Carcinomas in the superior pulmonary sulcus.

Carcinomas in the superior pulmonary sulcus produce a clinical pattern peculiar to their location. Pancoast (1932) defined tumors in this precise location and described a characteristic group of clinical findings now known as the Pancoast syndrome. Experience with a total of 92 patients with primary carcinomas in the superior pulmonary sulcus treated by combined preoperative irradiation and extended resection in 61 patients (66 per cent) reveals 16 of 46 patients eligible surviving over 5 years (34 per cent) and eight of 30 patients alive over 10 years (29 per cent). Stage of nodal involvement, extent of the tumor, cell type, and pathological effects of preoperative irradiation in the resected specimens are the important factors in prognosis.     

Posterior midline approach for single-stage en bloc resection and circumferential spinal stabilization for locally advanced Pancoast tumors. Technical note

The treatment of Pancoast (superior sulcus) tumors that extensively invade the vertebral column remains controversial. Different surgical approaches involving multistage resection techniques have been previously described for superior sulcus tumors that invade the chest wall and spinal column. Typically a posterior approach to stabilize the spine is followed by a second-stage thoracotomy (posterolateral or trap door) for definitive en bloc resection of stage T4 Pancoast tumors. The authors report and elaborate on a surgical technique successfully used for an en bloc resection as well as spinal stabilization through a single-stage posterior approach without any added morbidity. Two patients with histologically proven Pancoast tumors were treated by single-stage resection and stabilization through a posterior approach at the H. Lee Moffitt Cancer Center. A wedge lung resection or lobectomy was performed by the chest surgeon utilizing the chest wall defect. Placement of an anterior cage (in one case) and posterior cervicothoracic spinal instrumentation (in both cases) was performed during the same operation. Average blood loss was 675 ml and surgical time was 7 hours. The median hospital stay was 9 days (range 7-11 days). Both patients did well postoperatively and were free of recurrence at the 2-year follow-up. Radical resection of Pancoast tumors including lobectomy, chest wall resection, costotransversectomy, and partial or complete vertebrectomy with simultaneous instrumentation for spinal stabilization can be performed through a posterior single-stage approach.     

Treatment results of pancoast tumor

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

High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival

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

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.     

Pancoast tumour: a case report

Patients presenting with shoulder and arm pain can be a diagnostic challenge to the attending chiropractor. Although the majority of conditions presenting to a chiropractor are benign, occasionally a malignant life threatening one will present. One such condition is a Pancoast tumour, a cancerous growth developing in the lung apex. The resultant clinical entity, the Pancoast syndrome, presents as severe pain in the neck, shoulder and arm, and a Horner’s syndrome. It typically affects middle aged men who have a history of smoking. Pancoast tunours are frequently missed resulting in a delayed diagnosis. Appropriate chest radiographs are imperative in making the diagnosis. This report presents the clinical presentation and a case of Pancoast tumour, and emphasizes the importance of its inclusion in the differential diagnosis of patients presenting with persistent neck and shoulder pain.     

Influence of Staging in Superior Sulcus (Pancoast) Tumors of the Lung

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

Cases presenting to orthopedists with manifestations of lung cancer on skeletal radiographs

The value of cervical spine or shoulder radiography has been established for the detection of Pancoast tumors. However, for the detection of lung cancers other than Pancoast tumors, the value of these skeletal radiographies has not been assessed. The aim of our study was to determine how many patients first presented to orthopedists with manifestations of lung cancer on skeletal radiographs and to present several cases for illustration. From the registry of the pathology department of our hospital, we identified 345 lung cancer patients diagnosed histologically over 10 years. From these patients, we selected 310 who had no previous history of malignancies at histological diagnosis of lung cancer. The study population consisted of individuals from the selected patients who had presented once or more to orthopedists at our hospital for any reason, at up to 2 years prior to histological diagnosis of lung cancer. For the study population, all radiological examinations performed by the orthopedists were reviewed by radiologists. The study population included 46 patients constituting 14.8 % (46/310) of the selected patients. Of these 46 patients, 37 (80.4 %) received 97 skeletal radiographies. Reviewing these skeletal radiographies disclosed lung tumors on 13 in 11 (11/46, 23.9 %) of the patients. We found that more than 10 % of lung cancer patients with no previous history of malignancies had presented to orthopedists on one or more occasions, at up to 2 years before histological diagnosis, and that approximately 25 % of these patients had manifestations of lung cancer on skeletal radiographs.     

Postradiation Sarcoma of the Chest Wall: Report of Two Cases

Postradiation sarcoma is a rare late complication of external radiotherapy. We herein present two cases with this disease. A 54-year-old man had undergone a lobectomy and chest wall resection for Pancoast type lung cancer 7 years previously. He had undergone irradiation with a total dose of 50 Gy. Computed tomography (CT) demonstrated a tumorous expansion of the right lateral thoracic wall. A pathological examination confirmed a diagnosis of osteosarcoma. A 60-year-old woman had undergone a resection of the lateral chest wall mass, which was diagnosed to be Hodgkin's disease in 1991. Chemotherapy was given postoperatively. A tumorous lesion arose again and irradiation was performed with a total dose of 110 Gy. In 2000, two tumors appeared in the irradiation field. A pathological examination showed a sarcoma with divergent differentiation. In 2003, a tumor recurred and was diagnosed to be a liposarcoma. Patients who have received radiotherapy should therefore be followed up while taking into consideration the possible development of postradiation sarcoma.     

Operative strategy and results of operation for pancoast tumors

Summary Background: Pancoast or superior sulcus tumors are mostly bronchogenic carcinomas which involve the apex of the chest causing pain in the periscapular region or arm and characteristically are accompanied by Horner’s syndrome and minor or major destruction of ribs and vertebral infiltration. Although they often lack extrathoracic metastases at presentation, they are characterized by a high late mortality. Methods: Operative strategies aim at the resection of the upper lobe together with the invaded ribs, transverse processes, subclavian vessels, nerve roots, upper dorsal sympathetic chain and prevertebral muscles. The tumor may be approached through a posterolateral thoracotomy, through a transclavicular access, or through a hemiclamshell or trapdoor incision. Presence of tumor-positive mediastinal lymph nodes, invasion of the superior and middle trunks of the brachial plexus, spinal canal, esophagus or trachea indicate inoperability. Results: 5-year survival rates range from 10 to 40 % in different series. Controversy still exists as to what kind of radiosurgical approach is best in treating superior sulcus tumors and about the value of systemic chemotherapy before or after operative resection. Conclusions: Superior sulcus tumors not invading the thoracic inlet are completely resectable through the classical posterolateral approach. Invasion of the thoracic inlet is no contraindication and the tumor may be resected radically using the anterior transcervical approach. The value of preoperative chemotherapy remains uncertain, but the high incidence of extrathoracic metastases suggests that patients with superior sulcus tumors invading the thoracic inlet should receive postoperative systemic chemotherapy and prophylactic brain radiation.      

An effective and safe surgical approach for a superior sulcus tumor: A case report

IntroductionSuperior sulcus tumors, frequently referred to as Pancoast tumors, are a wide range of tumors invading a section of the apical chest wall called the thoracic inlet. For this reason, a surgical approach and complete resection may be difficult to accomplish. We experienced a locally advanced superior sulcus tumor (SST) located from the anterior to posterior apex thoracic inlet and performed complete resection after definitive chemoradiation.Presentation of caseA 71-year-old Japanese male presented at our hospital due to left back pain and an abnormal chest computed tomography (CT) scan showing 80 × 70 × 60-mm tumor located in the left middle apex thoracic inlet. This tumor was located near the subclavian artery, and the subclavian lymph nodes were swollen. The tumor was found to be an adenocarcinoma (clinical-T3N3M0 stage IIIB). Therefore, we performed definitive chemoradiation therapy. Slight reduction in the tumor size was noted after the treatment, and the subclavian lymph nodes were not swollen. We next performed surgical resection for this SST. Regarding the surgical approaches, the anterior approach was a transmanubrial approach, and the posterior approach was a Paulson’s thoracotomy. In this manner, we were able to perform complete en-bloc resection of this tumor.DiscussionThis surgical approach was effective and safe for treating a SST located from the anterior to posterior apex of the thoracic inlet. The patient remains healthy and recurrence-free at 2.5 years after the operation.ConclusionSurgical approach for SST is difficult. Therefore, this approach is effective and safety.     

Pancoast syndrome caused by a high grade B cell lymphoma

The case history is presented of a 20 year old man with Pancoast syndrome caused by a high grade B cell lymphoma.     

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.


     

Tumors of the cerebellopontine angle. Changing policy in treatment

One hundred and twenty-six cases of cerebellopontine-angle tumors with various histologies are presented. Results of 75 operated vestibular neurinomas, 22 meningiomas, and 16 tumors with other histologies are discussed. The method of irradiation and non-radical surgery may be an alternative for treatment.     

Hybrid video-assisted and limited open (VALO) resection of superior sulcus tumors

Purpose

To compare the postoperative recovery of patients with superior sulcus tumors (Pancoast tumors) following conventional open surgery vs. a hybrid video-assisted and limited open approach (VALO).

Methods

The subjects of this retrospective study were 20 patients we operated on to resect a Pancoast tumor. All patients received induction chemo-radiation followed by surgery, performed via either a conventional thoracotomy approach (n = 10) or the hybrid VALO approach (n = 10). In the hybrid VALO group, lobectomy and internal chest wall preparation were performed using a video technique, with rib resection and specimen removal through a limited incision.

Results

There was no mortality in either group. Two patients from the thoracotomy group required mechanical ventilation, but there was no major morbidity in the hybrid VALO group. The operative times were similar for the two procedures. The average length of hospital stay was shorter and the average pain scores were significantly lower in the hybrid VALO group. The incidence of chronic pain was 10 % in the hybrid VALO group vs. 50 % in the thoracotomy group.

Conclusions

Hybrid VALO resection of Pancoast tumors is feasible and safe, resulting in faster patient recovery and a significantly lower incidence of severe chronic pain than open thoracotomy. We conclude that centers experienced with video-assisted lobectomy should consider hybrid VALO surgery as the procedure of choice for Pancoast tumors.

     

Irradiation-induced polyglandular neoplasia of the head and neck.

Eighteen patients are presented with twenty-one tumors of the head and neck, which include ten salivary gland tumors and eight parathyroid adenomas. Eight of the patients also had thyroid neoplasms. All patients had a history of prior irradiation to the head and neck. Seventy per cent of the salivary gland tumors and 37 per cent of the thyroid tumors were malignant. Recommendations are made for detection and treatment.     

Management of non-germinal testicular tumors

Objectives  Non-germinal tumors account for less than 10% of all testicular tumors and consist of a wide array of benign and malignant lesions. Due to their rarity, little is known about the appropriate management of malignant non-germinal testicular tumors. Methods  A literature review directed at the variety of non-germinal testicular tumors using the Medline/PubMed database was performed. Our review was focused on the natural history of these diseases, the treatment regimens utilized, and the outcomes of the various treatments. Results  The majority of data on the treatment of non-germinal testicular tumors comes from case series and retrospective reviews; thus the management of many of these diseases is a matter of debate. Recommendations for the treatment of patients with these rare diseases are made based on available data. For many of these diseases, radical inguinal orchiectomy is the initial treatment of choice, and further treatment differs based on pathology and staging studies. Conclusion  Non-germinal testicular tumors are a diverse group of rare lesions, and as a result their management is often difficult. A multi-disciplinary approach to management is needed in these patients; however, efficacious chemotherapeutic regimens are often lacking. Due to poor alternatives, patients may benefit from early surgical intervention, including RPLND.     

Transclavicular approach for a large dumbbell tumor in the cervicothoracic junction

Neurogenic dumbbell tumors occur more frequently in the cervical than in the thoracic or lumbar spine. Cervical paravertebral masses usually do not become exceptionally large because they are superficial and are palpated easily. Thoracic tumors can become large before they are detected. The authors describe a large intrathoracic dumbbell tumor arising from the C8 nerve root. The intraspinal tumor was resected through a posterior approach. In the second stage, dividing the clavicle, the intrathoracic component was resected by separating it from the lung. Two years after treatment, the preoperative neurologic deficit had improved except for weakness of muscles innervated by the C8 nerve root. Radiographs showed no residual or recurrent mass at the apex of the lung. Sometimes a retroclavicular location may conceal a large paravertebral mass, such as Pancoast tumors. As described here, the transclavicular approach gave adequate access to the cervicothoracic junction.     

Malignant “Triton” tumor in the thyroid —A case report—

This report presents a very rare case of a malignant “Triton” tumor developing in the thyroid. Although malignant “Triton” tumors have often been known to develop in cases of neurofibromatosis, Von Recklinghausen's disease, this patient showed no clinical evidence of that disease. Total thyroidectomy including left standard radical neck dissection was followed by postoperative irradiation to the neck. Despite this, local and distant metastases developed four months after treatment and the recurrent foci did not respond to chemotherapy or irradiation. The clinical course of this case mimicked that of anaplastic carcinoma of the thyroid and interestingly, a minimal lesion of papillary adenocarcinoma was found to exist concurrently in the thyroid gland of this patient.     

25例脾脏肿瘤临床分析

目的 提高对脾脏肿瘤的诊治水平。方法 对25例脾脏肿瘤进行回顾性分析。结果 脾脏良性肿瘤病史一般超过半年,而恶性肿瘤则短于半年。B超首诊占40％(10/25),CT诊断的准确率超过B超,良性肿瘤13例行脾切除术,6例行脾部分切除术 脾移植。6例恶性肿瘤行脾切除术或广泛切除 化疗。25例脾切除术术后无一例死亡,亦未发现术后并发症。良性肿瘤全部治愈。恶性肿瘤3例,分别随访1年6个月,3年及3年8个月,患者仍然存活,失访3例。结论 原发性脾脏肿瘤在临床上罕见。良性肿瘤症状隐匿,病史长;恶性肿瘤病史短,伴有发热、消瘦、贫血。B超检查应作为首选方法。良性肿瘤尽量行保脾手术,恶性肿瘤行脾切除 化疗。