Pancoast (superior sulcus) neoplasms

Acroparesthesias: An Overview

Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.

Survival in Surgical and Nonsurgical Patients With Superior Sulcus Tumors

BACKGROUND

Treatments for superior sulcus tumor (SST) have evolved, with induction chemoradiotherapy providing an improved R0 resection rate. We reviewed the treatment and outcomes of SSTs in a single institution to identify prognostic factors and optimal treatment strategy.

METHODS

Details of patients who underwent any type of treatment for SST from 1997 through 2014 were retrospectively collected. Survival was calculated by the Kaplan-Meier method. Proportional hazards regression was used to test the prognostic significance of factors in univariate and multivariate models.

RESULTS

Eighty-nine patients were identified, 8 of whom had M1 disease and were excluded from the analysis. Of the 48 surgical patients, 44 received preoperative induction treatments, with 12 (25%) achieving a pathologic complete response (pCR), 23 with minimal residual disease, and 9 with gross residual disease. Complete resection was achieved in 40 surgical cases. As expected, nonsurgical patients had worse survival than did surgical patients (median survival, 2.1 versus 5.8 years; nonsurgical versus surgical hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2-3.7; p = 0.01). By multivariable Cox analysis, smoking status (HR, 4.4; 95% CI, 1.5-13.0; p = 0.01) and previous or concurrent malignancy (HR, 4.73; 95% CI, 1.6-13.9; p = 0.0.005) were prognostic factors for surgical patients. There were no statistically significant prognostic factors for nonsurgical patients.

CONCLUSIONS

Chemoradiotherapy followed by surgical treatment is our favored treatment for operable candidates. Preoperative induction treatments were associated with a 25% pCR rate for surgical patients. Candidates for surgical therapy are expected to have longer survival than those who are not candidates for resection.

Resection of the First Rib With Preservation of the T1 Nerve Root in Pancoast Tumors of the Lung

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.

Trimodality therapy for superior sulcus non-small cell lung cancer: Southwest Oncology Group-Intergroup Trial S0220

BACKGROUND

Although preoperative chemotherapy (cisplatin-etoposide) and radiotherapy, followed by surgical resection, is considered a standard of care for superior sulcus cancers, treatment is rigorous and relapse limits long-term survival. The Southwest Oncology Group-Intergroup Trial S0220 was designed to incorporate an active systemic agent, docetaxel, as consolidation therapy.

METHODS

Patients with histologically proven and radiologically defined T3 to 4, N0 to 1, M0 superior sulcus non-small cell lung cancer underwent induction therapy with cisplatin-etoposide, concurrently with thoracic radiotherapy at 45 Gy. Nonprogressing patients underwent surgical resection within 7 weeks. Consolidation consisted of docetaxel every 3 weeks for 3 doses. The accrual goal was 45 eligible patients. The primary objective was feasibility.

RESULTS

Of 46 patients registered, 44 were eligible and assessable; 38 (86%) completed induction, 29 (66%) underwent surgical resection, and 20 (45% of eligible, 69% surgical, and 91% of those initiating consolidation therapy) completed consolidation docetaxel; 28 of 29 (97%) underwent a complete (R0) resection; 2 (7%) died of adult respiratory distress syndrome. In resected patients, 21 of 29 (72%) had a pathologic complete or nearly complete response. The known site of first recurrence was local in 2, local-systemic in 1, and systemic in 10, with 7 in the brain only. The 3-year progression-free survival was 56%, and 3-year overall survival was 61%.

CONCLUSIONS

Although trimodality therapy provides excellent R0 and local control, only 66% of patients underwent surgical resection and only 45% completed the treatment regimen. Even in this subset, distant recurrence continues to be a major problem, particularly brain-only relapse. Future strategies to improve treatment outcomes in this patient population must increase the effectiveness of systemic therapy and reduce the incidence of brain-only metastases.

Pancoast tumor: the role of magnetic resonance imaging

We report imaging techniques in the definition of the therapeutic planning of a 65-year-old man with a diagnosis of Pancoast tumor. Computed Tomography has a pivotal role in the assessment of nodes involvement and distant metastasis. Magnetic Resonance allows a detailed study of locoregional extension for its high soft tissue resolution. We particularly highlight the actual importance of Magnetic Resonance Neurography, Diffusion-Weighted Imaging, and Magnetic Resonance Angiography techniques in the assessment of the superior sulcus vascular and nervous structures involvement. Their integrity has been showed in our patient with a complete surgical excision of the lesion.

Actinomicose pulmonar simulando tumor de Tobias-Pancoast

A actinomicose é uma infecção rara que pode envolver diversos órgãos. O envolvimento torácico é incomum (10-20%). No presente trabalho, é descrito o caso de um paciente de 33 anos, HIV negativo, com dor torácica posterior à esquerda em queimação com irradiação para membro superior esquerdo e diminuição da força com parestesias. A tomografia computadorizada evidenciou uma massa em contato com a parede torácica. Após realização de toracotomia foi visualizada lesão pulmonar sólida vascularizada aderida no lobo superior esquerdo, infiltrando a parede torácica posterior e ápice da cavidade. A biopsia incisional da lesão e o estudo microbiológico evidenciaram actinomicose.

Pancoast tumor resection with preservation of brachial plexus and hand function

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.

Multimodality therapy for Pancoast tumor

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.

A multidisciplinary approach to management in a patient with bilateral superior sulcus non-small-cell lung carcinoma

Superior sulcus tumors comprise a rare subset of non-small-cell lung carcinomas that are particularly challenging to treat because of their location and extent of nerve and vessel involvement. In this report, we present a case illustrating the uncommon situation of a patient presenting with bilateral superior sulcus tumors, and we review the latest combined therapeutic approach developed to aggressively treat the more common unilateral presentation of these tumors.

Superior Sulcus Tumors: A Mini‐Review

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.