Superior sulcus tumors: results of irradiation of 36 patients

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Evaluation of arm function and quality of life after trimodality treatment for superior sulcus tumours

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.

A prospective phase 2 study of surgery followed by chemotherapy and radiation for superior sulcus tumors

BACKGROUND

The optimal treatment for locally advanced superior sulcus tumors is not clear. The authors report long-term results of a trial examining the safety and efficacy of surgery followed by concurrent chemoradiation therapy for this disease.

METHODS

Thirty-two patients with resectable or marginally resectable superior sulcus tumors at The University of Texas MD Anderson Cancer Center from 1994 to 2010 were enrolled in a prospective trial. Surgery involved segmentectomy or lobectomy with en bloc resection of the involved chest wall and complete nodal staging; radiation therapy (RT) began 14 to 42 days later to a dose of 60 grays (Gy) in 50 1.2-Gy fractions if surgical margins were negative or 64.8 Gy in 54 1.2-Gy fractions if margins were positive. Two cycles of etoposide (50 mg/m(2) ) and cisplatin (50 mg/m(2) ) were given during RT, and another 3 cycles were given after RT. Eleven patients underwent prophylactic cranial irradiation (PCI).

RESULTS

The protocol completion rate was 78%. Gross total resection was accomplished in all 32 patients; 28% underwent R1 resection. Operative mortality was 0%. The most common surgical complication was postoperative pneumonia (25%). At a median follow-up time of 53.4 months (range, 2-154 months), the 2-year, 5-year, and 10-year rates of locoregional control were 84%, 76%, and 76%; distant metastasis-free survival, 52%, 48%, and 48%; disease-free survival, 49%, 45%, and 45%; and overall survival, 72%, 50%, and 45%, respectively. The brain was the most common site of distant failure (n = 5), but no patient who received PCI experienced brain metastasis.

CONCLUSIONS

Surgery followed by postoperative chemoradiation is safe and effective for the treatment of marginally resectable superior sulcus tumors.

Carcinoma de pequenas células na síndrome de Pancoast

A síndrome de Pancoast consiste de sinais e sintomas decorrentes do acometimento do ápice pulmonar e estruturas adjacentes por um tumor. Na maioria das vezes, o processo causal é uma neoplasia. O carcinoma broncogênico é a principal neoplasia causadora da síndrome. Os subtipos histológicos mais encontrados são o adenocarcinoma e o carcinoma epidermoide. A ocorrência de carcinoma de pequenas células de pulmão como gênese da síndrome de Pancoast é rara, com poucos relatos na literatura. Descrevemos o caso de um doente com síndrome de Pancoast causado por um carcinoma de pequenas células de pulmão, discutindo aspectos referentes ao diagnóstico e à terapêutica.

Special Treatment Issues in Lung Cancer

BACKGROUND

This chapter of the guidelines addresses patients who have particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLCs), solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, metaanalyses or large prospective studies of patients are not available. For ensuring that these guidelines were supported by the most current data available, publications that were appropriate to the topics covered in this chapter were obtained by performance of a literature search of the MEDLINE computerized database. When possible, we also referenced other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter), and reviewed by all members of the lung cancer panel before approval by the Thoracic Oncology NetWork, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach seems to be optimal, involving chemoradiotherapy and surgical resection, provided appropriate staging has been conducted. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. Such patients, however, seem to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone when carefully staged and selected. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment than what would be dictated by the primary tumor alone. However, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLCs do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and a second primary lung cancer, although criteria to distinguish them have not been defined. Selected patients with a solitary focus of metastatic disease in the brain or adrenal gland seem to benefit substantially from resection. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, as long as tumors can be completely resected and there is absence of N2 nodal involvement, primary surgical treatment should be considered.

CONCLUSIONS

Carefully selected patients may benefit from an aggressive surgical approach.

Traitement des tumeurs de l'apex: un modèle de stratégie multimodale dans les cancers bronchiques localement évolués

Superior sulcus tumors have been individualized among other non-small cell lung cancers because of their characteristic clinical presentation in connection with their local extension to the chest wall and the brachial plexus. For a long time considered as marginally resectable, superior sulcus tumors have been treated since the early 1960's, with a combined approach including preoperative radiotherapy and curative-intent surgery. Surgical resection includes both thoracic, cervical and neurosurgical approach, and aims at obtaining complete resection, which has been identified as a determining prognostic factor in most reported series. Two recent phase II trials showed the benefit, both regarding resectability and local control rates, and survival of combined therapeutic strategies including induction platinum-based chemoradiation, extensive surgical resection, and adjuvant chemotherapy. Adjuvant radiotherapy is not recommended at the time, but needs to be re-evaluated regarding its recent technical optimisation. Similarly to other locally advanced non-small cell lung cancers, exclusive chemoradiation is the standard treatment of unresectable superior sulcus tumors. In this way, radiotherapy has shown to offer a prolonged analgesia in more than 75% of cases, and is associated with concurrent or sequential chemotherapy, with comparable results to those observed in stage III lung cancer. These developments make superior sulcus tumors a therapeutic model for locally advanced non-small cell lung cancer, whereby the benefit of combined multimodal strategies including induction chemoradiation and surgical resection are currently evaluated in phase III trials.

Surgical approach in T4N0M0 (vertebral involvement) lung cancer

Approximately 5% of the cancers involve the chest wall and spine by direct extension and remain localized at the time of diagnosis. T4 lesions invading the vertebra are considered inoperable. We reviewed a new evolution in the surgical treatment of lung cancer involving the vertebra (T4N0M0) and report preliminary results of our approach. Four patients with T4N0M0 (vertebral involvement) lung cancer underwent en bloc surgical resection of tumor between 1998 and 2002. Posterior stabilization, hemilaminectomy, and osteotomy of the involved vertebral bodies below the corresponding pedicle were performed in the prone position and then, in the lateral position, en bloc resection was completed along with the lung resection (large wedge resection or lobectomy) and involved vertebral bodies. There was no immediate postoperative mortality. Three patients died during the follow-up period at the 6th, 8th, and 14th postoperative months with a postoperative recognized metastasis. The fourth patient was in follow-up at 20 months. Although T4N0M0 (vertebral involvement) lung cancers are considered inoperable, lung resection with hemivertebrectomy of the involved vertebra after neoadjuvant chemotherapy and radiotherapy is an alternative treatment in this type of lung cancer. Staging should be made meticulously for the expected surveillance.

Resection of superior sulcus tumors (posterior approach)

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.

Lung cancer. Special treatment issues

This chapter of the Lung Cancer Guidelines addresses patients with particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLC), and solitary metastases. For patients with a Pancoast tumor, a multimodality approach, involving chemoradiotherapy and surgical resection, appears optimal provided appropriate staging has been carried out. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. When carefully staged and selected, however, such patients appear to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment from what would be dictated by the primary tumor alone. On the other hand, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLC do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and those with a second primary lung cancer, although criteria to distinguish them have not been defined. Finally, some patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit substantially from resection.

Induction chemoradiation and surgical resection for non-small cell lung carcinomas of the superior sulcus: Initial results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160)

OBJECTIVE

The rate of complete resection (50%) and the 5-year survival (30%) for non-small cell lung carcinomas of the superior sulcus have not changed for 40 years. Recently, combined modality therapy has improved outcome in other subsets of locally advanced non-small cell lung carcinoma. This trial tested the feasibility of induction chemoradiation and surgical resection in non-small cell lung carcinoma of the superior sulcus with the ultimate aim of improving resectability and survival.

METHODS

Patients with mediastinoscopy-negative T3-4 N0-1 superior sulcus non-small cell lung carcinoma received 2 cycles of cisplatin and etoposide chemotherapy concurrent with 45 Gy of radiation. Patients with stable or responding disease underwent thoracotomy 3 to 5 weeks later. All patients received 2 more cycles of chemotherapy and were followed up by serial radiographs and scans. Survival was calculated by the Kaplan-Meier method and prognostic factors were assessed for significance by Cox regression analysis.

RESULTS

From April 1995 to September 1999, 111 eligible patients (77 men, 34 women) were entered in the study, including 80 (72.1%) with T3 and 31 with T4 tumors. Induction therapy was completed as planned in 102 (92%) patients. There were 3 treatment-related deaths (2.7%). Cytopenia was the main grade 3 to 4 toxicity. Of 95 patients eligible for surgery, 83 underwent thoracotomy, 2 (2.4%) died postoperatively, and 76 (92%) had a complete resection. Fifty-four (65%) thoracotomy specimens showed either a pathologic complete response or minimal microscopic disease. The 2-year survival was 55% for all eligible patients and 70% for patients who had a complete resection. To date, survival is not significantly influenced by patient sex, T status, or pathologic response.

CONCLUSIONS

(1) This combined modality treatment is feasible in a multi-institutional setting; (2) the pathologic complete response rates were high; and (3) resectability and overall survival were improved compared with historical experience, especially for T4 tumors, which usually have a grim prognosis.

Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas M. D. Anderson Cancer Center

PURPOSE

Superior sulcus tumors (SST) of the lung are uncommon and constitute approximately 3% of non-small cell lung cancer (NSCLC). These tumors cause specific symptoms and signs, and are associated with patterns of failure that differ from those seen for NSCLC tumors in other nonapical locations. Prognostic factors and most effective treatments are controversial. We conducted a retrospective study at The University of Texas M. D. Anderson Cancer Center to identify outcome predictors for patients with SST treated by a multidisciplinary approach.

METHODS AND MATERIALS

This retrospective review of 143 patients without distant metastasis at presentation is a continuation of a previous M. D. Anderson study now updated to 1994. In this study, we examine the 5-year survival rate by pretreatment tumor and patient characteristics and by the treatments received. Strict criteria were used to define SST. Actuarial life-table analyses and Cox proportional hazard models were used to compare survival rates.

RESULTS

Overall predictors of 5-year survival were weight loss (p < 0.01), supraclavicular fossa (p = 0. 03), or vertebral body (p = 0.05) involvement, stage of the disease (p < 0.01), and surgical treatment (p < 0.01). Five-year survival for patients with Stage IIB disease was 47% compared to 14% for Stage IIIA, and 16% for Stage IIIB. For patients with Stage IIB disease, surgical treatment (p < 0.01) and weight loss (p = 0.01) were significant independent predictors of 5-year survival. Among patients with Stage IIIA disease, the only predictor of survival was Karnofsky performance score (KPS) (p = 0.02). For patients with Stage IIIB disease, the only independent predictor of survival was a right superior sulcus location, which was associated with a worse 5-year survival rate than that for patients with tumors in the left superior sulcus (p = 0.02). More patients with adenocarcinoma than with squamous cell tumors experienced cerebral metastases within 5 years (p < 0.01). Patients without gross residual disease after surgical resection who received postoperative radiation therapy with total doses of 55 to 64 Gy had a 5-year survival rate of 82% as compared with the 5-year survival rate of 56% in patients who received 50 to 54 Gy. Twenty-three patients survived for longer than 3 years. Of these, 4 patients (17%) received radiation therapy alone or in combination with chemotherapy without surgical resection. The other 19 patients (83%) had resection combined with radiation therapy and/or chemotherapy.

CONCLUSIONS

The findings from this study confirm the importance of the new staging system, separating T3 N0 M0 (Stage IIB) from Stage IIIA, since there was a significant difference in the 5-year survival (p < 0.01). Interestingly, there was no significant 5-year survival difference between Stage IIIA (N2) and Stage IIIB (T4 or N3). This study also suggests that surgery is an important component of the multidisciplinary approach to patients with SST if their nodes were negative. Disease that is minimally invading surrounding normal structures can be resected followed by radiation therapy in doses of 55 to 64 Gy. Further investigation of treatment strategies combining high-dose radiation therapy (>/=66 Gy) with chemotherapy is indicated for patients with unresectable and/or node-positive (N2) SST.

The management of superior sulcus tumors

Lung cancers arising from the extreme apex of the lung-superior sulcus tumors (SST)-have distinct symptoms and signs at presentation and a characteristic appearance on imaging. However, in their early stages, these tumors are often missed by traditional anterior/posterior chest X-rays. Recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) have made selection of patients with potentially resectable of SST more accurate. If mediastinoscopy reveals no mediastinal lymph nodes involved, the patient can be treated with surgery followed by radiation therapy with or without chemotherapy. If mediastinoscopy reveals microscopic mediastinal lymph node involvement, the patient can be treated with induction radiation therapy and concurrent chemotherapy followed by surgery. If mediastinoscopy reveals gross mediastinal lymph node involvement (N2), or if CT reveals N3 or T4 lesions, the patient can be treated with concurrent chemotherapy and radiation therapy to relieve symptoms; the outcome of such treatment appears to be better than that of sequential chemotherapy followed by radiation therapy. Whenever possible, to enhance the patient's quality of life, surgery should be considered to improve function and relieve pain.

Pain-relieving posterior rod fixation with segmental sublaminar wiring for Pancoast tumor invading the vertebrae

We describe the case of a 44-year-old male patient with Pancoast lung cancer invading the vertebrae. Because irradiation did not relieve his symptoms, we conducted tumor resection with posterior rod fixation with segmental sublaminar wiring of the vertebrae. This enabled the patient to walk and to discontinue morphine immediately after surgery. Although the tumor recurred within the region of the fixation 4 months after surgery, the patient complained of no pain until his death. Although Pancoast lung cancer with extensive vertebral invasion cannot be cured surgically, posterior rod fixation with segmental sublaminar wiring with tumor resection can improve a patient's quality of life by providing immediate, long-term pain relief.

Superior sulcus lung tumors: impact of local control on survival

OBJECTIVES

Our goal was to assess patient survival and response to treatment for superior sulcus tumors treated with combined radiation therapy and surgery when possible, or with radiation alone when surgery was not possible.

METHODS

Seventy-three patients were treated for primary non-small cell carcinoma of the superior pulmonary sulcus. Thirty-four patients received combined resection and irradiation. Thirty-nine patients who had extensive primary disease, distant metastases, or who were medically unfit for surgery were treated with radiation alone. Thirty-one patients (91%) assigned to the resection/irradiation group completed treatment. Combined therapy patients routinely received 40 Gy before the operation, with additional postoperative irradiation based on the surgical findings.

RESULTS

Overall survival at 5 years was 19% and disease-specific survival was 20% for all patients. Overall survival and disease-specific survival at 5 years for the resection/irradiation group were 33% and 38%, respectively. Significant indicators of poor prognosis included unresected primary disease, low performance score, T4 stage, or positive node status. Eighty-two percent of the patients who received irradiation alone were treated with palliative intent. Freedom from local-regional progression, achieved initially in 66% of these patients, was associated with a median survival of 8 months. Median survival for 7 patients considered for definitive irradiation was 25 months. During the first 18 months, distant failures occurred in approximately 35% of patients in each treatment group.

CONCLUSIONS

Selection of medically fit patients with resectable disease for combined surgery and aggressive radiation therapy resulted in a high likelihood of local control. Overall survival for the resection/irradiation group was significantly poorer for patients with T4 stage, nodal disease, or Horner's syndrome. Distant metastases eventually developed in 56% of patients undergoing resection. Median survival in the resection/irradiation group was significantly prolonged for those patients who could tolerate high-dose radiation treatment.

Superior sulcus tumor (SST): management at the Institute of Oncology in Ljubljana, Slovenia, 1981-1994

During the 14-year period under study, 48 patients with SST were treated at the Institute of Oncology in Ljubljana, Slovenia. There were 46 males and two females, aged 29-88 years (median, 60 years). Of 37 cytologically or histologically confirmed tumors, 12 were squamous, eight large-cell, one small-cell, eight adeno, and eight unclassified carcinomas. Performance status (Karnofsky) was assessed as > 90 in eight, 70-90 in 31 and < 70 in nine patients. The duration of symptoms before diagnosis ranged from 1 to 36 months (median, 5 months). All patients had pain, while six also had hemophthysis, 14 Horner's syndrome, and four Horner's syndrome and upper limb paresis. Before the first chest X-ray, 19 patients- were treated for shoulder pain by different specialists. Apical tumor infiltration only on the chest X-ray was found in 13, destruction of the ribs in 31, and destruction of the ribs and vertebral bodies in four patients. Treatment was as follows: radiotherapy in 39 patients (22 with radical, 17 with palliative dose), a combination of surgery and radiotherapy in seven, radiotherapy and chemotherapy in one, and symptomatic therapy alone in one patient. One- and four-year survival of all treated patients was 27% and 11%, respectively. One of the seven patients operated on survived for 44 months, and 2/39 irradiated ones survived for 37 and 56 months, respectively, while others died within 24 months from diagnosis. In 81% of patients the pain was subdued after radiotherapy. The disease-specific survival of all patients included in the follow-up correlated with performance status and M stage, while that of those treated by irradiation alone correlated with tumor dose (P < 0.05).

Pancoast (superior sulcus) tumors

Primary carcinomas arising in the apex of the lung (Pancoast tumors) have attracted attention because of the characteristic syndrome that is produced by local extension into the chest wall and the brachial plexus. This article reviews the history of the treatment of this disease, the natural history of untreated patients, and the diagnosis of Pancoast tumors. The published data on results, prognostic factors, and technical aspects of treatment with combined irradiation and operation are examined, as well as those pertaining to treatment with irradiation alone.

Pancoast tumours: clinical assessment and long-term results of combined radiosurgical treatment

BACKGROUND

Many oncologists have now accepted a combined radiosurgical approach as the treatment of choice in patients with Pancoast tumour but most reports show an incorrect assessment of the disease.

METHODS

Stage III lung cancer was classified as Pancoast tumour if the pulmonary extent was limited to the upper apical segment and if at least one of the features of Pancoast syndrome, indicating tumour spread to the para-apical structures, was present. Between 1984 and 1988 15 consecutive patients were treated with primary radiotherapy followed by surgery or with primary excision and subsequent radiotherapy in the absence of an initial histological diagnosis.

RESULTS

The mortality of patients given the combined treatment was 6.6% (one death due to pulmonary embolism), and the five year survival rate was 26.6% for all patients and 57% for those who underwent complete resection without N2 disease. Long-term survival was 0% for those cases with incomplete resection, N2 disease, or malignant invasion of the first rib.

CONCLUSIONS

Stage III lung cancer, classified as Pancoast tumour according to strict, consistent criteria, is best treated by primary radiotherapy; combined treatment should be used only for patients with potentially resectable cancer without N2 disease and/or malignant invasion of the first rib.

Radiation treatment of superior sulcus lung carcinoma

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.

Influence of surgical resection and brachytherapy in the management of superior sulcus tumor

We analyzed the results of surgical treatment of all patients presenting with untreated superior sulcus tumors between 1974 to 1991 inclusive at our institution. Most patients received preoperative radiotherapy. We attempted to analyze the influence of surgical resection and intraoperative brachytherapy in obtaining locoregional control and disease-free survival. One hundred twenty-four patients underwent thoracotomy and 100 patients underwent resection. The overall 5-year survival rate was 26% for all patients and 30% for resected patients. Those patients receiving a complete resection achieved a 41% 5-year survival. The best single group were those patients undergoing a lobectomy (versus wedge resection) and en-bloc chest wall resection (60% 5-year survival). We were unable to demonstrate an advantage for the use of intraoperative brachytherapy in those patients with complete resection. For those patients with incomplete resection, the use of brachytherapy combined with preoperative or postoperative external radiation therapy resulted in a 9% 5-year survival. Locoregional failure was significant both in patients with complete resection and in patients with incomplete resection. Adverse prognostic factors included Horner's syndrome, N2 and N3 disease, T4 disease, and incomplete resections. In superior sulcus tumors, every attempt to completely resect the tumor by en-bloc chest wall resection combined with lobectomy and adequate nodal staging remains the surgical treatment of choice together with either preoperative, postoperative, or "sandwich" external radiation therapy.

Superior sulcus tumors: combined modality

Twenty-four patients with superior sulcus tumors were seen between 1955 and 1989. Fifteen of these patients received combined-modality therapy. In 2 patients, this consisted of primary operation followed by postoperative radiotherapy, and, in 13, high-dose conventionally fractionated preoperative radiotherapy (5,500 to 6,475 cGy) followed by en bloc resection. Of the 13 patients who received radiotherapy preoperatively, 7 survived free of disease beyond 5 years and 2 others remained without evidence of disease after a shorter follow-up (greater than 2 years). The long-term survival in the combined-modality patients in this small series is superior to that reported for other patients receiving combined-modality therapy, and the morbidity appears to be within accepted limits despite the aggressive preoperative radiotherapy program. One postoperative death occurred in our only octogenarian, but there were no other acute complications. High-dose preoperative radiotherapy using current techniques and fractionation appears to be feasible in conjunction with contemporary surgical techniques. We believe this type of preoperative radiotherapy contributed to the apparent superior survival rate in this series and may also be applicable in the setting of other locally advanced (stage III) bronchogenic carcinomas.

Combined radiosurgical treatment of Pancoast tumor

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.

Role of radiation therapy in the management of lung cancer

Most patients who have lung cancer will receive radiation therapy at some point during the course of their disease. For patients with non-small-cell lung cancer, radiation therapy is sometimes used after complete resection, particularly in patients with lymph node involvement. In addition, irradiation is commonly used after incomplete resection. In patients with unresectable non-small-cell lung cancer, radiation therapy alone is typically used, although recent studies of a combination of chemotherapy and radiation therapy, or radiation therapy given in twice-daily fractions, have yielded promising results. For patients with small-cell lung cancer who have limited (that is, nonmetastatic) disease, the addition of thoracic radiation therapy to chemotherapy has improved survival over that with chemotherapy only. The role of prophylactic cranial irradiation in small-cell lung cancer remains controversial. Radiation therapy has a major role in the management of locally recurrent and metastatic lung cancer. Both the bones and the brain are common metastatic sites in patients with lung cancer. Radiation therapy provides effective palliation of symptoms from these and other metastatic lesions.

Comparison of outcome between clinically staged, unresected superior sulcus tumors and other stage III non-small cell lung carcinomas treated with radiation therapy alone

Several studies suggest that patients with non-small cell lung carcinoma (NSCLC) of the superior sulcus fare better after radiation therapy than those patients with comparable tumors at other thoracic sites. There is limited data on stage-by-stage comparisons between patients with superior sulcus tumors (SST) and non-SST (NSST). Thirty patients had SST among 656 patients with American Joint Committee on Cancer clinically staged IIIA (n = 389) and IIB (n = 267) primary NSCLC who received definitive once-daily radiation therapy. The median patient age, sex ratio, histologic findings, grade, weight loss, and performance status were similar for SST and NSST. Minimum follow-up was 24 months, with 88% of patients followed until death. The survival of patients with SST (median, 10.3 months) was similar to that of patients with tumors at other pulmonary sites (median, 10.8 months; P = 0.39). Survival for favorable patients with performance status 0 to 1 and weight loss of 5% or less was comparable between patients with SST (median, 15.0 months) and NSST were similar for patients with SST and NSST (P = 0.48). The brain was the site of first failure in 20% of patients with SST and 10% of patients with NSCLC at other sites (P = 0.10). The lack of apparent difference in outcome of comparably staged patients with SST and NSST treated with radiation alone may have significant therapeutic implications.

Pancoast tumor: radiation therapy alone versus preoperative radiation therapy and surgery

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.

Pancoast tumour treated with combined radiotherapy and hyperthermia--a preliminary study

Six patients with Pancoast (superior sulcus) tumours were treated with combined radiotherapy and hyperthermia from April 1986 to December 1989. Radiotherapy was performed using 10 MV X-ray, and all patients received total doses of 60-74 Gy, in five fractions per week, during 5.5-15 weeks. Hyperthermia was performed once or twice a week within 30 min after each irradiation, using 8 MHz RF capacitive heating equipment (Thermotron RF-8). Partial response, defined as 50% or more regression of the tumour, was observed in four of the six patients. Three patients are alive 30, 28, and 14 months after their treatments. Radiotherapy combined with hyperthermia appears to be a promising and effective means for treating Pancoast tumours.

Non-small cell lung cancer. Part II: Treatment

Squamous, large cell, and adenocarcinoma, collectively termed non-small cell lung cancer (NSCLC), are diagnosed in approximately 75% of patients with lung cancer in the United States. The treatment of these three tumor cell types is approached in virtually identical fashion because, in contrast to small cell carcinoma of the lung, NSCLC more frequently presents with localized disease at the time of diagnosis and is thus more often amenable to surgical resection but less frequently responds to chemotherapy and irradiation. Cigarette smoking is etiologically related to the development of NSCLC in the great majority of cases. Genetic mutations in dominant oncogenes such as K-ras, loss of genetic material on chromosomes 3p, 11p, and 17p, and deletions or mutations in tumor suppressor genes such as rb and p53 have been documented in NSCLC tumors and tumor cell lines. NSCLC is diagnosed because of symptoms related to the primary tumor or regional or distant metastases, as an incidental finding on chest radiograph, or rarely because of a paraneoplastic syndrome such as hypercalcemia or hypertrophic pulmonary osteoarthropathy. Screening smokers with periodic chest radiographs and sputum cytologic examination has not been shown to reduce mortality. The diagnosis of NSCLC is usually established by fiberoptic bronchoscopy or percutaneous fine-needle aspiration, by biopsy of a regional or distant metastatic site, or at the time of thoracotomy. Pathologically, NSCLC arises in a setting of bronchial mucosal metaplasia and dysplasia that progressively increase over time. Squamous carcinoma more often presents as a central endobronchial lesion, while large cell and adenocarcinoma have a tendency to arise in the lung periphery and invade the pleura. Once the diagnosis is made, the extent of tumor dissemination is determined. Since most NSCLC patients who survive 5 years or longer have undergone surgical resection of their cancers, the focus of the staging process is to determine whether the patient is a candidate for thoracotomy with curative intent. The dominant prognostic factors in NSCLC are extent of tumor dissemination, ambulatory or performance status, and degree of weight loss. Stages I and II NSCLC, which are confined within the pleural reflection, are managed by surgical resection whenever possible, with approximate 5-year survival of 45% and 25%, respectively. Patients with stage IIIa cancers, in which the primary tumor has extended through the pleura or metastasized to ipsilateral or subcarinal lymph nodes, can occasionally be surgically resected but are often managed with definitive thoracic irradiation and have 5-year survival of approximately 15%.(ABSTRACT TRUNCATED AT 400 WORDS)

Superior sulcus tumors: treatment selection and results for 85 patients without metastasis (Mo) at presentation

Superior sulcus (Pancoast) tumors (SST) are uncommon carcinomas of the lung with distinctive failure patterns and a somewhat more favorable prognosis than other sites of lung cancer. The most effective use of surgery (S), radiation (R), and chemotherapy (C) is not resolved. Most reported series include patients treated before the era of computed tomography (CT). A retrospective study was undertaken of all previously untreated patients with SST who received definitive management at the University of Texas M.D. Anderson Cancer Center between January 1977 and December 1987. Eighty-five patients were treated: the male:female ratio was 2.7:1, and the ages ranged from 35 to 80 (median 59) years. Karnofsky performance status (KPS) was 80 or more in 70 patients (82%). Thirty patients (35%) had lost 5% or more body weight. All had histologic or cytologic confirmation of carcinoma: 25% were squamous cell, 2% small cell, 54% adenocarcinoma, and 6% were large cell carcinoma (12% were not classified). After complete evaluation, 43 were classified as clinical Stage IIIA and 42 were Stage IIIB. One Stage IIIA patient received surgery, 13 surgery + radiation therapy, 2 surgery + radiation therapy and chemotherapy, 19 radiation therapy and 8 radiation therapy + chemotherapy. Seven Stage IIIB patients received surgery + radiation therapy, 12 radiation therapy, 2 surgery + radiation therapy + chemotherapy, 17 radiation therapy + chemotherapy and 4 chemotherapy. Surgery was a component of therapy more frequently in Stage IIIA than IIIB (p less than .05) and systemic treatment chemotherapy was used significantly more often (p less than .01) in Stage IIIB. Twenty-six patients (31%) lived 2 years or more (25+ to 131+ months) after treatment. Stage IIIA patients had a 46.5% 2-year survival rate compared to 20.6% for Stage IIIB (p = .0042). The one patient treated with surgery alone lived 2 years; 23% (7/31) of patients who had radiation therapy alone and none of the 4 who had chemotherapy lived 2 years. When surgery was a component of treatment, 52% (13/25) lived 2+ years, compared with 22% (13/60) when surgery was not part of treatment. When radiation therapy was part of treatment 31% lived 2 years and when chemotherapy was used, 18% lived 2 years. Fifty-two patients (61%) had control of the local tumor: their survival was significantly greater (p less than .01) than those who had local failure.(ABSTRACT TRUNCATED AT 400 WORDS)

The current state of intraoperative interstitial brachytherapy in lung cancer

Low dose-rate intraoperative brachytherapy allows for a more precise tumor localization of the delivered radiation and its easier adaptation to the tumor shape than it is possible with external radiation. As a result a higher dose is usually delivered to the tumor volume and the damage to the normal lung is less. In an attempt to determine the value of lung brachytherapy we provide in this article a complete review of the evolution of brachytherapy in lung cancer at Memorial Sloan-Kettering Cancer Center, an experience which exceeds 1,000 patients. The use of encapsulated sources of I-125, greatly reduced radiation outside the treatment volume and simplified medical and nursing staff radiation protection. Lung brachytherapy in combination with surgery and postoperative external radiation, improved local tumor control in advanced tumors (from 63% to 76%) with no increase in late pulmonary morbidity, but only a modest survival advantage. The results of brachytherapy in patients with early lung cancer who had limited pulmonary reserve, suggest that intraoperative brachytherapy is an effective alternative treatment option. The limited experience with interstitial brachytherapy under fluoroscopic and CT guidance is encouraging, but needs more investigation.

Treatment of superior sulcus tumor (Pancoast tumor)

It appears that combined preoperative radiation and surgery continue to offer the best survival results in patients with superior sulcus tumors. Patients with involvement of the brachial plexus, Horner's syndrome, rib invasion, and ipsilateral neck node metastases are still candidates for combined modality therapy, with expectations of survival of about 30 to 40 per cent. However, those presenting with invasion of vertebrae, involvement of subclavian vessels, and mediastinal lymph node metastases do poorly. In this latter group, treatment by high-dose external radiation alone may prove to be as effective as combined modality treatment.

Brain metastasis in patients with superior sulcus tumors

During a 20-year period, from 1963 to 1983, 68 patients were treated for carcinoma of the lung presenting in the superior sulcus. Their ages ranged from 41 to 79 years (median, 56 years). Thirty-six patients had squamous cell carcinoma, 13 had adenocarcinoma, 14 had large cell carcinoma, two had small cell carcinoma, and three had clinical diagnosis only. All tumors were considered to be inoperable or unresectable and were treated with external irradiation alone. The 3-year disease-free survival was 25%. Brain metastasis developed in 23 patients (34%); the brain was the first site of metastasis in 16 patients (24%), five of whom eventually developed other sites of metastasis. The cumulative probability of brain metastasis was 53% at 3 years. Brain metastases were seen in ten patients (28%) with squamous cell carcinoma, five patients (38%) with adenocarcinoma, seven patients (50%) with large cell carcinoma, and one patient without a histocytologic diagnosis. The proportion of patients younger than 60 years (19/41, 46%) who developed brain metastasis was significantly greater than that for patients 60 years or older (4/27, 15%) (P less than or equal to 0.01). Nine of 11 patients with metastasis only to the brain died as a consequence of the intracranial disease 1 to 13 months (median, 6 months) after the diagnosis of brain metastases. The other two patients received therapeutic irradiation to the entire brain and survived longer than 5 days after the whole-brain irradiation: one died at 62 months of intercurrent disease, and the other is alive and well 129 months after diagnosis. The high probability of brain metastasis from superior sulcus tumors, regardless of histopathologic type and the frequency with which the brain is the only site of clinical failure, suggest that systematic prophylactic cranial irradiation could reduce the morbidity and perhaps even contribute favorably to the survival of these patients.

Pancoast tumors: improved survival with preoperative and postoperative radiotherapy

Long-term survival after treatment of Pancoast tumors has been limited in most series to those patients without positive lymph nodes or residual tumor. In our series of 18 consecutive patients treated with preoperative irradiation and resection, 14 underwent supplemental postoperative radiotherapy because of positive lymph nodes, tumor at the resection margin, or both. No hospital deaths occurred. Eight patients subsequently died, 6 because of metastatic disease; only 2 deaths were secondary to local recurrence. Ten patients are alive at 6 months to 13 years after resection, and 9 of the 10 have no evidence of tumor recurrence. The overall five-year observed survival (Kaplan-Meier) for the entire series was 56.1 +/- 12.7% (+/- standard error). Although the number of patients is small, the addition of postoperative radiotherapy for those with unfavorable operative findings resulted in long-term survival comparable to that of patients with negative nodes and margins.