Surgical Management of Superior Sulcus Tumors

Abstract

Superior sulcus tumor refers to any primary lung cancer presenting with constant pain in the nerve distribution of the eighth cervical, first and second thoracic nerve roots and Horner's syndrome caused by invasion of the stellate ganglion. The pain is steady, severe, and unrelenting, involving the shoulder, the vertebral margin of the scapula and ulnar distribution of the arm to the elbow and finally to the ulnar surface of the forearm, and the small and ring fingers of the hand (Pancoast‐Tobias syndrome). Weakness and atrophy of the hand muscles can also occur as the lesions spreads to involve the first and second ribs and vertebrae. Radiologically, there is a small shadow at the extreme apex of the lung with rib and possible vertebral body invasion. Pulmonary symptoms are less frequent because of the peripheral location of the lesions. Since Shaw and Paulson approached superior sulcus tumors in 1961 by using preoperative radiationtherapy (30 to 45 Gy in four weeks including the primary tumor, mediastinum and supraclavicular region) followed by surgical resection, this radiosurgical approach shortly became the standard treatment yielding better disease control and survival than that offered by other treatment modalities. It has now become evident that en bloc resection of the chest wall, involved adjacent structures as well as lobectomy must be considered the standard surgical approach for superior sulcus tumors combined with external radiation (preoperative, postoperative, or both). The goal of the operation is the complete and en bloc resection of the upper lobe in continuity with the invaded ribs, transverse processes, subclavian vessels, T1 nerve root, upper dorsal sympathetic chain and prevertebral muscles.

Carcinoma of the superior pulmonary sulcus: Results of multidisciplinary treatment

“…Dartevelle and Macchiarini stated the time elapsed between the onset of Pancoast-Tobias syndrome and diagnosis is still around 6 months. 3 There was a male preponderance in our study of 95.6%, this is in agreement with other studies by Alifano et al and Martinod et al that showed male predominance 85%. 4,5 This may be explained by a higher incidence of smoking among males.…”

“…They are relatively rare tumors, accounting for less than 5% of all subtypes of lung cancer 1,2 Three anatomic locations are possible for these tumors: (i) anteriorly located tumors lying anterior to the scalenus anterior muscle; (ii) tumors located between the anterior and middle scalene muscles; (iii) tumors lying posterior to the middle scalene muscle, usually located in the costovertebral groove. 3 Surgical resection is the gold standard treatment. Preoperative radiation has been part of the preoperative standard of care over the last five decades.…”

Transmanubrial osteomuscular sparing approach for resection of cervico-thoracic lesions

“…Even in cases of subclavian vessels infiltration, it can achieve an encouraging percentage of complete resection and acceptable percentage of morbidity and mortality (1,13). Over the last 20 years, a number of modified anterior approaches have risen to facilitate the resection of cervicothoracic tumors (5,9,14,15). In our practice, we also selected the anterior access for tumor in the anterior compartment or involving the subclavian vessels.…”

Long thoracic neuropathy caused by an apical pulmonary tumor

“…8,10,11,13 Iatrogenic causes account for 11% of LTN palsies; 9 posterolateral thoracotomies for apical lung tumors or cardiac congenital anomalies are known to have this complication. 1,4 About 17% of cases are idiopathic. 11 Other rare reports include hematoma secondary to anticoagulation therapy and infectious origins.…”