Posterior and Anterior Sulcus Tumors

Pancoast or superior sulcus tumors are rare lung lesions arising from the apex of the lung located above the level of the second rib invading vital structures such as first rib, lower roots of the brachial plexus, subclavian vessels, stellate ganglion, sympathetic trunk, and adjacent vertebral bodies. They may be responsible for characteristic symptoms such as pain from the shoulder to anterior chest wall, arm pain and weakness and atrophy of the hand, Claude-Bernard-Horner Syndrome and upper arm oedema. Pancoast tumors are frequently caused by non-small cell lung cancer and for many years they were considered fatal for their malignity and not amenable for surgery until 1950s when Chardack and MacCallum described a successful bimodal treatment including surgical resection followed by postoperative irradiation. In 1966 Paulson proposed a combined preoperative radiation therapy followed by en bloc resection of lung and chest wall through a postero-lateral approach. In the late 90s, some authors began to study a new trimodality approach based on the combination of chemo-radiotherapy followed by surgery obtaining an improvement of systemic and local control of the disease. However, a remarkable variability still exists between in terms of chemiotherapic medications, number and timing of administration, modality and dose of radiotherapy and eligibility criteria. Different surgical approaches have been described based on location of the tumor and invaded structures: anterior approach for superior sulcus tumors invading subclavian vessels and first rib; posterior approach for the management of tumors invading the posterior thoracic inlet, particularly the vertebrae; combined approaches according to the degree of inlet involvement.