Pancoast Tumors: Surgical Approaches and Techniques

1.1 History Tumors of the superior sulcus represent less than 5% of lung malignancies. The distinctive symptomatology was first described by Edwin Hare in 1838 [1], and it has been nearly 80 years since clinical and radiographic features of this tumor were described by Dr Henry Pancoast, a radiologist, in 1924 [2]. As a radiologist, he noted the difficulty in detecting the tumor on a plain chest radiograph. He initially thought that these tumors arose from epithelial crest cells from the fifth brachial cleft. These tumors have been named Pancoast tumors or Pancoast-Tobias tumors after further descriptions of their features by these authors in 1932 [3, 4]. This was the first time that bronchogenic carcinoma was recognised as the primary cause of this syndrome. Prior to the 1950s, superior sulcus tumors were uniformly fatal. Chardack and McCallum reported a long-term survival after surgical resection and postoperative irradiation therapy [5]. Paulson, using preoperative irradiation followed by surgical resection, published the first series, which included 18 patients, in 1966 [6]. Shaw and Paulson identified that preoperative irradiation and a well-defined resection were associated with a 5-year survival of 34% [7]. Based upon these studies, preoperative irradiation and an extended posterolateral paravertebral thoracotomy (Shaw Paulson approach) has been the “standard of care” over the last 5 decades. However surgical resection remained limited to tumors invading the ribs only, and any further involvement of vascular or neural structures was still considered to remain a contraindication for an operation. This was changed by Dartevelle who was the first to develop an anterior transcervical approach for the resection of tumors involving subclavian vessels. Later on several other modifications of this technique were reported but with no remarkable improvement on overall survival. In the last century, the management of the superior sulcus tumor changed from inoperability and incurability to the current regimen of preoperative chemoradiation therapy, with an attempt at complete resection. Interest in trimodality treatment led to the South-West Oncology Group (SWOG) 8805 study of induction chemoradiotherapy (cisplatin, etoposide, 45Gy) followed by surgery that resulted in a complete response rate of 22% and encouraging results [8]. A recent prospective phase II study (SWOG 9416) suggests that preoperative concurrent chemoradiation (cisplatin, etoposide, 45Gy) improves the rate of complete resection, intermediate survival and decreases the rate of local or distal recurrence [9]. The 2-year survival was 55% for all eligible patients and 70% for patients who had a complete resection.