Surgical Treatment of Superior Sulcus Tumors: Results and Prognostic Factors

Abstract

Background: This study aims to investigate the treatment modalities and factors influencing survival in surgically treated superior sulcus tumors. Patients and Method: Sixty-five cases of surgically treated non-small cell carcinoma of the lung occurring as superior sulcus tumors between 1994 and 2007 were retrospectively reviewed. Twenty-five patients underwent induction radiotherapy (RT), 10 had induction chemoradiotherapy (CT/RT). In thirty patients surgery was performed directly. The mortality rate was 6.2 %. Pathological stage was T3 in 55, T4 in 10, N0 in 52, and N1 in 5 and N2 in 8 patients. Results: Overall 5- and 10-year survival rates were 31 % and 28 %, respectively. Complete resection rate was 90 % for patients who received induction CT/RT and 80 % for patients who either received induction RT alone or patients in whom surgery was performed directly. In patients who received neoadjuvant therapy with complete tumor resection, the median survival time was 33 months (28 months for patients who received induction RT alone and 36 months for patients who received induction CT/RT), and the 5-year survival rate was 41 %. Median survival time and 5-year survival rate of patients treated by direct surgery with complete resection was 24 months and 37 %, respectively (p = 0.87). Five-year survival and 10-year survival rates were significantly higher after complete resection than after incomplete resection (38 % and 34 % vs. 0 %, p = 0.0001). In multivariate analysis, only N2 disease (p = 0.04) and incomplete resection (p = 0.03) were found to be poor prognostic factors. Conclusion: The presence of N2 disease and incomplete resection are the two most important factors affecting survival. Induction CT/RT may increase the ability to achieve complete surgical resection.

Key words

thoracic surgery - superior sulcus tumour - induction chemoradiation therapy - surgery - NSCLC

References

• 1 Mansour K A. Extended resection of bronchial carcinoma in the superior pulmonary sulcus. Shields TW General thoracic surgery. Baltimore, MD; Williams and Wilkins 1994: 572-578
• 2 Ginsberg R J, Martini M, Zaman M. et al . Influence of surgical resection and brachytherapy in the management of SST.  Ann Thorc Surg. 1994;  57 1440-1445
• 3 Kent M S, Bilsky M H, Rusch V W. Resection of superior sulcus tumors (posterior approach).  Thorac Surg Clin. 2004;  14 217-228
• 4 Arcasoy M S, Rett J. Superior sulcus tumors and Pankoast's syndrome.  New England J Med. 1997;  337 1370-1376
• 5 Wright C D, Moncure A C, Shepard J A. et al . Superior sulcus lung tumors. Results of combined treatment irradiation and radical resection.  J Thorac Cardiovasc Surg. 1987;  94 69-74
• 6 Alifano M, D'Aiuto M, Magdeleinat P. et al . Surgical treatment of superior sulcus tumors: results and prognostic factors.  Chest. 2003;  124 996-1003
• 7 Rusch V W, Parekh K R, Leon L. et al . Factors determining outcome after surgical resection of T3 and T4 lung cancer of the superior sulcus.  J Thorac Cardiovasc Surg. 2000;  119 1147-1153
• 8 Martinez-Monge R, Herreros J, Aritsu J J. et al . Combined treatment in superior sulcus tumors.  Am J Clin Oncol. 1994;  17 317-322
• 9 Goldberg M, Gupta D, Sasson A R. et al . The surgical management of superior sulcus tumors: a retrospective review with long-term follow-up.  Ann Thorac Surg. 2005;  79 1174-1179
• 10 Martinod E, D'Audiffret A, Thomas P. et al . Management of superior sulcus tumors: experience with 139 cases treated by surgical resection.  Ann Thorac Surg. 2002;  73 1534-1539 1539-1540
• 11 Wright C D, Menard M T, Wain J C. et al . Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus.  Ann Thorac Surg. 2002;  73 1541-1544
• 12 Kunitoh H, Kato H, Tsuboi M. et al . Japan Clinical Oncology Group. Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806.  J Clin Oncol. 2008;  26 644-649
• 13 Rusch V W, Giroux D J, Kraut M J. et al . Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160).  J Clin Oncol. 2007;  25 313-318
• 14 Mountain C F. Revisions in the International System for Staging Lung Cancer.  Chest. 1997;  111 1710-1717
• 15 Travis W D, Colby T V, Corrin B. et al .Histological classification of lung and pleural tumors. Travis WD WHO international classification of tumors: Histological typing of lung and pleural tumors. 3rd edn. Berlin; Springer Verlag 1999
• 16 Maggi G, Casadio C, Pischedda F. et al . Combined radiosurgical treatment of Pancoast tumor.  Ann Thorac Surg. 1994;  57 198-202
• 17 Demir A, Sayar A, Akın H. et al . Factors influencing survival in resected superior sulcus tumours.  Toraks Dergisi. 2005;  6 189-196
• 18 Dartevelle P, Macchiarini P. Surgical management of superior sulcus tumors.  Oncologist. 1999;  4 398-407
• 19 Attar S, Krasna M J, Sonett J R. et al . Superior sulcus (Pancoast) tumor: experience with 105 patients.  Ann Thorac Surg. 1998;  66 193-198
• 20 Shaw R R, Paulson D L, Kee J L. Treatment of SST by irradiation followed by resection.  Ann Surg. 1961;  154 29-40
• 21 Pitz C C, de la Rivière A B, van Swieten H A. et al . Surgical treatment of Pancoast tumours.  Eur J Cardiothorac Surg. 2004;  26 202-208
• 22 Neal C R, Amdur R J, Mendenhall W M. et al . Pancoast tumor: radiation therapy alone versus preoperative radiation therapy and surgery.  Int J Radiat Oncol Biol Phyis. 1991;  21 651-660
• 23 Dartevelle P G, Chapelier A R, Macchiarini P. et al . Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet.  J Thorac Cardiovasc Surg. 1993;  105 1025-1034
• 24 Stanford W, Barnes R P, Tucker A R. Influence of staging in superior sulcus (Pancoast) tumors of the lung.  Ann Thorac Surg. 1979;  29 406-411
• 25 Komaki R, Mountain C F, Holbert J M. et al . Superior sulcus tumors: treatment selection and results for 85 patients without presentation.  Int J Radiat Oncol Biol Phys. 1990;  19 31-40
• 26 Devine J W, Mandenhall W M, Million R R. Carcinoma of superior pulmonary sulcus treated with surgery and/or radiation therapy.  Cancer. 1986;  5 941-943
• 27 Masaoka A, Ito Y, Yasumitsu T. Anterior approach for tumors of the superior sulcus.  J Thorac Cardiovasc Surg. 1979;  78 413-415
• 28 Dartevelle P G, Chapelier A R, Macchiarini P. et al . Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet.  J Thorac Cardiovasc Surg. 1993;  105 1025-1034
• 29 Grunenwald D, Spaggiari L. Transmanubrial osteomuscular sparing approach for apical chest tumors.  Ann Thorac Surg. 1997;  63 563-566
• 30 Hilaris B S, Martini N, Wong G Y. et al . Treatment of SST (Pancoast tumor).  Surg Clin North Am. 1987;  67 965-978
• 31 Jones D R, Detterbeck F C. Pancoast tumours of the lung.  Curr Opin Pulm Med. 1998;  4 191-197
• 32 Okubo K, Wada H, Fukuse T. et al . Treatment of Pancoast tumors: combined irradiation and radical resection.  Thorac Cardiovasc Surg. 1995;  43 284-286
• 33 Muscolino G, Valente M, Andreani S. Pancoast tumors: clinical assessment and long-term results of combined radiosurgical treatment.  Thorax. 1997;  52 284-286
• 34 Anderson T M, Moy P M, Holmes E C. Factors affecting survival in superior sulcus tumours.  J Clin Oncol. 1986;  4 1598-1603
• 35 Shahian D, Neptune W, Ellis Jr F. Pancoast tumors: improved survival with preoperative and postoperative radiotherapy.  Ann Thorac Surg. 1987;  43 32-38
• 36 Sartori F, Rea F, Calabrò F. et al . Carcinoma of the superior pulmonary sulcus. Results of irradiation and radical resection.  J Thorac Cardiovasc Surg. 1992;  104 679-683
• 37 Hagan M P, Choi N C, Mathisen D J. et al . Superior sulcus lung tumors: impact of local control on survival.  J Thorac Cardiovasc Surg. 1999;  117 1086-1094
• 38 Marra A, Eberhardt W, Pöttgen C. et al . Induction chemotherapy, concurrent chemoradiation and surgery for Pancoast tumour.  Eur Respir J. 2007;  29 117-126
• 39 Kappers I, Belderbos J S, Burgers J A. et al . Non-small cell lung carcinoma of the superior sulcus: favourable outcomes of combined modality treatment in carefully selected patients.  Lung Cancer. 2008;  59 385-390
• 40 Pfannschmidt J, Kugler C, Muley T. et al . Non-small-cell superior sulcus tumor: results of en bloc resection in fifty-six patients – non-small-cell Pancoast.  Thorac Cardiovasc Surg. 2003;  51 332-337