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Superior Sulcus Tumors

Supeior Sulcus Tumors

1. Definition—a bronchogenic carcinoma located in the extreme apex of the lung which invades the pleura and adjacent structures and produces classic symptoms and signs.

A. The presenting symptom most frequently cited is pain localized to the shoulder. If left untreated the pain becomes unremitting and spreads medially to the scapula, extends along the ulnar nerve distribution of the arm to involve the elbow, forearm and hand.

Other involved structures include the cervical sympathetics (Horner’s syndrome), vagus and phrenic nerves, carotid artery, and the vertebral bodies.

B. Squamous cell is the most common cause followed by adenocarcinoma and large cell. Small cell is rare
C. Location—All are T3 since they invade the chest wall; classified as T4 when mediastinal and/or cervical invasion has taken place.
D. Posterior—stellate ganglion, posterior ribs, brachial plexus (upward extension), and vertebral bodies (medial extension)
E. Anterior—1st rib, scalene muscle, subclavian vessels, phrenic nerve

Resection possible even with brachial plexus, stellate ganglion, rib, transverse process, subclavian artery (adventitia), vertebral body (<25%). Mediastinal invasion (vena cava, vertebral foramina, vagus nerve) precludes cure Nodal involvement is the key to potential curability once resectability is established—lymph node involvement is usually late in these tumors

D. MSK series--129 patients
1) 109 patients—negative mediastinal nodes
a) median survival—20 months
b) 5yr—29%
2) 20 patients—positive mediastinal nodes
a) median survival—9 months
b) 5yr—10%
3)Paulson—131 patients
a) 78 patients resected (pre-op RT)—5yr survival 44%
b) 17 patients with positive lymph nodes—0% survival at 2 years
E. Radiologic evaluation—usual CXR finding mass in apex clouding the lung markings above the clavicle when contrasted to the clarity of the opposite side; however, may only resemble pleural thickening. Bony destruction may be apparent.
F. CT will identify involvement and invasion of the brachial plexus, the chest wall, vertebral bodies, vena cava, trachea, esophagus, and the subclavian vessels. Will also depict lymph node involvement
G. MRI is recommended to delineate the extent of cervical invasion and some consider routine in the preoperative evaluation.

2. Operative Approach

A. Posterior
B. Incision follows the contour of the scapula
1) Enter pleura 3rd or 4th intercostal space
2) Vascular structures identified
3) Brachial plexus involvement identified and resected
4) Vertebral bodies are assessed
5) Lobectomy performed
C. Along with the possibility of usual complications, one other possibility is spinal cord leakage that may lead to meningitis or pneomoencephally—from air leaks and causes severe headaches
D. Anterior transcervical approach
1) Usually combined with the posterior approach
E. Sternocleidomastoid incision
1) Scalene fat pad dissection
2) Clavicular resection
F. Vein dissection
G. Jugular and subclavian veins freed—exposure of thoracic duct and vertebral veins facilitated
H. Arterial dissection
I. Subclavian, IMA, thyrocervical trunk, vertebral artery
J. Nerve dissection
1) Brachial plexus
K. Overall, major advantage is the ability to deal with the invasion of the subclavian vein and related structures. It is not effective for tumors that invade the posterior aspects of the ribs and their transverse processes, the stellate ganglion and sympathetic chain, and the vertebral bodies.

3. Radiation Therapy

A. Primary therapy for unresectable or inoperable patients
B. Excellent for pain relief
C. No long term survival if primary tumor not controlled
D. Most common site of recurrence is the brain—consider prophylactic cerebral RT if local control achieved and histologic dx is adeno or large cell

4. Pre-op RT

A. MSK—126 patients; 100 resected; 117 pre/post op RT; 102 brachytherapy
B. 69 complete resection (49 of these had brachytherapy)
C. 22 had lobectomy; 47 large wedge resection
D. 5yr survival—60% for lobectomy; 33% for wedge resection
E. Intraoperative brachytherapy had no influence on loco-regional recurrence or survival in patients with completely resected tumors
F. Adverse prognostic factors—Horner’s syndrome, N2, N3, and vertebral body invasion

This series indicates that pre operative RT is useful in patients when combined with lobectomy. Unresectable disease should be treated with external RT. +/- Intraoperative brachytherapy in patients who are explored but incompletely resected.

5. Post-op RT

A. Not indicated in patients who are completely resected and have no nodal metastasis. There are some retrospective studies that show benefit in patients with nodal disease, however the LCSG showed no survival benefit in completely resected patients—it did decrease the incidence of local (intrathoracic) recurrence
B. MSK—Post operative RT following immediate operation and brachytherapy was as effective as pre-op RT and brachytherapy in achieving complete resection, loco-regional control, and ultimate curability
C. There are no studies documenting the usefulness of chemotherapy in this disease.