**12. Summary**

#### **12.1. Introduction**

Pancoast syndrome is due to lesions extending to the superior thoracic inlet. Pancoast tumour is a tumour of the apex of the lung with no intervening lung tissue between tumour and chest wall. The tumour rapidly involves the structures of the thoracic inlet & the root of neck.

Pain at the ulnar aspect of the forearm and hand is consistent with T1 involvement; furthermore symptomatology along the intrinsic hand muscles suggests the C8 root or lower trunk tumor deposits.

An understanding of the posterior location of neural structures and somewhat anterior location of vascular structures is important for adequate operative planning.

Pancoast tumours were thought to be located posteriorly and early attempts to resect those tumors were approached solely from the back. A percentage of these lesions might also be located at the front, with vascular rather than neuro- vertebral involvement. Therefore surgeons treating these cancers should be able to be familiar and adapt with the various approaches.

#### **12.2. Surgical Approaches**

preventing distant metastasis has now become the challenge in the treatment of these patients. Large randomised trials concluded a 5—15% survival benefit at 5 years of adjuvant chemo‐ therapy in patients with radically resected stages I—IIIA NSCLC [49, 50]. However, many patients with Pancoast tumours may not tolerate more extensive treatment. Moreover Martinod et al [26] reported that preoperative radiotherapy significantly improved the 5-year survival for stage IIB—IIIA, while postoperative radiotherapy and chemotherapy did not significantly alter survival. 7) Is the Survival with the use of anterior approach better versus

Pancoast tumours represent a small percentage of Lung cancer population (1-5%). Due to poor performance status and/or advanced tumour stages, only 30-40 % [10, 13] of those patients are

Careful patient selection and adherence to protocols enables Clinical groups to get an impres‐

Superior sulcus tumours remain an extremely severe condition, but cure may be achieved in a large percentage of cases. The surgical approach should be adapted to the different clinical and radiologic presentations in order to achieve a complete surgical resection, which repre‐ sents the most important positive prognostic factor. Surgery carries a high operative risk, especially if a combined approach is needed, so every effort should be made to identify patients

No single surgical approach however, provides the best access to all of the heterogeneous tumours of the thoracic inlet. The thoracic surgeon must be familiar with the potential advantages that the anterior approach offers under given circumstances. This knowledge enables the thoracic surgeon to explore new avenues and exciting challenges. Dartevilles approach and the various modifications are technically demanding, however once the anatomy has been appreciated, direct visualisation of the major structures of the Thoracic inlet aids to facilitate complete oncological clearance. Whether the anterior approach results in less

Pancoast syndrome is due to lesions extending to the superior thoracic inlet. Pancoast tumour is a tumour of the apex of the lung with no intervening lung tissue between tumour and chest wall. The tumour rapidly involves the structures of the thoracic inlet & the root of neck.

loco-regional recurrences and possibly better 5 year survival, remains to be seen.

sion of the efficacy of an intervention and to compare results between studies.

posterior approach for the same stage of Pancoast tumours?

eligible to be enrolled in multi-modality protocols of treatment.

expected to derive a benefit that outweighs risks.

**11. Conclusion**

120 Principles and Practice of Cardiothoracic Surgery

**12. Summary**

**12.1. Introduction**


We favour a modified Dartevelle approach We prefer to divide the sternum down to the angle of Luis and then extend the incision horizontally along the 2nd intercostal space, thus allowing the surgeon to lift the clavicle, subclavian muscle, and transected part of the manubrium and superior boby of the sternum without dividing the first costal cartilage and ligament.

Mobilisation & excision of the supraclavicular fat pad, allows exposure of the structures at the thoracic inlet; further division of the subclavius, omohyoid with preservation of the accessory nerve is carried out.

The distal part of the jugular veins is divided to expose the subclavian and innominate veins. If the subclavian vein is affected then it is resected. Following this, the scalenus anterior muscle is divided by taking care to preserve the phrenic nerve.

The subclavian artery is mobilized by, dividing most of its branches. Care is taken to preserve the vertebral artery and resection of the vessel is done only if it is involved with the tumor and no substantial extracranial occlusive disease can be detected on preoperative Doppler ultra‐ sound.

#### **12.3. The advantages of the anterior- cervical approach**

**1.** Direct visualization of major structures (eg. Subclavian artery), allowing control and elective sacrifice if necessary the artery and reconstruct directly to a safe outcome.


It is apparent however, that locoregional relapse is predominant in R1-2 resections, whereas

Superior Sulcus Tumour with some Emphasis on the Anterior Approach

http://dx.doi.org/10.5772/55724

123

In the future new neoadjuvant regimes including aggressive protocols of accelerated radio‐ therapy would potentially increase the pool of surgical candidates from patients diagnosed with a Pancoast tumor (currently 23% of the patients as per Kappers et al). However, several questions still remain unresolved such as the role of PET, nodal involvement especially recruiting patients with N2 disease. Lastly the role of trimodality treatment and prophylactic

Pancoast tumors represent a small percentage of Lung cancer population (1-5%). Due to poor performance status and/or advanced tumor stages, only 30-40 % of those patients are eligible

No single surgical approach however, provides the best access to all heterogeneous tumors of the thoracic inlet. What probably provides the most favorable outcome would be a team approach, where the thoracic surgeon coordinates with an experience neuro-spinal surgeon, in a background of limited disease that is responding well to neoadjuvant chemoradiotherapy.

Cardiothoracic Surgery Department, Royal Victoria Hospital, Belfast, Northern Ireland

[1] Bridgewater B KR, Walton P. Sixth National Adult Cardiac Surgical Database Report. Society for Cardiothoracic Surgery in Great Britain and Ireland2008. Report No.:

[2] Ginsberg RJ, Martini N, Zaman M, Armstrong JG, Bains MS, Burt ME, McCormack PM, Rusch VW, Harrison LB. Influence of surgical resection and brachytherapy in the management of superior sulcus tumor. Ann Thorac Surg1994 Jun;57(6):1440-5.

[3] Pancoast H. Superior pulmonary sulcus tumor: tumor characterized by pain, Horn‐ er's syndrome, destruction of the bone and atrophy of hand muscles. JA‐

distant recurrence is frequent in R0 resections.

to be enrolled in multimodality protocols of treatment.

, Alan Soo and Bassel Al-Alao

\*Address all correspondence to: hparissis@yahoo.co.uk

ISBN 1-903968-23-2. 2009.

MA1932;99:1391-6.

cranial irradiation

**12.7. Conclusion**

**Author details**

Haralabos Parissis\*

**References**

#### **12.4. Down-staging**

Pathological down-staging although it does not correlate with the radiological appearance is reported to be impressively above 30% in various series.

JCOG reported pathologic down-staging of the tumour in 40% of the patients; No residual viable tumour cells in the resected specimens, was achieved in 16% of the treated patients. Also SWOG summarised that pathologic no residual microscopic tumour was seen in one third of the resected specimens and minimal microscopic residual (few scattered tumour foci within a mostly necrotic or fibrotic mass), was observed in one third of the resected specimens.

#### **12.5. Results**

Unfavorable outcome is due to incomplete resection and life-threatening complications.

Current reports are quoting perioperative mortality not higher than for any other lung resection.

Adverse prognostic factors are including the presence of mediastinal nodal metastases (N2 disease), spine or subclavian-vessel involvement (T4 disease), and limited resection (R1 or R2.


**Table 1.** Survival with the use of the anterior versus posterior approach

#### **12.6. Recurrence**

With bimodality regimes the local recurrence rates were reported to be above 70%. Despite the advent in treatment regimes, local recurrence still occurs in about 40% of the patients; it is expected that local recurrence rate is higher in patients with T4 disease because complete resection can be achieved in less than half of the patients with c-T4 disease.

More specifically complete resection rate was achieved in only 64% of tumour stage T3 and nodal stage N 0 and 39% of T4N0 tumours.

It is apparent however, that locoregional relapse is predominant in R1-2 resections, whereas distant recurrence is frequent in R0 resections.

In the future new neoadjuvant regimes including aggressive protocols of accelerated radio‐ therapy would potentially increase the pool of surgical candidates from patients diagnosed with a Pancoast tumor (currently 23% of the patients as per Kappers et al). However, several questions still remain unresolved such as the role of PET, nodal involvement especially recruiting patients with N2 disease. Lastly the role of trimodality treatment and prophylactic cranial irradiation

#### **12.7. Conclusion**

**2.** Carry out hemi-vertebrectomy if the anterior body of the vertebra are involved.

plexus the T1 nerve root and Vertebral body

reported to be impressively above 30% in various series.

**12.4. Down-staging**

122 Principles and Practice of Cardiothoracic Surgery

**12.5. Results**

resection.

**12.6. Recurrence**

**3.** Provide complete oncological clearance of the structures of the Thoracic inlet. The structures which may be sacrificed if involved are the Subclavian artery, the Brachial

Pathological down-staging although it does not correlate with the radiological appearance is

JCOG reported pathologic down-staging of the tumour in 40% of the patients; No residual viable tumour cells in the resected specimens, was achieved in 16% of the treated patients. Also SWOG summarised that pathologic no residual microscopic tumour was seen in one third of the resected specimens and minimal microscopic residual (few scattered tumour foci within a mostly necrotic or fibrotic mass), was observed in one third of the resected specimens.

Unfavorable outcome is due to incomplete resection and life-threatening complications.

**Author (year) No. of Cases 5 year survival (%) Mortality (%)**

Paulson DL (1985) 79 35 3 Maggi et al (1994) 60 17.4 5 Ginberg et al (1994) 100 26 4 Okubo et al (1995) 18 38.5 5.6 Hagan et al (1999) 34 33 0 Dartevelle P (1999) 70 34 0

resection can be achieved in less than half of the patients with c-T4 disease.

**Table 1.** Survival with the use of the anterior versus posterior approach

nodal stage N 0 and 39% of T4N0 tumours.

Current reports are quoting perioperative mortality not higher than for any other lung

Adverse prognostic factors are including the presence of mediastinal nodal metastases (N2 disease), spine or subclavian-vessel involvement (T4 disease), and limited resection (R1 or R2.

With bimodality regimes the local recurrence rates were reported to be above 70%. Despite the advent in treatment regimes, local recurrence still occurs in about 40% of the patients; it is expected that local recurrence rate is higher in patients with T4 disease because complete

More specifically complete resection rate was achieved in only 64% of tumour stage T3 and

Pancoast tumors represent a small percentage of Lung cancer population (1-5%). Due to poor performance status and/or advanced tumor stages, only 30-40 % of those patients are eligible to be enrolled in multimodality protocols of treatment.

No single surgical approach however, provides the best access to all heterogeneous tumors of the thoracic inlet. What probably provides the most favorable outcome would be a team approach, where the thoracic surgeon coordinates with an experience neuro-spinal surgeon, in a background of limited disease that is responding well to neoadjuvant chemoradiotherapy.
