Posterolateral approaches to the superior sulcus

Abstract

S sulcus tumors are a complex subset of bronchogenic malignancies that pose significant technical challenges to the thoracic surgeon. A variety of approaches have been described in the literature, including a neoadjuvant treatment with radiation therapy followed by surgical resection. The dose of radiation therapy is often between 45 and 50 Gy. This approach often is associated with shrinkage of the tumor and perhaps facilitates resection. Unfortunately, if there are grossly positive or microscopic margins postoperatively, the dose of effective radiation therapy that can be given postoperatively is much reduced. We have enrolled patients with superior sulcus tumors on an institutional protocol in which the patients receive upfront resection followed by concurrent chemotherapy and radiation therapy postoperatively to a total of 69.6 Gy.1 Because of a great deal of experience with our spinal surgical colleagues at our institution, even tumors with extensive vertebral body involvement can be safely approached surgically.2-4 The preoperative assessment on all of these patients includes a physical examination with special attention to the evidence of a Horner’s syndrome and a neurologic examination of the affected upper limb. Patients who present with significant functional motor loss associated with these tumors often demonstrate involvement of the brachial plexus to a point where clear margins could not be obtained. Sensory changes and some hand changes, however, are generally still amenable to en bloc complete surgical resection. Magnetic resonance imaging (MRI) of the brachial plexus and thoracic spine is routine and mandatory in these cases. All patients undergo a mediastinoscopy to rule out N2 or N3 disease before proceeding to resection. The position of the superior sulcus tumor must be assessed for involvement of the subclavian vessels. If this involvement is evident, then the initial approach will be through an anterior incision, either a supraclavicular incision or a Darteville incision with hemimanubriumotomy and elevation of the clavicle away from the thoracic inlet. If the blood vessels need to be grafted, then this can be accomplished from an anterior approach. This article will focus on the typical posteriorly situated superior sulcus tumor that does not involve the vessels but may involve the C8 or T1 nerve root.