Superior Sulcus Tumors

Superior sulcus tumors are a special type of lung carcinoma invading the chest wall. This is usually a low grade squamous cell carcinoma arising at the apex of the upper lobes which invades the endothoracic fascia, and may involve the lower roots of the brachial plexus, the sympathetic chain, and adjacent ribs and often vertebral bodies (Fig. 12.3a-d). The history and physical examination are important, since these patients frequently develop characteristic pain in the shoulder, radiating down the arm in the ulnar distribution and may have the Horner's syndrome.

Superior sulcus tumors by definition are T3 disease (at least), and are Stage Illb if there is no nodal disease (N0), or Stage Ilia if there is intrapulmonary node involvement (N1). The management of superior sulcus tumors is important since this is perhaps one of the few stage III types of lung cancer that may actually be cured by surgery.

Radiation alone has been reported to relieve pain and prolong survival. The diagnosis is established by sputum cytology and bronchoscopy, and if these can-

Fig 12.3b. The CT confirms the superior tumor mass. The patient underwent left upper lobectomy with en bloc resection of the chest wall including ribs 1,2 and 3.
Fig 12.3c. A portion of the T1 nerve root of the brachial plexus was invaded and required resection (arrow). The subclavian artery and vein are seen in the operative field (large arrow). A utility fifth interspace thoracotomy (*) facilitated the lobec-tomy.

Fig 12.3d.A postoperative CXR shows the resected portion of chest wall and absence of tumor.

not establish the diagnosis then fine needle aspiration of the upper lobe lesion is performed. An assessment is made for resectability, both in terms of the patient as an operative candidate (pulmonary function tests and other co-morbid conditions are evaluated), as well as resectability in terms of the local tumor and possibility of metastases. The CT scan is invaluable for this, and requires scanning of the local lesion and evaluation of surrounding invasion, including bony erosion of the vertebral bodies. Evaluation of mediastinal nodes is required since if these appear large then mediastinoscopy or mediastinotomy is essential to see whether there is mediastinal node involvement which would preclude resection. Also the CT scan should include evaluation of the upper abdomen to look at the liver and adrenal glands.

Preoperative radiation (3000 rads over 3 weeks or 4000 rads over 4 weeks in another protocol) followed by a 3 week period of rest and recuperation, followed by resection is standard therapy. The patient is placed in the lateral decubitus position with the arm raised. A parascapular incision is made starting above the spine of the scapula and extending around the tip of the scapula to the anterior axillary line. The 4th (or the 3rd) intercostal space is entered and an exploration is performed. The resection is done in two phases: anterior and posterior. The anterior phase involves division of the 2nd and 3rd ribs anterior to the tumor. The first rib is separated at the costochondral junction. The anterior end of the first rib is grasped and the scalenus anterior and medius is divided. The lower roots of the plexus, subclavian artery and subclavian vein are identified and carefully avoided. If tumor involves the lower roots of the brachial plexus, these may be divided. The posterior phase begins at the lower most divided rib and extends superiorly. Transverse processes and the sympathetic chain are taken posteriorly. The scalene posterior is taken on the first rib. C8 is taken if it is involved. If C8 is not involved, then only T1 is taken. A portion of the vertebral body may be taken if needed (up to one-quarter of the vertebral body). There is no need for a prosthetic patch since support is provided by the scapula. An upper lobectomy is then performed en bloc with a resected chest wall.

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