Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus

En bloc chest wall resection in locally advanced cT3N2 (stage IIIB) lung cancer involving the chest wall: Revisiting guidelines

Objectives

Current National Comprehensive Cancer Network guidelines recommend definitive chemoradiation rather than surgery for patients with locally advanced clinical stage T3 and N2 (stage IIIB) lung cancer involving the chest wall. The data supporting this recommendation are controversial. We studied whether surgery confers a survival advantage over definitive chemoradiation in the National Cancer Database.

Methods

We identified all patients with clinical stage T3 and N2 lung cancer in the National Cancer Database from 2004 to 2017 who underwent a lobectomy with en bloc chest wall resection and compared them with patients with clinical stage T3 and N2 lung cancer who had definitive chemoradiation. We used propensity score matching to minimize confounding by indication while excluding patients with tumors in the upper lobes to exclude Pancoast tumors. We used 1:1 propensity score matching and Kaplan-Meir survival analyses to estimate associations.

Results

Of 4467 patients meeting all inclusion/exclusion criteria, 210 (4.49%) had an en bloc chest wall resection. Patients undergoing surgical resection were younger (mean age = 60.3 ± 10.3 years vs 67.5 ± 10.4 years; P < .001) and had more adenocarcinoma (59.0% vs 44.5%; P < .001) but were otherwise similar in terms of sex (37.1% female vs 42.0%; P = .167) and race (Whites 84.3% vs 84.0%; P = .276) compared with the definitive chemoradiation group. After resection, there was an unadjusted 30- and 90-day mortality rate of 3.3% and 9.5%, respectively. A substantial survival benefit with surgical resection persisted after propensity score matching (log-rank P < .001).

Conclusions

In this large observational study, we found that in select patients, en bloc chest wall resection for locally advanced clinical stage T3 and N2 lung cancer was associated with improved survival compared with definitive chemoradiation. National Comprehensive Cancer Network guidelines should be revisited.

Superior sulcus non-small cell lung cancers (Pancoast tumors): Current outcomes after multidisciplinary management

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.

Trimodality Treatment of Superior Sulcus Non-Small Cell Lung Cancer: An Institutional Series of 47 Consecutive Patients

OBJECTIVES

Treatment of superior sulcus tumors (SST) using concurrent chemoradiation followed by surgery is a current standard. However, due to the rarity of this entity, clinical experience in its treatment remains scarce. Here, we present the results of a large consecutive series of patients treated with concurrent chemoradiation followed by surgery at a single academic institution.

MATERIALS AND METHODS

The study group included 48 patients with pathologically confirmed SST. The treatment schedule consisted of preoperative 6-MV photon-beam radiotherapy (45-66 Gy delivered in 25-33 fractions over 5-6.5 weeks) and concurrent two cycles of platinum-based chemotherapy. Five weeks after completion of chemoradiation, pulmonary and chest wall resection was performed.

RESULTS

From 2006 to 2018, 47 of 48 consecutive patients meeting protocol criteria underwent two cycles of cisplatin-based chemotherapy and concurrent radiotherapy (45-66 Gy) followed by pulmonary resection. One patient did not undergo surgery due to brain metastases that occurred during induction therapy. The median follow-up was 64.7 months. Chemoradiation was well tolerated, with no toxicity-related deaths. Twenty-one patients (44%) developed grade 3-4 side effects, of which the most common was neutropenia (17 patients; 35.4%). Seventeen patients (36.2%) had postoperative complications, and 90-day mortality was 2.1%. Three- and five-year overall survival (OS) were 43.6% and 33.5%, respectively, and three- and five-year recurrence-free survival were 42.1% and 32.4%, respectively. Thirteen (27.7%) and 22 (46.8%) patients had a complete and major pathological response, respectively. Five-year OS in patients with complete tumor regression was 52.7% (95% CI 29.4-94.5). Predictive factors of long-term survival included age below 70 years, complete resection, pathological stage, and response to induction treatment.

CONCLUSIONS

Chemoradiation followed by surgery is a relatively safe method with satisfactory outcomes.

Anatomic evaluation of Pancoast tumors using three-dimensional models for surgical strategy development

OBJECTIVE

Pancoast tumor resection planning requires precise interpretation of 2-dimensional images. We hypothesized that patient-specific 3-dimensional reconstructions, providing intuitive views of anatomy, would enable superior anatomic assessment.

METHODS

Cross-sectional images from 9 patients with representative Pancoast tumors, selected from an institutional database, were randomly assigned to presentation as 2-dimensional images, 3-dimensional virtual reconstruction, or 3-dimensional physical reconstruction. Thoracic surgeons (n = 15) completed questionnaires on the tumor extent and a zone-based algorithmic surgical approach for each patient. Responses were compared with surgical pathology, documented surgical approach, and the optimal "zone-specific" approach. A 5-point Likert scale assessed participants' opinions regarding data presentation and potential benefits of patient-specific 3-dimensional models.

RESULTS

Identification of tumor invasion of segmented neurovascular structures was more accurate with 3-dimensional physical reconstruction (2-dimensional 65.56%, 3-dimensional virtual reconstruction 58.52%, 3-dimensional physical reconstruction 87.50%, P < .001); there was no difference for unsegmented structures. Classification of assessed zonal invasion was better with 3-dimensional physical reconstruction (2-dimensional 67.41%, 3-dimensional virtual reconstruction 77.04%, 3-dimensional physical reconstruction 86.67%; P = .001). However, selected surgical approaches were often discordant from documented (2-dimensional 23.81%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .084) and "zone-specific" approaches (2-dimensional 33.33%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .501). All surgeons agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction benefit surgical planning. Most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction would facilitate patient and interdisciplinary communication. Finally, most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction's benefits outweighed potential delays in care for model construction.

CONCLUSIONS

Although a consistent effect on surgical strategy was not identified, patient-specific 3-dimensional Pancoast tumor models provided accurate and user-friendly overviews of critical thoracic structures with perceived benefits for surgeons' clinical practices.

Clinicopathological analysis of a superior sulcus tumor treated by salvage surgery after concurrent definitive chemoradiotherapy followed by durvalumab: A case report

Surgical treatment of superior sulcus tumors (SSTs) is clinically challenging. Definitive chemoradiotherapy (CRT) is a standard treatment for SST. In operable cases, multimodal therapy (CRT followed by surgery) is another option, at least for experienced institutions. Immune checkpoint inhibitors (ICIs) have recently been developed, and several clinical trials have investigated definitive CRT followed by ICIs for consolidation or maintenance therapy of unresectable local advanced non-small cell lung cancer (NSCLC), including SSTs. Clinical studies of salvage surgery after CRT followed by ICIs are also ongoing. However, the clinical outcomes of salvage surgery after multimodal therapies and histopathological analyses of surgical specimens after such treatments remain unclear. Here, we report the case of a patient with SST comprising squamous cell carcinoma with invasion of the second to third rib and vertebrae who underwent salvage surgery after concurrent definitive CRT followed by the ICI durvalumab, and show the results of clinicopathological analyses of the resected specimen.

Five decades of progress in surgical oncology: Tumors of the lung and esophagus

During the past 50 years, there has been a remarkable transformation in the management of lung and esophageal cancers. Improved methods of diagnosis, better staging and patient selection for surgery, the advent of minimally invasive approaches to resection, decreasing operative mortality, greater insights into tumor biology, and the development of effective multimodality therapies and precision medicine have contributed to this transformation. Progress has been most notable in lung cancer.

Management of Stage III Non-Small-Cell Lung Cancer: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing clinicians on management of patients with stage III non-small-cell lung cancer (NSCLC).

METHODS

An Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary oncology, community oncology, research methodology, and advocacy experts was convened to conduct a literature search, which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 127 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Evidence-based recommendations were developed to address evaluation and staging workup of patients with suspected stage III NSCLC, surgical management, neoadjuvant and adjuvant approaches, and management of patients with unresectable stage III NSCLC.Additional information is available at www.asco.org/thoracic-cancer-guidelines.

Retrospective Planning Study of Patients with Superior Sulcus Tumours Comparing Pencil Beam Scanning Protons to Volumetric-Modulated Arc Therapy

AIMS

Twenty per cent of patients with non-small cell lung cancer present with stage III locally advanced disease. Precision radiotherapy with pencil beam scanning (PBS) protons may improve outcomes. However, stage III is a heterogeneous group and accounting for complex tumour motion is challenging. As yet, it remains unclear as to whom will benefit. In our retrospective planning study, we explored if patients with superior sulcus tumours (SSTs) are a select cohort who might benefit from this treatment.

MATERIALS AND METHODS

Patients with SSTs treated with radical radiotherapy using four-dimensional planning computed tomography between 2010 and 2015 were identified. Tumour motion was assessed and excluded if greater than 5 mm. Photon volumetric-modulated arc therapy (VMAT) and PBS proton single-field optimisation plans, with and without inhomogeneity corrections, were generated retrospectively. Robustness analysis was assessed for VMAT and PBS plans involving: (i) 5 mm geometric uncertainty, with an additional 3.5% range uncertainty for proton plans; (ii) verification plans at maximal inhalation and exhalation. Comparative dosimetric and robustness analyses were carried out.

RESULTS

Ten patients were suitable. The mean clinical target volume D95 was 98.1% ± 0.4 (97.5-98.8) and 98.4% ± 0.2 (98.1-98.9) for PBS and VMAT plans, respectively. All normal tissue tolerances were achieved. The same four PBS and VMAT plans failed robustness assessment. Inhomogeneity corrections minimally impacted proton plan robustness and made it worse in one case. The most important factor affecting target coverage and robustness was the clinical target volume entering the spinal canal. Proton plans significantly reduced the mean lung dose (by 21.9%), lung V5, V10, V20 (by 47.9%, 36.4%, 12.1%, respectively), mean heart dose (by 21.4%) and thoracic vertebra dose (by 29.2%) (P < 0.05).

CONCLUSIONS

In this planning study, robust PBS plans were achievable in carefully selected patients. Considerable dose reductions to the lung, heart and thoracic vertebra were possible without compromising target coverage. Sparing these lymphopenia-related organs may be particularly important in this era of immunotherapy.

Significant prognostic determinants in lung cancers of the superior sulcus: comparable analysis of resected and unresected cases

OBJECTIVE

In this study, we aimed to identify prognostic determinants and to comparably analyze clinical features of patients with both resected and unresected superior sulcus tumors (SSTs).

METHODS

The data of 56 patients who underwent any treatment for an SST from 2004 through 2016 in our hospital were reviewed. Overall survival (OS) rates were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to determine independent prognostic factors for patients with resected and unresected SST separately.

RESULTS

The number of patients with resected and unresected SSTs was 24 (43%) and 32 (57%), respectively. Of the 24 patients who underwent surgery, 20 received induction therapy, with 32% achieving pathological complete response. Complete resection (R0) was performed in 22 patients (92%). On multivariate survival analysis, preoperative serum carcinoembryonic antigen (CEA) level (median 8.3 ng/ml, p = 0.021) was identified as the independent determinant of OS in surgical patients; whereas, initial treatment response (complete response or partial response, p = 0.032) was the independent OS indicator in non-surgical patients. The 5-year OS of the patient with resected and unresected SST was 68.8% and 29.1% (p = 0.008), respectively.

CONCLUSION

Significant prognostic factors differ among patients stratified by the presence of surgical resection for SSTs. Preoperative CEA level in surgical candidates and initial treatment response in non-surgical patients were the independent factors associated with OS. Surgical candidates are expected to have more favorable survival than patients with unresectable SSTs.

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.

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.

Surgical Management of Lung Cancer Involving the Chest Wall

The prevalence of chest wall invasion by non-small cell lung cancer is < 10% in published surgical series. The role of radiation or chemotherapy around the complete resection of lung cancer invading the chest wall, excluding the superior sulcus of the chest, is poorly defined. Survival of patients with lung cancer invading the chest wall is dependent on lymph node involvement and completeness of en-bloc resection. In some patients harboring T3N0 disease, 5-year survival in excess of 50% can be achieved. Offering en-bloc resection of lung cancer invading chest wall to patients with T3N1 or T3N2 disease is controversial.

Trimodality therapy for Pancoast tumors: T4 is not a contraindication to radical surgery

OBJECTIVE

This study aims to evaluate the impact of T stage and extended surgery on the outcome of patients with Pancoast tumors after induction chemoradiation therapy.

METHODS

Forty-six consecutive patients who underwent chemoradiation therapy (platin-based, 45-66 Gy) followed by surgery between 1998 and 2013 were retrospectively reviewed and analyzed.

RESULTS

In 28 (61%) patients with T4 tumors, extended procedures (more than rib resection) were performed. There were 37 (80%) lobectomies, 6 (13%) pneumonectomies, and 3 (7%) sublobar resections. A total of 44 (96%) patients had R0 resection. About 30-day mortality was 0%, major surgical complications occurred in 9 (19.6%) patients. Overall survival (OS) at 5-years was 63%. Disease-free survival (DFS) at 5-years was 45%. At multivariate cox regression analysis adjusted for clinical factors, T factor (T3/T4) and extended surgical procedures did not impact survival. However, pathological positive N stage had a negative impact on OS and lack of pathological response negatively impacted both OS and DFS.

CONCLUSION

Trimodality treatment including radical resection for Pancoast tumors provides good surgical outcome and favorable long-term results. Survival of patients with T4 tumors and extended surgical procedures comparable to that of patients with T3 tumors undergoing rib resection only.

Single Posterior Approach for En-Bloc Resection and Stabilization for Locally Advanced Pancoast Tumors Involving the Spine: Single Centre Experience

STUDY DESIGN

Monocentric prospective study.

PURPOSE

To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors.

OVERVIEW OF LITERATURE

In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach.

METHODS

We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation.

RESULTS

Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment.

CONCLUSIONS

The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Primary lung tumors invading the chest wall

Chest wall (CW) involvement occurs in approximately 5% of all primary lung neoplasms. According to the most recent TNM classification, lung tumors invading CW are classified as T3, and they represent approximately 45% of all T3 lung cancers. The most common clinical symptom at presentation is chest pain (>60%), which is highly specific of CW infiltration (>90%). Dyspnoea and hemoptysis are also described, especially in case of large lesions. A realistic chance to cure locally advanced tumors invading CW is a surgical resection, consisting in the excision of the primary lung cancer along with the involved CW (sometimes an "en-bloc" resection) and an appropriate lymph-nodal dissection. However, such patients are at high-risk of facing postoperative complications; prognosis mainly depends on: (I) the completeness of resection; and (II) the lymph-nodal involvement. Hence, due to these reasons (incidence, symptoms, prognosis, post-operative complications), such category of patients are to be carefully assessed preoperatively and if deemed practicable, surgery should be taken into consideration. In this view, the aim of this paper is to critically review the most recent series of lung tumors invading the CW, with a particular focus on patients' preoperative evaluation, surgical techniques, postoperative complications and overall outcome.

Superior sulcus non-small cell lung carcinoma: A comparison of IMRT and 3D-RT dosimetry

AIM

A dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC).

BACKGROUND

IMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated.

MATERIAL AND METHODS

A dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation.

RESULTS

In the patients who received at least 66 Gy, the mean V95% was significantly better with IMRT than 3D-RT (p = 0.043). IMRT delivered a lower D2% compared to 3D-RT (p = 0.043). The IH was significantly better with IMRT (p = 0.043). The lung V 5 Gy and V 13 Gy were significantly higher in IMRT than 3D-RT (p = 0.043), while the maximal dose (D max) to the spinal cord was significantly lower in IMRT (p = 0.043). The brachial plexus D max was significantly lower in IMRT than 3D-RT (p = 0.048). For patients treated with 46 Gy, no significant differences were found.

CONCLUSION

Our study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose.

From 3-Dimensional Printing to 5-Dimensional Printing: Enhancing Thoracic Surgical Planning and Resection of Complex Tumors

PURPOSE

Three-dimensional (3D) printing of anatomic models for complex surgical cases improves patient and resident education, operative team planning, and guides the operation. Our group describes two additional dimensions.

DESCRIPTION

The process of 5-dimensional (5D) printing was developed for surgical planning. Pretreatment computed tomography and positron emission tomography scans were reformatted and fused. Selected anatomy from these studies, along with posttreatment computed tomography and magnetic resonance images, were coregistered and segmented. This fused anatomy was converted into stereolithography files for 3D printing.

EVALUATION

A patient presenting with a complex thoracic tumor was selected for 5D printing. 3D and 5D models were prepared to allow surgical teams to directly evaluate and compare the added benefits of information provided by printing in 5 dimensions.

CONCLUSIONS

Printing 5D models in patients with complex thoracic pathology facilitates surgical planning, selecting margins for resection, anticipating potential difficulties, teaching for learners, and education for patients.

Use of FDG PET/CT in Patients with Pancoast Tumors: Does It Add Any Contribution to Patient Management?

PURPOSE

To evaluate any potential value of 2-deoxy-2-[18F] fluoro-D-glucose with positron emission tomography/computerized tomography (FDG PET/CT) in staging of patients with Pancoast tumors and to investigate the relationship between volume-based quantitative PET parameters and prognosis.

MATERIALS AND METHODS

The authors retrospectively reviewed data of the 47 patients with Pancoast tumors who underwent initial staging by conventional imaging methods and FDG PET/CT. FDG-PET images were visually and quantitatively evaluated, and metabolic tumor volume (MTV), total lesion glycolysis, and maximum standardized uptake values of primary tumors were calculated. The correlations between quantitative PET parameters and tumor stages, as well as overall survival, were analyzed.

RESULTS

By detecting unknown distant metastasis, PET/CT upstaged 21% of patients. The sensitivity and specificity for detection of lymphatic involvement were 100% and 83.75%, respectively. Having surgery (p = 0.01) and being at an early stage (p = 0.004) were the most predictive factors for overall survival. Although there was no significant correlation between quantitative PET parameters and overall survival, MTV was the most powerful discriminator for operability and preoperative staging (p < 0.05).

CONCLUSIONS

FDG-PET imaging was found to be a valuable method for an accurate staging in the management of patients with Pancoast tumor. Having surgery and being at an early stage at presentation were found to be significant predictors for survival. Quantitative metabolic parameters may contribute to clarification of operable patient subgroups having an early disease stage with low MTV.

Case Report: En Bloc Resection of Pancoast Tumor with Adjuvant Aortic Endograft and Chemoradiation

"Pancoast" tumors frequently require a multidisciplinary approach to therapy and are still associated with high morbidity and mortality. Due to their sensitive anatomic location, complex resections and chemoradiation regimens are typically required for treatment. Those with signs of aortic invasion pose an even greater challenge, given the added risks of cardiopulmonary bypass for aortic resection and interposition. Placement of an aortic endograft can facilitate resection if the tumor is in close proximity to or is invading the aorta. Prophylactic endografting to prevent radiation-associated aortic rupture has also been described. This case describes a 60-year-old female who presented with a stage IIIa left upper lobe undifferentiated non-small-cell carcinoma encasing the subclavian artery with thoracic aorta and bony invasion. Following carotid-subclavian bypass with Dacron, en bloc resection of the affected lung, ribs, and vertebral bodies was performed. The aorta was prophylactically reinforced with a Gore TAG thoracic endograft prior to adjuvant chemoradiation. The patient remains disease-free at more than 5 years follow-up after completing her treatment course. Endovascular stenting with subsequent chemoradiation may prove to be a viable alternative to palliation or open operative management and prevention of aortic injury during tumor resection and/or adjuvant therapy in select patients with aortic involvement.

Results of surgical resection after induction chemoradiation for Pancoast tumours †

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.

Management of locally advanced pancoast (superior sulcus) tumors with spine involvement

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.

Superior sulcus non small cell lung carcinoma: retrospective analysis of 42 patients

Aims

Retrospective, monocentric analysis of localized superior sulcus non-small cell cancer (SS-NSCLC), article management.

Materials and methods

Between 2000 and 2010, 42 patients have been treated for a SS-NSCLC. Median age was 54.7 years (34.5-86.8). Nineteen tumors (45.2%) were stage IIB, 18 were stage IIIA (42.9%) and 5 were stage IIIB (11.9%). Twenty-two patients were treated by pre-operative radiotherapy or chemoradiotherapy, 20 received exclusive radiotherapy or chemoradiotherapy. Preoperative and exclusive median radiotherapy doses were 46 Gy (40–47 Gy) and 51.8 Gy (40–70 Gy), respectively. All patients treated with chemotherapy received at least platinum. Mean follow up was 44.1 months (0–128 months).

Results

Local, loco-regional and metastatic relapses occurred in 11 (26.2%), 2 (4.8%) and 15 patients (35.7%), respectively. Most common metastatic site was cerebral (7 patients, 46.7%). Median disease-free survival (DFS) was 9.7 months (8.9-10.4). One-, 2- and 5- years DFS rates were 44%, 33% and 26.5%, respectively. No prognostic factor was identified.

Median overall survival (OS) was 22.6 months (10.4-34.8). One-, 2- and 5- years OS rates were 61.9%, 44.9% and 30.1%, respectively. Univariate prognostic factors for OS were WHO (p = 0.027) and tumoral response (p = 0.05). In multivariate analysis, independent favorable prognostic factors were WHO 0–1 (p = 0.017; OR = 0.316 [CI95% 0.123-0.81) and complete response to treatment (p = 0.035; OR = 0.312 [IC95% 0.106-0.919]).

Conclusion

This study highlighted that a good performans status and complete response to treatment are independent factors of OS, whatever the delivered treatment. Brain was the most common metastatic relapse site.

The "cut-in patch-out" technique for Pancoast tumor resections results in postoperative pain reduction: a case control study

BACKGROUND

Since 2001 we have utilized a novel surgical approach for Pancoast tumors in which lobectomy and mediastinal lymph node dissection are performed directly though the chest wall defect. The defect is then patched at the completion of the procedure ("cut-in patch-out") thereby avoiding a separate thoracotomy with rib spreading. We undertook a study to compare outcomes of this novel "cut-in patch-out" technique with traditional thoracotomy for patients with Pancoast tumors.

METHODS

We retrospectively identified 41 patients undergoing surgical resection of Pancoast tumors requiring en-bloc removal of at least 3 ribs at our institution from 1999 to 2012. Surgery was accomplished by either a "cut-in patch-out" technique (n = 25) or traditional posterolateral thoracotomy and separate chest wall resection (n = 16). Multiple variables including patient demographics, neoadjuvant therapy, extent of resection, and pathology were analyzed with respect to outcomes from morbidity, narcotic use, and oncologic perspectives.

RESULTS

Baseline demographics, neoadjuvant therapy, and perioperative factors including extent of surgery, complete resections (R0), nodal status and lymph node number, morbidity, and mortality were similar between the two groups. The mean duration of out-patient narcotic use was significantly lower in the "cut-in patch-out" group compared to the thoracotomy group (80.6 days ± 62.4 vs. 158.2 days ± 119.2, p < 0.01). Using multivariate regression analysis, the traditional thoracotomy technique (OR 7.72; p = 0.01) was independently associated with prolonged oral narcotic requirements (>100 days). Additionally, five year survival for the "cut-in patch-out" group was 48% versus the traditional group at 12.5% (p = 0.04).

CONCLUSIONS

Compared with a traditional thoracotomy and separate chest wall resection approach for P-NSCLC, a "cut-in patch-out" technique offers an alternative approach that appears to have at least oncologic equivalence while decreasing pain. We have more recently adapted this technique to select patients with pulmonary neoplasms involving chest wall invasion and believe further investigation is warranted.

Therapeutic modalities for Pancoast tumors

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.

Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment

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.

Pancoast tumors: characteristics and preoperative assessment

Superior sulcus tumors (SSTs), or as otherwise known Pancoast tumors, make up a clinically unique and challenging subset of non-small cell carcinoma of the lung (NSCLC). Although the outcome of patients with this disease has traditionally been poor, recent developments have contributed to a significant improvement in prognosis of SST patients. The combination of severe and unrelenting shoulder and arm pain along the distribution of the eighth cervical and first and second thoracic nerve trunks, Horner's syndrome (ptosis, miosis, and anhidrosis) and atrophy of the intrinsic hand muscles comprises a clinical entity named as "Pancoast-Tobias syndrome". Apart NSCLC, other lesions may, although less frequently, result in Pancoast syndrome. In the current review we will present the main characteristics of the disease and focus on the preoperative assessment.

Anterior approach for Pancoast tumor resection

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.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Management of tumors involving the chest wall including pancoast tumors and tumors invading the spine

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.

Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy

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.

Use of CT to evaluate pleural invasion in non-small cell lung cancer: measurement of the ratio of the interface between tumor and neighboring structures to maximum tumor diameter

PURPOSE

To develop a simple noninvasive technique for evaluating pleural invasion by using routine preoperative computed tomography (CT).

MATERIALS AND METHODS

The institutional review board approved this retrospective study, and written informed consent was obtained for performing the initial and follow-up CT studies. Preoperative CT findings (169 patients with possible pleural invasion) and pathologic diagnoses after surgical resection were evaluated. The length of the interface between the primary tumor and neighboring structures (arch distance) and the maximum tumor diameter were measured on CT images, after which arch distance-to-maximum tumor diameter ratios were calculated. Receiver operating characteristic (ROC) curves were used to analyze the ratios.

RESULTS

Median arch distance-to-maximum tumor diameter ratios for pleural invasion categories (pl1, pl2, pl3) assessed by using the Union Internationale Contre le Cancer TNM staging system were as follows: pl1, 0.206 (25th-75th percentile, 0-0.486); pl2, 0.638 (25th-75th percentile, 0.385-0.830); and pl3, 1.092 (25th-75th percentile, 1.045-1.214) (P < .001 between groups). On the basis of the ROC curves, the cut-off value for invasion was an arch distance-to-maximum tumor diameter ratio of 0.9. When the ratio was greater than 0.9, the sensitivity and specificity for thoracic invasion and area under the ROC curve were 89.7%, 96.0%, and 0.976, respectively, which represents an improvement over values obtained by using conventional criteria (radiologists A and B: 46.7% and 74.2% and 91.3% and 84.8%, respectively).

CONCLUSION

When diagnosing T3 or T4 lung cancer based on arch distance-to-maximum tumor diameter ratios, a higher performance level was achieved than that with use of conventional criteria. Measurement of the ratios is a simple noninvasive technique for evaluating pleural invasion at CT.

Analysis of the surgical treatment for superior sulcus tumors

PURPOSE

This study was undertaken to assess the mortality, complication, and major morbidity rates of surgical treatment for superior sulcus tumors (SSTs), and to estimate the significance of prognostic factors.

METHODS

We retrospectively reviewed the hospital records of 50 consecutive patients undergoing surgical treatment for SSTs between 1992 and 2007. The significance of risk factors for an adverse outcome was investigated.

RESULTS

Both the thirty-day and in-hospital mortality rates were 0 %. Complications developed in 18.0 % (9/50) of the patients. The overall 5-year survival was 32.7 %. Pathological T4 and N1 or more were the risk factors predicting an adverse outcome. Survival was not significantly influenced by the preoperative symptoms, the histological type, the invaded organ or the curability.

CONCLUSION

Surgical treatment for SSTs is associated with acceptable overall morbidity and mortality rates. However, special care must be taken for the patients with pathological T4 and N1 or higher tumors. Preoperative chemoradiotherapy followed by surgical treatment has become a logical strategy for SSTs. Preoperative chemoradiotherapy for SSTs may yield better results than surgery alone.

Postoperative radiation therapy for non-small cell lung cancer and thymic malignancies

For many thoracic malignancies, surgery, when feasible, is the preferred upfront modality for local control. However, adjuvant radiation plays an important role in minimizing the risk of locoregional recurrence. Tumors in the thoracic category include certain subgroups of non-small cell lung cancer (NSCLC) as well as thymic malignancies. The indications, radiation doses, and treatment fields vary amongst subtypes of thoracic tumors, as does the level of data supporting the use of radiation. For example, in the setting of NSCLC, postoperative radiation is typically reserved for close/positive margins or N2/N3 disease, although such diseases as superior sulcus tumors present unique cases in which the role of neoadjuvant vs. adjuvant treatment is still being elucidated. In contrast, for thymic malignancies, postoperative radiation therapy is often used for initially resected Masaoka stage III or higher disease, with its use for stage II disease remaining controversial. This review provides an overview of postoperative radiation therapy for thoracic tumors, with a separate focus on superior sulcus tumors and thymoma, including a discussion of acceptable radiation approaches and an assessment of the current controversies involved in its use.

[Single French centre retrospective analysis of local control after high dose radiotherapy with or without chemotherapy and local control for Pancoast tumours]

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.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

[Chest wall surgery]

Despite the numerous differences among the distinct diseases of the chest wall, the surgery of this area shows certain common features. Treatment has progressively changed in the last few years due to advances in diagnostic techniques, minimally invasive procedures and reconstruction materials, and especially due to the multidisciplinary management of many diseases. Nuss' minimally invasive correction of pectus excavatum has gained devotees, although open approaches are performed with increasingly small incisions, almost comparable to the lateral incisions in Nuss' technique. Surgeons supporting the open approach also cite the evident disadvantages of the need for a steel implant for 2 or 3 years and for a second intervention to remove this implant. En-bloc resections with reconstruction using materials, which are increasingly better and covered by myocutaneous grafts in collaboration with plastic surgery departments, constitute a major advance in the treatment of chest wall tumors. Trimodal therapy for Pancoast tumors, consisting of induction chemotherapy and radiotherapy and subsequent surgical treatment of the tumor, currently provides the best results in terms of resectability and survival.

Trimodality treatment in patients with superior sulcus tumors: Hopes and realities

Aims and background

In late 2001 at our institution, we started offering induction radiochemotherapy as a treatment option for superior sulcus tumors. Our aim was to evaluate treatment choices and outcome in this patient group treated over the past 7 years at our institution.

Methods

The records of 34 patients were retrospectively reviewed and 33 were assessable for the analysis.

Results

Twenty of 28 patients with M0 disease had operable disease. The induction radiochemotherapy for superior sulcus tumors was possible in about two-thirds (14/20) of the cases with operable disease, with only one-third (5/14) of these having undergone surgery. The most common reason for not proceeding to surgery following induction radiochemotherapy was patient refusal (n = 5). The median follow-up of all 33 patients was 17 months. In curatively treated patients with (n = 11) or without surgery (n = 15), the median overall survival time was 26 months (range, 10–26) and 26 months (range, 7–71), respectively (P = 0.534). Local-regional and/or distant failure developed in 20 of 26 patients treated curatively. In patients treated with the trimodality regimen (n = 5), no local-regional failure was observed, and distant failure occurred in one case.

Conclusions

The trimodality treatment was possible in 25% of cases with operable disease due to the high rate of patient refusal to proceed to surgery following induction radiochemotherapy. No difference in survival was observed between patients treated with surgery and those treated with radiochemotherapy only because of a limited follow-up. So, the benefit of additional surgery is not clear, and a longer follow-up is needed before final conclusions can be drawn.

A prospective phase 2 study of surgery followed by chemotherapy and radiation for superior sulcus tumors

BACKGROUND

The optimal treatment for locally advanced superior sulcus tumors is not clear. The authors report long-term results of a trial examining the safety and efficacy of surgery followed by concurrent chemoradiation therapy for this disease.

METHODS

Thirty-two patients with resectable or marginally resectable superior sulcus tumors at The University of Texas MD Anderson Cancer Center from 1994 to 2010 were enrolled in a prospective trial. Surgery involved segmentectomy or lobectomy with en bloc resection of the involved chest wall and complete nodal staging; radiation therapy (RT) began 14 to 42 days later to a dose of 60 grays (Gy) in 50 1.2-Gy fractions if surgical margins were negative or 64.8 Gy in 54 1.2-Gy fractions if margins were positive. Two cycles of etoposide (50 mg/m(2) ) and cisplatin (50 mg/m(2) ) were given during RT, and another 3 cycles were given after RT. Eleven patients underwent prophylactic cranial irradiation (PCI).

RESULTS

The protocol completion rate was 78%. Gross total resection was accomplished in all 32 patients; 28% underwent R1 resection. Operative mortality was 0%. The most common surgical complication was postoperative pneumonia (25%). At a median follow-up time of 53.4 months (range, 2-154 months), the 2-year, 5-year, and 10-year rates of locoregional control were 84%, 76%, and 76%; distant metastasis-free survival, 52%, 48%, and 48%; disease-free survival, 49%, 45%, and 45%; and overall survival, 72%, 50%, and 45%, respectively. The brain was the most common site of distant failure (n = 5), but no patient who received PCI experienced brain metastasis.

CONCLUSIONS

Surgery followed by postoperative chemoradiation is safe and effective for the treatment of marginally resectable superior sulcus tumors.

Treatment of pancoast tumors from the surgeons prospective: re-appraisal of the anterior-manubrial sternal approach

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.

Preoperative concomitant chemo-radiotherapy in superior sulcus tumour: A mono-institutional experience

Superior sulcus tumour (SST) is an uncommon neoplasia whose optimal treatment remains controversial. Usually resected after induction RT or treated with definitive chemo-radiotherapy, it has recently aroused more interest because of preoperative chemo-radiotherapy. Treatment consisted of a platinum-based chemotherapy: carboplatin AUC 5 on days 1 and 22, combined with mitomycin-C 8 mg/m(2) on days 1 and 22, and vinblastine 4 mg/m(2) on days 1, 8, 22 and 29 (MVC) from 1994 to 1999, or combined with navelbine 25mg/m(2) on days 1, 8, 22 and 29 (NC), from 2000 to 2007. Radiotherapy was administered 5 days/week, 30 Gy in 10 fractions on days 22-35 (from 1994 to 1996), or 44 Gy in 22 fractions on days 22-52 (from 1997 to 2007). SURGERY was planned after 2-3 weeks since the completion of radiotherapy. Since 1994, 37 pts were treated with induction chemo-radiotherapy, 1 with induction radiotherapy only. Induction chemotherapy: 16 pts had MVC (43%) and 21 NC (57%); induction radiotherapy: 7 patients treated with MVC had 30 Gy/10F, 9 had 44 Gy/22F; all the patients treated with NC had 44 Gy/22F, but 2 of them did not complete radiotherapy because of early death (after 16 Gy/8F) and toxicity (after 38 Gy/19F). Grade 3-4 haematological toxicity of induction chemo-radiotherapy was found in 13 patients (35%); the most frequent non-haematological toxicities were constipation and oesophagitis. One complete, 18 partial and 8 minimal responses/stable disease were observed. Moreover, 1 progression disease and 1 early death occurred.

SURGERY

30 upper lobectomies (17 right, 13 left) and 4 segmentectomies, with chest wall resections, were performed (89% resection rate); 4 pts were not operated. Radical resections were achieved in 74% of the patients, with 5 pathologic complete remissions at resection. Twenty-seven patients (71%) had improvement of shoulder/arm pain. Median progression-free survival was 64 weeks and median survival was 148 weeks. The 5-year overall and progression-free survivals were 40% and 29%, respectively. In the multimodality treatment of SST, concurrent carboplatin-based chemotherapy plus radiotherapy were active and feasible without major toxicities. This resulted in high resectability rate and favourable progression-free and overall survival rates.

The Surgical Management of Lung Cancer

Since the introduction of the pneumonectomy as a technically feasible strategy for the treatment of lung cancer, surgical resection has played a pivotal role in the management of early stage non-small cell lung carcinoma (NSCLC). In the last two decades, surgical, medical, and radiation oncologists have produced a growing body of evidence to support the combination of neoadjuvant or adjuvant treatments with standard surgical resection, to improve disease-free and overall survival for specific patient subgroups. Furthermore, alternatives to aggressive surgical management have evolved for patients who are medically inoperable due to compromised pulmonary function or other comorbidities. In this review, surgical options and multimodal treatment strategies are discussed, as well as completed and ongoing clinical trials addressing the surgical management of NSCLC.