Superior Sulcus Tumors Research Articles

Creation of a multidisciplinary and multicenter study group for the use of 3D printing in general thoracic surgery: lessons learned in our first year experience.

Introduction: In recent years, the use of 3D printing in medicine has grown exponentially, but the use of 3D technology has not been equally adopted by the different medical specialties. Published 3D printing activity in general thoracic surgery is scarce and has been mostly limited to case reports. The aim of this report was to reflect on the results and lessons learned from a newly created multidisciplinary and multicenter 3D unit of the Spanish Society of Thoracic Surgery (SECT).Methods: This is a pilot study to determine the feasibility and usefulness of printing 3D models for patients with thoracic malignancy or airway complications, based on real data. We designed a point-of-care 3D printing workflow involving thoracic surgeons, radiologists with experience in intrathoracic pathology, and engineers with experience in additive manufacturing.Results: In the first year of operation we generated 26 three-dimensional models out of 27 cases received (96.3%). In 9 cases a virtual model was sufficient for optimal patient handling, while in 17 cases a 3D model was printed. Per pathology, cases were classified as airway stenosis after lung transplantation (7 cases, 25.9%), tracheal pathology (7 cases, 25.9%), chest tumors (6 cases, 22.2%) carcinoid tumors (4 cases, 14.8%), mediastinal tumors (2 cases, 7.4%) and Pancoast tumors (one case, 3.7%).Conclusion: A multidisciplinary 3D laboratory is feasible in a hospital setting, and working as a multicenter group increases the number of cases and diversity of pathologies thus providing further opportunity to study the benefits of the 3D printing technology in general thoracic surgery.

EP-1982 Pancoast tumours. A good candidate for proton spot scanning?

EP-1982 Pancoast tumours. A good candidate for proton spot scanning?

Induction chemoradiation is associated with improved survival in chest wall invasion lung cancer.

To determine if induction chemotherapy with concurrent high-dose radiation followed by resection is associated with improved survival in patients with nonsuperior sulcus lung cancer with chest wall invasion. We performed a retrospective review of clinical T3 (chest wall invasion) N0/N1 patients with non-small cell lung cancer who underwent surgical resection between January 1, 1992, and January 31, 2017. Exclusion criteria included superior sulcus tumors and resection performed for palliation/recurrence. Patients undergoing induction chemoradiation followed by surgical resection were compared to those undergoing resection first or those receiving induction radiation followed by resection. Overall survival was calculated using the Kaplan-Meier method. Thirty-four patients were included in the analysis, with 5-year overall survival (OS) of 30%. By clinical stage, 31 (91%) were IIB (T3N0) and 3 (9%) were IIIA (T3N1). Sixteen patients (47%) received induction chemoradiation before surgery. Of the remaining 18 patients, 5 (15%) received induction radiation followed by surgery, and 13 (38%) underwent surgery as the first treatment. Three patients belonging to the group not receiving induction chemoradiation died within 30 days after surgery and were excluded from survival analysis. In the remaining 31 patients, induction chemoradiation was associated with improved 5-year OS (53% for induction chemoradiation vs 7% for others; P<0.01). Disease recurrence was evident in 9 cases, 2 (12.5%) in the induction chemoradiation group and 7 (46.6%) in the others (median disease-free time 103.0 months for induction chemoradiation group vs 8.0 months for others; P<0.01). In patients with nonsuperior sulcus lung cancer with chest wall invasion, induction chemoradiation therapy followed by resection is associated with improved OS.

Pancoast tumour: current therapeutic options.

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. This work reviewed the current diagnostic and therapeutic approaches to Pancoast's tumors. 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. 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.

Investigation of pathologic response in patients with pancoast tumours after treatment with trimodality therapy

Investigation of pathologic response in patients with pancoast tumours after treatment with trimodality therapy

Trimodality therapy for superior sulcus tumour: experience of a single institution over 19 years.

Induction chemoradiotherapy followed by surgery is the standard treatment for superior sulcus tumours (SSTs). However, the protocols, chemotherapy agents and cycles used as well as the mode and intensity of radiotherapy vary between institutions. Thus, the objective of the study was to investigate the effects of trimodality therapy on the outcomes of patients with SSTs. Sixty patients with SSTs were enrolled between January 1999 and December 2017. Induction therapy consisted primarily of 2 cycles of mitomycin-vindesine-cisplatin or cisplatin-vinorelbine delivered concurrently to the tumour with 40-45 Gy of radiation. Surgery was performed 2-6 weeks after completion of induction therapy. Fifty-four (90%) patients underwent radical surgical resection. Complete pathological resection was achieved in 44 patients (81%). There was no 30-day mortality. After a median follow-up of 57.0 months, 19 (35%) patients experienced recurrence, and 8 (15%) patients showed brain metastasis. A pathological complete response (PCR) was observed in 12 (22%) patients. The 5-year survival rate for the entire population (n = 54) was 69% (95% confidence interval 55-81%). The survival rate was better for patients who underwent complete resection than for those who underwent incomplete resection (73% vs 51%, P = 0.46). A better survival rate was evident in patients with PCR than in those without PCR (92% vs 62%, P = 0.12). Trimodality therapy for SSTs was efficacious and associated with favourable outcomes, with acceptable morbidity and mortality. PCR in patients with resected SSTs reveals promising long-term survival prospects with the trimodality therapy.

An in-silico quality assurance study of contouring target volumes in thoracic tumors within a cooperative group setting

IntroductionTarget delineation variability is a significant technical impediment in multi-institutional trials which employ intensity modulated radiotherapy (IMRT), as there is a real potential for clinically meaningful variances that can impact the outcomes in clinical trials. The goal of this study is to determine the variability of target delineation among participants from different institutions as part of Southwest Oncology Group (SWOG) Radiotherapy Committee’s multi-institutional in-silico quality assurance study in patients with Pancoast tumors as a “dry run” for trial implementation. MethodsCT simulation scans were acquired from four patients with Pancoast tumor. Two patients had simulation 4D-CT and FDG-FDG PET-CT while two patients had 3D-CT and FDG-FDG PET-CT. Seventeen SWOG-affiliated physicians independently delineated target volumes defined as gross primary and nodal tumor volumes (GTV_P & GTV_N), clinical target volume (CTV), and planning target volume (PTV).Six board-certified thoracic radiation oncologists were designated as the ‘Experts’ for this study. Their delineations were used to create a simultaneous truth and performance level estimation (STAPLE) contours using ADMIRE software (Elekta AB, Sweden 2017). Individual participants’ contours were then compared with Experts’ STAPLE contours. ResultsWhen compared to the Experts’ STAPLE, GTV_P had the best agreement among all participants, while GTV_N showed the lowest agreement among all participants. There were no statistically significant differences in all studied parameters for all TVs for cases with 4D-CT versus cases with 3D-CT simulation scans. ConclusionsHigh degree of inter-observer variation was noted for all target volume except for GTV_P, unveiling potentials for protocol modification for subsequent clinically meaningful improvement in target definition. Various similarity indices exist that can be used to guide multi-institutional radiotherapy delineation QA credentialing.

Comparative assessment of primary and paraneoplastic gout in lung cancer

Introduction. Lung cancer (LС) is the most common cause of the so-called paraneoplastic syndrome (PNPS) development, caused by the complex immunoinflammatory, degenerative and vascular distant changes. The risk of LC development is increased in patients with gout which proves the connection between violations of purine metabolism and carcinogenesis. Paraneoplastic (neoplastic) gout is one of the relatively frequent manifestations of LC, but such a relationship of the diseases requires further study. The objective of the study: to compare the clinical and laboratory course of primary gout and disease in the LC patients compared with the tumor process clinical course in the other signs of PNPS presence and to identify risk factors. Materials and methods. 113 patients with gout (97 men and 16 women aged 33 to 79 years) were observed. They were divided into two groups: the first group consisted of 54 patients with primary gout and the second group consisted of 59 patients with paraneoplastic variant of LC. Whereas in the 1st group the ratio of men and women was 26:1, in the 2nd – only 3: 1, and the average age was 50 and 59 years, respectively. The clinical course of gout and tumor process in the 2nd (main) group was compared with that in 199 LC patients with PNPS (comparison group), which was diagnosed in 15.5 % of LC observations. Purine metabolism was assessed by blood levels of uric acid and oxypurinol, their renal clearance, serum activity of xanthine oxidase, xanthine deaminase, adenosine deaminase, and 5-nucleotidase. Results. Paraneoplastic (neoplastic) gout develops in 3.5 % of the LC patients and in 22.9 % of those with PNPS. It differs from the primary (idiopathic) gout by the greater frequency of the disease development in women, the hand joints involvement and the metabolic type of hyperuricemia, but less often observed urolithiasis, peripheral tophi, chronic form of arthritis and the absence of renal type of purine metabolism impairment. Patients with tumorous gout differ from other LC patients with PNPS by the absence of bilateral and median lobe localization of the lung process, but relatively frequent occurrence of Pancoast tumor, high levels of uric acid and xanthine oxidase in the blood. The development of paraneoplastic gout depends on the clinical course of the LC (tumor invasion into the thoracic wall and pericardium, the number of distant organs metastasis) and the power of chemotherapy, the use of alkylating antineoplastic agents and alkaloids. Treatment-associated myelodepression, radiation pneumofibrosis and acute thrombophlebitis development depends on paraneoplastic gout. The presence of gout does not worsen the survival of LC patients with PNPS. LC patients with hyperuricemia (> 420 μmol / l in men and > 360 μmol / L in women) should be prescribed with xanthine oxidase inhibitor - allopurinol in the complex of therapeutic measures. Conclusions . Paraneoplastic gout is a frequent PNPS manifestation in LC, its course has peculiarities compared with the primary gout and is closely related to the tumor process character and the power of chemotherapy, it can determine the complications development in the course of therapeutic interventions. The data presented in the study require further comparative analysis of the other signs of PNPS, comparison of tumor and idiopathic variants of the musculoskeletal system lesion, cutaneous vasculitis and autoimmune systemic syndromes, which might assist in developing of the additional prognostic criteria for the tumor process clinical course, increasing the efficiency of therapy and its control quality.

Neoadjuvant tedavi sonrası küçük hücreli dışı akciğer kanseri olan hastaların cerrahi sonuçları

Objective: Although, anatomical resection of non-small celllung cancer (NSCLC) following neoadjuvant therapy is stillcontroversial, it is a widely accepted approach for thoracic surgerypractice. The aim of this study is to briefly evaluate clinical results,long term survival, and factors affecting survival of the patientswith locally advanced NSCLC, pancoast tumour and lung cancerwith solitary brain metastasis, who have been operated at ourinstitution following neoadjuvant therapy.Materials and Method: Between March 2006 and March2012, 70 patients with NSCLC diagnosis who underwent anatomicpulmonary resection following neoadjuvant therapy were includedin the study.Results: A three year survival (39%) and a 5-year survival(29%) were 16±6.8 and 37±9.89 months, respectively. The meansurvival was found to be 37.15±3.06 months. When survival ratewas evaluated according to localization of tumor, it was lower incentral and left upper lobe tumors compared to other anatomicallocalizations (P=0.042). The mean 5-year survival times were50.00±5.65 months in stage 0 patients, 35.39±5.85 months in stage1 patients, 37.40±6.89 months in stage 2 patients and 21.44±3.10months in stage 3 patients.Conclusion: We can achieve significant survival results by theanatomical pulmonary resection following neoadjuvant therapy.

P3.17-05 Multimodality Treatment for Superior Sulcus Non-Small-Cell Lung Carcinomas

Superior sulcus tumor (SST), to this day remain a complex and challenging condition. The SWOG9416 (Intergroup0160) and the JCOG9806 trial culminated in showing that trimodality therapy with chemotherapy, radiation and surgery provided optimal outcomes. Since that time, the treatment of SST is evolving and preoperative chemoradiotherapy is increasingly used. Dramatic survival benefit, however, has not been reported recently. We reviewed our experience with patients undergoing thoracotomy for lung cancers invading the superior sulcus. Analysis of all consecutive patients in our retrospective database, who had potentially resectable SST (cT3-T4) and were treated with multimodality treatment. In the induction chemoradiotherapy cases, surgery with attempted complete resection was performed in patients showing response or stable disease on computed tomography after multidisciplinary discussion. From 2009 to 2017, 10 patients, included 9(90%) men and 1(10%) women with a median age of 63 years, underwent thoracotomy. Pathology revealed Ad.5(50%), Sq.4(40%) and La.1(10%) patient(s). The majority (80%) underwent preoperative therapy; chemoradiation in 7(70%) (i.e. CDDP+S-1+concurrent RT 66Gy in 5, CDDP+VNR+concurrent RT 45Gy in 2) and radiation alone in 1(10%) patient(s). Two cases(20%) did not have any preoperative treatment although they received adjuvant chemotherapy using platinum doublet (CDDP+VNR in 1(10%) and CDDP+DTX in 1(10%) patient). Clinical stages were IIB(T3N0) in 5(50%), IIIA(T3N1 or T4N0) in 4(40%), and IIIB(T3N2) in 1(10%) patient(s). Of 8 patients with induction therapy, down stage was obtained in 2(20%); c-T3N1 to yc-T3N0 in 1 and c-T3N2 to yc-T3N0 in 1 patient. Complete resection was achieved in all patients (100%) and pathologic therapeutic response was Ef3,Ef2,Ef1b in 4,3,1 patient(s), respectively. Operative mortality was 0%. With a mean observation time of 20 M, 8(80%) were alive and 2(20%) were dead. Of these one died from cancer relapse in small intestine and the other from diabetes mellitus. Actuarial 5-year overall survival (OS) was 43.8% and cancer specific survival (CSS) was 87.5%. In patients with induction chemoradiotherapy, 5-year OS and CSS were both 83.3%. In selected patients with SST, multimodrity treatment was feasible with acceptable morbidity and mortality. The complete resectability was high, and long-term survival was promising especially in whom underwent induction chemoradiotherapy followed by surgery. Our results may provide a benchmark against which new treatment regimens can be evaluated. The potential benefit of preoperative chemoradiotherapy must be assessed by whether it leads to higher rates of complete resection and a lower risk of local relapse. Further evaluation and long term follow up would be necessary.

P3.17-15 Therapeutic Outcome of Surgery for Superior Sulcus Tumor

Treatment of superior sulcus tumor (SST) is challenging and often requires multidisciplinary approach. Accumulation of treatment outcome is a principal issue for the future. We retrospectively reviewed clinical records of the patients those who were clinically diagnosed to have SST which involved to the 1st rib but was resectable. From 2000 to 2017, 16 patients were eligible in our hospital. Average age of the patients was 62.3 (40-74). The number of the patients with various properties was following; men 16/ women 3, right lung 5/ left lung 11, squamous cell carcinoma 5/ adenocarcinoma 9/ pleomorphic carcinoma 1, induction chemoradiotherapy 12/ induction chemotherapy 3/ no induction treatment 1, and clinical stage T3N0M0 9/ T3N2M0 2/ T4N0M0 4/ T4N3M0 1. Pathological information and clinical information regarding recurrence and survival were collected. Correlation between prognosis and clinicopathological factors were statistically evaluated by both univariate and multivariate analysis. P value was regarded as statistically significant when it was less than 0.05. Undertaken surgical approach was posterolateral for 8 cases/ median sternotomy for 6 cases/ transmanubrial approach (TMA) + thoracoscopy for 2 cases. Combined resection extended to the 1st rib for 6 cases/ 2nd rib for 4 cases/ parietal pleura for 4 cases/ vessels for 4 cases. For curativity, pathological curative (R0) was achieved in 12 cases, while macroscopic curative (R1) was noted in 4 cases. Effect of induction treatment was revealed as Ef1 for 4 cases/ Ef2 for 7 cases/ Ef3 for 2 cases. There was no death within 30 days after surgery. Morbidity (grade3) occurred in 6. Postoperative recurrence was observed in 8 cases and 7 of them dead from lung cancer. 5-year survival rate was 48.8%. By multivariate analysis, R0 resection was a statistically significant factor which correlates with survival. R0 resection was a critical factor for postoperative survival. Thoracoscopic approach combined with TMA might contribute to reduce surgical invasiveness according to the location of the disease.

P3.17-10 Outcome of Surgical Resection for Superior Sulcus Tumor: Experience at a Single Institution

P3.17-10 Outcome of Surgical Resection for Superior Sulcus Tumor: Experience at a Single Institution

Initial extended resection or neoadjuvant therapy for T4 non-small cell lung cancer-What is the evidence?

Locally advanced non-small cell lung cancer (NSCLC) tumors that invade surrounding structures within the chest (T4) are a heterogeneous group, and, as such, there are no straightforward guidelines for their management. Advances in imaging, invasive mediastinal staging, and neoadjuvant therapies have expanded the role of surgery with curative intent for this patient group and have also diminished the rate of explorative thoracotomies. Unlike for T4 superior sulcus tumors, the use of neoadjuvant therapy for central T4 tumors is not clearly defined. The most important determinants of a successful outcome after surgery are achieving an R0 resection and avoiding incidental pathologic N2 disease. Use of neoadjuvant therapy in this setting may yield better outcomes after surgery, as both of these variables can be altered if the tumor responds to neoadjuvant therapy. Moreover, response to induction therapy has been shown to have prognostic value.

Recurrent Diffuse Large B-Cell Lymphoma Presenting with Pancoast Syndrome: A Rare Cause of Radicular Neck Pain in the Emergency Department

BackgroundPancoast syndrome is an uncommon complication of apical lung tumors. Symptoms include pain, brachial plexopathy, and Horner's syndrome, and are the result of extrinsic compression of tissues within the thoracic inlet. Lymphoma is a very rare etiology. Case ReportWe describe the presentation of a 59-year-old male with recurrent diffuse large B-cell lymphoma presenting with Pancoast syndrome. Why Should an Emergency Physician Be Aware of This?Cancer is an uncommon cause of radicular neck pain but should be considered in the differential, particularly when constitutional complaints are also present. Symptoms and physical examination findings associated with Pancoast syndrome are the consequence of compression of the C7–T2 vertebral roots and sympathetic chain. Computed tomography is usually required to definitively visualize the mass.

Transmanubrial approach after video-assisted thoracoscopic surgery for left superior sulcus tumor after induction chemoradiotherapy

Transmanubrial approach after video-assisted thoracoscopic surgery for left superior sulcus tumor after induction chemoradiotherapy

Transmanubrial approach for resection requiring vertebrectomy for superior sulcus tumor invading the spine after induction chemoradiotherapy: A case report

Transmanubrial approach for resection requiring vertebrectomy for superior sulcus tumor invading the spine after induction chemoradiotherapy: A case report

Chemotherapy in Combination with Implantation 125i Seeds Treat Cannot Surgical Pancoast Tumor Curative Effect Analysis

To explore the therapeutic effect of radioactive 125I seeds combined with chemotherapy on the treatment of inoperative pancoast tumor by CT-guided percutaneous implantation of treatment planning system (TPS).

Advance of Treatment for Superior Sulcus Tumor of the Lung

肺上沟瘤是指发生在肺上沟区的的支气管源性肿瘤, 是非小细胞肺癌(non-small cell lung cancer, NSCLC)的一个独特的临床亚型, 占肺癌总数不足5%。它常侵犯第1肋、臂丛、锁骨下动静脉、交感神经链、星状神经节和(或)椎体等胸廓入口结构。近几十年, 肺上沟瘤的治疗取得了不断的进展, 最新发布的几个临床试验证实了同期放化疗加手术切除能够改善肿瘤的完整切除率、局部控制率和病理缓解率, 延长患者的总生存时间。已经成为肺上沟瘤的治疗最为有效的方式, 并成为美国国立综合癌症网络(National Comprehensive Cancer Network, NCCN)和美国胸科医师协会(American College of Chest Physicians, ACCP)指南推荐的肺上沟瘤治疗方案。本文回顾国内外相关文献, 简要介绍肺上沟瘤手术治疗及综合治疗的进展情况。

Induction chemoradiotherapy versus chemotherapy alone for superior sulcus lung cancer

ObjectivesAlthough treatment of superior sulcus tumors with induction chemoradiotherapy (CRT) followed by surgery employed in the Intergroup INT-0160 trial is widely adopted as a standard of care, there may be significant associated morbidity and mortality. We describe our experience using standard and alternative induction regimens to assess survival rates and treatment toxicity in these patients. Materials and methodsElectronic medical records of all patients who underwent multimodality treatment including resection of lung cancer invading the superior pulmonary sulcus between 1994 and 2016 were retrospectively reviewed. Multivariable Cox Proportional Hazards model was constructed. ResultsOf 102 consecutive patients, 53 (52%) underwent induction CRT, 34 (33%) underwent induction chemotherapy only (Ch) followed by adjuvant radiotherapy, and 15 (15%) underwent no induction therapy followed by adjuvant therapy. There were 2 postoperative deaths (1.9%). To date, 42 patients are alive with a median follow-up 72.5 months. Overall 5-year survival rate was 45.4%. Survival was significantly influenced by age, FEV1, positive resection margins, surgical complications, but not the induction regimen. CRT resulted in higher complete pathological response rate than Ch: 38% vs. 3% (p < 0.001). CRT was associated with higher post-operative re-intubation rate: 13% vs. 0% (p = 0.03). ConclusionsOur single-institutional experience indicated that while induction CRT produced greater complete pathological response than Ch, it also increased the risk of post-operative complications. With careful patient selection, induction Ch followed by adjuvant radiotherapy may provide comparable survival outcomes to induction CRT. Since induction Ch is associated with lower risk of complications, it may be a particularly desirable choice for patients with impaired performance status.

Modernes Management des Pancoast-Tumors

Pancoast or superior pulmonary sulcus tumour is a subset of lung carcinoma that invades the structures of the thoracic inlet - first ribs, distal roots of the brachial plexus, stellate ganglion, vertebrae, and subclavian vessels. The first symptom is usually shoulder pain; consequently, most patients are initially treated for osteoarthritis. Late diagnosis is common. Success of therapy depends on an accurate staging: standard imaging with CT scan of the chest, PET-CT scan, brain MRI are needed to rule out distant metastases, endobronchial ultrasound-guided needle biopsy (EBUS-TBNA) or mediastinoscopy are mandatory for reliable nodal staging. An MRI of the thoracic inlet allows to clearly define the boundaries of local invasion. Modern management of Pancoast tumour includes induction concurrent chemoradiotherapy followed by surgical resection. As compared with historical series treated by preoperative radiation, a trimodally approach did enhance complete resection rates and perhaps long-term survival - from about 30% 5-year survival rate to 60% in R0-resected patients. In patients who have unresectable but non-metastatic Pancoast tumours and appropriate performance status, definitive concurrent chemoradiotherapy and radiotherapy are recommended options.