Percutaneous needle biopsy of the lung in cases of superior sulcus tumor

The management of superior sulcus tumors

Lung cancers arising from the extreme apex of the lung-superior sulcus tumors (SST)-have distinct symptoms and signs at presentation and a characteristic appearance on imaging. However, in their early stages, these tumors are often missed by traditional anterior/posterior chest X-rays. Recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) have made selection of patients with potentially resectable of SST more accurate. If mediastinoscopy reveals no mediastinal lymph nodes involved, the patient can be treated with surgery followed by radiation therapy with or without chemotherapy. If mediastinoscopy reveals microscopic mediastinal lymph node involvement, the patient can be treated with induction radiation therapy and concurrent chemotherapy followed by surgery. If mediastinoscopy reveals gross mediastinal lymph node involvement (N2), or if CT reveals N3 or T4 lesions, the patient can be treated with concurrent chemotherapy and radiation therapy to relieve symptoms; the outcome of such treatment appears to be better than that of sequential chemotherapy followed by radiation therapy. Whenever possible, to enhance the patient's quality of life, surgery should be considered to improve function and relieve pain.

Cervical approach for percutaneous needle biopsy of Pancoast tumors

Aspiration needle biopsy techniques have simplified the cytohistological diagnosis of peripheral pulmonary lesions, particularly those close to or involving the chest wall. In the past, the inaccessibility of some Pancoast tumors in the thoracic inlet posed difficulty in obtaining histological proof before combined therapy was instituted, except in the case of large apical tumors. A safe and accurate technique for percutaneous needle biopsy of tumors in the superior pulmonary sulcus using a cervical approach has been developed. We have found that this technique is easy to perform and more productive for small or shallow lesions at the extreme apex than are needle biopsies performed through a posterior approach, and that it makes open biopsy unnecessary.

Pancoast's syndrome and small cell lung cancer

Four patients with small cell lung cancer (SCC) presenting with Pancoast's syndrome are described. Superior sulcus tumors are usually caused by epidermoid carcinoma or adenocarcinoma of the lung, and are routinely treated with radiotherapy followed by radical surgery. SCC, on the other hand, is widely disseminated at diagnosis and is best treated with chemotherapy. Although not previously reported as a cause of Pancoast's tumor, these four cases of SCC presenting as such clearly indicate the need for pretreatment histologic diagnosis to avoid unnecessary surgical intervention. Transcutaneous needle aspiration biopsy is a means by which the diagnosis can be safely made in patients presenting with apical lung tumors.