Surgery in superior sulcus tumors
Advanced Thoracic Surgery, Akademisyen Kitabevi, ss.727-736, 2021
- Yayın Türü: Kitapta Bölüm / Araştırma Kitabı
- Basım Tarihi: 2021
- Yayınevi: Akademisyen Kitabevi
- Sayfa Sayıları: ss.727-736
- Sağlık Bilimleri Üniversitesi Adresli: Evet
Özet
Superior sulcus tumors constitute 5-8% of non-small cell lung cancers. These tumors were first described by radiologist Henry Pancoast in 1924. Pancoast referred to these lesions as \"apical chest tumors\" originating from embryonic cells in the fifth brachial notch. However, in 1932, Tobias described the same clinical entity as bronchogenic carcinoma. In 2003, Detterbeck used the term \"superior sulcus tumor\" to define Pancoast-Tobias tumors. Detterbeck defined superior sulcus tumor as a lung cancer located at the apex of the lung and involving the structures of the apical chest wall, regardless of symptoms. Due to their location, these tumors have traditionally been considered inoperable. However, advancements in multimodal treatment approaches have improved outcomes.The most common symptom is pain. Shoulder and arm pain are particularly common due to invasion of the first rib and involvement of the branches of the brachial plexus. Pain occurs as a result of malignant invasion spreading to the T1 and C8 nerve roots, parietal pleura, and the region of the first rib. Pain in the pathway of the ulnar nerve suggests T1 nerve invasion, while weakness in the intrinsic muscles of the hand suggests involvement of the C8 or lower nerve roots. Pain can occur not only in the arm but also in the head and neck. Pain in these areas originates from C8-T1. Involvement of the stellate ganglion in the C7-C8 region manifests as Horner syndrome (anhidrosis, ptosis, miosis). Rarely, paralysis of the phrenic nerve and recurrent laryngeal nerve can cause aphonia and diaphragmatic eventration. Swelling of the face and dilation of neck veins indicate the mass effect of superior vena cava obstruction.Posteroanterior chest X-ray is one of the simplest diagnostic methods to identify the apical mass radiologically. Thoracic computed tomography (CT) is important for evaluating the relationship between the mass and adjacent tissues. CT is particularly useful in evaluating invasion of the ribs, vessels, and spine. Magnetic resonance imaging (MRI) is helpful in evaluating soft tissue structures in the thoracic inlet, brachial plexus, subclavian vessels, spine, and nerve foramina. Although respiratory dynamic MRI has 100% sensitivity and 83% specificity, it is generally not used. Positron emission tomography is an important method for evaluating locoregional and distant metastases.Transthoracic needle biopsies are used for pathological diagnosis. The diagnostic accuracy of needle biopsy is over 90%. Video-assisted thoracoscopic surgery (VATS) is preferred for diagnosis, but it is generally avoided due to concerns about compromising tumor integrity. The diagnostic value of sputum cytology is less than 20%. This is attributed to the difficulty of bronchoscopic diagnosis due to the peripheral location of these tumors. Important factors in patient selection include negative N2 status, absence of brachial nerve involvement at the C7 level or above, and absence of invasion of the anterior spinal artery, spinal canal, and esophagus. Similar to NSCLCs, histopathological examination of the tumor and mediastinal invasive staging should be performed before selecting a treatment method for superior sulcus tumors. Differential diagnosis includes aspergilloma, complicated hydatid cyst, and tuberculoma.Endobronchial ultrasound (EBUS) or mediastinoscopy is used to evaluate the mediastinal spread of superior sulcus tumors. Patients with mediastinal lymph node involvement (N2 or N3) are considered inoperable. Similar to NSCLCs, N2 is also an important factor affecting survival prognosis in superior sulcus tumors. However, Ginsberg et al. stated that skip N3 disease has a better prognosis than N2. Urschel et al. suggested that patients with right upper lobe lesions and mediastinal nodal involvement may be considered operable, and positive lymph nodes are considered \"regional.\".