Superior Sulcus Tumor
Related narrative: Pancoast Tumor, Left Upper Lobe
Superior sulcus lung tumors, arising at the apex of the lung and invading chest wall, account for less than 5% of all non-small cell (NSCLC) lung cancers (see lung cancer discussion). Treated appropriately, they have a relatively favorable prognosis (cumulative 30% five-year survival. In 1924 Pancoast described a syndrome associated with such tumors consisting of arm pain, atrophy of hand muscles, bone destruction and Hornerís syndrome. Assessing nodal status for staging is critical in such patients since N2 nodal disease (see lung cancer staging discussion) is rarely associated with long-term survival, and is treated non-surgically. Motor loss is a predictor of unresectability. Surgical treatment is contraindicated with direct involvement of the trachea or esophagus or brachial plexus invasion with motor loss.
Preoperative staging includes CT, MRI, mediastinoscopy. Neurosurgery consultation is obtained to assess possible neural foramina and nerve root involvement and the need for vertebral body resection and spine stabilization. Beneficial effects of preoperative (induction/neoadjuvant) radiotherapy have been extended in recent practice with the addition of concurrent induction chemotherapy for mediastinoscopy negative, T3-4, N0-1 tumors. Induction chemoradiation consists of two cycles of cisplatin and etoposide concurrent with 45Gy of radiation. Associated mortality with such treatment in the Memorial series (Rusch) was 2.7%, mainly from cytopenia. Patients with stable or responsive disease are then taken to the operating room at 3-5 weeks for resection. Induction chemoradiation improved resectability (92% complete) and overall survival.
Complete resection offers the best chance for local control and long-term survival. Superior sulcus tumor resection is one of the most technically challenging operations because of the complex anatomy and constrained access at the apex of the chest, complicated by the presence of the tumor mass. Complete resection is possible in most surgical candidates, and the margins are invariably close. In addition, left upper lobe resection is the most difficult because of the variability of the pulmonary artery branches and the location of the anterior segmental artery under the superior pulmonary vein. Some surgeons advocate precautionary placement of cervical tongs and beanbag to align the spine. If neural foramen and/or vertebral body involvement is suspected, preliminary posterior spine stabilization by neurosurgery may be indicated. A posterolateral thoracotomy through the 4th or 5th interspace is commonly used, with posterior extension toward the base of the neck through the trapezius, rhomboids, and serratus posterior superior. The scapula is elevated and the anterior-superior attachments of the serratus anterior are divided. If the first rib is to be resected, the scalene muscles are divided from the superior border of the rib, exposing the subclavian vessels and brachial plexus. The chest is explored for evidence of visceral invasion or pleural spread outside the local tumor area, and pleural fluid is sent for immediate cytology. Depending on the posterior extent of disease assessed by palpation within the chest, the ribs may need to be disarticulated posteriorly, or more extensive vertebral resection may be necessary. It is often necessary to sacrifice the T-1 nerve root to obtain clear margins.
If three or fewer ribs are resected, the scapula usually adequately covers the defect. If more than three ribs are resected, there is a danger of scapular intussusception and entrapment of the tip of the scapula beneath the highest remaining rib. Chest wall reconstruction is indicated in such cases, using a marlex/methacrylate sandwich (see chest wall resection). Such a prosthesis is placed no higher than the level of the second rib to avoid impingement on the subclavian vessels and brachial plexus. Some surgeons feel that reconstruction improves chest wall mechanics, and perform it routinely.
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