**10. Future thoughts**

There are concerns about functional and aesthetic results with the trans-clavicular approach,

Unfavourable outcome is due to incomplete resection and life-threatening complications Current reports are quoting peri-operative mortality not higher than for any other lung

The prognosis of this tumour remained poor until 1961 when Shaw et al [38] reported their satisfactory experience with a bi-modality treatment based on preoperative radiotherapy followed by surgery through a posterior thoracotomy approach. Several other reports [2, 10, 19, 29, 38-41] confirmed that 5-year survivals of approximately 10 to 35% could be achieved with this combined approach, which became the standard treatment. Although radiotherapy was performed prior to surgery in most series, in the experience of others [24, 26]it was often

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) [42-44]. Along the same lines Ginsberg et al [2] found Horner's syndrome, N2/N3 disease, T4 disease and incomplete resection, in general, to be adverse prognostic factors. Okubo and associates [29][16] found that incomplete resection particularly tumour invasion to the brachial

With bi-modality regimes the local recurrence rates were reported to be above 70% [10, 13]. Despite the advent in treatment regimes, local recurrence still occurs in about 40% of the patients [43]; 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 [17]. More specifically [44] 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 loco-regional relapse is predominant in R1-2 resections, whereas distant recurrence is frequent in R0

One would expect that a shift in the trend of clinical recurrences towards distant metastasis is to be currently expected because of the fact that tri-modality treatment facilitates better R0 resection. As per Pourel et al [15] the most frequent site of relapse was distant metastasis in 66% of the patients, (mainly brain) with the loco-regional recurrence rate of 18%. Likewise Kwong et al [18] reported brain metastasis in 25% and local recurrence rate in 19% of the cases. A small series that had bi-modality treatment however had an incidence of loco-regional

which includes removal of the medial half of the clavicle.

**8. Results from literature review**

118 Principles and Practice of Cardiothoracic Surgery

resection [16, 17].

carried out postoperatively.

plexus, influenced the prognosis.

**9. Recurrence & survival**

resections.

recurrence of 17.2% [14].

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 tumour (currently 23% of the patients as per Kappers et al [13]. However, several questions still remain unresolved:

1) The role of PET-CT in re-staging tumours (eg. The role of "late wash out" images in differentiating between inflammation and residual tumour) following neo-adjuvant treat‐ ment; Schmuecking et al [47] have shown that metabolic response after induction CT/RT evaluated within 1 week following its completion, is highly predictive of pathological response. 2) What is the significance and implications of ipsilateral supra-clavicular lymph node disease: The argument being that these nodes are in close vicinity of the tumour and therefore could have the characteristics of the biological behaviour of "N1 disease". 3) Recruiting patients with N2 disease: The argument being that inclusion of the hilar and mediastinal nodes in the irradiation field promotes downstaging. Kwong et al [18] did not exclude patients with positive mediastinal nodes from tri-modality treatment and found no difference in survival. In most papers, however, results of patients with persistent N2 disease turned out to be clearly inferior to those of patients with N0/1 only. On the other hand, no clinical trial has yet compared various tri-modality treatment regimes for patients with N2 disease. 4) The role of prophylactic cranial irradiation: Due to good loco-regional control with tri-modality treatment, distant metastases now represent the most common site of failure. Furthermore, the incidence of brain metastasis as a first site of recurrence in Pancoast tumour is between 15-30% [34, 48]. The negative impact of brain metastasis on survival has to be weighted against the risks benefits ration of the impact of prophylaxis with radiation to the brain. 5) The role of high dose of RT (up to 60Gy): Are there specific subgroups (eg. for patients with clinical T4 disease complete resection is feasible in less than 50% of the cases) that they would benefit. 6) The role of Adjuvant postoperative chemotherapy: distant metastases now represent the most common site of failure following treatment for Pancoast tumours therefore 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 posterior approach for the same stage of Pancoast tumours?

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

Superior Sulcus Tumour with some Emphasis on the Anterior Approach

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

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An understanding of the posterior location of neural structures and somewhat anterior

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

**1.** 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. Never the less the exposure of the neurovascular structures are limited.

**2.** The anterior-cervical approach proved to be the answer to the problem of limited exposure. It appears to be the optimal approach to anterior lung apex and first rib lesions.

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

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

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

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‐

**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.

superior boby of the sternum without dividing the first costal cartilage and ligament.

is divided by taking care to preserve the phrenic nerve.

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

location of vascular structures is important for adequate operative planning.

deposits.

approaches.

**12.2. Surgical Approaches**

nerve is carried out.

sound.
