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Management of Superior Sulcus Tumors: Posterior Approach

  • Daniel G. Cuadrado
    Affiliations
    Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

    Department of Surgery, Veterans Affairs Medical Center, Nashville, Tennessee
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  • Eric L. Grogan
    Correspondence
    Address reprint requests to Eric L. Grogan, MD, MPH, Department of Thoracic Surgery, Vanderbilt University Medical Center, 609 Oxford House, 1313 21st Avenue, South, Nashville TN 37232
    Affiliations
    Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee

    Department of Surgery, Veterans Affairs Medical Center, Nashville, Tennessee
    Search for articles by this author
      Non-small cell lung cancer involving the superior sulcus represents less than 5% of patients undergoing operative resection.
      • Ginsburg R.J.
      • Martini N.
      • Zaman M.
      • et al.
      Influence of surgical resection and brachytherapy in the management of superior sulcus tumors.
      Surgical resection of these tumors remains technically challenging due to the close proximity of the spine, subclavian vessels, brachial plexus, and mediastinal structures. Dr. Henry Pancoast, a radiologist, was the first to describe the clinical and radiographic features of these tumors in 1924.
      • Pancoast H.
      Importance of careful roentgen-ray investigations of apical chest tumors.
      The syndrome that now bears his name is marked by the triad of shoulder pain, Horner's syndrome (miosis, ptosis, and anhydrosis), and atrophy of the ipsilateral hand, which represents local bony and nerve involvement.
      Patients may present with hemoptysis or chest wall or shoulder pain and are rarely asymptomatic. Computerized tomography (CT) is necessary to evaluate the extent of the lesion and intravenous contrast is used to assess vascular involvement. Magnetic resonance imaging (MRI) may provide better tissue resolution to determine vascular or neural involvement and should be performed. 18F-fluorodeoxyglucose-positron emission tomography is useful for detecting occult extrathoracic metastatic disease and for radiographic staging of the mediastinal lymph nodes. A tissue diagnosis of the primary lesion may be obtained bronchoscopically either directly or via endobronchial ultrasound. CT-guided fine-needle aspiration remains the preferred means to obtain histologic diagnosis of the lesion. Given the high incidence of occult metastatic disease, CT or MRI of the brain should be considered.
      Pathologic staging of the mediastinum is essential as 20% of patients with superior sulcus tumors will have cancer in the mediastinal lymph nodes.
      • Anderson T.M.
      • Moy P.M.
      • Holmes E.C.
      Factors affecting survival in superior sulcus tumors.
      Surgical staging of the mediastinum is performed using mediastinoscopy, endobronchial ultrasound, or a combination of the 2. Supraclavicular nodes are also frequently positive and their presence denotes N3 disease. These nodes may be biopsied using image-guided fine-needle aspiration or an open nodal biopsy.
      Although initially thought to be inoperable, advances in the medical and surgical management of this complex disease have occurred in the past 60 years. The current multidisciplinary trimodality approach combines chemotherapy, radiotherapy, and operative resection to improve the 5-year survival rates to 44 to 54% in selected patients.
      • Rusch V.W.
      • Giroux D.J.
      • Kraut M.J.
      • et al.
      Induction chemoradiation and surgical resection for nonsmall cell lung carcinomas of the superior sulcus: initial results of Southwest Oncology Group trial 9416 (Intergroup trial 0160).
      Operative reconstructive techniques have progressed to provide resection options for patients with subclavian artery and vertebral body invasion in patients without mediastinal lymph node involvement. The most important prognostic factors for survival are obtaining a complete (R0) resection and absence of nodal involvement found on pathological staging.
      • Wright C.D.
      • Menard M.T.
      • Wain J.C.
      • et al.
      Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus.
      • Komaki R.
      • Roth J.A.
      • Walsh G.L.
      • et al.
      Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas M.D. Anderson Cancer Center.
      Superior sulcus tumors that involve the costovertebral junction are typically approached through a posterior approach. Shaw and colleagues first presented a series of 18 patients who underwent en bloc resection via posterior approach following preoperative radiotherapy.
      • Shaw R.R.
      • Paulson D.L.
      • Kee J.L.
      Treatment of superior sulcus tumors by irradiation followed by resection.
      Tumor involvement of the brachial plexus and vertebral body are best managed with this extended posterolateral thoracotomy. Tumor invasion of the C8 nerve root should be excluded by MRI because resection of T1 and C8 may render a deformed upper extremity with limited function. Subclavian vessel involvement must be ruled out as reconstruction of the subclavian vessels, although if possible, is best handled through an anterior approach. In patients with large apical tumors, an anterior approach to dissect the brachial plexus and potentially reconstruct the subclavian artery may be necessary followed by a posterior approach to remove the posterior ribs with partial spine resection and potential reconstruction. This article focuses on managing the typical superior sulcus tumor by the posterior approach.

      Operative Technique

      Figure thumbnail gr1
      Figure 1CT imaging reveals a non-small cell lung cancer in the superior sulcus in a patient presenting with chest pain. Following positron emission tomography scan and MRI of the brain to rule out metastatic disease, mediastinoscopy was performed to rule out N2 or N3 disease that would render the patient inoperable. This patient received concurrent cisplatin doublet based chemotherapy and radiation therapy to 60 Gy. Given the posterior involvement of the first rib and proximity to the vertebral body, a posterior approach is preferred for resection.
      Figure thumbnail gr2
      Figure 2A double-lumen endotracheal tube is positioned under bronchoscopic guidance and the lung is isolated. A posterolateral thoracotomy is performed. If necessary, the posterior border of the latissimus can be mobilized to reflect the muscle anterior or be divided. The serratus anterior muscle should be spared. For smaller tumors involving the first rib, the chest cavity can be entered in the fourth intercostal space but the fifth is necessary for larger tumors. A limited opening into the chest cavity allows for palpation of the tumor and chest wall to ensure entry at least 1 to 2 rib spaces below the tumor. With the interspace divided, the chest cavity is inspected to rule out intrathoracic metastasis. The incision is then extended between the spinous process and medial border of the scapula, with the incision taken to the base of the neck. This requires division of the trapezius and rhomboid muscles.
      Figure thumbnail gr3
      Figure 3A Burford (or other appropriately sized) retractor is positioned beneath the scapula and on the top of the fifth rib. This permits elevation of the scapula away from the thoracic inlet. This retraction allows for further examination and dissection of the apex of the chest.
      Figure thumbnail gr4
      Figure 4The chest wall resection begins with internal palpation and anterior division of the second and third ribs with a 5-cm margin of resection. The paraspinous muscles are mobilized with electrocautery. The posterior scalene muscle is divided from the second rib allowing access to the first rib.
      Figure thumbnail gr5
      Figure 5The first rib periosteum is scored with electrocautery and subperiosteal dissection is performed with a Cob elevator. The anterior scalene muscle is divided from its insertion on the first rib and the subclavian vessels and the brachial plexus are retracted superiorly with a Kittner. A blunt right-angled clamp is then passed around the first rib to allow for division with a Gigli saw for the anterior margin. Alternatively, a first rib shear can be utilized. Care must be taken to protect the subclavian vessels. a. = artery.
      Figure thumbnail gr6
      Figure 6(A) The paraspinous muscles are then freed from the transverse process. The costotransverse ligaments are divided with electrocautery. The rib heads are then disarticulated from the transverse process with a Cob elevator. The costovertebral ligament is identified and divided. (B) This maneuver is performed as a lift, with care taken not to use the transverse process as a fulcrum. Using the transverse process as a lever may risk injury to the neural foramina and possibly spinal cord injury. In patients requiring first rib resection, this is best accomplished from the superior aspect first.
      Figure thumbnail gr7
      Figure 7The ribs are disarticulated from inferior to superior with clipping or ligation of the intercostal neurovascular bundle with an absorbable suture to prevent possible cerebrospinal fluid leak and avoid a subsequent neuroma. The C8 and T1 nerves emanate from the lower trunk of the brachial plexus and are identified by dissection posterior along the first rib. As the lower trunk of the brachial plexus approaches the neck of the first rib, the trunk divides into C8 (above the neck of the first rib) and T1 (below the neck of the first rib). A Gigli saw, or rib shear, may be used to divide the rib proximal to the transverse junction to allow for better precision in dissecting the posterior aspect of the first rib, off the C8 and T1 nerve roots. The remaining first rib head can then be disarticulated after this dissection is complete with a Cobb elevator. The T1 nerve has both a motor and a sensory component and, if involved with tumor, can be killed with little change in hand function. Sacrifice of the C8 nerve root must be avoided, if at all possible, because it leads to significant impairment of intrinsic hand function with claw-hand deformity. With mobilization of the chest wall, anatomic resection of the right upper lobe and mediastinal lymph node dissection proceeds in the standard fashion and the specimen is removed en bloc. Alternatively, a wedge resection of the apical tumor can be performed to improve visualization for the chest wall dissection with lobectomy to follow. Frozen section analysis is performed on the soft-tissue margins to ensure a R0 resection.
      Figure thumbnail gr8
      Figure 8For more extensive tumors involving the vertebral bodies (CT not shown), extended resection can be performed and preoperative neurosurgery consultation may be beneficial. Two possible approaches exist, based on the preference of the consulting neurosurgeon. To allow for a direct approach to the midline, the extended incision may be altered as seen above. The patient may be positioned laterally, without flexion to allow for vertebral resection and spinal stabilization if required.
      • York J.E.
      • Walsh G.L.
      • Lang F.F.
      • et al.
      Combined chest wall resection with vertebrectomy and spinal reconstruction for the treatment of Pancoast tumors.
      Alternatively, the lobectomy and chest wall resection can be performed using the extended posterolateral incision (). After resection is complete, except for the vertebral body resection, the patient is placed in the prone position and a second midline posterior incision is made to allow a more direct approach for vertebral resection and/or stabilization.
      Figure thumbnail gr9
      Figure 9During the initial dissection, the paraspinous muscles are widely mobilized with electrocautery to allow for posterior retraction and evaluation of the vertebrae. Anterior division of the ribs proceeds as previously described. After mobilization of the chest wall, the vertebral bodies and neural foramina are inspected. Foraminectomy and resection of the vertebral bodies with stabilization may be required. These extended vertebral resections may be necessary for complex tumors.
      Figure thumbnail gr10
      Figure 10Multiple level vertebral body resections require anterior and posterior stabilization, all of which can be performed through this extended approach. Following stabilization, the paraspinous muscles can be utilized for soft-tissue coverage of the hardware. Prosthetic closure of the chest wall is not required for lesions that do not extended below the fourth rib. Lesions that require resection of the fourth and fifth rib require mesh reconstruction or partial resection of the scapular tip to avoid scapular entrapment postoperatively. The chest wall defect can be closed using polypropylene or 2-mm Gortex mesh anchored to the ribs anteriorly and transverse processes posterior where present. Two chest tubes are placed and the bronchial stump is tested for an air leak. Patients are typically extubated in the operating room.
      • Gokaslan Z.L.
      • York J.E.
      • Walsh G.L.
      • et al.
      Transthoracic vertebrectomy for metastatic spinal tumors.
      Figure thumbnail gr11
      Figure 11Partial and total vertebrectomy (chest x-ray from different patient than shown in ) can be performed in patients with T4 disease as part of a multimodality approach in highly selected patients at specialized centers. Median 2-year and 5-year survival are 47% and 27%, respectively.

      Conclusions

      Resection of superior sulcus tumors remains a clinical challenge for thoracic surgeons given their unique anatomic location. Multimodality therapy will improve the likelihood of an R0 resection. Complete resection is the only prognostic variable most associated with local control and survival. For tumors with brachial plexus (T1) or vertebral body involvement, the extended posterolateral thoracotomy provides excellent exposure. Chest wall reconstruction is not required for removal of ribs 1 to 4 as the scapula and thoracic musculature will provide adequate coverage. In patients requiring removal of the fifth rib, the lower third of the scapula should be resected and the chest wall reconstructed to prevent the scapular tip from becoming lodged beneath the rib. The “locked” scapula leads to severe pain and reoperation may be required. Postoperative analgesia is typically managed through the use of a thoracic epidural. In patients in whom vertebral resection has been performed, IV narcotics remain the mainstay of pain management but local pain infusion pumps may be considered.

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