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.