- Email: [email protected]
Superior sulcus tumors and Pancoast’s syndrome
Lung Cancer (2003) 42, S17—S21
CONFERENCE
Superior sulcus tumors and Pancoast’s syndrome 1. Introduction Pancoast’s syndrome is a constellation of symptoms and signs that include shoulder and arm pain along the distribution of the eighth cervical nerve trunk and first and second thoracic nerve trunks, Horner’s syndrome, and weakness and atrophy of the hand [1]. This most commonly is related to a local extension of an apical lung tumor located in the superior pulmonary sulcus. Pancoast’s original description of this entity was in 1924 with additional cases reported in 1932 [2,3].
2. Etiology While the primary and most common cause of this symptom complex is non-small cell lung cancer, there have been a large number of case reports of other types of tumors and infections accounting for Pancoast’s syndrome. Table 1 outlines a list of the most common causes. Rarely, small cell lung cancer may cause this syndrome. Emphasizing the fact that not all cases are due to lung cancer, a recent clinical pathological conference report from the Massachusetts General Hospital presented a case of a 45-year-old woman with a 3.5-year history of progressive neurological symptoms that included anhydrosis of the right face and shoulder and arm pain. After multiple non-diagnostic transthoracic needle biopsies, the eventual diagnosis at the time of surgical resection was that of a desmoid tumor (intrathoracic fibromatosis) [4].
3. Presentation The most common initial symptom is shoulder pain produced by tumor involvement of the parietal pleura, brachial plexus, vertebral bodies and first, second, and third ribs. The pain may radiate along the upper back or shoulder into the axilla and 0169-5002/$ – see front matter doi:10.1016/j.lungcan.2003.08.006
along the distribution of the ulnar nerve. Patients are commonly treated for arthritis or bursitis of the shoulder before the correct diagnosis is determined. In many cases, the diagnosis is delayed for 6—9 months before the correct diagnosis of a tumor is discovered. Horner’s syndrome consists of ptosis, myosis, and anhydrosis, and is caused by the invasion of the paravertebral sympathetic chain and the inferior cervical (stellate) ganglion [1]. Pancoast’s syndrome is present in approximately one-third of patients with superior sulcus tumors reported in the literature. Weakness and atrophy of the intrinsic muscles of the hands may occur as the tumor progresses. With further extension through the inter-vertebral foramina, spinal compression, and paraplegia may occur. In a series of 143 patients from MD Anderson Hospital, pain in the arm/shoulder occurred in 69%, chest pain in 39%, cough in 40%, dyspnea in 37%, and Horner’s syndrome in 19% [5]. In another series of 73 patients with superior sulcus tumor from Massachusetts General Hospital, Horner’s syndrome was present in 30%, shoulder pain in 88%, and arm weakness in 40% [6].
4. Radiographic findings The chest X-ray may show an apical tumor, although in some cases the chest X-ray may be negative and a tumor is only identified on the CT scan of the chest. Figs. 1 and 2 are examples of a chest X-ray and a CT scan showing a right apical superior sulcus tumor. If the diagnosis is suspected, but the chest X-ray is negative, the diagnostic evaluation should proceed to CT scan of the chest. The CT provides additional information about the extent of the superior sulcus tumor, and is especially helpful in identifying other pulmonary nodules and/or mediastinal adenopathy. Magnetic resonance imaging of the chest for staging lung cancer does not generally have any advantage over the standard CT scan.
S18
Table 1 Causes of Pancoast’s syndrome Neoplasms Primary bronchogenic carcinoma Other primary thoracic neoplasms Adenoid cystic carcinoma, hemangiopericytoma, mesothelioma Metastatic neoplasms Carcinoma of the larynx, cervix, urinary bladder, thyroid gland Hematologic neoplasms Plasmacytoma, lymphomatoid granulomatosis, lymphoma, amyloidoma Infectious processes Bacterial Staphylococcal and pseudomonal pneumonia, thoracic actinomycosis Fungal Aspergillosis, allescheriasis, cryptococcosis Tuberculosis Parasitic Hydatid cyst Modified from [1].
Conference However, MR is felt to be superior for evaluating patients with superior sulcus tumors [7]. MR offers a better assessment of invasion of the tumor through the pleura and the subpleural fat, better evaluation of plexus involvement, and better definition of subclavian vessel involvement. In one prospective trial, evaluating CT versus MR imaging, 31 patients were assessed with both imaging modalities. The study was limited to determining the invasion of the superior sulcus. Findings were compared with surgical and/or clinical symptoms. Thin section coronal and sagittal MR images were more accurate than CT scan in evaluating tumor invasion through the superior sulcus (accuracy 94% versus 63%) [7]. Fig. 3 is an example of an MR image of a superior sulcus tumor. More recently, magnetic resonance angiography (MRA) has been incorporated into the evaluation of Pancoast’s syndrome. In the report by Laissy et al., six patients with Pancoast’s syndrome were evaluated with MRA [8]. The MRA was compared to angiography in four cases and surgery in six cases. MRA demonstrated displacement (two cases) and encasement (two cases) of the subclavian and/or brachiocephalic arteries. It also demonstrated encasement or occlusion of the subclavian or brachiocephalic vein in three cases. There was very close correlation between the MRA findings and angiography or surgery. Accordingly, MRA appears to be superior for determining vascular involvement as compared to standard MR or CT scan. Positron emission tomography (PET) scanning is excellent for staging of non-small cell lung cancer. In a meta-analysis, PET scanning had a sensitivity of 79% and a specificity of 91% for detecting mediastinal lymph node metastasis [9]. In a prospective randomized trial from The Netherlands, PET scanning decreases the number of futile thoracotomies by 20% [10]. PET scanning applicability to superior sulcus tumor is not unique to this syndrome, but reflects its utility for staging all non-small cell lung cancers. It is most beneficial for detecting mediastinal lymph node involvement and/or distant metastasis.
5. Diagnosis
Fig. 1 Chest roentgenogram showing a superior sulcus tumor in the right apex due to non-small cell lung cancer.
The diagnostic yield of sputum cytology is generally 10—20% in patients with superior sulcus tumor. Because of the peripheral location of these tumors, the diagnostic yield from sputum cytology is generally less than with more centrally located tumors. Flexible fiberoptic bronchoscopy is a common first diagnostic test for biopsies of apical lesions. Because of the peripheral location, these lesions are not generally visible endoscopically and biopsy and brushings must take place under fluoroscopic
Superior sulcus tumors and Pancoast’s syndrome
S19
Fig. 2 CT scan of patient presenting with a Pancoast tumor and Horner’s syndrome due to right apical non-small cell lung cancer.
guidance. Diagnostic yield with flexible fiberoptic bronchoscopy is in the 40—60% range [11]. An additional advantage of bronchoscopy is assessment of the central airway, and if there are any me-
diastinal lymph nodes enlarged on CT scan then transbronchial needle aspiration of these nodes can be performed to assess possible lymph node metastasis. The most common diagnostic method
Fig. 3 MR scan showing a right apical lung cancer. On this T2 weighted image, the tumor is white and invading the T1 neuroforamen.
S20 for a superior sulcus tumor is transthoracic needle aspiration. In one report of 27 cases of Pancoast’s syndrome, a fine needle aspiration was positive for carcinoma in 26 of 27 patients [12]. With appropriate precautions, there is only a small risk of complication, such as pneumothorax.
6. Histology and staging The vast majority of superior sulcus tumors are due to non-small cell lung cancer. There has been one report of four cases of small cell carcinoma causing Pancoast’s syndrome, however, the majority of cases are due to non-small cell lung cancer. In a report on the MD Anderson series of 143 patients with superior sulcus tumors, 56% were due to adenocarcinoma, 27% squamous cell carcinoma, and 8% large cell carcinoma [5]. In the Massachusetts General Hospital series of 73 cases, 15% were due to adenocarcinoma, 38% squamous cell carcinoma, and 36% large cell carcinoma [6]. These differences in histology may very well reflect the time frames of the patients being studied. Currently, the most common cell type of all non-small cell lung cancers in North America is adenocarcinoma. Superior sulcus tumors can be staged as T3N0M0 (stage IIB) or higher [13,14]. T3 tumors are tumors of any size directly invade the chest wall, diaphragm, mediastinal pleura, or pericardium. T4 tumor is a tumor of any size that invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or involves the carina. While there are other criteria for T3 and T4 tumors, these are the primary ones that affect patients with superior sulcus tumors. Mediastinal lymph node involvement on the ipsilateral side (N2) or contralateral side (N3) or supraclavicular lymph node involvement (N3) are bad prognostic signs for superior sulcus tumor. In summary, superior sulcus tumors can be T3 or T4, N0—3. In a series reported from MD Anderson, 25% of patients were stage IIB (T3N0M0), 22% stage IIIA (T1-3N2), and 53% stage IIIB (T4 or N3) [5]. They purposefully excluded patients with M1 disease from their series so we do not have a clear understanding of a number of patients with stage IV disease at initial presentation at their institution. It is this author’s belief that from one-third to one-half of all patients with superior sulcus tumors will have identifiable distant metastasis at the time of initial diagnosis with careful staging.
Conference stage of disease and performance score. In the series from MD Anderson, they evaluated predictors of 5-year survival [5]. These predictive factors of worse prognosis included (a) weight loss ≥5%, (b) vertebral body involvement, (c) supraclavicular involvement, and (d) stage of disease. They observed a 5-year survival of 45% in their patients with stage IIB disease, but the 5-year survival with stage IIIA or IIIB disease was approximately 15%. Rusch and colleagues evaluated 225 patients with superior sulcus tumor who underwent thoracotomy at Memorial Sloan Kettering Cancer Center [15]. They intentionally excluded patients who were inoperable from their series. Based on multivariant analysis, the factors that they identified that were important in survival were T4 tumors, incomplete resections, and presence of N1 or N2 lymph node involvement. They specifically evaluated the effects of lymph node involvement on survival and noted that in patients with N0 disease that the 5-year survival was approximately 40% and was substantially better than in patients with N1 or N2 lymph nodes at the time of surgery. The group with N1 or N2 disease had virtually no 5-year survivors. Based on their data, the authors expressed their belief that mediastinoscopy should be a routine part of the preselection evaluation of patients with superior sulcus tumors. Those individuals with N2 or N3 lymph node involvement are not generally considered to be surgical candidates. This influence of lymph node involvement on poor survival has been documented by other investigators.
8. Brain metastasis A number of series have reported that the brain is the most common site of distant metastasis. In the MD Anderson series, the brain was the most frequent site of distant metastasis, and that occurred in 24 of 143 patients (17% within 5 years) [5]. In the series by Rusch and colleagues, the first postoperative site of relapse was the brain in 16 of 39 documented relapses [15]. Based on these reports and others, an MRI of the brain should be performed to rule out distant metastasis prior to any attempt at surgical resection.
7. Prognosis
9. Recommendations for pretreatment staging evaluation of patients with superior sulcus tumor
In general, the two most important prognostic factors for patients with non-small cell lung cancer are
Based on careful review of the literature and evidence as cited above, the following are my
Superior sulcus tumors and Pancoast’s syndrome recommendations for the pretreatment evaluation of these individuals: (1) careful history and physical examination, (2) baseline laboratory tests including a complete blood count and serum chemistries, (3) complete pulmonary function tests to assess operability, (4) CT scan of the chest through the liver and adrenal glands, looking for any obvious site of distant metastasis, (5) PET scan to rule out distant metastasis, (6) limited MRI of the brachial plexus and MRA, for vessel involvement, to determine resectability, and (7) MR of the head to rule out brain metastasis. These tests can be performed sequentially so that identification of distant metastases or inoperability of the tumor with one of these tests would preclude the need to obtain additional testing.
References [1] Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast’s syndrome. New Engl J Med 1997;337:1370—6. [2] Pancoast HK. Importance of careful roentgen-ray investigations of apical chest tumors. JAMA 1924;83:1407—11. [3] Pancoast HK. Superior pulmonary sulcus tumor: tumor characterized by pain, Horner’s syndrome, destruction of bone and atrophy of hand muscles. JAMA 1932;99:1391—6. [4] Case records of the Massachusetts General Hospital. Case 18-2000 New Engl J Med 2000;342:1814—1821. [5] Komaki R, Roth JA, Walsh GL, et al. Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas MD Anderson Cancer Center. Int J Radiat Oncol Biol Phys 2000;48:347—54.
S21 [6] Hagan MP, Choi NC, Mathisen DJ, et al. Superior sulcus lung tumors: impact of local control on survival. J Thorac Cardiovasc Surg 1999;117:1086—94. [7] Heelan RT, Demas BE, Caravelli JF, et al. Superior sulcus tumors: CT and MR imaging. Radiology 1989;170:637—41. [8] Laissy JP, Soyer P, Sekkal SR, et al. Assessment of vascular involvement with magnetic resonance angiography (MRA) in Pancoast syndrome. Magn Reson Imaging 1995;13:523— 30. [9] Dwemena BA, Sonnad SS, Angobaldo JO, Wahl RL. Metastases from non-small cell lung cancer: mediastinal staging in the 1990s. Meta-analysis of PET and CT. Radiology 1999;213:530—6. [10] van Tienteren H, Hoekstra OS, Smit EF. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small cell lung cancer: the PLUS multicentre randomized trial. Lancet 2002;359:1388—92. [11] Maxfield RA, Aranda CP. The role of fiberoptic bronchoscopy and transbronchial biopsy in the diagnosis of Pancoast’s tumor. N Y State J Med 1987;87:326—9. [12] Walls WJ, Thornburg JR, Naylor B. Pulmonary needle aspiration biopsy in the diagnosis of Pancoast tumors. Radiology 1974;111:99—102. [13] Detterbeck FC, Socinski MA. IIB or not IIB: the current question in staging non-small cell lung cancer. Chest 1997;112:229—34. [14] Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111:1710—7. [15] Rusch V, Parekh K, Leon L. Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus. J Thorac Cardiovasc Surg 2000;119:1147— 53.
James R. Jett Mayo Clinic, Thoracic Diseases and Medical Oncology, 200 First Street SW, Desk E18B Rochester, MN 55905, USA
CONFERENCE
Superior sulcus tumors and Pancoast’s syndrome 1. Introduction Pancoast’s syndrome is a constellation of symptoms and signs that include shoulder and arm pain along the distribution of the eighth cervical nerve trunk and first and second thoracic nerve trunks, Horner’s syndrome, and weakness and atrophy of the hand [1]. This most commonly is related to a local extension of an apical lung tumor located in the superior pulmonary sulcus. Pancoast’s original description of this entity was in 1924 with additional cases reported in 1932 [2,3].
2. Etiology While the primary and most common cause of this symptom complex is non-small cell lung cancer, there have been a large number of case reports of other types of tumors and infections accounting for Pancoast’s syndrome. Table 1 outlines a list of the most common causes. Rarely, small cell lung cancer may cause this syndrome. Emphasizing the fact that not all cases are due to lung cancer, a recent clinical pathological conference report from the Massachusetts General Hospital presented a case of a 45-year-old woman with a 3.5-year history of progressive neurological symptoms that included anhydrosis of the right face and shoulder and arm pain. After multiple non-diagnostic transthoracic needle biopsies, the eventual diagnosis at the time of surgical resection was that of a desmoid tumor (intrathoracic fibromatosis) [4].
3. Presentation The most common initial symptom is shoulder pain produced by tumor involvement of the parietal pleura, brachial plexus, vertebral bodies and first, second, and third ribs. The pain may radiate along the upper back or shoulder into the axilla and 0169-5002/$ – see front matter doi:10.1016/j.lungcan.2003.08.006
along the distribution of the ulnar nerve. Patients are commonly treated for arthritis or bursitis of the shoulder before the correct diagnosis is determined. In many cases, the diagnosis is delayed for 6—9 months before the correct diagnosis of a tumor is discovered. Horner’s syndrome consists of ptosis, myosis, and anhydrosis, and is caused by the invasion of the paravertebral sympathetic chain and the inferior cervical (stellate) ganglion [1]. Pancoast’s syndrome is present in approximately one-third of patients with superior sulcus tumors reported in the literature. Weakness and atrophy of the intrinsic muscles of the hands may occur as the tumor progresses. With further extension through the inter-vertebral foramina, spinal compression, and paraplegia may occur. In a series of 143 patients from MD Anderson Hospital, pain in the arm/shoulder occurred in 69%, chest pain in 39%, cough in 40%, dyspnea in 37%, and Horner’s syndrome in 19% [5]. In another series of 73 patients with superior sulcus tumor from Massachusetts General Hospital, Horner’s syndrome was present in 30%, shoulder pain in 88%, and arm weakness in 40% [6].
4. Radiographic findings The chest X-ray may show an apical tumor, although in some cases the chest X-ray may be negative and a tumor is only identified on the CT scan of the chest. Figs. 1 and 2 are examples of a chest X-ray and a CT scan showing a right apical superior sulcus tumor. If the diagnosis is suspected, but the chest X-ray is negative, the diagnostic evaluation should proceed to CT scan of the chest. The CT provides additional information about the extent of the superior sulcus tumor, and is especially helpful in identifying other pulmonary nodules and/or mediastinal adenopathy. Magnetic resonance imaging of the chest for staging lung cancer does not generally have any advantage over the standard CT scan.
S18
Table 1 Causes of Pancoast’s syndrome Neoplasms Primary bronchogenic carcinoma Other primary thoracic neoplasms Adenoid cystic carcinoma, hemangiopericytoma, mesothelioma Metastatic neoplasms Carcinoma of the larynx, cervix, urinary bladder, thyroid gland Hematologic neoplasms Plasmacytoma, lymphomatoid granulomatosis, lymphoma, amyloidoma Infectious processes Bacterial Staphylococcal and pseudomonal pneumonia, thoracic actinomycosis Fungal Aspergillosis, allescheriasis, cryptococcosis Tuberculosis Parasitic Hydatid cyst Modified from [1].
Conference However, MR is felt to be superior for evaluating patients with superior sulcus tumors [7]. MR offers a better assessment of invasion of the tumor through the pleura and the subpleural fat, better evaluation of plexus involvement, and better definition of subclavian vessel involvement. In one prospective trial, evaluating CT versus MR imaging, 31 patients were assessed with both imaging modalities. The study was limited to determining the invasion of the superior sulcus. Findings were compared with surgical and/or clinical symptoms. Thin section coronal and sagittal MR images were more accurate than CT scan in evaluating tumor invasion through the superior sulcus (accuracy 94% versus 63%) [7]. Fig. 3 is an example of an MR image of a superior sulcus tumor. More recently, magnetic resonance angiography (MRA) has been incorporated into the evaluation of Pancoast’s syndrome. In the report by Laissy et al., six patients with Pancoast’s syndrome were evaluated with MRA [8]. The MRA was compared to angiography in four cases and surgery in six cases. MRA demonstrated displacement (two cases) and encasement (two cases) of the subclavian and/or brachiocephalic arteries. It also demonstrated encasement or occlusion of the subclavian or brachiocephalic vein in three cases. There was very close correlation between the MRA findings and angiography or surgery. Accordingly, MRA appears to be superior for determining vascular involvement as compared to standard MR or CT scan. Positron emission tomography (PET) scanning is excellent for staging of non-small cell lung cancer. In a meta-analysis, PET scanning had a sensitivity of 79% and a specificity of 91% for detecting mediastinal lymph node metastasis [9]. In a prospective randomized trial from The Netherlands, PET scanning decreases the number of futile thoracotomies by 20% [10]. PET scanning applicability to superior sulcus tumor is not unique to this syndrome, but reflects its utility for staging all non-small cell lung cancers. It is most beneficial for detecting mediastinal lymph node involvement and/or distant metastasis.
5. Diagnosis
Fig. 1 Chest roentgenogram showing a superior sulcus tumor in the right apex due to non-small cell lung cancer.
The diagnostic yield of sputum cytology is generally 10—20% in patients with superior sulcus tumor. Because of the peripheral location of these tumors, the diagnostic yield from sputum cytology is generally less than with more centrally located tumors. Flexible fiberoptic bronchoscopy is a common first diagnostic test for biopsies of apical lesions. Because of the peripheral location, these lesions are not generally visible endoscopically and biopsy and brushings must take place under fluoroscopic
Superior sulcus tumors and Pancoast’s syndrome
S19
Fig. 2 CT scan of patient presenting with a Pancoast tumor and Horner’s syndrome due to right apical non-small cell lung cancer.
guidance. Diagnostic yield with flexible fiberoptic bronchoscopy is in the 40—60% range [11]. An additional advantage of bronchoscopy is assessment of the central airway, and if there are any me-
diastinal lymph nodes enlarged on CT scan then transbronchial needle aspiration of these nodes can be performed to assess possible lymph node metastasis. The most common diagnostic method
Fig. 3 MR scan showing a right apical lung cancer. On this T2 weighted image, the tumor is white and invading the T1 neuroforamen.
S20 for a superior sulcus tumor is transthoracic needle aspiration. In one report of 27 cases of Pancoast’s syndrome, a fine needle aspiration was positive for carcinoma in 26 of 27 patients [12]. With appropriate precautions, there is only a small risk of complication, such as pneumothorax.
6. Histology and staging The vast majority of superior sulcus tumors are due to non-small cell lung cancer. There has been one report of four cases of small cell carcinoma causing Pancoast’s syndrome, however, the majority of cases are due to non-small cell lung cancer. In a report on the MD Anderson series of 143 patients with superior sulcus tumors, 56% were due to adenocarcinoma, 27% squamous cell carcinoma, and 8% large cell carcinoma [5]. In the Massachusetts General Hospital series of 73 cases, 15% were due to adenocarcinoma, 38% squamous cell carcinoma, and 36% large cell carcinoma [6]. These differences in histology may very well reflect the time frames of the patients being studied. Currently, the most common cell type of all non-small cell lung cancers in North America is adenocarcinoma. Superior sulcus tumors can be staged as T3N0M0 (stage IIB) or higher [13,14]. T3 tumors are tumors of any size directly invade the chest wall, diaphragm, mediastinal pleura, or pericardium. T4 tumor is a tumor of any size that invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or involves the carina. While there are other criteria for T3 and T4 tumors, these are the primary ones that affect patients with superior sulcus tumors. Mediastinal lymph node involvement on the ipsilateral side (N2) or contralateral side (N3) or supraclavicular lymph node involvement (N3) are bad prognostic signs for superior sulcus tumor. In summary, superior sulcus tumors can be T3 or T4, N0—3. In a series reported from MD Anderson, 25% of patients were stage IIB (T3N0M0), 22% stage IIIA (T1-3N2), and 53% stage IIIB (T4 or N3) [5]. They purposefully excluded patients with M1 disease from their series so we do not have a clear understanding of a number of patients with stage IV disease at initial presentation at their institution. It is this author’s belief that from one-third to one-half of all patients with superior sulcus tumors will have identifiable distant metastasis at the time of initial diagnosis with careful staging.
Conference stage of disease and performance score. In the series from MD Anderson, they evaluated predictors of 5-year survival [5]. These predictive factors of worse prognosis included (a) weight loss ≥5%, (b) vertebral body involvement, (c) supraclavicular involvement, and (d) stage of disease. They observed a 5-year survival of 45% in their patients with stage IIB disease, but the 5-year survival with stage IIIA or IIIB disease was approximately 15%. Rusch and colleagues evaluated 225 patients with superior sulcus tumor who underwent thoracotomy at Memorial Sloan Kettering Cancer Center [15]. They intentionally excluded patients who were inoperable from their series. Based on multivariant analysis, the factors that they identified that were important in survival were T4 tumors, incomplete resections, and presence of N1 or N2 lymph node involvement. They specifically evaluated the effects of lymph node involvement on survival and noted that in patients with N0 disease that the 5-year survival was approximately 40% and was substantially better than in patients with N1 or N2 lymph nodes at the time of surgery. The group with N1 or N2 disease had virtually no 5-year survivors. Based on their data, the authors expressed their belief that mediastinoscopy should be a routine part of the preselection evaluation of patients with superior sulcus tumors. Those individuals with N2 or N3 lymph node involvement are not generally considered to be surgical candidates. This influence of lymph node involvement on poor survival has been documented by other investigators.
8. Brain metastasis A number of series have reported that the brain is the most common site of distant metastasis. In the MD Anderson series, the brain was the most frequent site of distant metastasis, and that occurred in 24 of 143 patients (17% within 5 years) [5]. In the series by Rusch and colleagues, the first postoperative site of relapse was the brain in 16 of 39 documented relapses [15]. Based on these reports and others, an MRI of the brain should be performed to rule out distant metastasis prior to any attempt at surgical resection.
7. Prognosis
9. Recommendations for pretreatment staging evaluation of patients with superior sulcus tumor
In general, the two most important prognostic factors for patients with non-small cell lung cancer are
Based on careful review of the literature and evidence as cited above, the following are my
Superior sulcus tumors and Pancoast’s syndrome recommendations for the pretreatment evaluation of these individuals: (1) careful history and physical examination, (2) baseline laboratory tests including a complete blood count and serum chemistries, (3) complete pulmonary function tests to assess operability, (4) CT scan of the chest through the liver and adrenal glands, looking for any obvious site of distant metastasis, (5) PET scan to rule out distant metastasis, (6) limited MRI of the brachial plexus and MRA, for vessel involvement, to determine resectability, and (7) MR of the head to rule out brain metastasis. These tests can be performed sequentially so that identification of distant metastases or inoperability of the tumor with one of these tests would preclude the need to obtain additional testing.
References [1] Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast’s syndrome. New Engl J Med 1997;337:1370—6. [2] Pancoast HK. Importance of careful roentgen-ray investigations of apical chest tumors. JAMA 1924;83:1407—11. [3] Pancoast HK. Superior pulmonary sulcus tumor: tumor characterized by pain, Horner’s syndrome, destruction of bone and atrophy of hand muscles. JAMA 1932;99:1391—6. [4] Case records of the Massachusetts General Hospital. Case 18-2000 New Engl J Med 2000;342:1814—1821. [5] Komaki R, Roth JA, Walsh GL, et al. Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas MD Anderson Cancer Center. Int J Radiat Oncol Biol Phys 2000;48:347—54.
S21 [6] Hagan MP, Choi NC, Mathisen DJ, et al. Superior sulcus lung tumors: impact of local control on survival. J Thorac Cardiovasc Surg 1999;117:1086—94. [7] Heelan RT, Demas BE, Caravelli JF, et al. Superior sulcus tumors: CT and MR imaging. Radiology 1989;170:637—41. [8] Laissy JP, Soyer P, Sekkal SR, et al. Assessment of vascular involvement with magnetic resonance angiography (MRA) in Pancoast syndrome. Magn Reson Imaging 1995;13:523— 30. [9] Dwemena BA, Sonnad SS, Angobaldo JO, Wahl RL. Metastases from non-small cell lung cancer: mediastinal staging in the 1990s. Meta-analysis of PET and CT. Radiology 1999;213:530—6. [10] van Tienteren H, Hoekstra OS, Smit EF. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small cell lung cancer: the PLUS multicentre randomized trial. Lancet 2002;359:1388—92. [11] Maxfield RA, Aranda CP. The role of fiberoptic bronchoscopy and transbronchial biopsy in the diagnosis of Pancoast’s tumor. N Y State J Med 1987;87:326—9. [12] Walls WJ, Thornburg JR, Naylor B. Pulmonary needle aspiration biopsy in the diagnosis of Pancoast tumors. Radiology 1974;111:99—102. [13] Detterbeck FC, Socinski MA. IIB or not IIB: the current question in staging non-small cell lung cancer. Chest 1997;112:229—34. [14] Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111:1710—7. [15] Rusch V, Parekh K, Leon L. Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus. J Thorac Cardiovasc Surg 2000;119:1147— 53.
James R. Jett Mayo Clinic, Thoracic Diseases and Medical Oncology, 200 First Street SW, Desk E18B Rochester, MN 55905, USA