**3. Applied surgical anatomy**

may be defined as primary lung cancers involving the apex of the chest wall and usually

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.

emphasis on the modified anterior approach for these cancers.

strained by dose-limiting toxicities upon the nearby organs.

This article alludes to the anatomy, initial assessment, and surgical approaches with an

**2. How does the treatment of pancoast tumours evolved the last decades**

For more than 40 years the treatment of Pancoast tumours has centred on a bi-modality regimen consisting of preoperative external beam radiotherapy followed by surgery. Trimodality treatment however with the addition of platinum based chemotherapy regimes has become currently the standard treatment, in order to achieve additive anti-tumour effects (chemotherapy as radiation sensitiser). According to Wright et al [14] induction chemoradiotherapy (CT/RT) can be administered with low morbidity, a higher complete resection rate, a high pathologic response rate, a reduced loco-regional recurrence rate and improved survival. Further improvement in radiotherapy with the advent of 3-dimensional conformal radiotherapy, the total radiation dose that could be safely delivered was not anymore con‐

Careful patient selection for tri-modality treatment, on the basis of staging and comorbidity, is of vitalimportanceinthetreatmentofPancoasttumours.Neverthelessonly30%ofM0patientswith Pancoast tumours were eligible for combined treatment according to Pourel et al [15]. Not only operability (patient fitness to surgery) but also ability to resect the tumour is of a major impor‐ tancebearinginmindthedifficultyofaccess,thecrowdedanatomyofthisregionandthetendency of the tumours in this area to involve important adjacent structures. As per the same group [15], following CT/RT, 67% of the patients were amenable to thoracotomy. The resection rate, which had remained unchanged at approximately 50%for almost 40 years with conventional preopera‐

Preoperative radiotherapy was part of the standard treatment, but a recent prospective phase II study (Southwest Oncology Group 9416, INT 0160)[16], suggests that preoperative concur‐

tive radiotherapy, was improved to above 70% in SWOG [16] and JCOG [17] studies.

associated with pain in the shoulder and/or arm[9, 10].

110 Principles and Practice of Cardiothoracic Surgery

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 thoracic surgeon.

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 protocols.

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