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

Deciphering the enigmatic symptoms of Pancoast tumors: Navigating the complex landscape of pain management-A case report

Pancoast tumors, also known as superior sulcus tumors, encompass a diverse spectrum of neoplasms that infiltrate the apex of the chest wall, yielding distinctive clinical presentations. One of the earliest signs of tumor growth is pain radiating to the upper limb, stemming from peripheral nerve involvement, which can mimic joint pain or spinal radicular irritation. In this case report, we present the clinical history of a 64-year-old female smoker who had previously been recommended for orthopedic elbow surgery due to epicondylitis. Subsequent to the development of additional symptoms and rigorous investigation, a Pancoast tumor was diagnosed. Furthermore, we discuss the characteristic treatment modalities available for Pancoast tumors, including pharmacological pain management and interventional strategies such as spinal cordotomy and spinal alcoholysis. This case underscores the significance of recognizing atypical presentations and emphasizes the importance of comprehensive evaluation in the diagnosis and management of Pancoast tumors.

Treatment patterns and outcomes in patients with Pancoast tumors: a national cancer database analysis

Background

Pancoast tumors represent 5% of non-small cell lung cancers. Complete surgical resection and no lymph node involvement are important positive prognostic factors. Previous literature has identified neoadjuvant chemoradiation treatment, followed by surgical resection, as the standard of care. But many institutions choose upfront surgery. Our goal was to identify the treatment patterns and outcomes in patients with node-negative Pancoast tumors using the National Cancer Database (NCDB).

Methods

The NCDB was queried from 2004 through 2017 to identify all patients who had undergone surgery for a Pancoast tumor. Treatment patterns, including the percentage of patients who received neoadjuvant treatment, were recorded. Logistic regression and survival analyses were used to determine outcomes based on different treatment patterns. Secondary analyses were performed on the cohort who received upfront surgery.

Results

A total of 2,910 patients were included in the study. Overall 30- and 90-day mortality were 3% and 7% respectively. Only 25% (717/2,910) of the group received neoadjuvant chemoradiation treatment prior to surgery. Patients who received neoadjuvant chemoradiation treatment experienced significantly improved 90-day survival (P<0.01) and overall survival (P<0.01). When analyzing the cohort who received upfront surgery, there was a statistically significant difference in survival based on adjuvant treatment pattern (P<0.01). Patients in this group who received adjuvant chemoradiation had the best survival, whereas patients who received adjuvant radiation only or no treatment had the worst outcomes.

Conclusions

Patients with Pancoast tumors receive neoadjuvant chemoradiation treatment in only a quarter of cases nationally. Patients who received neoadjuvant chemoradiation treatment had improved survival compared to patients who had upfront surgery. Similarly, when surgery is performed first, adjuvant chemoradiation treatment improved survival compared to other adjuvant strategies. These results suggest underutilization of neoadjuvant treatment for patients with node-negative Pancoast tumors. Future studies with a more clearly defined cohort are needed to assess the treatment patterns being utilized on patients with node-negative Pancoast tumors. It will be beneficial to see whether neoadjuvant treatment for Pancoast tumors has increased in recent years.

Pancoast tumor presenting with multiple joint pains: a case report

Background

Pancoast tumors represent a unique subset of lung cancers wherein a primary neoplasm arises in the lung’s apex and invades the surrounding soft tissues. One of the main challenges in the diagnosis and treatment of these apical lung cancers is that they are usually not visualized on initial chest x-ray and, by the time the patient presents with symptoms, the tumor has almost always invaded nearby structures.

Case presentation

Herein we report a case of a 58-year-old nonsmoking African American male who presented to the neurology clinic with a history of multiple chronic joint pains. The patient complained of shoulder pain that traveled into his right arm and right finger and had worsened over the past 9 months. The patient also reported decreased right proximal strength and swelling of his right hand. Magnetic resonance imaging of the shoulder and cervical region showed mild cervical spondylosis and a questionable right apical mass. A subsequent high-resolution computed tomography scan of the chest revealed a large right apical lung mass, with chest wall invasion and erosion of the adjacent ribs. Biopsy of the mass confirmed poorly differentiated non-small cell lung cancer. Radiation therapy was initiated, and the patient’s pain improved significantly. Given the size of the tumor, chemotherapy was recommended by the oncology team. The patient decided against chemotherapy.

Conclusion

This case highlights the importance of early diagnosis by expanding the differential diagnosis in patients presenting with weakness, sensory loss, and shoulder pain beyond radiculopathy or joint-related diseases. A comprehensive history and careful examination may lead to an earlier diagnosis, more appropriate treatment, and better outcome in cases of Pancoast tumor presenting with neuropathic or musculoskeletal pain.

Clinical outcomes of pancoast tumors treated with trimodality therapy

Background

Superior sulcus tumors, or Pancoast tumors, are challenging thoracic malignancies to treat due to their anatomical location posing difficult surgical access and potential involvement of adjacent vital structures. The current standard of care is trimodality treatment, which consists of induction chemoradiotherapy followed by radical surgical resection. This study aims to report the clinical outcomes of trimodality approach in British Columbia, Canada.

Methods

Patients with Pancoast tumors who underwent trimodality treatment between 2000–2015 were included in this provincial multi-center retrospective study. Patient-, disease-, and treatment-related data were collected, and treatment outcomes were recorded.

Results

We identified 32 patients who underwent induction chemoradiotherapy and subsequent surgical resection. Mean age was 59 (43–75 years) with median follow-up of 43 months (5–216 months). Complete resection was achieved in 31 patients (97%). Fourteen patients (44%) had pathological complete response after induction chemoradiotherapy. Thirteen (41%) showed minimal microscopic (>90% tumor necrosis) and 5 (16%) macroscopic residual disease (<90% tumor necrosis). Fourteen patients (44%) developed recurrence, which was distant in 9 cases. The 2-, 5-, and 10-year overall survival rates were 67.9%, 50.1%, 31.8% and the 2-, 5-, and 10-year disease-free survival rates were 65.1%, 47.1% and 28.2% respectively. There were no statistically significant differences in overall survival or disease-free survival rates with or without pathological complete response.

Conclusions

Complete surgical resection with negative margins can be achieved after induction chemoradiotherapy, and curative-intent trimodality treatment can lead to long-term survival in some patients. This study did not demonstrate any prognostic value of pathological complete response, likely due to small sample size.

Can MRI differentiate surrounding vertebral invasion from reactive inflammatory changes in superior sulcus tumor?

OBJECTIVES

Vertebral invasion is a key prognostic factor and a critical aspect of surgical planning for superior sulcus tumors. This study aims to further evaluate MRI features of vertebral invasion in order to distinguish it from reactive inflammatory changes.

METHODS

Between 2000 and 2016, a retrospective study was performed at a single institution. All patients with superior sulcus tumors undergoing surgery, including at least two partial vertebrectomies, were included. An expert radiologist evaluated qualitative and quantitative MRI signal intensity characteristics (contrast-to-noise ratio [CNR]) of suspected involved and non-involved vertebrae. A comparison of CNR of invaded and sane vertebrae was performed using non-parametric tests. Imaging data were correlated with pathological findings.

RESULTS

A total of 92 surgical samples of vertebrectomy were analyzed. The most specific sequences for invasion were T1 and T2 weighted (92% and 97%, respectively). The most sensitive sequences were contrast enhanced T1 weighted fat suppressed and T2 weighted fat suppressed (100% and 80%). Loss of extrapleural paravertebral fat on the T1-weighted sequence was highly sensitive (100%) but not specific (63%). Using quantitative analysis, the optimum cut-off (p < 0.05) to distinguish invasion from reactive inflammatory changes was CNR > 11 for the T2-weighted fat-sat sequence (sensitivity 100%), CNR > 9 for contrast-enhanced T1-weighted fat-suppressed sequence (sensitivity 100%), and CNR < - 30 for the T1-weighted sequence (specificity 97%). Combining these criteria, 23 partial vertebrectomies could have been avoided in our cohort.

CONCLUSION

Qualitative and quantitative MRI analyses are useful to discriminate vertebral invasion from reactive inflammatory changes.

KEY POINTS

• Abnormal signal intensity in a vertebral body adjacent to a superior sulcus tumor may be secondary to direct invasion or reactive inflammatory changes. • Accurate differentiation between invasion and reactive inflammatory changes significantly impacts surgical planning. T1w and T2w are the best sequences to differentiate malignant versus benign bone marrow changes. The use of quantitative analysis improves MRI specificity. • Using contrast media improves the sensitivity for the detection of tumor invasion.

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.

Pancoast Tumor as the Initial Presentation of a Metastatic Colon Adenocarcinoma

A Pancoast tumor is a rare condition, representing 3% to 5% of all lung cancers. The particular location of these lesions leads to the invasion of structures in the thoracic inlet, causing a constellation of symptoms known as Pancoast-Tobias syndrome. Diagnosis can be challenging due to their low prevalence and the possibility of being asymptomatic. Most of these tumors are non-small cell lung cancers. However, rare conditions might arise at the same location, and histologic confirmation is relevant. We report the case of a 45-year-old man admitted to the internal medicine department with a one-month history of night sweats. A full-body computed tomography (CT) scan revealed a mass on the upper lobe of the left lung, with soft tissue invasion. Histopathologic examination revealed an adenocarcinoma pattern originating from the colon. Colonoscopy showed two synchronous lesions. Hitherto, this is the second case ever described of a Pancoast tumor as metastasis of colon adenocarcinoma.

Pancoast-Tobias Syndrome: A Unique Presentation of Lung Cancer

A 65-year-old man with 50 pack-year smoking history presented to the emergency department for evaluation of upper back and right shoulder pain secondary to a fall. Physical examination was notable for anisocoria with a constricted left pupil (miosis), mild ptosis of the left eyelid, and bilateral shoulder pain, right more than left, with both passive and active movements. Chest computed tomography identified a soft tissue mass at the left lung apex with extension into the pleural surface, associated with destructive osseous changes of the right scapula, adjacent ribs, and thoracic vertebral bodies. Imaging of the brain revealed multiple masses suspicious of metastatic brain lesions. Biopsy of the right supraclavicular lymph node revealed lung tissue adenocarcinoma and negative Kirsten rat sarcoma viral oncogene homolog (K-Ras), epidermal growth factor receptor (EGFR), B-raf proto-oncogene (BRAF), C-ros oncogene 1 (ROS1), and anaplastic lymphoma kinase (ALK) rearrangement. Recognizing Pancoast syndrome in patients with significant smoking history, anisocoria, and shoulder pain is crucial for identifying the underlying etiology and expediting the treatment.

Case Report of a Complex Chest Wall Reconstruction with a Cadaveric Achilles Tendon

Patient: Female, 46-year-old

Final Diagnosis: Right superior sulcus tumor-squamous cell lung cancer

Symptoms: Right shoulder pain

Medication: —

Clinical Procedure: Right upper lobectomy (lung) • chest wall resection/reconstruction

Specialty: Surgery

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.

Pancoast's syndrome caused by lymph node metastasis from breast cancer

Pancoast's syndrome may be the result of neoplastic, inflammatory or infectious disease. We report an unusual case of Pancoast's syndrome in a patient with metastatic breast cancer. A 54-year-old woman, affected by metastatic breast cancer, presented for severe shoulder pain, paraesthesia and numbness in the right arm. Despite further multiple lines of systemic chemotherapy, she developed a progressive enlargement of retropectoral, supraclavicular and infraclavicular lymph node metastases, which involved brachial plexus, apex of lung and anterior mediastinum. Physical examination revealed severe weakness of proximal muscles of the right arm. Neuropathic pain was managed with pharmacological treatment. Lastly, the patient has been treated with intrathecal analgesia with morphine and ziconotide with a good control of pain. The patient died after 3 months.

Original "double-step" technique for large superior sulcus tumors invading the anterior chest wall without subclavian vessels involvement

Background

In some patients with complex Superior Sulcus tumors, a combination of surgical accesses may be required. For patients with very large tumors which invade the first ribs anteriorly and without subclavian vessels involvement, we developed a "double-step" technique to facilitate resection and reduce surgical trauma.

Methods

The technique was performed on five patients with a bulky non-small cell lung cancer (NSCLC), four of whom had a Superior Sulcus tumor. All patients received a radical wide thoracectomy en-bloc with an upper lobectomy. Neither significant flail chest nor postoperative respiratory complications were observed. The method is based on the possibility of interrupting the medial extremity of the first rib beneath the clavicle through a limited, preliminary parasternal incision. The remaining ribs involved in the resection are also interrupted at the costo-chondral junction, leaving the sternum and clavicle intact. Once the medial limit of the involved ribs has been sectioned, multiple stitches are placed through the peristernal tissues and temporarily left inside the chest. Through a second posterior incision, the en-bloc chest wall and lung resection is easily completed. The previously placed peristernal stitches are collected and used for the medial fixation of the prosthesis.

Results

Using this technique the resection was radical in all cases. No major postoperative complications were registered.

Conclusions

The technique has several advantages: trauma related to double access is negligible; radical resection is facilitated, anterior chest wall resection is accomplished without sternal or clavicular injury, en-bloc chest wall and lung resection is made straightforward despite the extended area of resected ribs attached to the tumor, released within the chest cavity; chest wall stabilization is simple and reliable. The only disadvantage is that the patient's surgical position needs to be changed.

Primary Lung Signet Ring Cell Carcinoma Presenting as a Cavitary Pancoast Tumor in a 32-Year-Old Man

Signet ring cell carcinoma, a subtype of adenocarcinoma, is a rare cause of primary lung cancer. The authors report a case of primary lung signet ring cell carcinoma presenting as a cavitary Pancoast tumor in a 32-year-old male smoker. Beyond the rarity of primary lung signet ring cell carcinoma itself, the youth of the patient, his smoking status, the presence of cavitation, and the location of the tumor in the superior sulcus make it especially atypical.

Advanced squamous lung cancer: therapeutic options, future directions, unmet needs and results of a monocentric survey

Lung cancer is the leading cause of cancer-related deaths in worldwide, and NSCLC represents around 85% of all lung cancers. Squamous cell lung cancer (SqCLC) is the second most common subtype and it is challenging to treat. New options have been discovered but progresses are still limited for the lack of 'druggable' mutations. Specific resources for SqCLC are limited and this condition affects treatment and outcomes. This paper describes available and emerging therapeutic options and resources that may help patients to face their disease. We have also performed a monocentric survey collecting information about smoking habit and sense of guilty and analyzed the possibility for patients to find helpful sources for their disease. The results suggest that more materials focused on SqCLC are still needed.

Magnetic resonance imaging in precision radiation therapy for lung cancer

Radiotherapy remains the cornerstone of curative treatment for inoperable locally advanced lung cancer, given concomitantly with platinum-based chemotherapy. With poor overall survival, research efforts continue to explore whether integration of advanced radiation techniques will assist safe treatment intensification with the potential for improving outcomes. One advance is the integration of magnetic resonance imaging (MRI) in the treatment pathway, providing anatomical and functional information with excellent soft tissue contrast without exposure of the patient to radiation. MRI may complement or improve the diagnostic staging accuracy of F-18 fluorodeoxyglucose position emission tomography and computerized tomography imaging, particularly in assessing local tumour invasion and is also effective for identification of nodal and distant metastatic disease. Incorporating anatomical MRI sequences into lung radiotherapy treatment planning is a novel application and may improve target volume and organs at risk delineation reproducibility. Furthermore, functional MRI may facilitate dose painting for heterogeneous target volumes and prediction of normal tissue toxicity to guide adaptive strategies. MRI sequences are rapidly developing and although the issue of intra-thoracic motion has historically hindered the quality of MRI due to the effect of motion, progress is being made in this field. Four-dimensional MRI has the potential to complement or supersede 4D CT and 4D F-18-FDG PET, by providing superior spatial resolution. A number of MR-guided radiotherapy delivery units are now available, combining a radiotherapy delivery machine (linear accelerator or cobalt-60 unit) with MRI at varying magnetic field strengths. This novel hybrid technology is evolving with many technical challenges to overcome. It is anticipated that the clinical benefits of MR-guided radiotherapy will be derived from the ability to adapt treatment on the fly for each fraction and in real-time, using 'beam-on' imaging. The lung tumour site group of the Atlantic MR-Linac consortium is working to generate a challenging MR-guided adaptive workflow for multi-institution treatment intensification trials in this patient group.

Pancoast tumor approach through oesophagus

Patient with Pancoast Tumor usually present in advanced stage of the disease which requires chemotherapy and radiotherapy as options of treatment. Histologic confirmation is a key for further treatment of these patients. Normally in bronchoscopy the lesion can't be visualised and in result making biopsy difficult to perform. Transthoracic biopsy through computed tomography poses anatomic difficulties and not always the pulmonary lesion can be reached.

We report a case of pancoast tumor in a 68 year old male who presented with left arm pain and upper lobe increased density mass in chest x ray. Computed tomography confirmed an upper lobe mass of the left lung with invasion of the chest wall. It was successfully diagnosed with biopsy taken through the oesophagus of intrapulmonary mass with the EBUS bronchoscope (EUS- B FNA). No complication were observed during and after the procedure.

To our knowledge this is the first case of making the diagnosis of lung carcinoma Pancoast tumor using EBUS bronchoscope with approach through oesophagus (EUS-B FNA). There may be a role in using EBUS specifically to diagnose a pancoast tumor in the right patient population.

Transmanubrial osteomuscular sparing approach for resection of cervico-thoracic lesions

Background

To review our experience of transmanubrial osteomuscular sparing approach (TMA) for resection of various lesions involving the thoracic inlet and to prove the feasibility and safety of the approach.

Methods

Retrospective review of 58 consecutive cases, from April 2007 to January 2016, with surgical resection of cervico-thoracic lesions via TMA.

Results

There were 22 neurogenic tumors, 21 bronchogenic tumors, and 15 other cases in the study. There was no intraoperative or postoperative mortality. Mean postoperative stay was 10.5 days (3-33 days). Mean operation time was 179.0 mins (57-328 mins) and the mean volume of blood loss for bronchogenic tumors was 900 mL, which was similar to non-bronchogenic tumors (474 mL, P=0.103). Moreover, patients with malignant tumors had more intraoperative blood loss than patients with benign diseases did (847 versus 194 mL, P=0.001). R0 resection was achieved in 28 of 33 (84.8%) malignant cases. Tumor size was related to incomplete resection (8.19 vs. 5.72 cm, P=0.023) in malignancy. Five (8.6%) cases were complicated with chylothorax and all occurred in patients with left incision. All of 21 cases (100%) with brachial plexus compression symptom were relieved after surgery and 3 of 4 (75%) cases with Horner's syndrome were ameliorated postoperatively.

Conclusions

TMA can be carried out safely in treating various cervico-thoracic lesions with good resection rate. Left side procedure should be cautious of thoracic duct injury.

A rare presentation of myxofibrosarcoma as a Pancoast tumor: a case report

Background

Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor.

Case presentation

A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable.

Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma.

Conclusions

Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner’s syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature.

Superior sulcus tumors (Pancoast tumors)

Superior Sulcus Tumors, frequently termed as Pancoast tumors, are a wide range of tumors invading the apical chest wall. Due to its localization in the apex of the lung, with the potential invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, the superior sulcus tumors cause characteristic symptoms, like arm or shoulder pain or Horner's syndrome. The management of superior sulcus tumors has dramatically evolved over the past 50 years. Originally deemed universally fatal, in 1956, Shaw and Paulson introduced a new treatment paradigm with combined radiotherapy and surgery ensuring 5-year survival of approximately 30%. During the 1990s, following the need to improve systemic as well as local control, a trimodality approach including induction concurrent chemoradiotherapy followed by surgical resection was introduced, reaching 5-year survival rates up to 44% and becoming the standard of care. Many efforts have been persecuted, also, to obtain higher complete resection rates using appropriate surgical approaches and involving multidisciplinary team including spine surgeon or vascular surgeon. Other potential treatment options are under consideration like prophylactic cranial irradiation or the addition of other chemotherapy agents or biologic agents to the trimodality approach.

[Anterior or Posterior Approach with Video-assisted Thoracoscopic Surgery for Superior Sulcus Tumors]

BACKGROUND AND OBJECTIVE

The surgical resection for pancoast tumors remains challenging. There are only few reports explaining the use of VATS in the treatment of Pancoast tumors. The aim of this study is to assess whether the use of video-assisted thoracoscopic surgery (VATS) for the surgical treatment of Pancoast tumors was feasible and safe.

METHODS

Between Janunary 2010 and June 2013, ten patients who were diagnosed as Pancoast tumors were recruited. Six patients were accepted for surgical treatment either through an anterior (n=3) or a posterior approach (n=3) combined with VATS. The observation index of this study included: Operation safety and mortality; The integrity of the tumor resection; General data of operation and postoperative complications; Tumor recurrence and metastasis at twelve months after operation.

RESULTS

There were no perioperative deaths. The average time of operation time was 242 min. The radical en bloc resection of the involved chest wall were done in each patients. The average amount of blood loss was 308 mL and the average time of hospital stay was 14 d. Only one patient had postoperative pneumonia and recovered after use of antibiotics. There was none of severe postoperative complications. No patient developed a local recurrence or distant metastasis within twelve months.

CONCLUSIONS

The use of VATS has practical value in the management of Pancoast tumors. It is useful to make an accurate extent of the resection of chest-wall and provides a better exposure. Anterior or posterior approach with VATS surgery can facilitate the safety management of Pancoast tumors.

Chest wall reconstruction after en bloc Pancoast tumour resection with the use of MatrixRib and SILC fixation systems: technical note

STUDY DESIGN

Technical note.

OBJECTIVE

In cases in which partial resection of the rib cage is accomplished with vertebrectomy, reconstruction of the chest wall may be challenging. That is because of lack of the anchor point which normally would be a proximal end of a rib or transverse process. We report a straightforward technique for chest wall reconstruction with the novel use of two systems of fixation commonly applied in spinal practice.

METHODS

The operation of a squamous cell carcinoma (Pancoast tumour) of the right lung infiltrating T2, T3 and T4 vertebrae was performed though T4 lateral thoracotomy. Posterior instrumentation with transpedicular screws T1-3-5 on the left and T1-5 on the right side was followed with the right upper lobectomy and hemivertebrectomy. The laminae and facet joints of T2-T4 vertebrae were removed on the side of the tumour. An osteotomy was performed medial to the pedicle at the lateral aspect of the dural sac on the side of the tumour. Proximal parts of four adjacent ribs were removed allowing radical en bloc resection with tumour-free margins. The distal end of each of four rib plates used (MatrixRib Precontoured Plate system) was attached to the proximal end of the rib. The proximal end of the plate was then attached to the rod of posterior fixation construct with the use of a flexible polyethylene terephthalate (PeT) band of the SILC™ fixation system. The other end of the PeT band was then passed through the top-loading clamp subsequently attached to the rod of the posterior fixation.

RESULTS

The patient did not require additional procedures for chest wall reconstruction. On the 7-month follow-up, in chest CT he was found with satisfactory expansion of the remaining lung tissue with proper spinal alignment and anatomical shape of the rib cage.

CONCLUSIONS

The reported technique can be applied for chest wall reconstruction in cases of total or subtotal vertebrectomy accomplished with the resection extending towards rib cage. It appears to be straightforward, safe and effective allowing good cosmetic and functional outcome.

Total video-assisted thoracoscopic (VATS) resection of a left-sided sulcus superior tumor after induction radiochemotherapy: video and review

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has gained increasing acceptance for surgical therapy of early stage non small cell lung cancer (NSCLC). Even for extended pulmonary resections in advanced tumor stages, increasing evidence suggests feasibility and safety of the VATS approach. However, so far very little experience has been reported on VATS management of sulcus superior tumors.

METHODS

We report on a 56-year-old female patient with a left-sided anterior sulcus superior adenocarcinoma (cT3 cN1 cM0), which was completely resected by VATS after induction radiochemotherapy.

RESULTS

The surgical procedure was performed completely minimally invasively via a three-incision anterior thoracoscopic approach. The total operating time was 285 min (composed of 116 min for hilar lobectomy, 103 min for sulcus superior preparation and chest wall resection, and 26 min for systematic en-bloc lymph node dissection). The single chest tube was removed on postoperative day two and the patient was discharged on postoperative day six. No intraoperative and no postoperative complications were observed. Histopathology confirmed a complete (R0) resection of an ypT2aN0M0 bronchogenic adenocarcinoma.

CONCLUSION

With increasing experience even extended pulmonary resections are safe and feasible by a video-assisted thoracoscopic approach. We propose that in sulcus superior tumors without tumor invasion of vascular structures VATS can be considered.