References for this review were identified by searches of MEDLINE and PubMed with the terms “Pancoast tumours”, “superior sulcus tumours”, “adjuvant therapy”, and “surgery”, and by looking through reference lists from relevant articles. Reports published between 1996 and 2006 were included, as well as historical material.
ReviewManagement of Pancoast tumours
Introduction
Non-small-cell lung carcinomas (NSCLC) of the superior sulcus, frequently termed Pancoast tumours, are some of the most challenging thoracic malignant diseases to treat because they generally invade adjacent vital structures, including the brachial plexus, subclavian vessels, and spine (figure 1).1 Originally described by a radiologist, Henry Pancoast, in 1932,2 superior sulcus NSCLC were deemed universally fatal until the 1950s, when the strategy of induction radiotherapy and en-bloc resection was shown to be potentially curative.3, 4 During the next 40 years, this approach remained standard care, with advances restricted to development of surgical techniques for T4 tumours infiltrating the subclavian vessels and spine.5, 6, 7 However, complete resection was usually achieved in only 60% of patients, and overall survival at 5 years generally did not exceed 30%, indicating a clear need for innovative treatments.8 During the 1990s, concurrent cisplatin-based chemotherapy and radiotherapy followed by resection was shown to be safe and effective for some stage III NSCLC.9 Findings of small studies10 suggested that this treatment strategy was appropriate for Pancoast tumours, which led to a large North American trial of induction chemoradiotherapy followed by resection, establishing this treatment as standard care. In this review, I discuss initial assessment and multimodality management of Pancoast tumours and the technical aspects of resection.
Section snippets
Anatomical definition
The original description by Pancoast of a superior pulmonary sulcus tumour was that of a carcinoma (of uncertain origin) arising in the extreme apex of the chest, associated with shoulder and arm pain, atrophy of the hand muscles, and Horner's syndrome. Anatomically, the pulmonary sulcus is synonymous with the costovertebral gutter, which extends from the first rib to the diaphragm. The superior pulmonary sulcus describes the uppermost extent of this recess.11, 12 Unknown to Pancoast, the most
Initial assessment
The clinical diagnosis of a Pancoast tumour does not invariably mean that the lesion is NSCLC. Patients with other diagnoses such as lymphoma, tuberculosis, or primary chest-wall tumours can present with an apical mass and chest-wall involvement. Lesions in this location are readily accessible for biopsy procedures via transthoracic fine-needle aspiration, and this technique should be done to confirm NSCLC.
Thorough preoperative assessment is needed before embarking on treatment that could lead
Evolution of multimodality management
Developments in the management of NSCLC of the superior sulcus during the past 70 years can be classified into four eras. At the onset of the first era, Pancoast described these tumours as “a peculiar neoplastic entity found in the upper portion of the pulmonary sulcus of the thorax…evidently epithelial in its histopathology, but its exact origin is uncertain”.2 During the ensuing 20 years, these tumours became recognised as primary lung carcinomas but were thought to be inoperable and
Future directions for multimodality treatment
Accrual to the phase II trial described above was completed successfully within the planned time frame, but needed the efforts of 76 surgeons from all North American cooperative groups to enrol 110 eligible patients. Thus, in future, randomised phase III trials that include resection are unlikely to complete accrual within an acceptable length of time for this uncommon NSCLC subset. However, the results highlight several issues that could be investigated in future trials of either single-group
Posterior approach
Figure 4 shows a patient positioned in the lateral decubitus position, rotated slightly anteriorly. With a posterior surgical approach, the chest is entered at the estimated level of chest-wall involvement via a posterolateral thoracotomy. The pleural cavity is examined to ascertain resectability, then an incision is made superiorly midway between the scapula and the spinous processes to the seventh cervical vertebra, dividing the trapezius and rhomboid muscles. This technique allows the
Conclusion
Superior sulcus NSCLC pose a formidable therapeutic challenge because of their proximity to several vital structures in the body. During the past 40 years, the development of effective combined modality treatments and of new surgical approaches has greatly increased local control and overall survival for patients with these tumours. Future studies are needed to address the continuing difficulties of systemic relapse after surgery, especially in the brain.
Search strategy and selection criteria
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