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Diagnostic and Interventional Radiology... Jul 2019The tumor, node, metastasis (TNM) staging system approved by International Association for the Study of Lung Cancer (IASLC) and the American Joint Committee on Cancer... (Review)
Review
The tumor, node, metastasis (TNM) staging system approved by International Association for the Study of Lung Cancer (IASLC) and the American Joint Committee on Cancer (AJCC) to stage lung cancer was recently revised. The latest revision is the 8th edition published in January, 2017. This new edition made some important changes to the previous edition, including modification of the T classification based on 1 cm increment, downstage of T descriptor including endobronchial tumor disregarding its distance from carina (T2), merging total and partial atelectasis/pneumonitis into the same T category (T2), upstage diaphragmatic invasion to T4, new classification concept of adenocarcinoma in situ and minimally invasive adenocarcinoma for pure and part-solid ground-glass nodules, and further division of extrathoracic metastasis into M1b and M1c based on the number and sites of extrathoracic metastases. Consensus is reached for debating situations not covered in the previous edition of staging system, such as the classification of pancoast tumor based on its invasion depth and staging tumors that extend directly across the fissure as T2a. Classification of multiple sites of pulmonary involvement, including multiple primary lung cancer, separate lung cancer nodules, multiple ground-glass or lepidic lesions, and consolidation, is also discussed. Even though the 8th edition of the TNM lung staging system provides us with more precise classification based on prognostic analysis of each TNM descriptors, there are still some potential limitations and clinical situations that have not yet been clarified in terms of clinical staging by imaging. It is important for radiologists to understand the major changes introduced in the 8th edition of TNM staging and to recognize the potential pitfalls and limitations of imaging interpretation to precisely classify the clinical stage of lung cancer.
Topics: Adenocarcinoma in Situ; Aged; Carcinoma; Female; Humans; Incidental Findings; Lung Neoplasms; Lymphangitis; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Invasiveness; Neoplasm Metastasis; Neoplasm Staging; Pleural Neoplasms; Prognosis; Radiologists; Solitary Pulmonary Nodule; Thorax; Tomography, X-Ray Computed
PubMed: 31295144
DOI: 10.5152/dir.2019.18458 -
Journal of Personalized Medicine Jul 2023Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated... (Review)
Review
Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated multimodality treatment. The morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively, and the 5-year survival rate has significantly improved in recent years thanks to the advancement of treatments. Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Surgical resection still plays a pivotal role within the multimodality approach. Here, we focus on surgical approaches to both anterior and posterior Pancoast tumors: the anterior transclavicular approach (Dartevelle); the anterior transmanubrial approach (Grunenwald-Spaggiari); the anterior trap-door approach (Masaoka, Nomori); the posterior approach (Shaw-Paulson); the hemiclamshell approach; and hybrid approaches. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario.
PubMed: 37511781
DOI: 10.3390/jpm13071168 -
La Clinica Terapeutica 2019Pancoast's syndrome is caused by malignant neoplasm of superior sulcus of the lung which produces destructive lesions of thoracic inlet and comes along with the... (Review)
Review
BACKGROUND
Pancoast's syndrome is caused by malignant neoplasm of superior sulcus of the lung which produces destructive lesions of thoracic inlet and comes along with the involvement of brachial plexus and stellate ganglion. Computed tomography (CT) or magnetic resonance imaging (MRI) scans can detect early lesions otherwise missed by routine radiographs and can also define the local extent or metastatic progression of the disease. Protocols involving combinations of irradiation, chemotherapy, and surgery are currently being under investigation to determine the best management.
AIMS
This work reviewed the current diagnostic and therapeutic approaches to Pancoast's tumors.
DISCUSSION
Patients with lung superior sulcus carcinoma should be considered for surgery only after an appropriate diagnostic assessment. The perfect candidate for surgery should have a confined to the chest disease with T3N0M0 staging. Inoperable patient with severe pain after irradiation therapy may benefit from palliative surgical resection. Medical therapy plays only a secondary role in lung cancers, patients with disseminated lung cancer might require palliative treatment and medical management of paraneoplastic syndrome symptoms. Following surgery, radiation and chemotherapy may improve local and systemic control by addressing individual adverse findings.
CONCLUSIONS
The cooperation of surgeons, clinicians and radiologists represents the gold standard today and a multidisciplinary approach is essential to achieve the best outcome possible. Further studies are advisable in order to define the best surgical approach and the real advantage of mini-invasive surgery by comparison with open surgery.
Topics: Humans; Pancoast Syndrome
PubMed: 31304518
DOI: 10.7417/CT.2019.2150 -
Journal of Thoracic Disease Feb 2024Chemoradiotherapy followed by surgical resection (trimodality therapy) is a guideline recommended treatment for sulcus superior tumors (SST). By definition, SSTs invade... (Review)
Review
Chemoradiotherapy followed by surgical resection (trimodality therapy) is a guideline recommended treatment for sulcus superior tumors (SST). By definition, SSTs invade the chest wall and therefore require en-bloc chest wall resection with the upper lung lobe or segments. The addition of a chest wall resection, potentially results in higher morbidity and mortality rates when compared to standard anatomical pulmonary resection. This, together with their anatomical location in the thoracic outlet, and varying grades of fibrosis and adhesions resulting from induction chemoradiotherapy in the operation field, make surgery challenging. Depending on the exact location of the tumor and extent to which it invades the surrounding structures, the preferred surgical approach may vary, e.g., anterior, posterolateral, hemi-clamshell, or combined approach; all with their own potential advantages and morbidities. Careful patient selection, adequate staging and discussion in a multidisciplinary tumor board in a center experienced in complex thoracic oncology leads to the best long-term survival outcomes with the least morbidity and mortality. Enhanced recovery guidelines are now available for thoracic surgery, promoting faster recovery and helping to minimize complications and morbidity, including infections and thoracotomy pain. Although minimally invasive surgery can enhance recovery and reduce chest wall morbidity, and is in widespread use in thoracic oncology, its use for SST has been limited. However, this is an evolving area and hybrid surgical approaches (including use of the robot) are being reported. Chest wall reconstruction is rarely necessary, but if so, the prosthetic materials are preferably radiolucent/non-scattering, rigid enough while still being somewhat flexible, and inert, providing structural support, allowing chest wall movement, and closing defects, while inciting a limited inflammatory response. New techniques such as 3D image reconstructions/volume rendering, 3D-printing, and virtual reality modules may help pre-operative planning and informed patient consent.
PubMed: 38505012
DOI: 10.21037/jtd-23-828 -
Annals of Translational Medicine Oct 2021Superior pulmonary sulcus tumor is a cancer arising in the apex of the lung that with potential invasion of the brachial plexus, upper ribs, vertebrae, subclavian...
Superior pulmonary sulcus tumor is a cancer arising in the apex of the lung that with potential invasion of the brachial plexus, upper ribs, vertebrae, subclavian vessels, and stellate ganglion. Induction concurrent chemoradiotherapy followed by radical surgical resection with lobectomy combined with any structures in the thoracic inlet invaded by tumor and thorough mediastinal lymph node dissection is the preferred treatment. Both anterior and posterior approaches are applied for resection. Here, we report a 61-year-old man with an 8.6 cm × 5.1 cm mass arising from the right upper lobe invading the apex of the chest wall. Brachial plexus magnetic resonance imaging suggested tumor invasion of the inferior trunk of the brachial plexus, anterior portion of the first 2 ribs, and suspicious involvement of the subclavian artery. Biopsy of the mass showed stage cT4N2M0, IIIB, poorly differentiated adenocarcinoma. The patient was treated by induction concurrent chemoradiotherapy, which was followed by surgical resection of the right upper lobe and the affected chest wall via the transmanubrial approach. The patient suffered prolonged postoperative air leak and empyema. After continuous chest tube drainage and intrapleural fibrinolytic therapy, he recovered well and was discharged safely. Final pathology showed no viable residue tumor, pathologic complete response of the tumor to induction treatment, a tumor size of 4.1 cm, and no lymph nodes; therefore, the final stage was ypT0N0M0. The transmanubrial approach is feasible for resection of tumor invading the branches of the subclavian artery; however, postoperative empyema which might have resulted from prolonged air leak should be carefully treated by meticulous air leak management.
PubMed: 34790809
DOI: 10.21037/atm-21-4698 -
Journal of Investigative Medicine High... 2023Pancoast tumor is a rare and aggressive form of lung cancer; cardiac metastasis is very uncommon. We present a case of advanced Pancoast tumor, with extensive cardiac...
Pancoast tumor is a rare and aggressive form of lung cancer; cardiac metastasis is very uncommon. We present a case of advanced Pancoast tumor, with extensive cardiac metastases and intracardiac thrombosis in a woman presenting with dyspnea, shoulder pain, and weight loss. A contrast-enhanced chest computed tomographic scan revealed an apical mass, metastatic thoracic nodes, and filling defects within both ventricles. Further imaging with cardiac magnetic resonance imaging revealed 2 left ventricular masses infiltrating into the myocardium suggestive of metastatic disease, and a multilobulated mass within the right ventricle suggestive of intracardiac thrombus. She was initiated on anticoagulation for intracardiac thrombosis. Surgical pathology of biopsied tissue samples was consistent with advanced metastatic lung adenocarcinoma. She was a poor candidate for surgical intervention. Given the patient's goals of care, she was ultimately transitioned to comfort care.
Topics: Female; Humans; Pancoast Syndrome; Heart Neoplasms; Lung Neoplasms; Thrombosis; Adenocarcinoma of Lung
PubMed: 36772879
DOI: 10.1177/23247096231154642 -
JTO Clinical and Research Reports Apr 2023Superior sulcus tumors (SSTs) are uncommon, and their anatomical location can make treatment challenging. We analyzed late outcomes of patients with SST treated with...
INTRODUCTION
Superior sulcus tumors (SSTs) are uncommon, and their anatomical location can make treatment challenging. We analyzed late outcomes of patients with SST treated with concurrent chemoradiotherapy followed by surgical resection (trimodality) in a single tertiary institution.
METHODS
Patients with non-small cell SSTs, who underwent trimodality therapy between 2002 and 2017, were selected from a prospective institutional surgical database. Patients were uniformly staged with 18F-fluorodeoxyglucose-positron emission tomography, computed tomography scan of the chest and upper abdomen, and brain imaging. Patients undergoing resection of the lung plus chest wall were grouped as limited SST and those needing extensive resections (e.g., including the vertebral body) as extended SST. Kaplan-Meier survival analysis was performed to determine difference in survival. Multivariate Cox regression was used to identify prognostic factors.
RESULTS
A total of 123 patients were identified with a median follow-up of 4.9 years (interquartile range: 1.6-8.9 y). The 90-day postoperative mortality and morbidity (Clavien-Dindo grades III-V) were 6.5% and 21.1%, respectively. Patients with a radical resection (R0: 92.7%) had better survival ( = 0.002), as did those who had major pathologic response (73%) ( = 0.001). Ten-year overall survival (OS) and disease-free survival were 48.1% and 42.6%, respectively. There were no differences in 90-day mortality ( = 0.31) and OS ( = 0.79) between extended SST and limited SST patients.
CONCLUSIONS
In patients with SST, trimodality resulted in a 10-year estimated OS and disease-free survival of 48.1% and 42.6%, respectively, which were improved after radical resection (R0) and major pathologic response. Survival for limited and extended resections was comparable, and distant relapse was the main pattern of failure. Better systemic treatments are therefore needed.
PubMed: 36969550
DOI: 10.1016/j.jtocrr.2023.100475 -
The American Journal of Case Reports Jul 2022BACKGROUND Pancoast tumors, also called superior sulcus tumors, are a rare type of cancer affecting the lung apex. These tumors can spread to the brachial plexus and... (Review)
Review
BACKGROUND Pancoast tumors, also called superior sulcus tumors, are a rare type of cancer affecting the lung apex. These tumors can spread to the brachial plexus and spine and present with symptoms that appear to be of musculoskeletal origin. CASE REPORT A 59-year-old Asian man presented to a chiropractor in Hong Kong with a 1-month history of neck and shoulder pain and numbness that had been treated unsuccessfully with exercise, medications, and acupuncture. He had an active history of tuberculosis, which was currently treated with antibiotics, and a 50-pack-year history of smoking. Cervical magnetic resonance imaging (MRI) was performed urgently, revealing a small cervical disc herniation thought to correspond with radicular symptoms. However, as the patient did not respond to a brief trial of care, a thoracic MRI was urgently ordered, revealing a large superior sulcus tumor invading the upper to mid-thoracic spine. The patient was referred for medical care and received radiotherapy and chemotherapy with a positive outcome. A literature review identified 6 previously published cases in which a patient presented to a chiropractor with an undiagnosed Pancoast tumor. All patients had shoulder, spine, and/or upper extremity pain. CONCLUSIONS Patients with a previously undiagnosed Pancoast tumor can present to chiropractors given that these tumors may invade the brachial plexus and spine, causing shoulder, spine, and/or upper extremity pain. Chiropractors should be aware of the clinical features and risk factors of Pancoast tumors to readily identify them and refer such patients for medical care.
Topics: Brachial Plexus; Chiropractic; Humans; Intervertebral Disc Displacement; Male; Middle Aged; Neck Pain; Pancoast Syndrome
PubMed: 35797264
DOI: 10.12659/AJCR.937052