**5. What are the various surgical approaches**

The approach of Paulson [19] is completely satisfactory in dealing with posteriorly located tumours; however, it is not fully adequate in the presence of invasion of anteriorly located structures (especially subclavian vessels or their branches). Therefore, different anterior approaches have been developed in the last 25 years, including the cervicosterno-thoracoth‐ omy[20] or the hemi-clamshell incision [21, 22], the transcervical-transthoracic approach with resection of the clavicle [23, 24], and the trans-manubrial approach [25]. Exact indications for these different approaches remain controversial, and few data are available about long-term outcome of patients treated by anterior approaches [22, 24, 26].

Posterior approach (Paulson)/ posterolateral-paravertebral thoracotomy: This is an extension of the conventional postero-lateral thoracotomy; the incision is extending around the tip of the scapula, then it continuous upwards and further midway between the posterior edge of the scapula and the spinous processes, up to the level of C7. By taking the scapula of the chest wall this incision allows good exposure of the posterior chest wall, including the transverse processes, the vertebrae and the roots of the thoracic nerves and the plexus [27]. Nevertheless the exposure of the neuro-vascular structures are limited. This is due to the fact that brachial plexus and vascular structures often lie above the tumour mass and access to such structures, is significantly limited using approaches from below.

According to Vanakesa et al [28], Posterior approach, does not provide adequate access to the many important structures which may be involved by apical chest tumours of bronchogenic origin. This restricted access may be one of the reasons for the high rate of incomplete resections [29] and high surgical morbidity and mortality using this approach [10]. The anterior-cervical entry [24] proved to be the answer to the problem of limited exposure. It appears to be the optimal approach to anterior lung apex or first rib lesions [30].

We would facilitate a case like the one presented in Figure 1 by using an anterior-manubrialsternal approach for access.

Accurate and thorough staging & re-staging (Radiological response is defined according to the RECIST criteria [31]following neoadjuvant treatment is necessary prior to surgery (see Figure 2) and typically includes CT-PET and magnetic resonance imaging (Contrast-enhanced MRI of Chest and Brain). MRA is a noninvasive diagnostic method complementary to MR imaging for detecting vascular involvement in bronchogenic carcinoma with Pancoast syndrome [32].

**Figure 1.** CXR, CT Chest imaging, MRI and bone scan of a Pancoast tumor of a 47 yrs old female, Ex smoker (25 cigs per day up to 13 years ago). Six weeks history of shoulder pain radiating to the median aspect of the right arm. CXR mass at apex of right chest. Percutanteous Biopsy NSCLC. PMH: Hysterectomy for Ca cervix 1996 - no evidence of re‐

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currence. Clinical examination fullness in right supra-clavicular fossa.

complete response was observed in 39.5% of the patients, necrosis of tumoural tissues between 50% and 95% in 22.5% and less than 50% in 38% of the patients. Along the same lines JCOG reported [17] pathologic downstaging 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. Finally SWOG [16] 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.

The approach of Paulson [19] is completely satisfactory in dealing with posteriorly located tumours; however, it is not fully adequate in the presence of invasion of anteriorly located structures (especially subclavian vessels or their branches). Therefore, different anterior approaches have been developed in the last 25 years, including the cervicosterno-thoracoth‐ omy[20] or the hemi-clamshell incision [21, 22], the transcervical-transthoracic approach with resection of the clavicle [23, 24], and the trans-manubrial approach [25]. Exact indications for these different approaches remain controversial, and few data are available about long-term

Posterior approach (Paulson)/ posterolateral-paravertebral thoracotomy: This is an extension of the conventional postero-lateral thoracotomy; the incision is extending around the tip of the scapula, then it continuous upwards and further midway between the posterior edge of the scapula and the spinous processes, up to the level of C7. By taking the scapula of the chest wall this incision allows good exposure of the posterior chest wall, including the transverse processes, the vertebrae and the roots of the thoracic nerves and the plexus [27]. Nevertheless the exposure of the neuro-vascular structures are limited. This is due to the fact that brachial plexus and vascular structures often lie above the tumour mass and access to such structures,

According to Vanakesa et al [28], Posterior approach, does not provide adequate access to the many important structures which may be involved by apical chest tumours of bronchogenic origin. This restricted access may be one of the reasons for the high rate of incomplete resections [29] and high surgical morbidity and mortality using this approach [10]. The anterior-cervical entry [24] proved to be the answer to the problem of limited exposure. It appears to be the

We would facilitate a case like the one presented in Figure 1 by using an anterior-manubrial-

Accurate and thorough staging & re-staging (Radiological response is defined according to the RECIST criteria [31]following neoadjuvant treatment is necessary prior to surgery (see Figure 2) and typically includes CT-PET and magnetic resonance imaging (Contrast-enhanced MRI of Chest and Brain). MRA is a noninvasive diagnostic method complementary to MR imaging for detecting vascular involvement in bronchogenic carcinoma with Pancoast

**5. What are the various surgical approaches**

112 Principles and Practice of Cardiothoracic Surgery

outcome of patients treated by anterior approaches [22, 24, 26].

is significantly limited using approaches from below.

sternal approach for access.

syndrome [32].

optimal approach to anterior lung apex or first rib lesions [30].

**Figure 1.** CXR, CT Chest imaging, MRI and bone scan of a Pancoast tumor of a 47 yrs old female, Ex smoker (25 cigs per day up to 13 years ago). Six weeks history of shoulder pain radiating to the median aspect of the right arm. CXR mass at apex of right chest. Percutanteous Biopsy NSCLC. PMH: Hysterectomy for Ca cervix 1996 - no evidence of re‐ currence. Clinical examination fullness in right supra-clavicular fossa.

Root of neck anatomy as in Figure 3 is depicting carefully the relationship of the most important neuro-vascular structures to the scalene musculature and the first rib. The anterior and middle scalene muscles are attached to the first rib and can be used as landmarks: in front of the anterior scalene muscle situated the subclavian and internal jugular veins and the sternoclei‐

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The subclavian artery, the trunks of the brachial plexus, and the phrenic nerve are emerging above the lateral part of the1st rib between the anterior and middle scalene muscles. The nerve roots of the brachial plexus, the stellate ganglion, and the vertebral column are situated behind

We favour a modified Dartevelle approach [24] an L shaped incision at the anterior edge of Sterno-cleido-mastoid (a). Division of the upper sternum extended into 2nd intercostal space (b). This is a modified access something between Grunenwald [25] and Klima et al [33] approach. Grunenwald has described a trans-manubrial approach, which avoids division of the clavicle. Klima and colleagues suggested extending the L-shaped section of the manubrium down to the first intercostal space. 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 body of the sternum without dividing the first costal cartilage and ligament. The internal mammary artery is encountered and divided during the horizontal intercostal

Mobilisation & excision of the supra-clavicular fat pad (c), allows exposure of the structures at the thoracic inlet; further division of the subclavious, omohyoid with preservation of the

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 (d) & (e). The subclavian artery is mobilised 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 tumour and no substantial extra-

If the subclavian artery is taken up by tumour, the affected portion is resected and recon‐ structed, usually with a 6-8 mm PTFE vascular graft. Small dose of heparin is usually admin‐

Following anterior traction of the subclavian artery, the scalenus medius muscle comes into good view. The muscle is divided above its insertion on the first rib, giving access to the branchial plexus. Familiarity with the anatomy of the plexus is important. At this stage, the anterior surface of the vertebral bodies of C7 and T1 are in view. The sympathetic chain and stellate ganglion are lying in front of the anterior surface of the vertebral bodies of C7 and T1.

cranial occlusive disease can be detected on preoperative Doppler ultrasound.

domastoid and omo-hyoid muscles.

**6. Exposure and surgical steps (Figure 4)**

the middle scalene muscle.

incision.

accessory nerve is carried out.

istered during vascular clamping.

**Figure 2.** Staging algorithm for patients prior to resection of a Pancoast Tumor. MRI of the thoracic inlet may yield further information's on the status of vertebra involvement.

**Figure 3.** Root of neck anatomy, depicting carefully the relationship of the most important neurovascular structures to the scalene musculature and the first rib.

Root of neck anatomy as in Figure 3 is depicting carefully the relationship of the most important neuro-vascular structures to the scalene musculature and the first rib. The anterior and middle scalene muscles are attached to the first rib and can be used as landmarks: in front of the anterior scalene muscle situated the subclavian and internal jugular veins and the sternoclei‐ domastoid and omo-hyoid muscles.

The subclavian artery, the trunks of the brachial plexus, and the phrenic nerve are emerging above the lateral part of the1st rib between the anterior and middle scalene muscles. The nerve roots of the brachial plexus, the stellate ganglion, and the vertebral column are situated behind the middle scalene muscle.
