Surgical Treatment of Superior Sulcus Tumors: A 15-Year Single-center Experience

A Patient With Pancoast Tumor Presenting With Cervical Radiculopathy: A Case Report

Objective

The purpose of this report was to describe a patient with a Pancoast tumor who presented for chiropractic care with neck and arm pain.

Clinical Features

A 52-year-old male patient with right-sided cervicothoracic pain and numbness in the right upper extremity presented to a chiropractic office for care. The patient reported an occupational history of repetitive lifting motions and overuse injuries. The patient denied history of smoking at the time of presentation.

Intervention and Outcome

Radiographic imaging revealed tracheal deviation. A chest computed tomography image demonstrated a large lesion in the apex of the right lung, suggestive of bronchogenic carcinoma. The patient was referred to an oncology clinic, where he admitted to having a 20-year history of smoking. The diagnosis of adenocarcinoma was made via biopsy, and the oncologist's evaluation confirmed the cancer to be stage IIIC. The patient received palliative care treatments, as the advanced state of his condition determined that he was not a candidate for surgical intervention.

Conclusion

Chiropractors and other first-contact health care providers must keep in mind unusual presentations masquerading as common conditions. This case demonstrates the importance of including apical lung tumors in the differential diagnosis of unilateral arm and neck pain and neurologic deficits of the upper extremity. This case demonstrates the importance of thorough follow-up on images ordered, including the ordering clinicians viewing the images themselves.

Surgical management of superior sulcus tumors: A twenty-year experience of an oncological high volume referral centre

Objectives

Superior sulcus tumour, which affects the lung's apex, is an uncommon subtype of non-small cell lung cancer (NSCLC). The current study examined the clinical characteristics and management of superior sulcus NSCLC patients in a high-volume referral oncological centre over 22 years.

Methods

Retrospective review of 100 surgeries with curative intent for superior sulcus NSCLC over 22 years (July 1998 - December 2020). The surgical approach was defined according to the lesion site and the anatomy of the thoracic inlet. Survival curves, including non-cancer-related deaths, were drawn using the Kaplan-Meier methods, and the log-rank test was used to evaluate differences in survival across groups of patients. Cox proportional hazards regression was used to assess the association between selected clinical and pathologic characteristics on OS.

Results

54 patients received induction treatments. The surgical approach was anterior thoracotomy in 53 patients, Paulson incision in 30, and a combined in 8. The median postoperative length of stay was 11 days (range: 5 - 27 days). Overall 90-day mortality was 6.93%. The median OS was 24.3 months. After a median follow-up of 3 years, 5-year and 10-year OS rates were 33.9% and 26.4%, respectively. A significantly lower 5-year OS was observed in patients with the nodal disease (46.6% in pN0 vs 13.2% in pN+; p = 0.024), without preoperative treatments (41.0% in patients without preoperative treatments versus 17.4%; p = 0.09) and anteriorly located tumour (anterior vs posterior: 17.4% vs 49.1%; p = 0.032). Cox proportional hazards regression showed better survival in the pT1 stage (HR = 4.6; 95% CI: 1.9 - 11.2; p = 0.00076) and in R0 (HR = 4.2; 95% CI: 1.4 - 12.5; p = 0.010).

Conclusions

Superior sulcus tumours still represent a life-threatening condition that, while curable in a significant proportion of cases, requires complex procedures with high surgical risks and a multimodality treatment setting. An optimal surgical approach should be planned to maximise resection completeness and survival. Other factors affecting survival are related to tumour staging, emphasising the importance of a meticulous preoperative workup and candidate selection to identify those expected to benefit from a survival benefit.

Cost-effectiveness analysis of the new oncological drug durvalumab in Italian patients with stage III non-small cell lung cancer

Background

The monoclonal antibody durvalumab, an immune‐checkpoint inhibitor (ICI) antiprogrammed death ligand 1 (PD‐L1), is available for unresectable stage III NSCLC patients as consolidation therapy following induction chemoradiotherapy, with very promising overall survival (OS) and progression‐free survial (PFS) results in registration trials. The purpose of this study was to provide policymakers with an estimate of the cost‐effectiveness of durvalumab in the treatment of non‐small cell lung cancer (NSCLC).

Methods

The study developed a Markov model covering a 5‐year period to compare costs and outcomes of treating PD‐L1 positive patients with or without durvalumab. We conducted a series of sensitivity analyses (Tornado analysis and Monte Carlo simulation) by varying some parameters to assess the robustness of our model and identify the parameters with the greatest impact on cost‐effectiveness.

Results

Prior to the release of durvalumab, the management of NSCLC over a 5‐year period cost €33 317 per patient, with an average life expectancy of 2.01 years. After the introduction of the drug, this increased to €37 317 per patient, with an average life expectancy of 2.13 years. Treatment with durvalumab led to an incremental cost‐effectiveness ratio (ICER) of €35 526 per year. OS is the variable that contributes the most to the variability of the ICER.

Conclusions

The study observed that durvalumab is a cost‐effective treatment option for patients with unresectable stage III NSCLC.

Individualized surgical treatment for patients with tumours of the cervicothoracic junction

OBJECTIVES

The cervicothoracic junction is a special section that connects the neck, thoracic cavity, mediastinum and axilla. Tumours in the region often invade or compress surrounding tissues and organs, which makes the surgical treatment difficult.

METHODS

A retrospective analysis involving 69 patients with tumours at the cervicothoracic junction. Clinical data with regard to manifestation, surgical approach, resection degree, outcome and pathological types were collected.

RESULTS

A total of 48 cases of asymptomatic patients and 21 cases of patients with ≥1 clinical manifestation were enrolled in the study. Twenty-seven patients received radical resection with video-assisted thoracoscopic surgery. Anterior approach was the predominant treatment method in open surgery (25 cases, 36.2%), while the anterolateral approach was used in 8 cases (6 cases of hemiclamshell incisions and 2 cases of trap-door incisions). In addition, we observed 1 case of posterior approach, 2 cases of posterolateral approach and 1 case of supraclavicular approach combined with posterolateral approach. Pathological examination results revealed 67 cases of radical resection and 2 cases of microscopic residual. Neurilemmoma was the most widespread pathological type (30 cases, 43.5%), followed by tumour originating from fibrous tissues (5 cases, 7.2%). A 3-year overall survival rate of the 69 patients was 89.9%, while a 5-year overall survival rate was 85.5%.

CONCLUSIONS

Tumours associated with the cervicothoracic junction are characterized by their unique location, complex anatomy and various histopathological subtypes. An individualized approach during surgery enhances safety and standardized of treatments for patients with tumours located at the cervicothoracic junction.

Estimated direct costs of non-small cell lung cancer by stage at diagnosis and disease management phase: A whole-disease model

Background

Non‐small cell lung cancer (NSCLC) is the first cause of cancer‐related death among men and the second among women worldwide. It also poses an economic threat to the sustainability of healthcare services. This study estimated the direct costs of care for patients with NSCLC by stage at diagnosis, and management phase of pathway recommended in local and international guidelines.

Methods

Based on the most up‐to‐date guidelines, we developed a very detailed “whole‐disease” model listing the probabilities of all potentially necessary diagnostic and therapeutic actions involved in the management of each stage of NSCLC. We assigned a cost to each procedure, and obtained an estimate of the total and average per‐patient costs of each stage of the disease and phase of its management.

Results

The mean expected cost of a patient with NSCLC is 21,328 € (95% C.I. −20 897−22 322). This cost is 16 291 € in stage I, 19530 € in stage II, 21938 € in stage III, 22175 € in stage IV, and 28 711 € for a Pancoast tumor. In the early stages of the disease, the main cost is incurred by surgery, whereas in the more advanced stages radiotherapy, medical therapy, treatment for progressions, and supportive care become variously more important.

Conclusions

An estimation of the direct costs of care for NSCLC is fundamental in order to predict the burden of new oncological therapies and treatments on healthcare services, and thus orient the decisions of policy‐makers regarding the allocation of resources.

Key points

Significant findings of the study

The high costs of surgery make the early stages of the disease no less expensive than the advanced stages.

What this study adds

An estimation of the direct costs of care is fundamental in order to orient the decisions of policy‐makers regarding the allocation of resources.

The Favorable Prognostic Factors for Superior Sulcus Tumor: A Systematic Review and Meta-Analysis

Background: Superior sulcus tumor is a rare non-small cell lung cancer with poor prognosis. Exploring the potential prognostic factors of patients with superior sulcus tumor and adopting individualized treatment for patients with different prognostic factors are of great significance for the prolongation of patients' lives. To figure out the prognostic factors of upper sulcus tumors, a meta-analysis was conducted.

Method: We searched all the articles published until January 2020 in PubMed, Embase, and Web of Science databases, and the search strategy included the following terms, combining superior sulcus tumor and prognosis. Hazard ratio (HR) with associated confidential interval (CI) was evaluated for the purpose of investigating prognostic factors for superior sulcus tumor. STATA 16.0 was used for analysis of extracted data and assessment of publication bias.

Result: Fifteen eligible studies, which had 1,009 patients with superior sulcus tumor, were included in this meta-analysis. The studies were published between 1994 and 2018, and the patient recruitment periods ranged from 1974 to 2016. The median follow-up time ranged from 18 to 95 months. The meta-analysis indicated that lower T stage (HR, 1.63; 95% CI, 1.35–1.97), lower N stage (HR, 3.08; 95% CI: 2.37–3.99), negative surgical margin (HR, 0.25; 95% CI, 0.17–0.38), and pathologic complete response (HR, 0.55; 95% CI, 0.39–0.77) were favorable prognostic factors.

Conclusion: We found that T stage, N stage, surgical margin, and pathologic complete response are prognostic factors for superior sulcus tumor. To reach a better long-term survival, patients with these negative prognostic factors may need a more aggressive treatment, while more studies should be conducted to further validate these results and explore a more effective treatment.

Treatment of clinical T4 stage superior sulcus non-small cell lung cancer: a propensity-matched analysis of the surveillance, epidemiology, and end results database

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.

Robotic Hybrid Approach for an Anterior Pancoast Tumor in a Severely Obese Patient

Several different surgical approaches to anterior Pancoast tumors have been proposed. The osteomuscular-sparing transmanubrial approach allows optimal exposure and control of apical chest wall structures, but it requires an additional thoracotomy to perform the lobectomy with radical lymph node resection. The presented technique combines the osteomuscular-sparing transmanubrial approach with robotic-assisted upper lobectomy in a severely obese patient, thereby reducing the invasiveness of the surgical approach and the postoperative complications.