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Reconstruction After Pancoast Tumor Resection

  • Harold C. Urschel Jr
    Correspondence
    Address reprint requests to Harold C. Urschel Jr, MD, Department of Thoracic and Cardiovascular Surgery, University of Texas Southwestern Medical School, 3600 Gaston Ave, Suite 1201, Dallas, TX 75246
    Affiliations
    From the Department of Thoracic and Cardiovascular Surgery, University of Texas Southwestern Medical School, Dallas, TX
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      Pancoast tumor or superior pulmonary sulcus carcinoma are primary lung tumors that have invaded the chest wall at the thoracic apex. Anatomically, the superior pulmonary sulcus is the area on the superior surface of the lung traversed by the subclavian vessels and is circled by the first rib and spine; it may also be described as the thoracic outlet or the thoracic inlet. Although the classic presentation is posterior, it also may be anterior. These cancers include a wide variety of pathological entities that are encompassed by the term Pancoast's syndrome. The classic syndrome includes pain in the shoulder, arm, and hand in the distribution of C8 and Tl nerve roots; Horner's syndrome; weakness and atrophy of the hand muscles; and first rib erosion secondary to the tumor invading the superior thoracic inlet.
      The treatment of choice is preoperative radiation (3, 000 rads over 2 to 3 weeks) followed by surgical en bloc resection of the lung, chest wall, lower brachial plexus, and subclavian vessels, if involved. This may be performed from the posterior or anterior approach. Approximately 35% 5-year survival occurs with stage NO-1 (Table 1).
      TABLE 1Superior Pulmonary Sulcus Diagnosis and Treatment Algorithym

      Surgical Technique

      Figure thumbnail fx1
      1(A) The anterior approach to the resection of a superior pulmonary sulcus carcinoma is described by Dartevelle et al.
      • Dartevelle PG
      • Chapelier AR
      • Macchiarini P
      • et al.
      Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet.
      The patient is placed in a supine position and the incision is made as noted. (B) The tumor is resected en bloc with the lower trunk of the brachial plexus, the subclavian artery, the middle third of clavicle, the upper 3 ribs anteriorly, and the apical segment of lung.
      Figure thumbnail fx2
      2The clavicle has been stabilized with an intercavitary rod. The subclavian artery has been reconstructed with a Dacron interposition graft by using 5-0 Prolene sutures for the anastamoses at each end. (Saphenous vein may also be used.)
      Figure thumbnail fx3
      3The resection of the first, second, and third ribs anteriorly requires reconstruction of the chest wall (unlike the posterior resection that is covered by the scapula). A Marlex patch covers the defect and stabilizes the chest wall. It is stretched tight and sutured in place with 2-0 running and interrupted Prolene sutures. It serves as the base for the muscle flap that will cover it.
      Figure thumbnail fx4
      4One possible pedicle flap is the cutaneous-latissimus dorsi muscle flap. It is constructed posteriorly as shown and based on the thoracodorsal artery and nerve. It is passed through the transaxillary space as a viable pedicle flap to cover the Marlex anteriorly.
      Figure thumbnail fx5
      5The cutaneous-latissimus dorsi muscle pedicle flap is in place covering the Marlex chest wall reconstruction, the clavicle, and supraclavicular defect. It is sutured in the appropriate position.
      Figure thumbnail fx6
      6A rectus muscle flap, based on the superior epigastric artery and vein, may be used as a pedicle flap passed subcutaneously over the anterior chest into the area of the anterior superior pulmonary sulcus tumor resection.
      Figure thumbnail fx7
      7A pectoral muscle flap, based on the lateral thoracic artery and vein, may be rotated from inferiorly, after detaching it from the sternum. It covers the Marlex mesh, clavicular rod and the anterior defect of the superior sulcus resection. It may use the thoracoacromial artery and vein of the subclavian artery, if it is available after the resection and interposition subclavian graft. The inferior portion of the pectoralis major may be left in place for cosmesis.
      Figure thumbnail fx8
      8(A) The posterior resection of a superior pulmonary sulcus carcinoma is performed through a thoracoplasty incision extended inferiorly along the line of the scapula in thoracotomy fashion. (B) The operation involves the posterior resection of the first 3 or 4 ribs, the lower trunk of the brachial plexus (Tl and C8 nerve roots), any blood vessels involved, as well as the lung apex. The main chest wall defect is covered by the scapula. Therefore, it does not need a Marlex graft to stabilize the chest wall. For the usual resection of 3 or 4 ribs, the normal scapular position is satisfactory.
      Figure thumbnail fx9
      9(A) If 5 ribs have been resected, sometimes the tip of the scapula will slip inside the chest wall and get trapped by the fifth or sixth rib, causing extreme pain and dysfunction. (B) In this situation the tip of the scapula is resected, as shown, so that it does not get stuck behind the remaining rib.

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