**1. Introduction**

sion: The Importance of an Early Intervention J Pain Symptom Manage. 2005 ; 30:

[140] Trotter D, Aly A, Siu L, Knight S. Video-assisted thoracoscopic (VATS) pleurodesis for malignant effusion: an Australian teaching hospital's experience. Heart Lung and

[141] Gu LJ, Wang WJ. Comparative study of video-assisted thoracoscopic surgery vs thoracic tube drainage in synthetic therapy for malignant pleural effusion secondary to non-small cell lung cancer. Nan Fang Yi Ke Da Xue Xue Bao 2006; 26: 1023–1026

[142] Luh SP, Chen CY, Tzao CY. Malignant pleural effusion treatment outcomes: pleurod‐ esis via video-assisted thoracic surgery versus tube thoracostomy. Thorac Cardiovasc

[143] Crnjac A. The significance of thoracoscopic mechanical pleurodesis for the treatment

[144] Neragi-Miandoab S. Surgical and other invasive approaches to recurrent pleural ef‐ fusion with malignant etiology. Support Care Cancer. 2008 Dec;16(12):1323-31. [145] Rusch VW. Pleurectomy/decortication in the setting of multimodality treatment for diffuse malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg 1997; 9: 367–

[146] Bernard A, de Dompsure R, Hagry O, Favre J. Early and late mortality after pleurod‐

[147] Brega-Massone P, Conti B, Magnani B, Ferro F, Lequglie C. Minimally invasive thoracic surgery for diagnostic assessment and palliative treatment in recurrent neo‐

esis for malignant pleural effusion. Ann Thorac Surg 2002; 74: 213–217.

plastic pleural effusion. Thorac Cardiovasc Surg 2004; 52: 191–195.

of malignant pleural effusions. Wien Klin Wochenschr 2004; 116: 28–32

75-9.

372.

Circulation 2005; 14: 93–97.

108 Principles and Practice of Cardiothoracic Surgery

Surg 2006; 54: 332–336

Superior sulcus tumours are rarely encountered in clinical practice, representing < 5% of all bronchogenic carcinomas [1, 2]. In 1932, Pancoast [3] published his classic article in which he reported four patients who had a similar presentation including pain in the shoulder and arm, weakness and wasting of the muscles of the hand, and ipsilateral Horner syndrome together with a lesion situated at the apex of the lung. Pancoast [3] rejected the pulmonary origin of the tumour that was recognised by Tobias [4], who described the same clinical syndrome in four other patients.

Pancoast syndrome is due to lesions extending to the superior thoracic inlet. Specific symp‐ tomatology mainly due to brachial plexus invasion accounts for the majority of those cases [5-7]. Pancoast tumour is a tumour of the apex of the lung with no intervening lung tissue between tumour and chest wall. Subsequently, there is an involvement of structures of the apical chest wall above the level of the second rib. Almost half of the treated cancers are squamous cell carcinomas (45-50%), while the rest are either adenocarcinomas (36-38%) or undifferentiated large-cell carcinomas (11-13%). The tumour rapidly involves the structures of the thoracic inlet & the root of neck. Due to its localisation in the apex of the lung, invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, occurs [8-10]. The classical Pancoast presentation, with shoulder pain radiating to the ulnar side of the arm and the hand, is presented in 55 to 60% of the patients. Pain at the ulnar aspect of the forearm and hand is consistent with T1 involvement; furthermore symp‐ tomatology along the intrinsic hand muscles suggests the C8 root or lower trunk tumour deposits. Horner's syndrome is reported in up to 30% of the cases.

Superior sulcus tumours are not necessarily associated with the classic Pancoast syndrome. Though some controversy exists about their exact definition, it is generally accepted that they

© 2013 Parissis et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

may be defined as primary lung cancers involving the apex of the chest wall and usually associated with pain in the shoulder and/or arm[9, 10].

rent CT/RT (platinum-based chemotherapy and 45Gy of radiotherapy) improves the rate of complete resection, local recurrence, and intermediate-term survival. Like wise, the Japan Clinical Oncology Group JCOG trial 9806 [17]in a prospective report concluded along the same lines. Furthermore, Kwong et al [18] reported that high dose radiotherapy targeting up to 60 Gy (rather than 45 Gy) could be given in the neoadjuvant setting; it is successfully tolerated

Superior Sulcus Tumour with some Emphasis on the Anterior Approach

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

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The limited access and poor visualisation of the thoracic inlet is due to: 1) the unique course of the upper ribs downwards and outwards that render the neuro-vascular bundle inaccessible to posterior approaches, 2) the musculature of the area and also 3) the overlapping bulky pectoral-shoulder girdle with the clavicle and the manubrium to further restrict access from the neck. These anatomical idiosyncrasies create a hostile but challenging environment for the

The main goal for cure is to achieve local control of the disease and aim for relapse-free, metastasis-free outcome. Local control is obtained by removing the upper lobe, chest wall and invaded structures (subclavian artery or vertebra), aiming for R0 resection margins. Radically resected cases yield better survival whereas R1 resections are associated with high incidence of local and distal recurrences. Involvement of the vertebral body or brachial plexus, once considered unresectable is nowadays amenable to advanced techniques of spinal reconstruc‐ tion and should be planned jointly with a spine neurosurgeon. Finally, according to recent reports [16, 17], the rate of R0 resection could be above 85%, with the use of tri-modality

Contraindications for surgery would be due to metastasis, invasion of the brachial plexus above C7 & invasion of the spinal canal. Resection of the T1nerve root is usually well tolerated, but removal of the C8 root or lower trunk of the brachial plexus leads to loss of hand and arm function. N2 disease is a relative contraindication and some groups enrol those patients after extended hilar radiation. As per JCOG [17]rib involvement occurs in 77.2% of the patients (usually 3 ribs or more), vertebra involvement in 10.5% of the patients, and major vessels in

According to Wright et al [10], marked difference in pathologic response based on the induction therapy is favouring CT/RT. Surgical resection of Pancoast tumours after neoadju‐ vant high-dose CT/RT was carried out in 40.5% of patients according to Kwong et al [18].

Pathological downstaging although it does not correlate with the radiological appearance [16] is reported to be impressively above 30% in various series. As per Pourel et al [15], pathological

5.3%. T1 involvement is the commonest root involved in up to 85% of the cases.

**4. Various treatment modalities and tumour down-staging**

and associated with improved resection rate.

**3. Applied surgical anatomy**

thoracic surgeon.

protocols.

AlthoughthosetumoursrepresentawiderangeofstageIIBtostageIVdisease,(IIB(25-27%),stage IIIA (6-8%), stage IIIB (40-42%) and stage IV (21-23%) it is the T3, T4, N0-N1 subgroup of this spectrumthatcouldbeamenabletosurgicalintervention[11].Thissubgroupofpatients(lessthan 5% of Bronchogenic Carcinomas) however, is difficult to be treated surgically due to the loca‐ tion of the tumour and the complex anatomy of the area involved [12]. Historically, Pancoast tumourshavebeenassociatedwithhighratesofincompleteresection,localrecurrence,anddeath.

Pancoast tumours were thought to be located posteriorly and early attempts to resect those tumourswereapproachedsolelyfromtheback.Apercentageoftheselesionsmightalsobelocated at the front, with vascular rather than neuro-vertebral involvement. Various reports suggested spinal involvement in 15%, brachial plexus in 15% and subclavian vessels in 6% of the cases [13]. Thereforesurgeonstreatingthesecancersshouldbeabletobefamiliarandadaptwiththevarious approaches. An understanding of the posterior location of neural structures and somewhat anterior location of vascular structures is important for adequate operative planning.

This article alludes to the anatomy, initial assessment, and surgical approaches with an emphasis on the modified anterior approach for these cancers.
