannes R Kratz
- Department of Thoracic Surgery, University of California, San Francisco, Box 0118, San Francisco, CA 94143-0118, USA.
| | - Gavitt Woodard
- Department of Surgery, University of California, San Francisco, Box 0470, 513 Parnassus Avenue, 321, San Francisco, CA 94122, USA
| | - David M Jablons
- Department of Thoracic Surgery, University of California, San Francisco, 1600 Divisadero Street, Room A-743, San Francisco, CA 94143-1724, USA
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Filis AK, Robinson LA, Vrionis FD. Resection of the First Rib With Preservation of the T1 Nerve Root in Pancoast Tumors of the Lung. Cancer Control 2016; 23:295-301. [PMID: 27556670 DOI: 10.1177/107327481602300313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Surgical outcomes for Pancoast (superior sulcus) tumors of the lung have significantly changed during the last few decades and have improved with use of curative-intent surgery by utilizing en bloc complete resections. METHODS A retrospective analysis was conducted of 11 selected patients treated at Moffitt Cancer Center from 2007 to 2016. Data from patient records were collected and analyzed. RESULTS All 11 patients with a Pancoast tumor involving the first rib had their T1 root preserved at surgery. In 10 patients (90.9%), the tumor was removed en bloc. Clear margins of resection were documented in 4 cases (36.0%). No patient developed postoperative hand weakness, but 3 patients (27.3%) had minor postoperative complications, including air leak, chylothorax, and pericardial effusion. One iatrogenic injury to the subclavian artery was reported during surgery; the injury was subsequently repaired. No operative mortality was reported. CONCLUSIONS Radical resection of Pancoast tumors is considered to be safe, and preserving the T1 nerve root provides more favorable, functional outcomes.
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Torii I, Tateishi U, Terauchi T, Inoue T. Prognostic implications of diffusion-weighted magnetic resonance imaging in patients with superior sulcus tumors receiving induction chemoradiation therapy. Jpn J Clin Oncol 2016; 46:264-9. [PMID: 26848076 DOI: 10.1093/jjco/hyv200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/10/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate a diffusion-weighted magnetic resonance imaging to represent therapeutic response of induction chemoradiation and outcome in patients with non-small cell lung cancer of the superior sulcus. METHODS Seventeen patients with non-small cell lung cancer of the superior sulcus (median age, 57 years; range, 44-70 years) received induction chemoradiation, followed by surgery. Diffusion-weighted magnetic resonance imaging of the lesion using b values of 0 and 800 s/mm(2) was acquired before treatment and after induction chemoradiation. Changes in tumoral apparent diffusion coefficient were compared with clinical and histopathological response. Cumulative disease-free survival and proportion of surviving were estimated by the Kaplan-Meier method. Survival of diffusion responders and non-responders were compared by log-rank test. RESULTS A significant correlation was observed between changes of diffusion response after induction chemoradiation and overall survival. Using a defined threshold of percent increase in mean apparent diffusion coefficient, nine out of 17 patients (53%) were classified as diffusion responders and had a mean increase in mean apparent diffusion coefficient of 40.7 ± 11.2%, while eight diffusion non-responding patients (47%) had a mean increase of 11.0 ± 15.5% (P < 0.0001). Significant difference was found in overall survival between diffusion responders and diffusion non-responders (88.9 months versus 20.3 months, P = 0.002). CONCLUSIONS Diffusion-weighted magnetic resonance imaging represented therapeutic effect and prognosis after induction chemoradiation in patients with non-small cell lung cancer of the superior sulcus.
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Affiliation(s)
- Ikuo Torii
- Department of Radiology, Yokohama City University Graduate School of Medicine, Kanagawa
| | - Ukihide Tateishi
- Department of Diagnostic Radiology and Nuclear Medicine, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo
| | - Takashi Terauchi
- Division of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomio Inoue
- Department of Radiology, Yokohama City University Graduate School of Medicine, Kanagawa
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Jiao J, Huang H, Tian L, Wu Q, Ge M. [Anterior or Posterior Approach with Video-assisted Thoracoscopic Surgery for Superior Sulcus Tumors]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2015; 18:696-700. [PMID: 26582226 PMCID: PMC6000312 DOI: 10.3779/j.issn.1009-3419.2015.11.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE The surgical resection for pancoast tumors remains challenging. There are only few reports explaining the use of VATS in the treatment of Pancoast tumors. The aim of this study is to assess whether the use of video-assisted thoracoscopic surgery (VATS) for the surgical treatment of Pancoast tumors was feasible and safe. METHODS Between Janunary 2010 and June 2013, ten patients who were diagnosed as Pancoast tumors were recruited. Six patients were accepted for surgical treatment either through an anterior (n=3) or a posterior approach (n=3) combined with VATS. The observation index of this study included: Operation safety and mortality; The integrity of the tumor resection; General data of operation and postoperative complications; Tumor recurrence and metastasis at twelve months after operation. RESULTS There were no perioperative deaths. The average time of operation time was 242 min. The radical en bloc resection of the involved chest wall were done in each patients. The average amount of blood loss was 308 mL and the average time of hospital stay was 14 d. Only one patient had postoperative pneumonia and recovered after use of antibiotics. There was none of severe postoperative complications. No patient developed a local recurrence or distant metastasis within twelve months. CONCLUSIONS The use of VATS has practical value in the management of Pancoast tumors. It is useful to make an accurate extent of the resection of chest-wall and provides a better exposure. Anterior or posterior approach with VATS surgery can facilitate the safety management of Pancoast tumors.
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Affiliation(s)
- Jia Jiao
- Department of Thoracic Surgery, the First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Hao Huang
- Department of Thoracic Surgery, the First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Lei Tian
- Department of Thoracic Surgery, the First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Qingchen Wu
- Department of Thoracic Surgery, the First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
| | - Mingjian Ge
- Department of Thoracic Surgery, the First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, China
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Nun AB, Simansky D, Rokah M, Zeitlin N, Avi RB, Soudack M, Golan N, Apel S, Bar J, Yelin A. Hybrid video-assisted and limited open (VALO) resection of superior sulcus tumors. Surg Today 2015. [DOI: 10.1007/s00595-015-1225-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Marulli G, Battistella L, Perissinotto E, Breda C, Favaretto AG, Pasello G, Zuin A, Loreggian L, Schiavon M, Rea F. Results of surgical resection after induction chemoradiation for Pancoast tumours †. Interact Cardiovasc Thorac Surg 2015; 20:805-11; discussion 811-2. [PMID: 25757477 DOI: 10.1093/icvts/ivv032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/23/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pancoast tumour is a rare neoplasia in which the optimal therapeutic management is still controversial. The traditional treatment of Pancoast tumour (surgery, radiotherapy or a combination of both) have led to an unsatisfactory outcome due to the high rate of incomplete resection and the lack of local and systemic control. The aim of the study was to determine the efficacy of the trimodality approach. METHODS Fifty-six patients (male/female ratio: 47/9, median age: 64 years) in stage IIB to IIIB were treated during a period between 1994 and 2013. Induction therapy consisted of 2-3 cycles of a platinum-based chemotherapy associated with radiotherapy (30-44 Gy). After restaging, eligible patients underwent surgery 2 to 4-week post-radiation. RESULTS Thirty-two (57.1%) patients were cT3 and 24 (42.9%) cT4, 47 (83.9%) were N0 and 9 (16.1%) N+. Forty-eight (85.7%) patients underwent R0 resection and 10 (17.9%) had a complete pathological response (CPR). Thirty-day mortality rate was 5.4%, major surgical complications occurred in 6 (10.7%) patients. At the end of the follow-up, 17 (30.4%) patients were alive and 39 (69.6%) died (29 for cancer-related causes), with an overall 5-year survival of 38%. At statistical analysis, stage IIB (P = 0.003), R0 resection (P = 0.03), T3 tumour (P = 0.002) and CPR (P = 0.01) were significant independent predictors of better prognosis. CONCLUSIONS This combined approach is feasible, and allows for a good rate of complete resection. Long-term survival rates are acceptable, especially for early stage tumours radically resected. Systemic control of disease still remains poor, with distant recurrence being the most common cause of death.
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Affiliation(s)
- Giuseppe Marulli
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
| | - Lucia Battistella
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
| | - Egle Perissinotto
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
| | - Cristiano Breda
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
| | | | - Giulia Pasello
- Department of Oncology, Istituto Oncologico Veneto, Veneto, Italy
| | - Andrea Zuin
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
| | - Lucio Loreggian
- Department of Radiotherapy, Istituto Oncologico Veneto, Veneto, Italy
| | - Marco Schiavon
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
| | - Federico Rea
- Department of Cardiologic, Thoracic and Vascular Sciences, Thoracic Surgery Unit, University of Padova, Padova, Italy
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Setzer M, Robinson LA, Vrionis FD. Management of locally advanced pancoast (superior sulcus) tumors with spine involvement. Cancer Control 2015; 21:158-67. [PMID: 24667403 DOI: 10.1177/107327481402100209] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The preferred treatment for locally aggressive lung cancers is triple modality therapy with concurrent and induction chemotherapy with radiation therapy followed by surgery. Patients with locally advanced T4 Pancoast tumors with spine involvement, without mediastinal N2 lymph node involvement and without distant metastases, are appropriate candidates for complete resection with subsequent spine reconstruction. This review addresses the questions of whether triple modality therapy with complete en bloc resection of locally advanced Pancoast tumors offers an advantage in terms of overall survival and complication rates compared with other therapeutic modalities or therapies with incomplete resection. METHODS A comprehensive literature search was conducted using common medical databases. Inclusion and exclusion criteria for the articles were prospectively defined. The articles were independently reviewed and a consensus decision was made about each article. Selected papers were graded by level of evidence. RESULTS A total of 1,001 abstracts and 93 articles fulfilled the criteria; from these studies, 14 were included in this systematic review. No level 1 study was found in this search. Four level 2 studies and 10 level 3 retrospective case series were found. The overall 5-year survival rate reported in these studies ranged from 37% to 59% and the mortality rate ranged from 0% to 6.9%. CONCLUSIONS Evidence suggests that triple modality therapy with complete resection of locally advanced Pancoast tumors with involvement of the spine offers an advantage over other therapeutic modalities or therapies with incomplete resections.
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Affiliation(s)
- Matthias Setzer
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany.
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Nikolaos P, Vasilios L, Efstratios K, Panagiotis A, Christos P, Nikolaos B, Antonios H, Tsakiridis K, Zarogoulidis P, Zarogoulidis K, Katsikogiannis N, Kougioumtzi I, Machairiotis N, Tsiouda T, Machairiotis N, Madesis A, Vretzakis G, Kolettas A, Dimitrios D. Therapeutic modalities for Pancoast tumors. J Thorac Dis 2014; 6 Suppl 1:S180-93. [PMID: 24672693 DOI: 10.3978/j.issn.2072-1439.2013.12.31] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 12/16/2013] [Indexed: 01/21/2023]
Abstract
A Pancoast tumor, also called a pulmonary sulcus tumor or superior sulcus tumor, is a tumor of the pulmonary apex. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most Pancoast tumors are non-small cell cancers. The growing tumor can cause compression of a brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve, vagus nerve, or, characteristically, compression of a sympathetic ganglion resulting in a range of symptoms known as Horner's syndrome. Pancoast tumors are named for Henry Pancoast, a US radiologist, who described them in 1924 and 1932.The treatment of a Pancoast lung cancer may differ from that of other types of non-small cell lung cancer (NSCLC). Its position and close proximity to vital structures may make surgery difficult. As a result, and depending on the stage of the cancer, treatment may involve radiation and chemotherapy given prior to surgery. Surgery may consist of the removal of the upper lobe of a lung together with its associated structures as well as mediastinal lymphadenectomy. Surgical access may be via thoracotomy from the back or the front of the chest and modification. Careful patient selection, improvements in imaging such as the role of PET-CT in restaging of tumors, radiotherapy and surgical advances, the management of previously inoperable lesions by a combined experienced thoracic-neurosurgical team and prompt recognition and therapy of postoperative complications has greatly increased local control and overall survival for patients with these tumors.
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Affiliation(s)
- Panagopoulos Nikolaos
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Livaditis Vasilios
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Koletsis Efstratios
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Alexopoulos Panagiotis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Prokakis Christos
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Baltayiannis Nikolaos
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Hatzimichalis Antonios
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Kosmas Tsakiridis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Paul Zarogoulidis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Konstantinos Zarogoulidis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Nikolaos Katsikogiannis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Ioanna Kougioumtzi
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Nikolaos Machairiotis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Theodora Tsiouda
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Nikolaos Machairiotis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Athanasios Madesis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Georgios Vretzakis
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Alexandros Kolettas
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
| | - Dougenis Dimitrios
- 1 Department of Cardiothoracic Surgery, Patras University School of Medicine, Patra, Greece ; 2 Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece ; 3 Cardiothoracic Surgery Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece ; 4 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 5 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 6 Internal Medicine Department, "Theagenio" Cancer Hospital, Thessaloniki, Greece ; 7 Cardiothoracic Surgery Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 8 Anesthesiology Department, University of Larisa, Larisa, Greece ; 9 Anesthesiology Department, "Saint Luke" Private Clinic of Health Excellence, Thessaloniki, Panorama, Greece
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Foroulis CN, Zarogoulidis P, Darwiche K, Katsikogiannis N, Machairiotis N, Karapantzos I, Tsakiridis K, Huang H, Zarogoulidis K. Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment. J Thorac Dis 2014; 5 Suppl 4:S342-58. [PMID: 24102007 DOI: 10.3978/j.issn.2072-1439.2013.04.08] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/09/2013] [Indexed: 11/14/2022]
Abstract
Pancoast tumors account for less than 5% of all bronchogenic carcinomas. These tumors are located in the apex of the lung and involve through tissue contiguity the apical chest wall and/or the structures of the thoracic inlet. The tumors become clinically evident with the characteristic symptoms of the "Pancoast-Tobias syndrome" which includes Claude-Bernard-Horner syndrome, severe pain in the shoulder radiating toward the axilla and/or scapula and along the ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in edema of the upper arm. The diagnosis will be made by the combination of the characteristic clinical symptoms with the radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1(st) and/or 2(nd) ribs. A tissue diagnosis of the tumor via CT-guided FNA/B should always be available before the initiation of treatment. Bronchoscopy, thoracoscopy and biopsy of palpable supraclavicular nodes are alternative ways to obtain a tissue diagnosis. Adenocarcinomas account for 2/3 of all Pancoast tumors, while the rest of the tumors are squamous cell and large cell carcinomas. Magnetic resonance imaging of the thoracic inlet is always recommended to define the exact extent of tumor invasion within the thoracic inlet before surgical intervention. Pancoast tumors are by definition T3 or T4 tumors. Induction chemo-radiotherapy is the standard of care for any potentially resectable Pancoast tumor followed by an attempt to achieve a complete tumor resection. Resection can be made through a variety of anterior and posterior approaches to the thoracic inlet. The choice of the approach depends on the location of the tumor (posterior - middle - anterior compartment of the thoracic inlet) and the depth/extent of invasion. Prognosis depends mainly on T stage of tumor, response to preoperative chemo-radiotherapy and completeness of resection. Resection of the invaded strictures of the thoracic inlet should me made en bloc with pulmonary parenchyma resection, preferably an upper lobectomy. Invasion of the vertebral column is not a contraindication for surgery which, however, should be performed in oncologic centers with experience in spinal surgery. Surgery for Pancoast tumors is associated with 5% mortality rate and the complication rate varies from 7-38%. The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%). The main pattern of recurrence is that of distant metastases, especially in the brain.
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Affiliation(s)
- Christophoros N Foroulis
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Aristotle University Medical School, Thessaloniki, Greece
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Spaggiari L, D'Aiuto M, Veronesi G, Leo F, Solli P, Elena Leon M, Gasparri R, Galetta D, Petrella F, Borri A, Scanagatta P. Anterior approach for Pancoast tumor resection. Multimed Man Cardiothorac Surg 2014; 2007:mmcts.2005.001776. [PMID: 24415052 DOI: 10.1510/mmcts.2005.001776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tumors arising anteriorly in the apex of the chest were long considered unresectable because of early invasion of vascular structures limiting radical resection through the conventional Paulson approach. These tumors became operable in 1993 when Dartevelle popularized the cervico-thoracic transclavicular technique for resecting these neoplasms. Since then several different surgical approaches to anterior Pancoast tumors have been proposed, drastically improving the rate of radical resections of these tumors. However, there is no consensus on which anterior surgical approach provides the best access to all of the apical non-small cell lung cancers of the thoracic inlet. Moreover, it is still unclear if integrated neoadjuvant and adjuvant treatments can improve the rates of complete resection, local recurrence and long-term survival.
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Affiliation(s)
- Lorenzo Spaggiari
- University of Milan, School of Medicine, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
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Lahon B, Mercier O, Fadel E, Mussot S, Fabre D, Hamdi S, Le Chevalier T, Dartevelle P. Subclavian Artery Resection and Reconstruction for Thoracic Inlet Cancer: 25 Years of Experience. Ann Thorac Surg 2013; 96:983-8; discussion 988-9. [DOI: 10.1016/j.athoracsur.2013.04.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/06/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
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Deslauriers J, Tronc F, Fortin D. Management of tumors involving the chest wall including pancoast tumors and tumors invading the spine. Thorac Surg Clin 2013; 23:313-25. [PMID: 23931015 DOI: 10.1016/j.thorsurg.2013.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Bronchogenic carcinomas involving the chest wall include tumors invading the ribs and spine, as well as Pancoast tumors. In the past, such neoplasms were considered to be incurable, but with new multimodality regimens, including induction chemoradiation followed by surgery, they can now be completely resected and patients can benefit from prolonged survival. The most important prognostic factors are the completeness of resection and the pathologic nodal status.
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Affiliation(s)
- Jean Deslauriers
- Division of Thoracic Surgery, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Laval University, 2725 chemin Sainte-Foy, L-3540, Quebec City, Quebec G1V 4G5, Canada.
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Ripley RT, Rusch VW. Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy. Thorac Surg Clin 2013; 23:273-85. [PMID: 23931012 DOI: 10.1016/j.thorsurg.2013.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.
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Affiliation(s)
- R Taylor Ripley
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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[Single French centre retrospective analysis of local control after high dose radiotherapy with or without chemotherapy and local control for Pancoast tumours]. Cancer Radiother 2012; 16:107-14. [PMID: 22341507 DOI: 10.1016/j.canrad.2011.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 09/23/2011] [Accepted: 10/11/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE Superior sulcus non-small cell lung cancer represents less than 5% of all lung cancers and is a challenge for the physicians because of clinical presentation, treatments related toxicities and poor prognosis. The aim of this preliminary retrospective report is to present outcomes of patients affected by a superior sulcus non-small cell lung cancer, treated by high dose radiotherapy (>60 Gy) with or with our chemotherapy. PATIENTS AND METHODS All adult inoperable or unresectable patients (≥18 years) with a clinical and radiological diagnosis of superior sulcus non-small cell lung cancer treated in our department by radiotherapy with or without chemotherapy were retrospectively analysed. Primary endpoint was the local control. Overall survival, metastasis free survival and toxicity rates were also analysed and reported. RESULTS From January 1999 to June 2009, 12 patients were treated by exclusive high-dose radiochemotherapy. Median age was 53 years (range: 33-64 years); mean follow-up time was 20 months (range: 2-75 months). Mean local control, overall survival and metastasis free survival were 20.2, 22 and 20 months, respectively. At the time of this analysis, seven patients died of cancer and three of them presented only a metastatic disease progression. One patient died of acute cardiac failure 36 months after the end of radiochemotherapy and was disease free. Treatment was well tolerated and any acute and/or late G3-4 toxicity was recorded (NCI-CTC v 3.0 score). CONCLUSION This analysis confirms the interest of exclusive high-dose radiochemotherapy in treating inoperable superior sulcus non-small cell lung cancer patients, in achieving good local control and overall survival rates.
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Caronia FP, Ruffini E, Lo Monte AI. The use of video-assisted thoracic surgery in the management of Pancoast tumors☆. Interact Cardiovasc Thorac Surg 2010; 11:721-6. [DOI: 10.1510/icvts.2010.244657] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Parissis H, Young V. Treatment of pancoast tumors from the surgeons prospective: re-appraisal of the anterior-manubrial sternal approach. J Cardiothorac Surg 2010; 5:102. [PMID: 21050456 PMCID: PMC2992054 DOI: 10.1186/1749-8090-5-102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 11/04/2010] [Indexed: 11/23/2022] Open
Abstract
Pancoast tumours are now amenable to multimodality treatment with an acceptable survival. This is because trimodality treatment improves tumor sterilization and hence outcome. Moreover the development of an anterior approach to access the tumor, further improved the technical challenges for a sound resection.The Anterior-manubrial sternal approach was described more than a decade ago and although this method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels, its popularity has not reached high levels. We felt that by re-addressing this topic we would stimulate reconsideration of the anterior approach.
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Affiliation(s)
| | - Vincent Young
- Cardiothoracic Dept, St James Hospital, Dublin 8, Dublin, Ireland
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Abdelrahman AM, Mourad IA, Gaafar RM, Elhossieny HA. Carcinoma of the superior pulmonary sulcus: Results of multidisciplinary treatment. Thorac Cancer 2010; 1:163-168. [PMID: 27755818 DOI: 10.1111/j.1759-7714.2010.00025.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Superior sulcus tumors are a complex subset of tumors accounting for less than 5% of lung tumors. METHODS Twenty-three patients admitted between 2001 and 2007 were included in the study,. Computed tomography scan of the chest was considered the primary diagnostic and staging investigation for all patients. Radiation therapy was given preoperatively to 20 patients, neoadjuvant chemotherapy was given to 13 patients. RESULTS There were 22 men and one woman in the study. The mean age was 53 years. Lobectomy was performed in 20 patients and wedge resection was done for three patients. Three to five ribs were resected in all patients. Extended resections were performed in eight patients. Positive mediastinal lymph nodes were found six patients. The staging was: Stage IIB (11 patients); Stage IIIA (four patients), Stage IIIB (six patients) and Stage IV (two patients). Negative resection margin was achieved in 18 patients. Postoperative complications developed in nine patients, there was one operation related mortality. Tumor recurrence developed in 16 patients. The mean survival time was 2.8 years and the overall 5-years survival was 26%. CONCLUSION Multimodality treatment gives satisfactory results with low morbidity and mortality rates and acceptable survival.
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Affiliation(s)
- Abdelrahman Mohamed Abdelrahman
- Department of Surgery, National Cancer Institute, Cairo University, Cairo, Egypt Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt Department of Radiotherapy, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ismael Abdelmonem Mourad
- Department of Surgery, National Cancer Institute, Cairo University, Cairo, Egypt Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt Department of Radiotherapy, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Rabab Mohamed Gaafar
- Department of Surgery, National Cancer Institute, Cairo University, Cairo, Egypt Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt Department of Radiotherapy, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Hisham Abdelkader Elhossieny
- Department of Surgery, National Cancer Institute, Cairo University, Cairo, Egypt Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt Department of Radiotherapy, National Cancer Institute, Cairo University, Cairo, Egypt
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Current treatment concepts of Pancoast tumors. Eur Surg 2010. [DOI: 10.1007/s10353-010-0556-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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State of the art management in spine oncology: a worldwide perspective on its evolution, current state, and future. Spine (Phila Pa 1976) 2009; 34:S7-20. [PMID: 19816243 DOI: 10.1097/brs.0b013e3181bac476] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A review of the past and current status of the evolving field of spine oncology. OBJECTIVE To provide a framework of reference for developments in the field, particularly the rapidly evolving field of molecular biology, as well as contemporary practice in the management of spine tumors. METHODS Literature review of the surgical treatment of spine tumors in the past and present, the emerging radiologic and biologic technologies, as well as the field of targeted therapy in cancer and the economic implications of technological advances. RESULTS A vast contemporary literature is currently available that provides a clear rational basis for treatment. Most treatment recommendations are currently based on retrospective data and small Phase II prospective studies. Treatment paradigms continue to evolve without their relative merits being evaluated by randomized controlled trials. The current lack of randomized trials in spine oncology reflect both the rarity of spine tumors and strongly held biases based on retrospective studies and institutional bias. CONCLUSION Spine oncology is a rapidly evolving field with contributions in surgery, radiation therapy, and targeted chemotherapy resulting in overall improvement in quality of life and survival in patients with spine tumors. However, the economic consequences of these improvements are substantial and need to be kept in proper perspective.
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Abstract
Pancoast tumors (superior sulcus tumors or apical lung tumors) typically invade structures at the thoracic outlet, including the inferior elements of the brachial plexus (C8, T1 nerve roots and lower trunk). Historically, these tumors are rapidly fatal, but newer treatment with induction chemotherapy and radiotherapy, followed by surgical resection of the tumor has resulted in improved patient survival. To accomplish oncologic excision, resection of the involved brachial plexus elements is still standard practice in most centers, resulting in loss of hand function and/or development of neuropathic pain. We present a modification of this protocol that incorporates induction chemoradiation, surgical resection of the lung tumor by a thoracic surgeon, and neurolysis and preservation of the brachial plexus by a neurosurgeon. Improved survival outcome, especially in patients demonstrating a pathologic complete response, with preservation of hand function, supports our hypothesis that involved brachial plexus does not need resection in these patients.
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Yıldızeli B, Dartevelle PG, Fadel E, Mussot S, Chapelier A. Results of Primary Surgery With T4 Non–Small Cell Lung Cancer During a 25-Year Period in a Single Center: The Benefit is Worth the Risk. Ann Thorac Surg 2008; 86:1065-75; discussion 1074-5. [PMID: 18805134 DOI: 10.1016/j.athoracsur.2008.07.004] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 07/01/2008] [Accepted: 07/02/2008] [Indexed: 10/21/2022]
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Bruzzi JF, Komaki R, Walsh GL, Truong MT, Gladish GW, Munden RF, Erasmus JJ. Imaging of Non–Small Cell Lung Cancer of the Superior Sulcus. Radiographics 2008; 28:551-60; quiz 620. [DOI: 10.1148/rg.282075709] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kunitoh H, Kato H, Tsuboi M, Shibata T, Asamura H, Ichinose Y, Ichonose Y, Katakami N, Nagai K, Mitsudomi T, Matsumura A, Nakagawa K, Tada H, Saijo N. Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806. J Clin Oncol 2008; 26:644-9. [PMID: 18235125 DOI: 10.1200/jco.2007.14.1911] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of preoperative chemoradiotherapy followed by surgical resection for superior sulcus tumors (SSTs). PATIENTS AND METHODS Patients with pathologically documented non-small-cell lung cancer with invasion of the first rib or more superior chest wall were enrolled as eligible; those with distant metastasis, pleural dissemination, and/or mediastinal node involvement were excluded. Patients received two cycles of chemotherapy every 4 weeks as follows; mitomycin 8 mg/m(2) on day 1, vindesine 3 mg/m(2) on days 1 and 8, and cisplatin 80 mg/m(2) on day 1. Radiotherapy directed at the tumor and the ipsilateral supraclavicular nodes was started on day 2 of each course, at the total dose of 45 Gy in 25 fractions, with a 1-week split. Thoracotomy was undertaken 2 to 4 weeks after completion of the chemoradiotherapy. Those with unresectable disease received boost radiotherapy. RESULTS From May 1999 to November 2002, 76 patients were enrolled, of whom 20 had T4 disease; 75 patients were fully assessable. Chemoradiotherapy was generally well tolerated. Fifty-seven patients (76%) underwent surgical resection, and pathologic complete resection was achieved in 51 patients (68%). There were 12 patients with pathologic complete response. Major postoperative morbidity, including chylothorax, empyema, pneumonitis, adult respiratory distress syndrome, and bleeding, was observed in eight patients. There were three treatment-related deaths, including two deaths owing to postsurgical complications and one death owing to sepsis during chemoradiotherapy. The disease-free and overall survival rates at 3 years were 49% and 61%, respectively; at 5 years, they were 45% and 56%, respectively. CONCLUSION This trimodality approach is safe and effective for the treatment of patients with SSTs.
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Affiliation(s)
- Hideo Kunitoh
- Department of Medical Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
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Massard G. Critères de qualité de la chirurgie d’exérèse des cancers bronchiques non microcellulaires. Rev Mal Respir 2007. [DOI: 10.1016/s0761-8425(07)78133-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Davis GA, Knight S. Pancoast tumor resection with preservation of brachial plexus and hand function. Neurosurg Focus 2007. [DOI: 10.3171/foc.2007.22.6.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Pancoast tumors are aggressive bronchogenic lesions of the lung apex that are rapidly fatal if untreated. Modern treatment includes induction chemotherapy and radiotherapy prior to resection, but many authors also resect the T-1 nerve root (with or without the C-8 nerve root and the lower trunk of the brachial plexus) as part of the therapy, causing significant loss of hand function in many patients. The current authors determined whether a different approach allowing preservation of the brachial plexus and hand function could be adopted without compromising patient survival. An extensive historical review of Pancoast tumors is presented as a baseline for clinical comparison.
Methods
Five patients harboring Pancoast tumors with brachial plexus involvement underwent surgery performed by both a neurosurgeon and thoracic surgeon. In all cases the tumor was resected from the brachial plexus using neurolysis while preserving the C-8 and T-1 nerve roots and lower trunk of the brachial plexus.
Results
One patient died 3 years posttreatment; the other four patients remain alive and well 2 to 5 years postoperatively. Hand function improved or remained normal in all four survivors, with postoperative intrinsic hand muscle function being Louisiana State University Medical Center Grade 5 in each patient. These results (2-year survival rate of 100%) compare favorably with the Southwest Oncology Group Data (overall 2-year survival rate of 55%; 70% in patients who had undergone complete resection). With a minimum 2-year follow-up, 80% of patients remained alive and well, with normal hand function.
Conclusions
Although this patient series is small, the findings are extremely encouraging and suggest that the described treatment paradigm preserves survival as well as hand function in patients with Pancoast tumors.
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Affiliation(s)
- Gavin A. Davis
- 1Department of Neurosurgery, Cabrini Hospital
- 2Department of Neurosurgery, Austin Hospital and
| | - Simon Knight
- 3Department of Thoracic Surgery, Austin Hospital, Victoria, Australia
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Rusch VW, Giroux DJ, Kraut MJ, Crowley J, Hazuka M, Winton T, Johnson DH, Shulman L, Shepherd F, Deschamps C, Livingston RB, Gandara D. Induction Chemoradiation and Surgical Resection for Superior Sulcus Non–Small-Cell Lung Carcinomas: Long-Term Results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol 2007; 25:313-8. [PMID: 17235046 DOI: 10.1200/jco.2006.08.2826] [Citation(s) in RCA: 260] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTraditional treatment for superior sulcus non–small-cell lung cancers (SS NSCLC), radiation plus surgery, yields a 50% rate of complete resection and a 30% 5-year survival. On the basis of improved outcomes in other subsets of stage III NSCLC, this trial tested the feasibility of induction chemoradiotherapy for SS NSCLC.Patients and MethodsPatients with T3-4, N0-1 SS NSCLC received two cycles of cisplatin and etoposide concurrently with radiation (45 Gy). Patients with stable or responding disease underwent thoracotomy. All patients received two more cycles of chemotherapy. Survival was calculated by the Kaplan-Meier method and prognostic factors were assessed by Cox regression analysis.ResultsFrom April 1995 to November 1999, 110 eligible patients (76 men, 34 women) were entered onto the study (78 T3, 32 T4 tumors). Induction therapy was completed by 104 (95%) patients. Of 95 patients eligible for surgery, 88 (80%) underwent thoracotomy, two (1.8%) died postoperatively, and 83 (76%) had complete resection. Pathologic complete response (CR) or minimal microscopic disease was seen in 61 (56%) resection specimens. Five-year survival was 44% for all patients and 54% after complete resection, with no difference between T3 and T4 tumors. Pathologic CR led to better survival than when any residual disease was present (P = .02). Disease progression occurred mainly in distant sites.ConclusionThis combined-modality approach is feasible and is associated with high rates of complete resection and pathologic CR in both T3 and T4 tumors. Local control and overall survival seem markedly improved relative to previous studies of radiation plus resection.
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Affiliation(s)
- Valerie W Rusch
- Thoracic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Girard N, Mornex F. Traitement des tumeurs de l'apex: un modèle de stratégie multimodale dans les cancers bronchiques localement évolués. Cancer Radiother 2007; 11:59-66. [PMID: 17197220 DOI: 10.1016/j.canrad.2006.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 11/21/2006] [Accepted: 11/23/2006] [Indexed: 10/23/2022]
Abstract
Superior sulcus tumors have been individualized among other non-small cell lung cancers because of their characteristic clinical presentation in connection with their local extension to the chest wall and the brachial plexus. For a long time considered as marginally resectable, superior sulcus tumors have been treated since the early 1960's, with a combined approach including preoperative radiotherapy and curative-intent surgery. Surgical resection includes both thoracic, cervical and neurosurgical approach, and aims at obtaining complete resection, which has been identified as a determining prognostic factor in most reported series. Two recent phase II trials showed the benefit, both regarding resectability and local control rates, and survival of combined therapeutic strategies including induction platinum-based chemoradiation, extensive surgical resection, and adjuvant chemotherapy. Adjuvant radiotherapy is not recommended at the time, but needs to be re-evaluated regarding its recent technical optimisation. Similarly to other locally advanced non-small cell lung cancers, exclusive chemoradiation is the standard treatment of unresectable superior sulcus tumors. In this way, radiotherapy has shown to offer a prolonged analgesia in more than 75% of cases, and is associated with concurrent or sequential chemotherapy, with comparable results to those observed in stage III lung cancer. These developments make superior sulcus tumors a therapeutic model for locally advanced non-small cell lung cancer, whereby the benefit of combined multimodal strategies including induction chemoradiation and surgical resection are currently evaluated in phase III trials.
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Affiliation(s)
- N Girard
- Département de radiothérapie-oncologie, centre hospitalier Lyon-Sud, 165, hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, Lyon, France
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Chadeyras JB, Mazel C, Grunenwald D. Résection vertébrale monobloc pour cancer pulmonaire : 12 ans d'expérience. ACTA ACUST UNITED AC 2006; 131:616-22. [PMID: 16859631 DOI: 10.1016/j.anchir.2006.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 06/22/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To report a single-institution retrospective study of radical en bloc resection for lung cancer invading the spine. METHODS Between 1993 and 2004, 32 patients underwent partial or total vertebrectomy for non-small cells lung cancer with spinal extension. Twenty-one received induction treatment (chemotherapy, N=16; radiation, N=1 and chemoradiotherapy, N=4). Pneumonectomy was performed in 3 patients, lobectomy in 26 patients and wedge resection in 3 patients. Partial vertebrectomy was performed in 26 patients and total vertebrectomy was performed in 6 patients. Tumor stage was IIb in 9 patients, IIIa in 2 patients and IIIb in 21 patients. RESULTS There was no immediate postoperative mortality. Major morbidity was observed in 10 patients (31%), including 4 complications related to spinal surgery. For 28 patients, a completed resection was achieved (87%). 2-years survival was 65% and 5-years survival was 24%. Completed resection and induction chemotherapy appear to be determinant prognostics factors (respectively p=0,01 and p=0,04 in univariate analysis). CONCLUSION Radical en bloc resection with vertebrectomy for lung cancer is technically demanding. Encouraging long-term survival suggest that this surgical approach could be a valid option for selected patients with vertebral involvement of lung cancer.
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Affiliation(s)
- J-B Chadeyras
- Service de Chirurgie Générale à Orientation Thoracique, CHU Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
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Abstract
Non-small-cell lung carcinomas of the superior sulcus, frequently termed Pancoast tumours, are some of the most challenging thoracic malignant diseases to treat because of their proximity to vital structures at the thoracic inlet. Originally deemed universally fatal, Pancoast tumours are now amenable to curative treatment because of improvements in combined modality therapy and development of new techniques for resection. This review includes discussion of anatomical considerations, initial assessment, multimodality treatment, and surgical approaches for these cancers.
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Affiliation(s)
- Valerie W Rusch
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Narayan S, Thomas CR. Multimodality therapy for Pancoast tumor. ACTA ACUST UNITED AC 2006; 3:484-91. [PMID: 16955087 DOI: 10.1038/ncponc0584] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 05/31/2006] [Indexed: 11/09/2022]
Abstract
The management of Pancoast tumors has challenged surgeons and radiation and medical oncologists over several decades. Retrospective studies have raised a greater awareness of the importance of positive N2 lymph nodes in terms of prognosis and treatment decision making. While patients with positive N2 lymph nodes have generally been excluded from trials of preoperative chemoradiation for superior sulcus tumors, the potential of surgery for these patients is still being evaluated. The role of PET for initial staging as well as for assessment of disease response to induction therapy continues to evolve. The use of combined treatment modalities has enhanced the progress in successfully treating Pancoast tumors. The historical data showing improved results with a combination of surgery and radiation compared with surgery alone for patients with positive N2 nodes provides the basis for several important clinical trials that integrate the use of chemotherapy into the treatment paradigm. The Southwest Oncology Group and Japanese Clinical Oncology Group have shown dramatic improvements in complete resection rates following a neoadjuvant course of combined chemotherapy and radiation therapy compared with historical series. We discuss relevant ongoing clinical trials that include consolidative taxane-based chemotherapy and the role of prophylactic cranial irradiation in complete responders. Future potential areas of investigation, including the role of surgery for patients with N2-positive disease and the use of imaging to assess response after induction therapy, are discussed.
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Affiliation(s)
- Samir Narayan
- Department of Radiation Oncology, University of California Davis Health System, 4501 X Street, Sacramento, CA 95817, USA.
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Affiliation(s)
- Juan A Garcia
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
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Abstract
The management and outcome for superior sulcus tumors have remained unchanged for 40 years. The rarity of these tumors has led to varying treatment techniques spanning decades, from which no solid conclusions can be drawn. Recent advances in combined-modality therapy have offered the first inkling that a paradigm shift is on the horizon. Here, we review the history and new advances in treating this challenging pulmonary neoplasm.
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Affiliation(s)
- Victor C Archie
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, Texas 78229, USA
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Aydinli U, Gebitekin C, Bayram S, Ozturk C, Ersozlu S. Surgical approach in T4N0M0 (vertebral involvement) lung cancer. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2004; 14:142-6. [PMID: 27517179 DOI: 10.1007/s00590-004-0147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2004] [Accepted: 03/15/2004] [Indexed: 10/26/2022]
Abstract
Approximately 5% of the cancers involve the chest wall and spine by direct extension and remain localized at the time of diagnosis. T4 lesions invading the vertebra are considered inoperable. We reviewed a new evolution in the surgical treatment of lung cancer involving the vertebra (T4N0M0) and report preliminary results of our approach. Four patients with T4N0M0 (vertebral involvement) lung cancer underwent en bloc surgical resection of tumor between 1998 and 2002. Posterior stabilization, hemilaminectomy, and osteotomy of the involved vertebral bodies below the corresponding pedicle were performed in the prone position and then, in the lateral position, en bloc resection was completed along with the lung resection (large wedge resection or lobectomy) and involved vertebral bodies. There was no immediate postoperative mortality. Three patients died during the follow-up period at the 6th, 8th, and 14th postoperative months with a postoperative recognized metastasis. The fourth patient was in follow-up at 20 months. Although T4N0M0 (vertebral involvement) lung cancers are considered inoperable, lung resection with hemivertebrectomy of the involved vertebra after neoadjuvant chemotherapy and radiotherapy is an alternative treatment in this type of lung cancer. Staging should be made meticulously for the expected surveillance.
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Affiliation(s)
- Ufuk Aydinli
- Department of Orthopedic Surgery, Faculty of Medicine, Uludag University, 16059, Görükle, Bursa, Turkey.
| | - Cengiz Gebitekin
- Department of Thorax Surgery, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Sami Bayram
- Department of Thorax Surgery, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Cagatay Ozturk
- Department of Orthopedic Surgery, Faculty of Medicine, Uludag University, 16059, Görükle, Bursa, Turkey
| | - Salim Ersozlu
- Department of Orthopedic Surgery, Faculty of Medicine, Uludag University, 16059, Görükle, Bursa, Turkey
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Thomas-de-Montpréville V, Chapelier A, Fadel E, Mussot S, Dulmet E, Dartevelle P. Chest wall resection for invasive lung carcinoma, soft tissue sarcoma, and other types of malignancy. Pathologic aspects in a series of 107 patients. Ann Diagn Pathol 2004; 8:198-206. [PMID: 15290670 DOI: 10.1053/j.anndiagpath.2004.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
With improvements in surgical techniques for resection and reconstruction of the chest wall, pathologists are confronted with complicated surgical specimens. There are no currently available guidelines specifically dedicated to the handling of these specimens. Extended resections of lung carcinoma chest wall invasions may change the clinical value of some TNM subsets. We reviewed a series of 107 consecutive malignant tumors involving the chest wall and resected in our institution during a 3-year period. The 107 patients included 39 females and 68 males aged 6 to 80 years (mean, 53 years). Ninety-eight cases (92%) were en bloc resection. There were 55 invasions by lung carcinomas including 19 Pancoast tumors. With the current TNM classification, five lung carcinomas, treated with vertebral body resection because of vertebral foramina invasion, were T3. Four lung carcinomas were N3 or M1 only because of supraclavicular or chest wall lymph node invasion. Other tumors included 20 primary soft-tissue tumors, 13 primary skeletal tumors, 12 metastases, four local invasions by breast tumors, and three miscellaneous lesions. Resected structures included one to six ribs (mean, 2.6; n = 89), thoracic inlet (n = 24), three or four vertebral bodies (n = 13), sternum (n = 17), clavicles (n = 15), shoulder blade (n = 4), upper limb (n = 2), skin (n = 29), lung (n = 64), diaphragm (n = 2), and mediastinum (n = 2). Ten cases were incomplete resections including five because of vertebral body or vertebral foramina tumor invasion. The study of surgical specimens resulting from resection of malignant tumors of the chest wall is complicated because of the variety of both tumor histologic types and involved anatomic structures. Specimen radiograms have a great informative value. Assessment of surgical margins, especially vertebral foramina, is imperative. In lung carcinomas invading the chest wall, we suggest that vertebral foramina invasion could be classified T4 and that the prognostic value of chest wall lymph nodes isolated invasions should be assessed for a possible N1 classification.
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Abstract
PURPOSE OF REVIEW The treatment of lung cancer has been most successful when surgery is involved. This review is a succinct overview of lung cancer treatment from the thoracic surgeon's perspective over the past 2 years. RECENT FINDINGS Starting with the evidence-based guidelines developed by the American College of Chest Physicians, the main themes in the literature are a multimodality approach and the miniaturization of surgical approaches. Palliative procedures, staging, and extension of surgery to patients previously thought inoperable are other subjects covered. SUMMARY We are standing on the verge of having a definitive answer to the 20-year-old question whether adjuvant or neoadjuvant chemotherapy benefits patients with early-stage non-small cell lung cancer. Sufficient data will be available shortly to determine whether minimally invasive surgical approaches yield similar long-term outcomes as traditional approaches.
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Affiliation(s)
- Thomas V Bilfinger
- Department of Surgery, State University of New York at Stony Brook, Stony Brook, New York 11794, USA.
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Fibla JJ, Penagos JC, León C. [Pseudo-pancoast syndrome caused by a solitary fibrous tumor of the pleura]. Arch Bronconeumol 2004; 40:244-5. [PMID: 15117627 DOI: 10.1016/s1579-2129(06)70093-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Tumors of the superior sulcus are an uncommon form of NSCLC and historically have been associated with high rates of incomplete resection, local recurrence, and death. Recent data from a multi-institutional study suggest that preoperative chemoradiation may improve the rates of complete resection and cure. Involvement of the vertebral body or brachial plexus, areas once considered unresectable, is amenable to advanced techniques of spinal reconstruction and may lead to long-term survival in selected patients.
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Affiliation(s)
- Michael S Kent
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, USA
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Fibla J, Penagos J, León C. Seudosíndrome de Pancoast por un tumor fibroso solitario pleural. Arch Bronconeumol 2004. [DOI: 10.1016/s0300-2896(04)75514-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Alifano M, D'Aiuto M, Magdeleinat P, Poupardin E, Chafik A, Strano S, Regnard JF. Surgical treatment of superior sulcus tumors: results and prognostic factors. Chest 2003; 124:996-1003. [PMID: 12970029 DOI: 10.1378/chest.124.3.996] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To study the clinical characteristics, treatment modalities, and outcome of patients with superior sulcus tumors who underwent surgery over a 15-year period. DESIGN Retrospective clinical study. METHODS Clinical records of all patients operated on for superior sulcus tumors by the same surgical team between 1988 and 2002 were reviewed retrospectively. RESULTS Sixty-seven patients were operated on in this period. All the patients underwent en bloc lung and chest wall resection. Surgical approaches were as follows: posterolateral thoracotomy according to Paulson (n = 33), combined transcervical and transthoracic approach (n = 33), and isolated transcervical approach (n = 1). Types of pulmonary resection included lobectomies (n = 59), pneumonectomies (n = 2), and wedge resections (n = 6). Pathologic stages were IIB, IIIA, and IIIB in 49 cases, 12 cases, and 6 cases, respectively. Resection was complete in 55 patients (82%). Operative mortality was 8.9% (n = 6). Postoperative treatment was administered in 53 patients (radiotherapy, n = 42; chemoradiotherapy, n = 9; and chemotherapy, n = 2). Overall 2-year and 5-year survival rates were 54.2% and 36.2%, respectively. Five-year survival was significantly higher after complete resection than after incomplete resection (44.9% vs 0%, p = 0.000065). The presence of associated major illness negatively affected the outcome (5-year survival, 16.9% vs 52%; p = 0.043). Age, weight loss, respiratory impairment, tumor size, presence of nodal disease, and histologic type did not influence the long-term outcome. At multivariate analysis, only the completeness of resection and the absence of associated major comorbidities had an independent positive prognostic value. CONCLUSIONS Superior sulcus tumor remains an extremely severe condition, but long-term survivals may be achieved in a large percentage of cases. The presence of associated major illness and the completeness of resection are the two most important factors affecting the long-term outcome.
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Affiliation(s)
- Marco Alifano
- Unité de Chirurgie Thoracique, Hôtel-Dieu, AP-HP, 1 Place du Parvis Nôtre-Dame, 75004 Paris, France
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Abstract
Our understanding of superior sulcus tumors has evolved over time. The unique feature of Pancoast tumors is their location, in which the anatomy poses limitations to resection. Many resections are found to be incomplete, and the majority of recurrences have involved local failure. New surgical approaches allow greater flexibility according to tumor location and may improve these outcomes. Furthermore, new approaches permit complete resection of tumors involving vertebral bodies or the neural foramina. Traditionally, preoperative radiotherapy has been used, but a recent prospective phase II study suggests that preoperative concurrent chemoradiotherapy improves the rate of complete resection, local recurrence, and intermediate-term survival.
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Affiliation(s)
- Frank C Detterbeck
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7065, USA.
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Spaggiari L. Anterior approach versus posterior approach in apical chest tumor: surgeon's choice or oncological need? Ann Thorac Surg 2003; 75:633-4; author reply 634. [PMID: 12607698 DOI: 10.1016/s0003-4975(02)04268-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Anterior approach versus posterior approach in apical chest tumor: surgeon’s choice or oncological need?: Reply. Ann Thorac Surg 2003. [DOI: 10.1016/s0003-4975(02)04267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Affiliation(s)
- Ugo Pastorino
- Thoracic Surgery Division, European Institute of Oncology, Milan, Italy.
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