Management of Carcinoma of the Superior Pulmonary Sulcus

Johnson and Goldberg provide a comprehensive review of the managementof the Pancoast tumor, a bronchogenic carcinoma located in the superiorpulmonary sulcus. Due to this specific location, Pancoast tumors can invadenerves, blood vessels, and musculoskeletal structures located at the levelof the thoracic inlet. Such invasion can produce a wide range of clinicalsigns and symptoms, recognized as the Pancoast syndrome.

Nevertheless, the presence of the Pancoast syndrome is not pathognomonicfor a malignant neoplasm. There is a group of benign conditions that, dueto similar anatomic location, can behave like a Pancoast tumor. For thisreason, as stated by the authors, tissue diagnosis is mandatory.

The authors review the literature on the diagnosis of and treatmentoptions for this fascinating tumor. They provide historical data, includingthe initial clinical description by Drs. Edwin Hare and H. K. Pancoast,as well as an interesting discussion on current controversies over theoptimal diagnostic strategy (CT vs MRI) and, most recently, the use ofultrasound-guided fine-needle aspiration, which is supported by Dr. Yanget al.

The authors also discuss the importance of accurate staging and therole of mediastinoscopy. They emphasize that a complete metastatic work-upshould be performed because most of the treatment failures are secondaryto distant metastases, usually to bone or brain.

The authors review several treatments reported in the literature, includingDr. Shaw's approach, which is based on preoperative radiotherapy followedby radical resection, including resection of the chest wall, lobectomy/wedgeresection or pneumonectomy, and resection of the most inferior trunks ofthe brachial plexus. Paulson[1] reported that this approach achieved a34% 5-year survival rate in a series of 61 patients. This treatment strategyis used frequently by thoracic surgeons with experience in the managementof Pancoast tumors.

Unfortunately, most of the series are retrospective, and several importantissues have not been clarified. These include: (1) the benefits of surgeryover radiation, (2) the question of which modality should be given first,and (3) the value of single- vs combined-modality therapy. Currently, mostof the treatment strategies are based on the experiences of individualinstitutions. Also, the impact of chemotherapy on the outcome of patientswith Pancoast tumors has not been determined.

A Surgical Approach for "Unresectable" Tumors

Positive mediastinal lymph nodes, as well as extensive vertebral body,brachial plexus, and subclavian vascular invasion, indicate a poor prognosis,and these are considered contraindications to resection, as noted by theauthors. These criteria have been challenged by Dartevelle et al,[2] whohave developed an anterior transcervical-thoracic approach to apical lesionsthat maximizes the exposure to the thoracic inlet. This approach facilitatesvascular control, resection of the subclavian artery, and reanastomosiswith a polytetrafluorethylene (PTFE) graft, as well as resection and ligationof the subclavian vein. The technique also facilitates dissection at thelevel of the trunks of the brachial plexus.

This procedure does not preclude combination with the most traditionalapproach, which uses a posterolateral thoracotomy. The combination of thetwo approaches may permit resection of very difficult tumors invading thethoracic inlet. With the combined approach, selected patients who werepreviously considered to be unresectable have undergone resection witha 29% 5-year survival rate. There is no upfront radiotherapy with thisapproach. Instead, patients receive postoperative radiotherapy in combinationwith chemotherapy.

Several authors have demonstrated improved survival in patients withN2 disease (no Pancoast tumors) who receive neoadjuvant chemotherapy forthe purpose of downstaging.[3,4] This treatment may be applicable to superiorsulcus tumors with N2 disease.

It is also very important to document invasion through the cortex ofthe vertebral body before denying surgical resection based on minor deformities.Despite the advances in local control, most patients still die of distantmetastases. As mentioned by the authors, surgery remains a very importantcomponent of the treatment plan, especially in those patients with no evidenceof metastatic disease, which remains an absolute contraindication to radicalresection.

References:

1. Paulson DL: Carcinomas in the superior sulcus. J Thorac CardiovascSurg 70:1095-1104, 1975.

2. Dartevelle P, Chapelier A, Macchiarini P, et al: Anterior transcervical-thoracicalapproach for radical resection of lung tumors invading the thoracic inlet.J Thorac Cardiovasc Surg 105:1025, 1993.

3. Albain K, Rush V, et al: Concurrent cisplatin/etoposide plus chestradiotherapy followed by surgery for stage IIIA (n2) and IIIB non-small-celllung cancer: Mature results of Southwest Oncology Group phase II study8805. J Clin Oncol 13: 1880-1892, 1995.

4. Sugarbaker DJ, Herdon J, Kohman L, et al: Results of Cancer and LeukemiaGroup B protocol 8935: A multi-institutional phase II tri-modality trialfor stage IIIa (N2) non-small cell lung cancer. J Thorac Cardiovasc Surg109(3):473-483, 1995.