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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.
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.
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.
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.
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.
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.
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.
Influence of surgical resection and brachytherapy in the management of superior sulcus tumors.