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Introduction: Pancoast tumors encompass any tumor located on the lung apex, extending into structures in the thoracic inlet and, often, leading to the characteristic clinical syndrome. The main goal of this study is to analyze the response to multimodal treatment and outcome of patients with Pancoast tumors., Materials and Methods: We performed a retrospective cohort single center study of patients with superior sulcus nonsmall cell lung carcinomas who underwent surgery between January of 2011 and February of 2022., Results: A total of ten patients were considered, 80,0% were male with a mean age of 53,6 (±6,6) years. At diagnosis, two tumors were stage II and eight were stage III. Histopathology revealed eight were adenocarcinomas and two were sarcomatoid carcinomas. All patients underwent neoadjuvant treatment before surgery. Nine patients received lung lobectomy, with en bloc resection comprising, predominantly, the chest wall (80,0%) and brachial plexus (30,0%). In one patient, surgery was aborted. Surgical histopathology showed free surgical margins were achieved in eight patients (80,0%). Two patients achieved full tumoral remission (ypT0N0, 22,2%), two tumors were stage I (22,2%), two were stage II (22,2%), two were stage III (22,2%) and one tumor was stage IV (11,1%). Mean disease-free survival was 83,9 (CI95% 42,1-125,8) months. 3-month disease-free survival rate was 88,9% and 1-year and 5-year disease-free survival rates were 63,5%. After the first-year follow-up, there was no evidence of disease progression. Mean overall survival was 115,7 (CI95% 89,3-142,1) months. At 3-month, 1-year and 5-years, overall survival was 88,9%., Conclusion: Although considering the small sample of patients, the survival of Pancoast tumors in our institution exhibits a positive outcome, when compared to current literature, Significant improvements have been reported recently, in understanding the nature of Pancoast tumors, emphasizing the importance of a multidisciplinary approach but still, further research is required.

Objective: In this study, we aimed to identify prognostic determinants and to comparably analyze clinical features of patients with both resected and unresected superior sulcus tumors (SSTs)., Methods: The data of 56 patients who underwent any treatment for an SST from 2004 through 2016 in our hospital were reviewed. Overall survival (OS) rates were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to determine independent prognostic factors for patients with resected and unresected SST separately., Results: The number of patients with resected and unresected SSTs was 24 (43%) and 32 (57%), respectively. Of the 24 patients who underwent surgery, 20 received induction therapy, with 32% achieving pathological complete response. Complete resection (R0) was performed in 22 patients (92%). On multivariate survival analysis, preoperative serum carcinoembryonic antigen (CEA) level (median 8.3 ng/ml, p = 0.021) was identified as the independent determinant of OS in surgical patients; whereas, initial treatment response (complete response or partial response, p = 0.032) was the independent OS indicator in non-surgical patients. The 5-year OS of the patient with resected and unresected SST was 68.8% and 29.1% (p = 0.008), respectively., Conclusion: Significant prognostic factors differ among patients stratified by the presence of surgical resection for SSTs. Preoperative CEA level in surgical candidates and initial treatment response in non-surgical patients were the independent factors associated with OS. Surgical candidates are expected to have more favorable survival than patients with unresectable SSTs.

Objective: This study aims to evaluate the impact of T stage and extended surgery on the outcome of patients with Pancoast tumors after induction chemoradiation therapy., Methods: Forty-six consecutive patients who underwent chemoradiation therapy (platin-based, 45-66 Gy) followed by surgery between 1998 and 2013 were retrospectively reviewed and analyzed., Results: In 28 (61%) patients with T4 tumors, extended procedures (more than rib resection) were performed. There were 37 (80%) lobectomies, 6 (13%) pneumonectomies, and 3 (7%) sublobar resections. A total of 44 (96%) patients had R0 resection. About 30-day mortality was 0%, major surgical complications occurred in 9 (19.6%) patients. Overall survival (OS) at 5-years was 63%. Disease-free survival (DFS) at 5-years was 45%. At multivariate cox regression analysis adjusted for clinical factors, T factor (T3/T4) and extended surgical procedures did not impact survival. However, pathological positive N stage had a negative impact on OS and lack of pathological response negatively impacted both OS and DFS., Conclusion: Trimodality treatment including radical resection for Pancoast tumors provides good surgical outcome and favorable long-term results. Survival of patients with T4 tumors and extended surgical procedures comparable to that of patients with T3 tumors undergoing rib resection only., (© 2017 Wiley Periodicals, Inc.)

This paper reports on the characteristics, treatment modalities, and outcomes of patients with superior sulcus tumors who underwent surgery over a period of 15 years in 1 institution. Clinical records of 94 consecutive patients operated on by the same surgical team for non-small cell lung cancer between July 1998 and December 2013 were retrospectively reviewed. All patients received lung and chest wall en bloc resection. Forty-eight (51%) received induction treatments. Surgery was an anterior approach in 46 patients (48.9%), Paulson incision in 35 (37.2%), and a combined approach in 13 (13.8%). Lung resections were 78 lobectomies (83%), 3 were pneumonectomies (3.2%), 6 were bronchoplastic reconstructions (6.4%), and 7 were wedge resections (7.4%). Nodal dissection was systematic in 96% of patients. The median number of resected ribs was 2 (1-5), chest wall residual defect was reconstructed in 42 patients (44.7%), and 21 patients had an associated vascular resection (22.3%). Resection was radical in 85 patients (90.4%). Overall 90-day mortality was 9.6%. After a median follow-up of 1.9 years, 5-year and 10-year overall survival rates were 35% and 23%, respectively. A lower 5-year survival was observed in patients with nodal disease (48% in N0 vs 18% in N+; P < 0.0001), incomplete resection (21% for incomplete vs 37% for complete resection; P = 0.15), and anteriorly located tumor (anterior vs posterior: 26% vs 50%; P = 0.05). Pancoast tumor is a severe condition, but long-term survival may be achieved in selected cases. Nodal involvement, completeness of resection, and vascular invasion are the most important prognostic factors, and induction treatment may play a role., (Copyright © 2017. Published by Elsevier Inc.)

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether induction (neoadjuvant) chemoradiotherapy (iCRT) compared with other therapeutic strategies improves survival in patients with Pancoast tumours. Altogether 248 papers were identified using the below-mentioned search. Ten of them represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. Four studies were retrospective comparative studies of induction chemoradiotherapy and surgery (trimodal therapy) versus other therapeutic strategies. Two studies were retrospective and four were prospective investigating trimodal therapy. These papers comprised a total of 550 patients. The overall survival was better with trimodal therapy compared with RT (radiotherapy) followed by surgery group in all three comparative studies. The 2-year survival varied in the trimodal therapy group from 70 to 93%, in comparison to RT group where variation was from 22 to 49%. Five-year survival for trimodal therapy varied between 36.4 and 84% in the results of two comparative studies, compared with 11 and 49% for RT and surgery, respectively. One paper looked at survival in patients who underwent surgery alone [30% at 2-year and 20% at 4-year overall survival (OS)]. The 5-year OS in the retrospective group varied between 38 and 59%. Similar results were reported for the prospective group with 5-year OS between 44 and 56%. Despite a large variation in pCR (complete pathological response) (15-93%) and R0 (77-100%) reported, both represented a positive prognostic factor for survival. Three papers looked at the impact of staging following induction chemoradiotherapy. The majority of patients had T3 disease. An advantage in survival was seen in patients with early disease compared with advanced stage. No randomized controlled trials were identified. All the 10 articles suggested there was a benefit in trimodal therapy with improvement in overall survival. We conclude that combining induction chemoradiotherapy with surgery for Pancoast tumour may offer a survival benefit compared with radiotherapy with surgery or surgery alone., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To update the long-term outcomes after subclavian artery (SA) resection and reconstruction during surgery for thoracic inlet (TI) cancer through the anterior transclavicular approach., Methods: Between 1985 and 2014, 85 patients (60 men and 25 women; mean age, 52 years) underwent en bloc resection of thoracic-inlet non-small cell lung cancer (NSCLC) (n=69), sarcoma (n=11), breast carcinoma (n=3) or thyroid carcinoma (n=2) involving the SA. L-shaped transclavicular cervicothoracotomy was performed, with posterolateral thoracotomy in 18 patients or a posterior midline approach in 15 patients. Resection extended to the chest wall (>2 ribs, n=60), lung (n=76), and spine (n=15). Revascularization was by end-to-end anastomosis (n=48), polytetrafluoroethylene (PTFE) graft interposition (n=28), subclavian-to-common carotid artery transposition (n=8), or grafting of the autologous superficial femoral artery in an anterolateral thigh free flap (n=1). Complete R0 resection was achieved in 75 patients and microscopic R1 resection in 10 patients. Postoperative radiation therapy was given to 51 patients., Results: There were no cases of postoperative death, neurological sequelae, graft infection or occlusion, or limb ischemia. Postoperative morbidity consisted of pneumonia (n=16), phrenic nerve palsy (n=2), recurrent nerve palsy (n=4), bleeding (n=4), acute pulmonary embolism (n=1), cerebrospinal fluid leakage (n=1), chylothorax (n=1), and wound infection (n=2). Five-year survival and disease-free survival rates were 32% and 22%, respectively. Long-term survival was not observed after R1 resection., Conclusions: Subclavian arteries invaded by TI malignancies can be safely resected and reconstructed through the anterior transclavicular approach, with good long-term survival provided complete R0 resection is achieved.

Background: A retrospective monocentric study of consecutive patients with superior sulcus tumor non-small cell lung cancer (SS-NSCLC), treated by induction concurrent chemoradiotherapy (CRT), article management., Methods: From 1994 to 2005, 36 patients (15 T3, 21 T4 tumors, including N2-N3 node involvement) received induction CRT with cisplatin/vinorelbine/fluorouracil combined with 44 Gy radiotherapy (5 daily 2 Gy fractions/week). After CRT completion, RECIST evaluation and operability were assessed. In resectable patients, surgery was performed one month after CRT. Patients with unresectable disease followed CRT up to 66 Gy. The median of follow-up period was 38.6 months [2-206]., Results: Induction CRT was completed for 94.4% with 71% radiological objective response (OR). Sixteen patients (44%) underwent surgical resection, and pathologic complete resection was performed in 93.8%. There were 7 patients (44%) with pathologic complete response. The median disease-free survival (DFS) time was 12.9 months with DFS rates at 1 and 2 years 53.6% and 39.1% respectively. The median overall survival (OS) was 46.4 months. The OS rates at 2 and 5 years were 68.8% and 37.5% respectively with no difference between T3 and T4 tumors. In unresectable disease, the median DFS time was 8.1 months. The DFS rate at 1 year was 25.2%. The median OS was 9.1 months. The OS rates at 1 and 2 years were 45% and 16.9% respectively. Recurrences were found in 72% of patients. Brain metastasis was the most common site of recurrence. Prognostic factors for OS were the response to induction treatment, the possibility of surgery, and pathologic complete response., Conclusions: This trimodality treatment regimen confers a survival outcome in agreement with previous studies. Patients with pretreatment N3 lymph node should be included in trimodality treatment.

Objective: Pancoast tumors are lung carcinomas that invade the apical chest wall and surrounding structures. Treatment is complex and often involves surgery together with radio- and chemotherapy. We studied the outcome of surgical resection for Pancoast tumors in Iceland., Materials and Methods: A retrospective study including all patients that underwent resection of a Pancoast tumor with curative intent in Iceland in the years 1991-2010. Data on symptoms, complications, TNM-stage, relapse and survival were analyzed., Results: Twelve patients were operated on; 7 on the right lung. Shoulder pain (n=5) and/or chest pain (n=3), cough (n=6) and weight loss (n=5) were the most common presenting symptoms. Adenocarcinoma (n=5) and squamous cell carcinoma (n=4) were the most frequent histological types. Average tumor size was 5,9 cm (range: 2,8-15). Five cases were stage IIB and 7 stage IIIA according to operative staging. In 10 cases (83%) the surgical margins were free of tumor. All patients survived surgery and only one patient suffered a major operative complication, an intraoperative bleeding. In one case induction chemo-radiation prior to surgery was administrated, and 8 patients received postoperative radiotherapy. Recurrent disease was diagnosed in 9 patients; four had local or regional recurrence, four had distant metastases and one patient was diagnosed with both local and distant recurrences simultaneously. Survival at 5 years was 33% and median survival was 27,5 months (range: 4-181)., Conclusions: Operative and short-term outcomes for patients with Pancoast tumors in Iceland are excellent. However, long-term outcomes are not as favorable and recurrence rate is high compared to other studies, possibly due to incomplete preoperative staging and less use of chemo-radiation therapy prior to surgery among these patients.

Objectives: Pancoast tumour is a rare neoplasia in which the optimal therapeutic management is still controversial. The traditional treatment of Pancoast tumour (surgery, radiotherapy or a combination of both) have led to an unsatisfactory outcome due to the high rate of incomplete resection and the lack of local and systemic control. The aim of the study was to determine the efficacy of the trimodality approach., Methods: Fifty-six patients (male/female ratio: 47/9, median age: 64 years) in stage IIB to IIIB were treated during a period between 1994 and 2013. Induction therapy consisted of 2-3 cycles of a platinum-based chemotherapy associated with radiotherapy (30-44 Gy). After restaging, eligible patients underwent surgery 2 to 4-week post-radiation., Results: Thirty-two (57.1%) patients were cT3 and 24 (42.9%) cT4, 47 (83.9%) were N0 and 9 (16.1%) N+. Forty-eight (85.7%) patients underwent R0 resection and 10 (17.9%) had a complete pathological response (CPR). Thirty-day mortality rate was 5.4%, major surgical complications occurred in 6 (10.7%) patients. At the end of the follow-up, 17 (30.4%) patients were alive and 39 (69.6%) died (29 for cancer-related causes), with an overall 5-year survival of 38%. At statistical analysis, stage IIB (P = 0.003), R0 resection (P = 0.03), T3 tumour (P = 0.002) and CPR (P = 0.01) were significant independent predictors of better prognosis., Conclusions: This combined approach is feasible, and allows for a good rate of complete resection. Long-term survival rates are acceptable, especially for early stage tumours radically resected. Systemic control of disease still remains poor, with distant recurrence being the most common cause of death., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of the present paper was to conduct a comparative analysis of outcomes after thoracoscopic resection versus standard thoracotomy approach in the treatment of Pancoast tumours., Methods: All consecutive patients with Pancoast tumours undergoing surgical treatment from March 2000 to November 2012 were enrolled. Patients were divided into 2 groups according to whether a thoracoscopic or standard thoracotomy approach was adopted. In addition to morbidity and mortality, (i) intensity of pain; (ii) respiratory function focusing on the postoperative value and its variation with respect to the predicted value (Delta); (iii) analgesic consumption at different times during the postoperative course; and (iiii) survival rate were recorded in both groups and the inter-group differences were statistically compared., Results: Of the 45 enrolled patients, 34 (75%) were included in the final analysis (18 in the thoracoscopic group and 16 in the standard group). Eleven (25%) patients were excluded because they (i) were unfit for surgery after induction therapy (n = 4); (ii) refused the operation (n = 1) or (iii) had unexpected pleural involvement (n = 6). Compared with the standard group, in the thoracoscopic group we observed less pain (P = 0.01), better recovery of forced vital capacity (P = 0.01) and forced expiratory value in 1 s (P < 0.001), and a reduction in opioid (P = 0.01) and analgesic consumption (P = 0.02). The median survival for all patients was 15 months. Patients with N0/N1 disease had better median survival than N2 patients (47 vs 9 months; P = 0.009). One local recurrence in the standard group was observed 1 year after operation, whereas 2 local recurrences, 1 in the thoracoscopic group and another in the standard group, were registered 2 years after the operation (P = 1.0). Finally, 4 (22%) extrathoracic metastases in the thoracoscopic group and 5 (31%) in the standard group (P = 0.8) were found over the 2 years following the procedure., Conclusions: In the management of Pancoast tumours, a thoracoscopic approach is safe and may be an effective adjunct to standard surgical resection in selected cases. Such an approach enabled surgeons to explore the pleural cavity and avoid exploratory thoracotomy in cases of unexpected pleural involvement., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Lung cancer invading the spine historically has been considered unresectable. Nevertheless, considerable surgical progress has been made since the 1990s potentially allowing for curative resection. Here, we describe our surgical experience and long-term results., Methods: All patients who underwent en bloc resection of non-small-cell lung cancer invading the pulmonary sulcus and spine between 1991 and 2012 were retrospectively reviewed., Results: Forty-eight patients were included. Induction therapy consisted mostly of two cycles of cisplatin-etoposide and 45 Gy of concurrent radiation. All tumors were resected en bloc, including the lung, spine, and chest wall. Total vertebrectomy, hemivertebrectomy, and partial vertebrectomy were required in 10 patients (21%), 31 patients (64%), and seven patients (15%), respectively. Complete resection was achieved in 42 patients (88%). Postoperatively, 18 patients (38%) stayed in the intensive care unit for a median of 15 (1-140) days. Thirty-day and in-hospital mortality was 6%. Pathologic response to induction treatment was complete (n = 18) or near complete (n = 6) in 24 patients (50%). After a median follow-up of 26 (0-151) months, 24 patients are alive without recurrence. Overall 5-year survival was 61%. Response to induction therapy (complete/near complete versus other, p = 0.012), resection margin (R0 versus R1/R2, p = 0.009), and length of intensive care unit stay (p = 0.003) were significant prognostic factors in univariate analysis. Response to induction was maintained as prognostic factor in multivariable analysis (p = 0.048)., Conclusions: En bloc resection of the lung, chest wall, and spine for non-small-cell lung cancer invading the pulmonary sulcus and spine is feasible in experienced centers with excellent long-term outcome after careful patient selection. Response to induction was an independent significant prognostic factor.

Purpose of Review: Pancoast tumors, also known as superior sulcus tumors, to this day remain a complex and challenging condition. This review will explore the evolution of the treatment of these tumors over the better part of a century. It will illustrate how with a multidisciplinary approach and the use of trimodality therapy this entity has evolved from a universally fatal disease to one that is treatable with outcomes similar to those of other stage-matched nonsmall cell lung cancers., Recent Findings: The Southwest Oncology Group 9416 Intergroup 0160 trial reported in 2007 By Rusch et al. culminated years of research showing that trimodality therapy with chemotherapy, radiation and surgery provided optimal outcomes. Since that time, there have been studies corroborating these outcomes and utilization of novel surgical approaches including Video-assisted thoracoscopic surgery; however, no change in survival has been reported., Summary: The treatment of tumors of the superior sulcus has evolved over the years, so that outcomes approach those of other stage-matched nonsmall cell carcinomas. In the future, new approaches, perhaps the detailed genetic analysis of tumors and guided treatments, will have a positive impact on nonsmall cell carcinomas. The tumors of the superior sulcus will hopefully follow suit in their improved outcomes.

The objective was to define the relationship between histopathological changes after pre-operative chemo-radiotherapy (CRT) and clinical outcome following tri-modality therapy in patients with superior sulcus tumours. A retrospective analysis of tumour material was performed in a series of 46 patients who received tri-modality therapy between 1997 and 2007. Median follow-up was 34 months (5-154). Pathological complete response (pCR) was present in 20/46 tumours (43 %). The most common RECIST score after CRT in patients with pCR was a partial response (PR; 10/17, three unknown), whereas in patients without a pCR, stable disease was the most common (22/26) (p = 0.002). In 26 specimens with residual tumour, this was mainly located in the periphery of the lesion rather than the centre (Spearman's correlation = 0.67, p < 0.001). Prognosis was significantly better after a pCR compared to residual tumour (70 % 5-year overall survival vs. 20 %; p = 0.001) and in patients with fewer than 10 % vital tumour cells as compared to those with >10 % (65 % 5-year overall survival vs. 18 %; p < 0.001). A low mitotic count was associated with a longer disease-free survival (p = 0.02). Complete pathological response and the presence of fewer than 10 % vital tumour cells after pre-operative CRT are both associated with a more favourable prognosis. A modification of the pathological staging system after radiotherapy, incorporating the percentage of vital tumour cells, is proposed.

Objectives: Following trimodality treatment for superior sulcus tumours (SSTs), the 5-year survival rate has significantly improved. Quality of life and potential negative effects of this strategy have become more important. The objective of this study was to investigate the quality of life and the arm and shoulder function after the resection of superior sulcus tumours following neoadjuvant chemoradiation., Methods: Patients were selected from a thoracic surgery database. Between January 2002 and December 2010, 72 patients received trimodality treatment of whom 39 were alive at the start of this study in 2010. The following arm function tests were used: nine-hole peg test, range of motion test and action research arm test. Quality of life was assessed using the Disability of the arm and shoulder and SF-36 questionnaires. Analyses of the arm function were conducted comparing the treated side with the untreated side. For quality of life, patients treated on their dominant side were compared with those treated on their non-dominant side., Results: In total, 19 patients participated in this study (15 men and 4 women). The median age was 59 years (range 39-73), median radiation dose 50 Gy (range 39-66) and median follow-up 40 months (range 4-101). There was no statistically significant difference in arm and shoulder function between the treated and the untreated arm. However, statistically significantly less pain was found if patients were treated on their dominant side., Conclusions: After the resection of SSTs following chemoradiotherapy, the arm and shoulder function on the affected side is comparable with the functions at the contralateral side. Patients treated for an SST on their dominant side are less affected in their quality of life regarding pain compared with those treated on their non-dominant side.

Objective: Pancoast tumors are some of the most challenging thoracic malignant diseases to treat because of their proximity to vital structures at the thoracic inlet. We retrospectively analyzed 23 patients with pT3-4, N0-3 Pancoast tumors who underwent combined chest wall resection including the 1st rib, and discuss the anatomical considerations, assessment of induction therapy, and surgical approaches for these cancers., Methods: Between 1983 and 2006, 23 patients with Pancoast tumors underwent combined resection of the 1st rib at our institute. Of those, 21 were male and 2 were female, with an average age of 58 years. There were 10 each of squamous cell carcinoma and adenocarcinoma, 2 large cell carcinoma, and 1 adenosquamous carcinoma. Over the past decade, induction chemoradiotherapy (>40Gy) was employed before surgery., Results: A posterior approach was employed in 14 patients, an anterior approach in 7, and a combined anterior and posterior approach in 2. Sixteen patients underwent complete resection. One of 7 patients undergoing incomplete resection (4.3%) died on the 45th postoperative day. The 3- and 5-year survival rates were 50 and 22%, respectively, for patients with complete resection. No case survived for more than 8 months out of the 7 patients with incomplete resection. Fourteen patients with pN0 showed significantly better survival than those with pN1-3 (p = 0.0053)., Conclusion: Recent literature and our results suggest that patients with pN0 and/or a pathological complete response (pCR) after induction chemoradiotherapy could achieve long-term survival after complete resection.

Background: Optimal management of SST is still controversial several years after the proposal of a multidisciplinary approach including neoadjuvant chemotherapy and external radiation. Our objective is to report our experience of this multidisciplinary approach from the surgical point of view., Patients and Methods: From January 1997 to January 2008, 24 patients were treated surgically (18 with induction chemotherapy and 15 with radiotherapy). The surgical approach was thoracic (14 cases, 1 with a spinal approach) or cervical (10 patients, 2 thoracotomies). Pulmonary surgery performed consisted of 11 wedge resections, 10 lobectomies, 1 pneumonectomy and 2 cases without lung resection (1 exploratory thoracotomy and 1 local progression after a previously resected tumor). Intraoperative radiotherapy (IORT) was given in 7 cases. Partial vertebral body resection was performed in 5 cases. A pathologically complete response (pT0) was found in 7 cases (29 %)., Results: Surgery-related morbidity was mainly due to respiratory distress (5 patients). Two patients died in the first month after surgery (mortality: 8 %). The surgical approach (cervical vs. thoracic) did not influence postoperative morbidity ( p = NS). Overall 5-year survival was 56.6 % according to the Kaplan-Meier method. No influence on survival was observed with regard to the approach (cervical vs. thoracic), the use of IORT, or the performance of spinal surgery. Patients with a complete pathological response had a better 5-year survival, but this did not reach statistical significance., Conclusion: Surgery has a role in the multidisciplinary approach, especially when we consider long-term survival. A multidisciplinary approach using neoadjuvant chemo and radiotherapy has a high rate of complete pathological response. It is also associated with a high incidence of postoperative distress syndrome. The 5-year survival is acceptable., (Georg Thieme Verlag KG Stuttgart New York.)

Lung cancer invasion of the chest wall is not a common challenge and represents only about 5% of all patients resected for lung cancer. In T3N0M0 tumours, long-term survival reaches 40-50%, provided certain conditions are fulfilled. The number of explorative thoracotomies and the rate of non-radical resections might be high due to the local extension of an aggressive tumour. Mortality after resection is as high as for pneumonectomy. For historical and anatomical reasons, we have to divide the patients into two groups: infiltration of, and above, the second rib (Pancoast) and tumours located caudally to the second rib. We have to define the two entities. There is a problem concerning correct diagnosis: many tumours reach the chest wall. If the lung is not adherent to the parietal pleura, a standard lobectomy can be performed. However, in the case of adhesions, the differentiation between tumour invasion and inflammation may be difficult. We do not want to perform over-treatment since lung resection en bloc with the chest wall has a higher morbidity and mortality than lobectomy. But we have to avoid opening the tumour intraoperatively or perform a non-radical resection. Therefore, we need a preoperative diagnostic tool answering the question of extrapulmonary infiltration. In this context, we will discuss whether extrapleural lung resection is acceptable in the case of pleural invasion without chest wall involvement. The prognosis of patients with tumours invading the chest wall and mediastinal lymph node metastasis is worse. But patients with ipsilateral supraclavicular lymph node metastasis are not excluded. Thus, careful clinical investigations are necessary. To achieve complete resection, the surgeon should use anatomical knowledge to choose the best form of access to make radical resection more feasible. The problem of pain after thoracotomy is accentuated after chest wall resection, especially after paravertebral resection. The use of modern pain treatment is very important.

The treatment of Pancoast tumours has been a combined-modality effort for several decades. In a recent Dutch publication, the results in 36 patients are described with a mean follow-up of 26 months. These are in line with internationally-achieved outcomes: the overall and disease-free survival after 2 years was 45 and 31%, respectively, and after 5 years 28 and 19%. As such, the approach to superior-sulcus tumours is a very good example of how the modern treatment of lung cancer has developed, and it underlines the need for close collaboration between specialists with different backgrounds. The patients will benefit from centralisation of the treatment in a limited number of institutions in the Netherlands.

The traditional treatment of Pancoast tumour with local approaches (surgery, radiotherapy or a combination of both) leads to a poor outcome due to the high rate of incomplete resection and the lack of systemic control. The aim of the present prospective feasibility study was to determine whether a trimodality approach improves local control and survival. Patients with stage IIB-IIIB Pancoast tumour received induction chemotherapy (three courses of split-dose cisplatin and etoposide or paclitaxel) followed by concurrent chemoradiotherapy (a course of cisplatin/etoposide combined with 45 Gy hyperfractionated accelerated radiotherapy). After restaging, eligible patients underwent surgery 4-6 weeks post-radiation. A total of 31 consecutive patients with T3 (81%) or T4 (19%) Pancoast tumour were enrolled in the study. Induction chemoradiotherapy was completed in all patients without treatment-related deaths. Grade 3-4 toxicity was observed in 32% of cases. In total, 29 (94%) patients were eligible for surgery. Complete resection was achieved in 94% of patients. The post-operative mortality rate was 6.4% and major complications arose in 20.6% of the patients. The median survival was 54 months with 2- and 5-yr survival rates of 74 and 46%, respectively. In conclusion, this intensive multimodality treatment of Pancoast tumour is feasible and improves local resectability rates and long-term survival as compared with historical series.

To study the clinical characteristics, treatment modalities, and outcome of patients with Pancoast tumors who underwent surgery over 11-year period. From January 1994 to May 2005, 13 patients (12 men, 1 woman) with Pancoast tumor and histology of non-small cell lung cancer underwent surgical resection. Nine patients were received induction therapy (8 chemoradiation, 1 radiation only), and there were no treatment-related deaths. Twelve lobectomies, 1 pneumonectomy, and none of wedge resections or partial resection were performed. The number of ribs resected ranged from 2-6 (median 2.8). Chest wall reconstruction was performed in 2 patients, total vertebrectomy in 2, bronchoplasty in 2, and pulmonary arterioplasty in 1. Twelve of 13 patients (92.3%) had a complete resection. Pathologic stages were IB, IIB, IIIA and IIIB in 1, 7, 2, and 1, respectively, and pathologic complete responses was noted in 1. After a median follow-up of 34 months, the 3-year survival was 78.6% for all 13 patients and 85.7% for patients who had a complete resection. It is thought that induction chemoradiation for Pancoast tumors have potential to be able to become the treatment strategy in the future.

Objective: We sought to study the clinical characteristics and outcomes of patients treated with a surgery-inclusive multimodality approach for Pancoast tumors., Methods: Clinical records of patients with Pancoast lung cancer who were enrolled for multimodality treatment between 1993 and 2003 at our institution were reviewed retrospectively., Results: Thirty-six patients completed neodjuvant chemoradiation followed by en bloc surgical resection, whereas one patient received high-dose radiation alone followed by surgical intervention. There were 22 men and 15 women. Thirty-four lobectomies and 3 pneumonectomies were performed. Pretreatment non-small cell lung cancer stages were IIB, IIIA, IIIB, and IV (presenting with solitary brain metastasis) in 18, 8, 6, and 5 cases, respectively. R0 resection was achieved in 36 (97.3%) patients. Operative mortality was 2.7% (n = 1). High-dose radiotherapy was successfully tolerated in all but 1 patient. Mean total radiation dose was 56.9 Gy. Pathologic complete response was found in 40.5% (n = 15) of patients. Recurrences were found in 50% (n = 18) of patients. Brain metastasis was the most common recurrence (n = 9), followed by other distant recurrences (n = 4) and local recurrences (n = 5). Median survival time for the group is 2.6 years, and median survival time (pathologic complete response) is 7.8 years. It is noteworthy that median survival time of patients with positive pretreatment lymph nodes (12 patients) was not reached., Conclusions: Surgical resection of Pancoast tumors after neoadjuvant high-dose radiation and chemotherapy can be safely performed. High-dose radiation in trimodality treatment is well tolerated and might be beneficial. Similar to other studies, late central nervous system relapse is problematic and indicates a need for assessing the role of prophylactic cranial irradiation in this disease.

Physicians' understanding of the anatomy, biology [9], and treatment outcome [12] for superior sulcus carcinoma has changed greatly during the last decade [2,3]. One of the major advances in this regard has been the introduction of anterior approaches for resection. These approaches increase the likelihood of complete resection and permit resection of tumors that were previously considered technically unresectable. Each approach must be understood in detail to avoid incomplete operations and life-threatening complications. These technical advances, with recent evidence that preoperative chemoradiotherapy leads to higher complete resection rates, overall survival, and local control than do radiation and surgery alone [32], have changed physicians' attitudes toward superior sulcus carcinomas, especially for those tumors (eg, T4) previously considered technically unresectable and oncologically incurable. It is hoped that, in the future, resection of disease invasion of the brachial plexus above C7 will be technically feasible [33], and that new drugs will reduce the risk of systemic relapse after resection.

Tumors of the superior sulcus are an uncommon form of NSCLC and historically have been associated with high rates of incomplete resection, local recurrence, and death. Recent data from a multi-institutional study suggest that preoperative chemoradiation may improve the rates of complete resection and cure. Involvement of the vertebral body or brachial plexus, areas once considered unresectable, is amenable to advanced techniques of spinal reconstruction and may lead to long-term survival in selected patients.

Background: Various multidisciplinary approaches are taken in the treatment of superior sulcus tumors. The purpose of this study was to determine the outcome, long-term results, and factors associated with prolonged survival after administering different combined radiosurgical regimens in a single institution., Methods: Between 1986 and 2000, 56 patients (43 men, 13 women) with superior sulcus tumor and histology of non-small-cell lung cancer underwent surgical resection. There were four treatment groups: I - preoperative radiation and operation (n = 15); II - preoperative radiation, operation and postoperative radiation (n = 22); III - operation and postoperative radiation (n = 10) and IV - no radiotherapy (n = 9). Survival was calculated by the Kaplan-Meier method and prognostic factors were assessed for significance by log-rank test and Cox regression analysis., Results: The five-year survival rate after complete resection and N0/1 was 34 %. Of the prognostic factors analyzed, the histology, type of irradiation regimen and Horner's syndrome did not influence survival. Completeness of resection and mediastinal lymph node involvement clearly influences survival in univariate analysis. Age, sex and TNM classification were found to be independent significant prognostic factors for survival following resection., Conclusion: With superior sulcus tumors, every attempt should be made to resect the tumor completely by en bloc chest-wall resection with lobectomy and systematic hilar and mediastinal lymph node dissection. Mediastinal exploration by routine mediastinoscopy is recommended for identification of patients with advanced nodal involvement. Long-term survival may be relative to care taken in patient selection and extent of the resection performed. No significant difference in survival of patients with different irradiation regimens could be demonstrated in this study.

Objectives: To study the clinical characteristics, treatment modalities, and outcome of patients with superior sulcus tumors who underwent surgery over a 15-year period., Design: Retrospective clinical study., Methods: Clinical records of all patients operated on for superior sulcus tumors by the same surgical team between 1988 and 2002 were reviewed retrospectively., Results: Sixty-seven patients were operated on in this period. All the patients underwent en bloc lung and chest wall resection. Surgical approaches were as follows: posterolateral thoracotomy according to Paulson (n = 33), combined transcervical and transthoracic approach (n = 33), and isolated transcervical approach (n = 1). Types of pulmonary resection included lobectomies (n = 59), pneumonectomies (n = 2), and wedge resections (n = 6). Pathologic stages were IIB, IIIA, and IIIB in 49 cases, 12 cases, and 6 cases, respectively. Resection was complete in 55 patients (82%). Operative mortality was 8.9% (n = 6). Postoperative treatment was administered in 53 patients (radiotherapy, n = 42; chemoradiotherapy, n = 9; and chemotherapy, n = 2). Overall 2-year and 5-year survival rates were 54.2% and 36.2%, respectively. Five-year survival was significantly higher after complete resection than after incomplete resection (44.9% vs 0%, p = 0.000065). The presence of associated major illness negatively affected the outcome (5-year survival, 16.9% vs 52%; p = 0.043). Age, weight loss, respiratory impairment, tumor size, presence of nodal disease, and histologic type did not influence the long-term outcome. At multivariate analysis, only the completeness of resection and the absence of associated major comorbidities had an independent positive prognostic value., Conclusions: Superior sulcus tumor remains an extremely severe condition, but long-term survivals may be achieved in a large percentage of cases. The presence of associated major illness and the completeness of resection are the two most important factors affecting the long-term outcome.

Our understanding of superior sulcus tumors has evolved over time. The unique feature of Pancoast tumors is their location, in which the anatomy poses limitations to resection. Many resections are found to be incomplete, and the majority of recurrences have involved local failure. New surgical approaches allow greater flexibility according to tumor location and may improve these outcomes. Furthermore, new approaches permit complete resection of tumors involving vertebral bodies or the neural foramina. Traditionally, preoperative radiotherapy has been used, but a recent prospective phase II study suggests that preoperative concurrent chemoradiotherapy improves the rate of complete resection, local recurrence, and intermediate-term survival.

Introduction: Although the treatment of Pancoast tumours usually combines radiotherapy and surgery, poor prognosis has been reported. The influence of clinical signs and extension of surgical resection on long-term survival has not yet been systematically investigated., Methods: Between 1977 and 1997, among 1129 patients operated consecutively in our institution for a bronchogenic carcinoma, 14 (1.2%) presented a Pancoast tumour. Delay between the onset of symptoms and definite diagnosis ranged from 1 to 14 months (median 7 months). A complete surgical resection was performed in 7 patients, 6 of whom did not have mediastinal lymph node metastasis. Radiotherapy or radiochemotherapy was performed in all patients., Results: Overall 5-year survival rate is 36%. However, 5-year survival rate increases up to 60% if the diagnosis is established within 6 months after the onset of symptoms, and up to 67% if the tumour has been removed without mediastinal lymph node metastasis. In contrast, the 5-year survival rate decreases to 20% or 0% respectively, if symptoms last more than 6 months, or if tumoral resection is incomplete., Conclusions: The incidence of Pancoast tumours compared to other bronchogenic carcinomas is low. An early diagnosis allows complete resection of the tumour and contributes to improve survival.

It has been suggested that T3/N0-1/M0 non-small cell lung cancer should be classified as stage IIB rather than IIIA. This is the result of a widespread perception that the survival of patients with T3/N0-1 lung cancers greatly exceeds that of patients with stage IIIA (N2) lung cancers. This perception is based primarily on the survival of T3/N0-1 patients who have chest wall involvement. However, the T3 classification also includes tumors that involve mediastinal structures, the main stem bronchus <2 cm from the carina, and the brachial plexus as seen in Pancoast tumors. Survival for each of these T3 categories is examined in this articles and found to be somewhat different. The available data show that patients with T3/N0-1 tumors involving the chest wall have a good prognosis after resection, whereas patients with central T3/N0-1 tumors (mediastinal or main stem bronchial involvement) have a prognosis similar to that of patients with resected IIIA (N2) tumors. If a new classification of T3/N0-1 tumors as stage IIB is to be adopted, it will be important for future studies to document which type of T3 tumor is being discussed.

Tumors of the superior pulmonary sulcus (Pancoast tumors) are bronchogenic carcinomas that occur at the thoracic inlet and typically involve, by direct extension, the lower trunks of the brachial plexus, the intercostal nerves, the stellate ganglion, and adjacent ribs and vertebrae. These tumors are rare, comprising 5% of all lung cancers. Treatment of Pancoast tumors has traditionally consisted of preoperative radiation to a dose of 3,000 to 4,500 cGy followed by surgical resection. Overall 5-year survival rates range from 30% to 50%. Even if treatment achieves local disease control, distant failure (brain or bone) is common. Recent treatment efforts have focused on the use of induction chemoradiation followed by surgery and further chemotherapy. This combined-modality approach may become the new treatment paradigm for Pancoast tumors.

The survival of patients with superior sulcus lung carcinoma and the effects of treatment were reviewed. From a prospective database of 4123 consecutive new patients with lung carcinoma, 131 (3.2%) cases of superior sulcus lung carcinoma were identified. Seventy-four patients were planned to receive radiation with palliative intent, 53 radical radiotherapy and one was observed only. The remaining three patients, with small-cell carcinoma, were treated with chemotherapy with or without radiotherapy. Of the 53 radically treated patients, nine were treated with pre-operative radiation prior to intended radical resection. Analysis was carried out on the effect on survival of performance status, nodal involvement, weight loss, vertebral body or rib involvement, treatment intent and radical combined modality treatment compared with radical radiation alone. The estimated median survival for the whole group was 7.6 months; for those treated radically it was 18.3 months, while for the palliatively treated patients it was 3.7 months. Radically treated patients with no initial nodal involvement had an estimated median survival of 22 months, while radically treated patients with nodal involvement had an estimated median survival of 8.4 months (P = 0.003). There were no statistically significant differences in survival between radically treated patients grouped according to initial weight loss, performance status, or vertebral body and rib involvement. Patients treated with pre-operative radiation did not survive significantly longer than patients treated with radiation alone, although the numbers are small.

Eighteen patients underwent combined preoperative irradiation and radical resection for a Pancoast tumor at the Department of Thoracic Surgery, Chest Disease Research Institute, Kyoto University between 1977 and 1993. Four patients were applied a full radiation dose of 50-70 Gy and fourteen patients were applied a reduced dose of 33-40 Gy preoperatively. Eleven of these fourteen were applied a supplemental dose postoperatively up to a total dose of at least 50 Gy. Fourteen lobectomies, three partial resections, and one pneumonectomy were performed with combined resection of chest wall or adjacent structures: rib in 14, vertebra in 4, brachiocephalic vein in 3, subclavian artery in 2, spinal nerve in 3, sympathetic truncus in 2, phrenic nerve in 2 cases. Chest walls were reconstructed with marlex mesh in 5 patients, and two subclavian arteries and one brachiocephalic vein were repaired with artificial grafts. In 13 patients complete resections were achieved, but in the other 5 only incomplete resections leaving residual tumor were achieved. Incomplete resections consisted of 4 positive stumps at the brachial plexus of the apex and one aortic involvement by a metastatic lymph node. There was one operative death. Median survival was 21.6 months and the 5-year-survival rate was 38.5% for all 18 patients. In the complete resection group 5-year-survival was 56.4%, but in the incomplete-resection group 0%, showing a significantly more favorable result for the complete resection group. It is considered that evidence of incomplete resection influences the prognosis and that particularly tumor invasion to the brachial plexus may serve as a limiting factor for surgery.

Operative technique and long-term results of seventeen patients with apical invading lung cancers were evaluated. External radiation therapy was administered preoperatively in all but one. Thirteen lobectomies, three wedge resections and one pneumonectomy were performed with combined resections of chest wall (and adjacent structures) 12, vertebra 3, brachicephalic vein 2, subclavian artery 1, lower part of brachial plexsus 3, sympathetic trunk 2 and phrenic nerve 1. Chest walls were reconstructed with marlex meshes in 5, the subclavian artery and one brachiocephalic vein were with artificial grafts. Operations were considered relative curative in 10, relative non-curative in 2 and absolutely non-curative in 5. Absolutely non-curative operations were due to cancer-positive stump of brachial plexus in the apex in four and metastatic lymph node invading aorta in one. Over all five-year survival rate was 35.3% and median survival was 20 months. Five-year survivals in patients with curative operations and non-curative operations were 60% and 0%, respectively, and the former was significantly higher. Surgical margin is a large factor for long-term result and invasion to the brachial plexus is thought to be a limiting factor for surgery.

Operative technique and long-term results of 60 consecutive patients with Pancoast tumor treated with combined radiosurgical treatment were evaluated. External radiation therapy was administered preoperatively in a dose of 30 Gy in 50 patients. Operation was considered radical (R0) in 36 patients (60%). A microscopic invasion of the margin of resection (R1) was observed in 5 patients (8.3%). In 19 patients (31.6%) the operation was considered presumably not radical (R2). Three patients died in the postoperative period (5%). Fourteen major postoperative complications occurred in 13 patients (21%). Seven patients had recurrence of pain postoperatively. Overall 3- and 5-year actuarial survival rates were 34% and 17.4%, respectively. The corresponding figures for the R0 and combined R1-R2 groups were 45.8% and 23.5% (R0), and 11.4% (R1-R2; no 5-year survivors were observed in this group) (p < 0.025). Median survivals in the R0 and combined R1-R2 patients were 19 and 7 months, respectively. Different median survivals for the patients with residual tumor were as follows: intervertebral foramina, 5 months; subclavian artery (isolated), 9 months; subclavian artery (in association), 7 months; brachial plexus, 4 months; and vertebral body, 7 months. We conclude that combined radiosurgical treatment represents a valuable therapeutic option in the treatment of Pancoast tumor. In case of residual tumor a poor outcome may usually be anticipated, but in the majority of these patients the operation permits good control of the pain.

We describe an original anterior transcervical-thoracic approach required for a safe exposure and radical resection of non-small-cell lung cancer that has invaded the cervical structures of the thoracic inlet. Through a large L-shaped anterior cervical incision, after the removal of the internal half of the clavicle, the following steps may be performed: (1) dissection or resection of the subclavian vein; (2) section of the anterior scalenus muscle and resection of the cervical portion of the phrenic nerve, if invaded; (3) exposure of the subclavian and vertebral arteries; (4) dissection of the brachial plexus up to the spinal foramen; (5) section of invaded ribs; and (6) en bloc removal of chest wall and lung tumor, either directly or through an extension of the cervical incision into the deltopectoral groove. An additional posterior thoracotomy may be required for resection of the chest wall below the second rib. Between 1980 and 1991, 29 patients underwent radical en bloc resection of the inlet tumor, chest wall (ribs 1 and 2), and underlying lung, either through the anterior transcervical approach alone (n = 9) or with an additional posterior thoracotomy (n = 20). The inferior root of the brachial plexus, either alone (n = 11) or with the phrenic nerve (n = 4), was involved and resected in 15 patients (52%). Twelve patients (41%) had a vascular involvement that included the subclavian artery alone (n = 3); subclavian artery and subclavian vein (n = 3); subclavian artery, subclavian vein, and vertebral artery (n = 2); subclavian artery and vertebral artery (n = 1); subclavian vein alone (n = 1); vertebral artery alone (n = 1), or subclavian artery and vertebral artery (n = 1). The subclavian artery was revascularized either with a prosthetic replacement (n = 7) or an end-to-end anastomosis (n = 2), and the median graft patency was 18.5 months (range, 6 to more than 73 months); only 1 patient had postradiotherapy graft occlusion in the revascularized artery 6 months after operation. We performed 14 wedge resections, 14 lobectomies, and 1 pneumonectomy. There were no operative or hospital deaths. Postoperative radiotherapy (median, 56 Gy) was given to 25 (86%) patients, either alone (n = 14) or in combination with adjuvant systemic chemotherapy (n = 11). With a median follow-up time of 2.5 years, overall 2- and 5-year survivals were 50% and 31%, respectively. This transcervical-thoracic approach affords a safe exposure and radical resection of non-small-cell lung cancer involving the thoracic inlet and results in encouraging long-term survival.

The treatment of superior pulmonary sulcus (Pancoast) tumor is not uniform and is still discussed. Literature data and our retrospective study are presented. Fourteen patients were operated for a Pancoast tumor. Nine patients underwent mediastinoscopy followed by preoperative radiotherapy. Five patients received adjuvant radiotherapy after incomplete resection. Five patients who did not have preoperative radiotherapy, received postoperative irradiation. All three patients who survived five years or more, had preoperative radiotherapy and two of them underwent a complete resection. Literature data are discussed and emphasis is laid on the importance of preoperative staging, including mediastinoscopy, preoperative radiotherapy and complete "en bloc" resection.

Fifty-six patients with superior sulcus syndrome were evaluated at the First Surgical Department of the University of Padua between 1981 and 1990. Forty-two patients with the characteristic of Pancoast's tumor received preoperative irradiation and then en bloc resection of the tumor, chest wall, and adjacent structures. Seven lobectomies and 35 segmentectomies or wedge resections were performed. There was one early postoperative death. Median survival was 14 months, and actuarial survival was 25% at 5 years. Patients with pain relief had better 5-year survival (36.4%) than patients without pain relief (9%). We have no patients with vertebral invasion who survived more than 1 year. Of the five patients with subclavian artery invasion, only one survived more than 1 year. Of five patients with N2 disease, only one survived more than 1 year. Our results suggest that pain relief after irradiation is a good prognostic factor, whereas N2 involvement and vertebral body and great vessel invasion are ominous factors. Another ominous prognostic factor is the Claude Bernard-Horner syndrome even if it is not a contraindication to resection.

We report our experience with 21 patients with superior sulcus tumors. Demographic features and survival were analyzed according to the stage of disease. Eleven patients had stage IIIA disease, 2 had stage IIIB disease and 8 had stage IV disease. Only 4 (19%) were amenable to surgery at the time of diagnosis and only 1 underwent combined preoperative radiotherapy and surgery. The majority of our patients were nonresectable at the time of diagnosis because of extensive disease or coexisting medical conditions. Overall, the probability of survival approached zero at 1 year. This poor survival is a reflection of nonresectability in the majority of our patients, which may be unique to our patient population.

This is a retrospective analysis of 73 patients with non-oat cell carcinoma of the lung presenting as a Pancoast tumor. All patients were treated with curative intent between October 1964 and September 1987 (minimum follow-up 2 years). The treatment plan consisted of preoperative radiation therapy (usually 3000 cGy in 2 weeks or 4500 cGy in 5 weeks) in 41 patients and radiation therapy alone (usually 6500-7000 cGy in 6.5-8.0 weeks) in 32 patients. In general, radiation therapy alone was reserved for poor-prognosis patients (extensive disease or medical inoperability). Although 41 patients were initially scheduled to receive preoperative radiation therapy and surgery, the surgery was not performed in 12 cases (29%) because of patient refusal (4 patients), poor response to radiation therapy (4 patients), distant metastasis (2 patients), or debilitation (2 patients). Separate calculations were carried out for the patients who completed the surgery as planned (preoperative radiation therapy and surgery) and the entire group originally scheduled for combined-modality therapy. There was no significant difference in the absolute or cause-specific survival rates between treatment groups, but severe complications were significantly more common in patients receiving combined therapy.

Fifty-five patients with superior sulcus syndrome were treated at the UCLA Medical Center and Wadsworth VA Hospital (Los Angeles) between 1956 and 1985. Twenty-eight underwent surgery, six of whom were found unresectable at the time of thoracotomy. Twenty-one of 22 in the resected group received preoperative irradiation. Twenty-seven patients received radiation only. Surgical morbidity was 21%, and there were two in-hospital deaths. Five-year survival for extended resection patients was 34%. The radiation only group had no 5-year survivors. Factors associated with a worse prognosis include positive margins, N2 disease, and vertebral body involvement. The best results for superior sulcus tumors are obtained by preoperative irradiation followed by en bloc resection of the tumor. In the event complete resection is impossible, radiation has a role in palliation of pain with occasional prolonged survival.

A retrospective analysis of 35 patients treated for superior sulcus tumors of the lung at UCLA was performed for the years 1960-1983. Follow-up ranged from 19 months to 21 years, with all but one patient followed at least 2 years. The 28 patients with localized disease were treated by megavoltage irradiation with or without surgical resection and had a 5-year survival (product-limit) of 21%. However, the 15 patients receiving combined treatment had a 48% 5-year survival (p = 0.009). An effort was made to identify those factors affecting survival. Patients presenting with no radiographic evidence of nodal enlargement appeared to have a survival advantage with a survival of 31% at 3 years, versus no survivors among those with positive nodes (p = 0.059). Bony erosion contiguous with the primary tumor at presentation was found not to affect the prognosis. Patients with local control of the primary tumor showed a survival of 71% vs 0% for those locally recurring. Those patients receiving at least 55 Gy showed a trend toward increased survival though not with statistical significance. The pattern of failure was evaluable in 25 patients. Local recurrence was observed in 18 patients (72%) with seven (39%) of these manifesting as spinal cord compressions. Distant metastases were seen in 35% of recurrences, and as the sole site of disease in only 10%. Three patients developed brain metastases, all of whom had concomitant local failure. Significant pain relief was achieved in 74% of patients. However, it was transient in 60% of these. We conclude that superior sulcus tumors remain primarily a localized problem, and that aggressive treatment is indicated even with apparently local invasive disease.

From January, 1971, to January, 1977, 26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoast's syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at least 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.

Fifty-three patients with superior sulcus (Pancoast) tumors of the lung followed for up to 12 years by the Armed Forces Central Medical Registry were divided into three groups. In Group 1, preoperative stagin as determined by bone, brain, and liver scans or combinations thereof and the presence of local nodal extension as determined by mediastinoscopy or scalene fat pad biopsy were negative. These 16 patients received preoperative irradiation followed by en bloc resection of the lung and of the involved chest wall in most of them. Five-year survival as determined by the actuarial method was 49.7%. The 12 patients in Group 2 either had localized nodal involvement or were not diagnosed preoperatively. Survival in this group was 13.1%. Group 3 patients were considered inoperable and were given palliative irradiation. There were 25 patients in this group, and survival was 5.5% at 4 years. It would appear that preoperative irradiation and en bloc resection give improved survival in those patients judged free from metastatic disease preoperatively.

From 1960 to 1980, 45 patients with superior sulcus cancer of the lung were seen in our hospital. 39 were male and 6 were female. The youngest was 28 years old and the eldest was 75. The presenting symptoms and signs were back and shoulder pain in 32 patients, compression of the brachial plexus in 17, Horner's syndrome in 12, supraclavicular mass in 11, superior cava vena obstruction in 4, shadow in the apex in 45, destruction of the rib in 19 (10 in the second rib), destruction of the adjacent vertebra in 8 (5 in T3) and destruction of the clavicle in 1. In 18 patients proved by pathology and cytology, 8 were adenocarcinoma, 3 squamous cell carcinoma, 3 undifferentiated and 4 unclassified carcinoma. 27 patients were diagnosed by X-ray films. 40 patients were admitted for treatment. 3 recieved chemotherapy alone and all of them died in one year. Of the 6 treated by radiation plus chemotherapy, 3 survived for one year but all died in two years. 2 were treated by radiation plus operation and none survived for more than 3 years. 29 were treated by radiation only. The 1, 3 and 5 year survival rates were 51%, 13.7% and 6.9%. Destruction of the rib or the adjacent vertebral body was irrelative to the prognosis but the presence of supraclavicular mass reduced the survival rate. Cause of death was local recurrence in 48% (13/27) and distant metastasis in 48% (13/27). The authors suggest that radical en bloc resection together with radiation the worth further study.

The authors analyse the results up to death in 103 followed-up patients undergoing unilateral percutaneous cervical cordotomy for persistent cervico-thoracic malignant pain (45 cases of Pancoast syndrome and 58 cases of thoracic pain associated with lung cancer or metastases). On the basis of epidemiological data, relationships emerge between onset of pain, stage of cancer, patient survival and lasting efficacy of pain relief. Twenty (44%) of 45 patients with Pancoast syndrome were pain-free up to death as a result of cordotomy alone, while only 13/58 patients (22%) with thoracic pain were pain-free as a result of cordotomy alone owing to the very high incidence of mirror pain in this group of patients (42/58 patients, 72%) compared to those with Pancoast syndrome (14/45 patients, 31%). The type and intensity of mirror pain, however, were of such a nature in both groups as to be amenable to control with analgesic drugs. In both groups of patients, there was a low incidence of the causes of post-cordotomy pain recurrence contralateral to the lesion, i.e., deafferentation pain, fading of analgesia, and pain above the levels up to which deep pin-prick analgesia had been obtained. Cordotomy alone or, as necessary, in conjunction with analgesic drugs afforded complete pain control in 34/45 patients (75%) with Pancoast syndrome and in 50/58 patients (86%) with thoracic pain. These data provide evidence of the unique usefulness of the procedure in controlling otherwise intractable persistent cervicothoracic malignant pain, when the technique is correctly performed.