**7. Anterior approach: Advantages and dis-advantages**

#### **7.1. Advantages**

According to Machiarini et al [36] one of the major advances in the treatment of Pancoast tumours has been the introduction of anterior approaches for resection. These approaches increase the likelihood of complete resection and permit resection of tumours that were previously considered technically unresectable [37].

Furthermore anterior approach facilitates: 1) Direct visualisation of major structures (eg. Subclavian artery, superior vena cava) thus allowing control and elective sacrifice of the artery if necessary and reconstruct directly to a safe outcome. 2) Excellent exposure of the brachial plexus, sympathetic chain, and stellate ganglion. 3) Carry out hemi-vertebrectomy if the anterior body of the vertebra are involved. 4) Resection of the lower parts of the Brachial plexus, especially of the C8, T1 roots; however T1 root resection results in diffuse weakness of the intrinsic muscles of the hand, whereas resection of the C8 nerve root of the lower trunk of the brachial plexus results in permanent paralysis of the hand muscles. 5) Optimal access, for resection of the chest wall. 6) Oncological clearance of the structures of the Thoracic inlet, because the tumour is the last to be encountered. 7) Lower morbidity than the posterior approach.

Moreover as per Vanakesa et al [28]the cervical-trans-sternal approach has several advantages, chiefly that of avoiding disfigurement and loss of function of the pectoral girdle, whilst providing excellent exposure of the brachial plexus, sympathetic chain, and stellate ganglion. Such an approach results in a short postoperative stay (3–6 days), and yet allows extension as per Grunenwald [25], or by a high, anterior thoracotomy if necessary.

#### **7.2. Disadvantages**

The C8 and T1 nerve roots are visualised and dissected medially up to the lower trunk of the brachial plexus. The C8 nerve component of the plexus is preserved if possible, for better

Lobectomy (f): can be performed through the neck incision or a posterolateral thoracotomy.

**Figure 4.** Step by step resection of a Pancoast tumor through an Antero-cervical approach. Incision at the anterior edge of Sterno-cleido-mastoid (a). Division of the upper sternum extended into 2nd intercostal space(b). Mobilisation-Excision of supraclavicular fat pad (c). Exposure of the structures at the thoracic inlet by dividing the subclavius, omohyoid with preser‐ vation of the accessory nerve. Division of the Scalenus anterior with preservation of the phrenic nerve (d) & (e). Right upper

Care is taken then, to access tumour invasion and plan with the neurosurgeon the "spinal

Chest wall resection is carried out by dividing the first 2-3 ribs at the sternal-costo-chondral junction following by disarticulation of the ribs from the transverse processes at the back. The

functional outcome of the upper limp.

116 Principles and Practice of Cardiothoracic Surgery

component" of the operation.

Removal of transverse processes and the head of the ribs in order to disarticulate them, could be difficult with the anterior access; furthermore more posterior seated tumours with vertebra involvement may require a complimentary posterior incision.

There are concerns about functional and aesthetic results with the trans-clavicular approach, which includes removal of the medial half of the clavicle.

Survival has been extensively reviewed by Attar et al [45]. Overall survival at 5 years after surgery was 46% for T3N0, 13% for T4N0, and 0% for lesions with N2 disease [44]. Particularly noteworthy [17]was the reproducibility of the favourable survival data, with a 5-year overall survival rate of 44% in the United States trial (SWOG) and 56% in JCOG trial, which were

Superior Sulcus Tumour with some Emphasis on the Anterior Approach

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There is wide variability in overall 5-year survival rates reported in larger series,[19, 24, 26, 39, 41, 44, 46] with figures ranging 10 to 35% probably because of the heterogeneity in studied populations, operative techniques, and preoperative and postoperative treatments. Such heterogeneity is probably responsible for the difference in the percentage of T3 and T4 tumours as well as in the rates of complete resection. Comparison of long-term results of different studies is difficult also for the frequent lack of information about survival according to the

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,

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

clearly superior to the historical value of 30%.

pathologic stage.

**10. Future thoughts**

several questions still remain unresolved:
