TRANSCERVICAL TECHNIC FOR REMOVAL OF SPECIMEN FROM SUPERIOR SULCUS TUMOR FOR PATHOLOGIC STUDY

Resection of superior sulcus carcinomas (anterior approach)

Physicians' understanding of the anatomy, biology [9], and treatment outcome [12] for superior sulcus carcinoma has changed greatly during the last decade [2,3]. One of the major advances in this regard has been the introduction of anterior approaches for resection. These approaches increase the likelihood of complete resection and permit resection of tumors that were previously considered technically unresectable. Each approach must be understood in detail to avoid incomplete operations and life-threatening complications. These technical advances, with recent evidence that preoperative chemoradiotherapy leads to higher complete resection rates, overall survival, and local control than do radiation and surgery alone [32], have changed physicians' attitudes toward superior sulcus carcinomas, especially for those tumors (eg, T4) previously considered technically unresectable and oncologically incurable. It is hoped that, in the future, resection of disease invasion of the brachial plexus above C7 will be technically feasible [33], and that new drugs will reduce the risk of systemic relapse after resection.

Surgical exposure of superior sulcus lung tumors with vascular involvement

Choice of exposure route for surgical excision of superior sulcus lung tumors depends on involvement at the thoracic inlet. From December 1985 to September 1999, we performed surgical treatment of superior sulcus tumors in 42 patients, including 22 with vascular involvement. Various exposure techniques were used, including a novel technique combining transverse supraclavicular cervicotomy and posterolateral thoracotomy in 11 cases, anterior transclavicular cervicothoracotomy in 7 cases, isolated posterolateral thoracotomy in 3 cases, and cervicosternotomy in 1 case. Vascular procedures consisted of subadventitial dissection of the subclavian artery in 5 patients, arterial resection-anastomosis in 7, and prosthetic bypass in 10. Postoperative mortality was 11.9% in the overall series of 42 patients (n = 5) and 9% (n = 2) in the subgroup of patients with vascular involvement. During follow-up, 13 patients died of tumor recurrence and 1 patient died of respiratory insufficiency. Actuarial 5-year survival was 22.7 +/- 17.5% overall and 18 +/- 17.9% in the subgroup of patients with vascular involvement. This study indicates that the combined exposure route with transverse supraclavicular cervicotomy and posterolateral thoracotomy was useful for treatment of superior sulcus lung tumors requiring lobectomy and pneumonectomy.

The management of superior sulcus tumors

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

Subclavian artery resection and reconstruction for thoracic inlet cancers

PURPOSE

We previously described an original transcervical approach to resect primary or secondary malignant diseases that invade the thoracic inlet (TI). The purpose of this study was to evaluate the technical aspects and long-term results of the resection and revascularization of the subclavian artery (SA).

METHODS

Between 1986 and 1998, 34 patients (mean age, 49 years) underwent en bloc resection of TI cancer that had invaded the SA. The surgical approach was an L-shaped transclavicular cervicotomy in 33 patients. In 14 of these patients, this approach was associated with a posterolateral thoracotomy (n = 10) or a posterior midline approach (n = 4). In one patient, the procedure was achieved with a single posterolateral thoracotomy approach. An end-to-end anastomosis was performed in 16 patients. In one patient, a subclavian-left common carotid artery transposition was performed. In one other patient, an end-to-end anastomosis was performed between the proximal innominate artery and the SA. The right carotid artery was transposed into the SA in an end-to-side fashion. In 16 patients, prosthetic revascularization with a polytetrafluoroethylene graft was performed. Thirty-three patients underwent postoperative radiation therapy.

RESULTS

There were no cases of perioperative death, neurologic sequelae, graft infections or occlusions, or limb ischemia. There were two delayed asymptomatic polytetrafluoroethylene graft occlusions at 12 and 31 months. The 5-year patency rate was 85%. During this study, 20 patients died: 18 died of tumor recurrence (5 local and systemic and 13 systemic), one of respiratory failure, and one of an unknown cause at 74 months. The overall 5-year survival rate was 36%, and the 5-year disease-free survival rate was 18%.

CONCLUSION

Tumor arterial invasion per se should not be a contraindication to TI cancer resection. This study shows that cancers that invade the SA can be resected through an L-shaped transclavicular cervicotomy, with good results with a concomitant revascularization of the SA.

Ultrasonography of Pancoast tumor

Eleven patients with Pancoast tumor, who failed to yield diagnostic materials by conventional sputum cytology and fiberoptic bronchoscopy, were studied by real-time linear-array and sector ultrasonography. The sector scanner through the supraclavicular approach adequately visualized the external profile and the internal texture of the lesions in all 11 patients, which is a significant improvement (p less than 0.05) over what can be accomplished with linear-array scanner through the intercostal approach. All patients received percutaneous transthoracic aspiration under ultrasound guidance. Positive cytologic diagnosis was established in ten of the 11 patients (91 percent). Additional biopsies performed in seven patients under similar ultrasonic guidance also provided concordant results. No complications were observed in this series. This study has clearly shown that ultrasound-guided aspiration biopsy can be a safe and useful means for obtaining materials for pathologic confirmation of Pancoast tumor. It may also assist in defining the tumor extension to pleura and adjacent structures.

Cervical approach for percutaneous needle biopsy of Pancoast tumors

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

Carcinoma of the superior pulmonary sulcus

From January, 1971, to January, 1977, 26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoast's syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at least 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.

Supraclavicular thoracotomy for diagnosis of apical lung and superior mediastinal lesions

Despite the use of mediastinoscopy, anterior mediastinotomy, transcarinal biopsy, needle biopsy, and transbronchial fluoroscopic brushing, thoracotomy is necessary to obtain tissue for diagnosis in patients suspected of having carcinoma of the lung. A technique we have employed is exploratory thoracotomy, as described for the approach to cervical and upper dorsal sympathetic ganglion, with entrance into the pleural space through a supraclavicular incision. Five patients, 3 with marginal pulmonary function and 2 with brachial plexus and upper mediastinal or vertebral involvement, had tissue diagnosis of lung carcinoma by this method without postoperative complication. Supraclavicular thoracotomy offers a safe, easy, and definitive method of tissue diagnosis of apical lung and superior mediastinal lesions.

Diagnosis of a thoracic inlet tumour by transbronchial biopsy

A 67-year-old man presented to the pulmonary service with left shoulder and arm pain. Examination disclosed a left Horner's syndrome. Supraclavicular exploration at another hospital was not helpful. Transbronchial biopsy through a flexible fibreoptic bronchoscope retrieved tissues showing poorly differentiated carcinoma. There are no previous reports of the use of the technique in the diagnosis of a Pancoast tumour with a normal standard chest radiograph.