Chapter 68

Approximately 5% of all non-small cell lung cancers (NSCLC) are located in the extreme apex of the lung, frequently with involvement of some combination of the first and second ribs, brachial plexus, subclavian vessels, and upper thoracic vertebral bodies. This phenomenon is referred to as a superior sulcus tumor, indicating tumor location in the uppermost portion of the costovertebral gutter within the chest. Pancoast's syndrome refers to superior sulcus tumors along with the triad of (1) shoulder and arm pain, (2) wasting of the hand muscles, and (3) ipsilateral Horner's syndrome (i.e., ptosis, miosis, and anhidrosis owing to invasion of the stellate ganglion). Henry Pancoast was a radiologist who described these findings in 1932 but failed to recognize the pulmonary origin of these tumors. Unaware of Pancoast's report, Tobias, an Argentine physician, described similar clinical findings and ascribed them to the presence of peripheral lung tumors. Pancoast-Tobias syndrome is perhaps a more appropriate eponym for this entity.

For the next 25 years, these tumors were considered unresectable and uniformly fatal. In 1961, Shaw and colleagues described successful outcomes in 18 patients undergoing 30 Gy of radiation, followed by resection, and this became the standard of care for the next 20–30 years.1 Recently, the Intergroup 0160 phase II trial demonstrated superior outcomes by using trimodality therapy for superior sulcus tumors, which now represents the standard of care.2

Surgical techniques have evolved considerably since the initial description of these tumors. By virtue of their location in proximity to the thoracic inlet, their resection represents one of the more challenging operations for thoracic surgeons. In addition to apical chest wall involvement, nerve roots, subclavian vessels, and vertebral bodies may be involved. Advances in surgical techniques have contributed significantly to improved outcomes in the last two decades—capabilities for vertebral resection and the development of anterior approaches to the thoracic inlet have provided a greater likelihood of obtaining a complete resection.

Factors that predict a favorable outcome after resection of superior sulcus tumors include R0 resection, absence of N2 or N3 metastases,3 lobectomy rather than limited pulmonary resection,4 and a complete pathologic response after induction chemoradiotherapy.5,6 Surprisingly, tumor stage (T3 versus T4 status) may be less important prognostically in this subset of patients; in the Intergroup 0160 study, this criterion was not a significant determinant of survival. The need for vertebral or subclavian vessel resection should not be considered an absolute contraindication to surgical treatment. Fadel and colleagues reported 5-year survival rates after resection of 36% in the presence of subclavian artery invasion.7

Limited survival benefit occurs with surgical resection alone. Local recurrences are common and extremely debilitating in terms of pain and limb function. Even with induction radiotherapy, complete resection is achieved in only 60% of patients, and overall 5-year survival is no better than 30%. Resectability, local control, and long-term survival have been positively affected ...

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