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

Extended salvage surgery after high-dose chemoradiation therapy for tumors in the cervico-thoracic junction with invasion of the chest wall and the spine: a case series

The treatment of malignant tumors localized in the upper thoracic cavity and involving the spine at the cervico-thoracic junction (CTJ) is challenging. We report on three patients with malignant tumors invading the thoracic inlet and the spine at the CTJ. All three patients underwent radical tumor resection and 360° spine fusion following the posterior pedicle screw instrumentation and anterior vertebrectomy combined with implantation of an expandable titanium cage. Postoperatively, a mild paresis with hypesthesia of the ipsilateral arm occurred in one patient because of brachial plexus involvement. Two patients were still alive at last follow-up after 83 and 143 months, the third patient succumbed to tumor progression 13 months after extended salvage surgery. We display the possibilities of extended 'salvage' therapy in well-selected patients that were deemed hopeless regarding neurological function, biomechanical stability and tumor control after multiple courses of combined radio-chemotherapy.

En Bloc Resection of Thoracic Tumors Invading the Spine: A Single-Center Experience

BACKGROUND

Vertebral involvement by a thoracic tumor has long been considered as a limit to surgical treatment, and despite advances, such an invasive operation remains controversial. The aim of this study was to characterize a single-center cohort and to evaluate the outcome, focusing on survival and complications.

METHODS

We retrospectively reviewed the data of all patients operated on for tumors involving the thoracic spine in an 8-year period. En bloc resection was generally performed by a double team involving thoracic and orthopedic surgeons. Distant follow-up was recorded for oncologic and functional analysis.

RESULTS

There were 31 patients operated on. An induction therapy was administered in 20 patients. Spinal resection (mostly including ≥2 vertebral levels) was combined with lobectomy in 48.3% of the patients, and osteosynthesis was required in 22 patients. We observed no in-hospital death and a major complications rate of 32.3%, including 5 patients with early neurologic complications. There were 61.3% primary lung carcinomas, 12.9% extrapulmonary primaries, 9.7% metastases, and 16.1% benign tumors. Mean follow-up was 32.1 months. The 5-year overall survival rate was 81.3% in the entire cohort and 75.0% in patients with a malignant tumor. Occurrence of an early postoperative major complication was the only factor significantly associated with shorter overall survival (p = 0.03). The 5-year disease-free survival rate was 37.0% in malignancies. Delayed complications occurred in 35.5% of patients, including persistent neurologic deficit in 12.9%, instrumentation migration in 19.4%, and local infection in 12.9%.

CONCLUSIONS

En bloc resection of spinal thoracic tumors offers long-term survival and few recurrences in highly selected patients but is associated with significant delayed mechanical or infectious complications.

Diagnosing and treating pancoast tumors

INTRODUCTION

According to the American College of Chest Physician definition, a Pancoast tumor is a tumor which invades any of the structures of the apex of the chest including the first thoracic ribs or periosteum, the lower nerve roots of the bronchial plexus, the sympathetic chain and stellate gaglion near the apex of the chest or the subclavian vessels. Pancoast tumors account for less than 3-5 % of lung tumors. Areas covered: We searched the libraries scopus and pub med and found 124 related manuscripts. From those we chose 18 to include in our short commentary based on the most up-date information included. Expert commentary: The present status of the recommended treatment of Pancoast tumors for patients medically fit for surgical resection is trimodality (chemoradiation followed by radical surgery excersion) as state of the art. Patients with unresectable Pancoast tumors and poor PS 4 or distant metastasis are candidate for radiation therapy for palliation of symptoms and best supportive care. In this mini review we will present up to date information regarding diagnosis and treatment management.

Superior sulcus tumors (Pancoast tumors)

Superior Sulcus Tumors, frequently termed as Pancoast tumors, are a wide range of tumors invading the apical chest wall. Due to its localization in the apex of the lung, with the potential invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, the superior sulcus tumors cause characteristic symptoms, like arm or shoulder pain or Horner's syndrome. The management of superior sulcus tumors has dramatically evolved over the past 50 years. Originally deemed universally fatal, in 1956, Shaw and Paulson introduced a new treatment paradigm with combined radiotherapy and surgery ensuring 5-year survival of approximately 30%. During the 1990s, following the need to improve systemic as well as local control, a trimodality approach including induction concurrent chemoradiotherapy followed by surgical resection was introduced, reaching 5-year survival rates up to 44% and becoming the standard of care. Many efforts have been persecuted, also, to obtain higher complete resection rates using appropriate surgical approaches and involving multidisciplinary team including spine surgeon or vascular surgeon. Other potential treatment options are under consideration like prophylactic cranial irradiation or the addition of other chemotherapy agents or biologic agents to the trimodality approach.

A Case of Pancoast Tumor with Unusual Presentation

INTRODUCTION

 The Pancoast syndrome (PS) has been termed after Henry Pancoast. Its neurologic core symptoms include pain, radicular sensory and motor syndromes, and Horner syndrome. A PS is often the presenting sign of lung cancer and bears a grim prognosis.

METHODS

 This case report describes an atypical onset of a lung tumor causing a PS. Electrophysiological examination was not conclusive. The diagnosis was confirmed by MRI, CT scan, and biopsy. The intervention consisted of preoperative chemo- and radiotherapy and was followed by an extensive surgical approach with histologically confirmed perineural invasion of the brachial plexus.

RESULTS

 The postoperative period was dominated by neuropathic pain. Despite considerable loss of distal sensorimotor function of the right hand, the patient uses the extremity and has returned to professional life.

DISCUSSION

 This observation triggered by the advances in general oncology and surgery also demonstrates the management of a lesion of the peripheral nervous system caused by cancer.

Management of locally advanced pancoast (superior sulcus) tumors with spine involvement

BACKGROUND

The preferred treatment for locally aggressive lung cancers is triple modality therapy with concurrent and induction chemotherapy with radiation therapy followed by surgery. Patients with locally advanced T4 Pancoast tumors with spine involvement, without mediastinal N2 lymph node involvement and without distant metastases, are appropriate candidates for complete resection with subsequent spine reconstruction. This review addresses the questions of whether triple modality therapy with complete en bloc resection of locally advanced Pancoast tumors offers an advantage in terms of overall survival and complication rates compared with other therapeutic modalities or therapies with incomplete resection.

METHODS

A comprehensive literature search was conducted using common medical databases. Inclusion and exclusion criteria for the articles were prospectively defined. The articles were independently reviewed and a consensus decision was made about each article. Selected papers were graded by level of evidence.

RESULTS

A total of 1,001 abstracts and 93 articles fulfilled the criteria; from these studies, 14 were included in this systematic review. No level 1 study was found in this search. Four level 2 studies and 10 level 3 retrospective case series were found. The overall 5-year survival rate reported in these studies ranged from 37% to 59% and the mortality rate ranged from 0% to 6.9%.

CONCLUSIONS

Evidence suggests that triple modality therapy with complete resection of locally advanced Pancoast tumors with involvement of the spine offers an advantage over other therapeutic modalities or therapies with incomplete resections.

Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment

Pancoast tumors account for less than 5% of all bronchogenic carcinomas. These tumors are located in the apex of the lung and involve through tissue contiguity the apical chest wall and/or the structures of the thoracic inlet. The tumors become clinically evident with the characteristic symptoms of the "Pancoast-Tobias syndrome" which includes Claude-Bernard-Horner syndrome, severe pain in the shoulder radiating toward the axilla and/or scapula and along the ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in edema of the upper arm. The diagnosis will be made by the combination of the characteristic clinical symptoms with the radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1(st) and/or 2(nd) ribs. A tissue diagnosis of the tumor via CT-guided FNA/B should always be available before the initiation of treatment. Bronchoscopy, thoracoscopy and biopsy of palpable supraclavicular nodes are alternative ways to obtain a tissue diagnosis. Adenocarcinomas account for 2/3 of all Pancoast tumors, while the rest of the tumors are squamous cell and large cell carcinomas. Magnetic resonance imaging of the thoracic inlet is always recommended to define the exact extent of tumor invasion within the thoracic inlet before surgical intervention. Pancoast tumors are by definition T3 or T4 tumors. Induction chemo-radiotherapy is the standard of care for any potentially resectable Pancoast tumor followed by an attempt to achieve a complete tumor resection. Resection can be made through a variety of anterior and posterior approaches to the thoracic inlet. The choice of the approach depends on the location of the tumor (posterior - middle - anterior compartment of the thoracic inlet) and the depth/extent of invasion. Prognosis depends mainly on T stage of tumor, response to preoperative chemo-radiotherapy and completeness of resection. Resection of the invaded strictures of the thoracic inlet should me made en bloc with pulmonary parenchyma resection, preferably an upper lobectomy. Invasion of the vertebral column is not a contraindication for surgery which, however, should be performed in oncologic centers with experience in spinal surgery. Surgery for Pancoast tumors is associated with 5% mortality rate and the complication rate varies from 7-38%. The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%). The main pattern of recurrence is that of distant metastases, especially in the brain.

Venous thromboembolism in patients undergoing operations for lung cancer: a systematic review

BACKGROUND

The risk of venous thromboembolism is perceived to be high in patients with lung cancer. However, existing studies in patients undergoing operations for lung cancer draw inconsistent conclusions and recommendations in terms of thromboprophylaxis. The aim of this study was to perform a systematic review of the risk of perioperative and postoperative venous thromboembolism for patients undergoing potential curative surgical procedures for primary lung cancer

METHODS

This was a systematic review including studies of patients with primary lung cancer undergoing operations with curative intent.

RESULTS

We included 19 studies with a total of 10,660 patients. All studies, except 1, were observational in design. Marked heterogeneity was found between the studies in terms of methodologic aspects, patient characteristics, and findings. The mean risk of venous thromboembolism (VTE) was estimated at 2.0% (range, 0.2%-19%), with a mean observation period of 16 months (range, 0.1-22), and the risk was nearly identical in studies with 1 month of follow-up and studies with a longer follow-up.

CONCLUSIONS

The evidence for using thromboprophylaxis after lung cancer operations is relatively sparse, and the use is based predominantly on clinical consensus. However, the risk of VTE seems to occur predominantly within the initial postoperative period, and subsequently the risk falls. Future research should focus on identifying patients and surgical procedures that increase the risk of VTE. This could be accomplished by large observational studies in addition to randomized controlled trials evaluating different thromboprophylaxis strategies.

Anterior approach for Pancoast tumor resection

Tumors arising anteriorly in the apex of the chest were long considered unresectable because of early invasion of vascular structures limiting radical resection through the conventional Paulson approach. These tumors became operable in 1993 when Dartevelle popularized the cervico-thoracic transclavicular technique for resecting these neoplasms. Since then several different surgical approaches to anterior Pancoast tumors have been proposed, drastically improving the rate of radical resections of these tumors. However, there is no consensus on which anterior surgical approach provides the best access to all of the apical non-small cell lung cancers of the thoracic inlet. Moreover, it is still unclear if integrated neoadjuvant and adjuvant treatments can improve the rates of complete resection, local recurrence and long-term survival.

[Chest wall surgery]

Despite the numerous differences among the distinct diseases of the chest wall, the surgery of this area shows certain common features. Treatment has progressively changed in the last few years due to advances in diagnostic techniques, minimally invasive procedures and reconstruction materials, and especially due to the multidisciplinary management of many diseases. Nuss' minimally invasive correction of pectus excavatum has gained devotees, although open approaches are performed with increasingly small incisions, almost comparable to the lateral incisions in Nuss' technique. Surgeons supporting the open approach also cite the evident disadvantages of the need for a steel implant for 2 or 3 years and for a second intervention to remove this implant. En-bloc resections with reconstruction using materials, which are increasingly better and covered by myocutaneous grafts in collaboration with plastic surgery departments, constitute a major advance in the treatment of chest wall tumors. Trimodal therapy for Pancoast tumors, consisting of induction chemotherapy and radiotherapy and subsequent surgical treatment of the tumor, currently provides the best results in terms of resectability and survival.

Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806

PURPOSE

To evaluate the safety and efficacy of preoperative chemoradiotherapy followed by surgical resection for superior sulcus tumors (SSTs).

PATIENTS AND METHODS

Patients with pathologically documented non-small-cell lung cancer with invasion of the first rib or more superior chest wall were enrolled as eligible; those with distant metastasis, pleural dissemination, and/or mediastinal node involvement were excluded. Patients received two cycles of chemotherapy every 4 weeks as follows; mitomycin 8 mg/m(2) on day 1, vindesine 3 mg/m(2) on days 1 and 8, and cisplatin 80 mg/m(2) on day 1. Radiotherapy directed at the tumor and the ipsilateral supraclavicular nodes was started on day 2 of each course, at the total dose of 45 Gy in 25 fractions, with a 1-week split. Thoracotomy was undertaken 2 to 4 weeks after completion of the chemoradiotherapy. Those with unresectable disease received boost radiotherapy.

RESULTS

From May 1999 to November 2002, 76 patients were enrolled, of whom 20 had T4 disease; 75 patients were fully assessable. Chemoradiotherapy was generally well tolerated. Fifty-seven patients (76%) underwent surgical resection, and pathologic complete resection was achieved in 51 patients (68%). There were 12 patients with pathologic complete response. Major postoperative morbidity, including chylothorax, empyema, pneumonitis, adult respiratory distress syndrome, and bleeding, was observed in eight patients. There were three treatment-related deaths, including two deaths owing to postsurgical complications and one death owing to sepsis during chemoradiotherapy. The disease-free and overall survival rates at 3 years were 49% and 61%, respectively; at 5 years, they were 45% and 56%, respectively.

CONCLUSION

This trimodality approach is safe and effective for the treatment of patients with SSTs.

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.

MR imaging of brachial plexus

The brachial plexus is a complex anatomic component originating from ventral rami of the lower cervical nerve roots from C5 to C8 and upper thoracic spinal nerve roots from T1, providing sensory and motor innervation to the upper extremities. As it is inaccessible to palpation, clinical evaluation of the brachial plexus is very challenging and localizing lesions along its course is very difficult. The gamut of pathologic conditions involving the brachial plexus includes primary tumor, direct extension of adjacent tumor, metastasis, trauma, or an inflammatory condition. MR imaging provides superior diagnostic ability due to its ability of multiplanar imaging and greater soft tissue contrast. This article discusses MR imaging findings in a variety of pathologic conditions, with special emphasis on neoplastic process.

Surgical treatment of superior sulcus tumors: results and prognostic factors

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.

Changes in the treatment of Pancoast tumors

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.

MR imaging of the brachial plexus: current imaging sequences, normal findings, and findings in a spectrum of focal lesions with MR-pathologic correlation

Currently in many centers, magnetic resonance (MR) imaging is the technique of choice for the assessment of brachial plexopathies. The anatomy of the brachial plexus is complex, and is surrounded by other anatomic structures, making artifact-free imaging quite challenging. With the faster breathing-independent and breath-hold MR imaging sequences, brachial plexopathies can be assessed with more confidence. Over a 2-year period, 20 patients underwent MR imaging of the brachial plexus at our department. MR imaging was based on a comprehensive protocol, including T(1)-weighted gradient echo, T(2)-weighted single-shot fast spin-echo, and gadolinium-enhanced T(1)-weighted gradient echo with fat suppression. Nine of the 20 patients had proved diagnoses at pathology, and included schwannoma (n = 2), ganglioneuroblastoma (n = 1), hemangioma (n = 1), metastatic breast cancer (n = 2), Pancoast tumor (n = 1), and metastatic lung cancer (n = 2). Most of the lesions had presenting symptoms, such as pain, swelling, paresthesia, and arm weakness. At MR imaging, the location and characteristics of the lesions on different types of T(1)-weighted and T(2)-weighted sequences were described with pathologic correlation.

Surgical treatment of superior sulcus tumors with spinal and brachial plexus involvement

OBJECT

Non-small cell lung carcinomas with spinal and brachial plexus involvement have traditionally been considered to be Stage IIIb lesions and therefore unresectable. Advances in spinal surgery, the application of magnetic resonance (MR) imaging, and improvements in neoadjuvant therapy require a reassessment of the potential for complete resection.

METHODS

The authors conducted a retrospective review of all procedures involving the resection of superior sulcus tumors with spinal or brachial plexus involvement performed between 1985 and 1999. Assessment or resectability and operative planning were based on an MR imaging classification scheme in which the extent of spinal involvement was considered. Class A tumors involved the periosteum of the vertebral body (VB) (16 patients); Class B, distal neural foramen without epidural compression (eight patients); Class C, proximal neural foramen with epidural compression (four patients); and Class D, bone involvement (VB or posterior elements) with or without epidural involvement (14 patients). Brachial plexus involvement was present in 21 patients, including 17 with T-1 nerve root only and four with C-8 or lower-trunk infiltration. Complete tumor resection was achieved in 27 patients and incomplete resection in 15. Complications occurred in 14 patients, two of which were related to instrumentation failures. The overall median survival was 1.44 years. The median survival for the complete and incomplete resection groups were 2.84 and 0.79 years, respectively (p = 0.0001). There was no statistical difference in survival among classification groups.

CONCLUSIONS

Complete tumor resection of superior sulcus tumors is possible in selected patients in whom involvement of the spinal column and/or brachial plexus is present. Preoperative MR imaging is essential for evaluation of the spine and surgical planning. Survival and cure are dependent on complete resection, regardless of the extent of spinal involvement.

Management of superior sulcus tumors: experience with 139 cases treated by surgical resection

BACKGROUND

The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival.

METHODS

Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV.

RESULTS

The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival.

CONCLUSIONS

The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.

En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina

OBJECTIVE

In patients with non-small cell lung cancer invading the thoracic inlet, the transcervical approach does not permit removal of tumor in the intervertebral foramina. We report a variant that lifts this limitation.

METHODS

Through the transcervical approach, resectability was assessed and tumor-bearing structures were removed, leaving tumor-free margins. Standard upper lobectomy was performed, leaving the lobe in place. A posterior midline approach was used for multilevel unilateral laminectomy, nerve root division inside the spinal canal, and vertebral body division along the midline. The tumor was removed en bloc with the lung, ribs, and vessels through the posterior incision. Fixation of the spine was performed. Medical charts of patients treated with this technique between October 1994 and April 2001 were reviewed retrospectively.

RESULTS

Seventeen patients (mean age 45 years) were treated. Resection of the upper lobe and T1 root was done in all 17 cases; 3- and 4-level hemivertebrectomies were done in 13 and 3 cases, respectively; 2-level total vertebral body resection and 2-level hemivertebrectomy were done in 1 case; and resections of the phrenic nerve and subclavian artery were done in 7 and 6 patients, respectively. There were no perioperative deaths or residual neurologic impairments. Postoperative complications were pneumonia (n = 6), cerebrospinal fluid leakage (n = 1), wound breakdown (n = 1), and bleeding necessitating reoperation (n = 1). The overall 3- and 5-year survivals were 39% and 20%, respectively.

CONCLUSIONS

Non-small cell lung cancers invading the thoracic inlet and intervertebral foramina can be removed completely through a combined anterior transcervical and posterior midline approach, with good results.

Therapy for stage I and stage II non-small cell lung cancer

Despite complete resection of what seems to be all evident tumor, one third to three quarters of patients with stages I and II NSCLC ultimately succumb to this neoplasm. Patients who are cured of an original NSCLC or small cell cancer remain at risk for a new primary lung cancer. Although the importance of lifelong surveillance is clear, the extent and timing of optimal follow-up remain undefined. Although clinicians refer to the development after treatment of clinically discernible sites of tumor as "recurrence," it is probably more accurate to consider these foci as "persistence"--that is, the locoregional site was not sterilized by surgery, and the distant implants were present from the outset but undetected. Although data are sparse, induction and improved adjuvant therapy for early NSCLC may be helpful. Much further experience is needed. Further study and application of biologic indicators in addition to TNM staging likely will help identify patients at high risk for surgical failure who may benefit by combination treatment.

Concomitant weekly cisplatin and thoracic radiotherapy for Pancoast tumors of the lung: pilot experience of the San Antonio Cancer Institute

Pancoast (superior sulcus tumors) comprise a subset of non-small-cell lung cancers that have a unique clinical presentation by virtue of the locoregional pattern of disease progression. We herein report a brief report on our group's pilot experience in managing these challenging lung neoplasms with an aggressive concomitant modality approach. These results and those of the recent Southwest Oncology-lead Intergroup prospective phase 2 trial (SWOG-9416/INT-0160) support the use of concomitant chemoradiation followed by an attempt at surgical 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.

Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus

BACKGROUND

The treatment of superior sulcus lung cancers is evolving and preoperative chemotherapy is increasingly used. To establish a historical benchmark against which new therapies can be assessed, we reviewed our 24-year experience with patients undergoing thoracotomy for lung cancers of the superior sulcus.

METHODS

Data were acquired through retrospective chart review. Overall survival was calculated by the method of Kaplan and Meier, and prognostic factors were examined by log rank and Cox proportional hazards modeling.

RESULTS

From 1974 to 1998, 225 patients underwent thoracotomy. The patients included 144 men (64%) and 81 women with a median age of 55 years. The majority of patients (55%) received preoperative radiation, but 35% did not have any preoperative treatment. Tumor stages were IIB (T3 N0) in 52%, IIIA in 15%, and IIIB in 27% of patients. Complete resection was achieved in 64% of T3 N0 tumors, 54% of T3 N2 tumors, and 39% of T4 N0 tumors. Operative mortality was 4%. Median survival was 33 months for stage IIB and 12 months for both stages IIIA and IIIB. Actuarial 5-year survivals were 46% for stage IIB, 0% for stage IIIA, and 13% for stage IIIB. By univariate and multivariable analyses, T and N status and complete resection had a significant impact on survival. Locoregional disease was the most common form of relapse.

CONCLUSIONS

Our results provide a benchmark against which new treatment regimens can be evaluated. Control of locoregional disease remains the major challenge in treating lung cancers of the superior sulcus. The potential benefit of preoperative chemotherapy or chemoradiotherapy must be assessed by whether it leads to higher rates of complete resection and a lower risk of local relapse.

Superior sulcus (Pancoast) tumor: experience with 105 patients

BACKGROUND

The evolution of therapy in 105 patients with superior sulcus (Pancoast) tumor over the past 42 years was reviewed.

METHODS

There were 82 men and 23 women aged 30 to 75 years. Tumor cell types were: squamous, 41 (39%); adenocarcinoma, 23 (21.9%); anaplastic, 14 (13.3%); undetermined, 12 (11.4%); mixed, 9 (8.7%); and large cell 6 (5.7%). Therapy was based on extent of disease and lymph node involvement. There were 5 treatment groups: I, preoperative radiation and operation (n = 28); II, operation and postoperative radiation (n = 16); III, radiation (n = 37); IV, preoperative chemotherapy, radiation, and operation (n = 11); and V, operation (n = 12).

RESULTS

The median survival for group I was 21.6 months; group II, 6.9 months; group III, 6 months; and group V, 36.7 months. Median survival for group IV has not yet been reached (estimated at 72% at 5 years). On univariate analysis, mediastinal lymph node involvement, Horner syndrome, TNM classification, and method of therapy affected survival. On multivariate regression analysis, only N2 and N3 disease and method of therapy were significant (p < 0.05).

CONCLUSIONS

The optimal treatment for superior sulcus tumor was preoperative radiation and operation. However, triple modality therapy, although promising, requires longer follow-up.