In human solid cancer, lymph node status is the most important indicator for clinical outcome. Recent developments in the sentinel lymph node concept and technology have resulted in a more precise way of examining micrometastasis in the sentinel lymph node and the role of lymphovascular system in the facilitation of cancer metastasis. Different patterns of metastasis are described with respect to different types of solid cancer. Expect perhaps for papillary carcinoma and sarcoma, the overwhelming evidence is that solid cancer progresses in an orderly progression from the primary site to the regional lymph node or the sentinel lymph node in the majority of cases with subsequent dissemination to the systemic sites. The basic mechanisms of cancer metastasis through the lymphovascular system form the basis of rational therapy against cancer. Beyond the clinical patterns of metastasis, it is imperative to understand the biology of metastasis and to characterize patterns of metastasis perhaps due to heterogeneous clones based on their molecular signatures.

The management and outcome for superior sulcus tumors have remained unchanged for 40 years. The rarity of these tumors has led to varying treatment techniques spanning decades, from which no solid conclusions can be drawn. Recent advances in combined-modality therapy have offered the first inkling that a paradigm shift is on the horizon. Here, we review the history and new advances in treating this challenging pulmonary neoplasm. The Oncologist 2004;9:550-555 The Oncologist 2004;9:550-555 www.TheOncologist.com Antonio, 7703 Floyd Curl Dr., San Antonio, Texas 78229, USA. Telephone: 210-616-5684; Fax: 210-949-5085; e-mail: cthomas@ctrc.net; Website: http://www.uthscsa.edu/radiationoncology Received January 27, 2004; accepted for publication May 10, 2004. ©AlphaMed Press 1083-7159/2004 In 1924, Pancoast [1] reported the clinical and radiographic findings associated with superior sulcus tumors. He initially thought that these tumors arose from epithelial rest cells from the fifth brachial cleft. Eight years later, Tobias [2] and Pancoast [3] simultaneously, correctly recognized that bronchogenic carcinoma was the primary cause of this syndrome. Correspondence: Charles R. Thomas Jr., M.D., Department of Radiation Oncology, University of Texas Health Science Center at San HISTORYSuperior sulcus tumors usually arise in the apex of the lung and may invade the second and third ribs, the brachial plexus, the subclavian vessels, the stellate ganglion, and adjacent vertebral bodies [4]. Pancoast syndrome is characterized by pain, which may arise in the shoulder or chest wall or radiate to the neck. Pain characteristically radiates to the ulnar surface of the hand. Horner's syndrome, which is composed of ptosis, meiosis, and anhydrosis, results from invasion of the paravertebral sympathetic chain. Weakness and atrophy of the hand and parasthesias are a common clinical finding resulting from invasion into the C8 and T1 roots of the brachial plexus. More infrequent manifestations include supraclavicular adenopathy, superior vena cava syndrome, and involvement of the phrenic or laryngeal nerves [5].Prior to the 1950s, superior sulcus tumors were uniformly fatal. Chardack and MacCallum [6] reported the The Oncologist ® Lung Cancer LEARNING OBJECTIVESAfter completing this course, the reader will be able to:1. Describe the diagnostic work-up for superior sulcus (Pancoast) tumors of the lung.2. List the major prognostic factors pertaining to outcome in patients with superior sulcus (Pancoast) tumors.3. Discuss the recent (SWOG 94-16) and current (SWOG-0220) intergroup trials for superior sulcus (Pancoast) tumors.Access and take the CME test online and receive 1 hour of AMA PRA category 1 credit at CME.TheOncologist.com CME CME by guest on May 9, 2018 http://theoncologist.alphamedpress.org/ Downloaded fromThis material is protected by U.S. Copyright law.Unauthorized reproduction is prohibited. For reprints contact: Reprints@AlphaMedPress.com first successful treatment with resection followed by postoperative radiation...

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