A comparative analysis of Pancoast tumour resection performed via video-assisted thoracic surgery versus standard open approaches.

OBJECTIVES: The aim of the present paper was to conduct a comparative analysis of outcomes after thoracoscopic resection versus standard thoracotomy approach in the treatment of Pancoast tumours. METHODS: All consecutive patients with Pancoast tumours undergoing surgical treatment from March 2000 to November 2012 were enrolled. Patients were divided into 2 groups according to whether a thoracoscopic or standard thoracotomy approach was adopted. In addition to morbidity and mortality, (i) intensity of pain; (ii) respiratory function focusing on the postoperative value and its variation with respect to the predicted value (Delta); (iii) analgesic consumption at different times during the postoperative course; and (iiii) survival rate were recorded in both groups and the inter-group differences were statistically compared. RESULTS: Of the 45 enrolled patients, 34 (75%) were included in the final analysis (18 in the thoracoscopic group and 16 in the standard group). Eleven (25%) patients were excluded because they (i) were unfit for surgery after induction therapy (n = 4); (ii) refused the operation (n = 1) or (iii) had unexpected pleural involvement (n = 6). Compared with the standard group, in the thoracoscopic group we observed less pain (P = 0.01), better recovery of forced vital capacity (P = 0.01) and forced expiratory value in 1 s (P < 0.001), and a reduction in opioid (P = 0.01) and analgesic consumption (P = 0.02). The median survival for all patients was 15 months. Patients with N0/N1 disease had better median survival than N2 patients (47 vs 9 months; P = 0.009). One local recurrence in the standard group was observed 1 year after operation, whereas 2 local recurrences, 1 in the thoracoscopic group and another in the standard group, were registered 2 years after the operation (P = 1.0). Finally, 4 (22%) extrathoracic metastases in the thoracoscopic group and 5 (31%) in the standard group (P = 0.8) were found over the 2 years following the procedure. CONCLUSIONS: In the management of Pancoast tumours, a thoracoscopic approach is safe and may be an effective adjunct to standard surgical resection in selected cases. Such an approach enabled surgeons to explore the pleural cavity and avoid exploratory thoracotomy in cases of unexpected pleural involvement.

Evaluation of arm function and quality of life after trimodality treatment for superior sulcus tumours.

OBJECTIVES: Following trimodality treatment for superior sulcus tumours (SSTs), the 5-year survival rate has significantly improved. Quality of life and potential negative effects of this strategy have become more important. The objective of this study was to investigate the quality of life and the arm and shoulder function after the resection of superior sulcus tumours following neoadjuvant chemoradiation. METHODS: Patients were selected from a thoracic surgery database. Between January 2002 and December 2010, 72 patients received trimodality treatment of whom 39 were alive at the start of this study in 2010. The following arm function tests were used: nine-hole peg test, range of motion test and action research arm test. Quality of life was assessed using the Disability of the arm and shoulder and SF-36 questionnaires. Analyses of the arm function were conducted comparing the treated side with the untreated side. For quality of life, patients treated on their dominant side were compared with those treated on their non-dominant side. RESULTS: In total, 19 patients participated in this study (15 men and 4 women). The median age was 59 years (range 39-73), median radiation dose 50 Gy (range 39-66) and median follow-up 40 months (range 4-101). There was no statistically significant difference in arm and shoulder function between the treated and the untreated arm. However, statistically significantly less pain was found if patients were treated on their dominant side. CONCLUSIONS: After the resection of SSTs following chemoradiotherapy, the arm and shoulder function on the affected side is comparable with the functions at the contralateral side. Patients treated for an SST on their dominant side are less affected in their quality of life regarding pain compared with those treated on their non-dominant side.

[Tumour of the right lung vertex that produced a Pancoast syndrome: description of a case]. / Tumor del vértice pulmonar derecho que produce un síndrome de Pancoast. Descripción de un caso clínico.

We describe a clinical case of an 80 year-old woman, with a history of Alzheimer's disease, who presented with right shoulder pain, numbness and decreased strength in the right arm, with right eye ptosis, cough and dysphagia. The chest X-Ray and thoracic-abdominal computed tomography scan showed a large mass in the upper lobe and apex of the right lung, supraclavicular metastatic lymph nodes. In the fine needle aspiration biopsy: poorly differentiated non-small cell carcinoma. She was referred to Oncology to start chemotherapy treatment.

Pancoast tumors.

Pancoast tumors (superior sulcus tumors or apical lung tumors) typically invade structures at the thoracic outlet, including the inferior elements of the brachial plexus (C8, T1 nerve roots and lower trunk). Historically, these tumors are rapidly fatal, but newer treatment with induction chemotherapy and radiotherapy, followed by surgical resection of the tumor has resulted in improved patient survival. To accomplish oncologic excision, resection of the involved brachial plexus elements is still standard practice in most centers, resulting in loss of hand function and/or development of neuropathic pain. We present a modification of this protocol that incorporates induction chemoradiation, surgical resection of the lung tumor by a thoracic surgeon, and neurolysis and preservation of the brachial plexus by a neurosurgeon. Improved survival outcome, especially in patients demonstrating a pathologic complete response, with preservation of hand function, supports our hypothesis that involved brachial plexus does not need resection in these patients.

Pancoast tumor resection with preservation of brachial plexus and hand function.

OBJECT: Pancoast tumors are aggressive bronchogenic lesions of the lung apex that are rapidly fatal if untreated. Modern treatment includes induction chemotherapy and radiotherapy prior to resection, but many authors also resect the T-1 nerve root (with or without the C-8 nerve root and the lower trunk of the brachial plexus) as part of the therapy, causing significant loss of hand function in many patients. The current authors determined whether a different approach allowing preservation of the brachial plexus and hand function could be adopted without compromising patient survival. An extensive historical review of Pancoast tumors is presented as a baseline for clinical comparison. METHODS: Five patients harboring Pancoast tumors with brachial plexus involvement underwent surgery performed by both a neurosurgeon and thoracic surgeon. In all cases the tumor was resected from the brachial plexus using neurolysis while preserving the C-8 and T-1 nerve roots and lower trunk of the brachial plexus. RESULTS: One patient died 3 years posttreatment; the other four patients remain alive and well 2 to 5 years postoperatively. Hand function improved or remained normal in all four survivors, with postoperative intrinsic hand muscle function being Louisiana State University Medical Center Grade 5 in each patient. These results (2-year survival rate of 100%) compare favorably with the Southwest Oncology Group Data (overall 2-year survival rate of 55%; 70% in patients who had undergone complete resection). With a minimum 2-year follow-up, 80% of patients remained alive and well, with normal hand function. CONCLUSIONS: Although this patient series is small, the findings are extremely encouraging and suggest that the described treatment paradigm preserves survival as well as hand function in patients with Pancoast tumors.

Inefficacy of high-dose transdermal fentanyl in a patient with neuropathic pain, a case report.

Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58-year-old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 microg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1-2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

Cytodiagnosis of hydatid disease presenting with Horner's syndrome: a case report.

BACKGROUND: The diagnosis of echinococcosis is based on clinical, radiologic and serologic findings. Fine needle aspiration (FNA) is useful in evaluating the lesion when the presentation is atypical. We report a case of hydatid cyst at the lung apex in which the diagnosis was made on FNA, with no adverse reaction to the aspiration. CASE: A 30-year-old male, a chronic smoker, presented with pain radiating to the medial two fingers of the right hand for two years. He also had miosis and ptosis of the right eye and anhidrosis of the right side of theface. There was wasting of small muscles in the right hand. Magnetic resonance imaging revealed a hyperintense mass at the apex of the right lung, thoracic inlet and adjacent vertebral bodies. A clinical diagnosis of Horner's syndrome due to pancoast tumor was rendered. Ultrasound-guided FNA showed protoscolices, scattered hooklets and bits of acellular laminated membrane, characteristic of echinococcosis. Surgical excision of the cyst was done. Gross and histopathologic examination of the excised cyst confirmed the diagnosis. CONCLUSION: FNA, though traditionally contraindicated, is a highly desirable, rapid, noninvasive diagnostic mode for echinococcosis. In view of its pathognomonic cytomorphologic features and numerous reports on cytodiagnosis in the literature, it is time to evaluate the diagnostic benefits and weigh the risks against the advantages of the technique.

Pain-relieving posterior rod fixation with segmental sublaminar wiring for Pancoast tumor invading the vertebrae.

We describe the case of a 44-year-old male patient with Pancoast lung cancer invading the vertebrae. Because irradiation did not relieve his symptoms, we conducted tumor resection with posterior rod fixation with segmental sublaminar wiring of the vertebrae. This enabled the patient to walk and to discontinue morphine immediately after surgery. Although the tumor recurred within the region of the fixation 4 months after surgery, the patient complained of no pain until his death. Although Pancoast lung cancer with extensive vertebral invasion cannot be cured surgically, posterior rod fixation with segmental sublaminar wiring with tumor resection can improve a patient's quality of life by providing immediate, long-term pain relief.

Tumor de Pancoast y masas del opérculo torácico superior: evaluación por resonancia magnética

Introducción: Las masas del opérculo torácico superior conforman un grupo especial dentro de los tumores de tórax ya que tienen características clínicas, imnagenológicas, diagnósticas y terapéuticas particulares. La tomografía axial computarizada (TAC) y la resonancia magnética (RM) del tórax han significado un avance importante en la evaluación de estas masas. Objetivo: Describir los hallazgos en la RM de los tumores del opérculo torácico superior evaluados en la Fundación Santafé de Bogotá en un período definido de tiempo y compararlos con los hallazgos en la TAC. Diseño: Estudio observacional, descriptivo de una serie de casos. Pacientes y Métodos: Se revisaron los registros de todos los estudios de RM realizados en el Departamento de Imágenes de la Fundación Santafé de Bogotá entre abril de 1993 y septiembre de 1995. Se seleccionaron los estudios de RM del tórax, dentro de los cuales 6, correspondieron a masas del opérculo torácico superior; se analizaron los estudios de TAC realizados a estos mismos pacientes. Resultados: Se describen los hallazgos de RM de 6 pacientes con masas del opérculo torácico superior y se compararon con los encontrados por TAC. Conclusión: La RM fue más informativa que la TAC en definir las características y la extensión de las lesiones en estos 6 pacientes, tal como está descrito en la literatura mundial.

[Pain assessment and therapy in bronchial carcinoma]. / Schmerzanalyse und -therapie beim Bronchialcarcinom.

In the period from 1983-1991 133 patients (102 men, 31 women) with lung cancer were treated in our pain clinic for 8083 days. Pain was associated with tumour infiltration in 86% of patients and related to therapy in 15%. Even in 6 of 8 patients who were admitted with a diagnosis of "postthoracotomy syndrome" and in all 4 patients with "postradiation syndrome" local recurrence was diagnosed during follow-up. All 17 cases of brachial plexus lesions were caused by local tumour spread. Symptomatic treatment according to WHO guidelines resulted in good pain relief in 92% of patients and on 82% of days. The incidence of dyspnea decreased from 51% of the patients to 16%. Strong opioids were used on 56% of treatment days. Parenteral or spinal administration of opioids was necessary on 3% of days only.

Sensory disorder of the chest as presenting symptom of lung cancer.

Four patients with pancoast's syndrome had burning pain in the axilla and abnormal sensation in the intercostobrachial nerve territory. The intercostobrachial nerve is the first component of the brachial plexus to be invaded by lung tumours.

[Pain in pulmonary neoplasms]. / Il dolore da neoplasie polmonari.

The authors review the cases of 81 patients complaining of pain due to lung cancer referred to a Pain Clinic. The cause and characteristics of pain together with treatments and results were assessed. The time elapsed from beginning of pain complaints to diagnosis, referral to the Pain Clinic and death was calculated. The data collected are discussed keeping in mind the aim of providing these patients a better quality of life.

Pancoast tumor presenting as cervical radiculopathy.

A case of Pancoast tumor presenting as cervical radiculopathy is reported, including the clinical, EMG, and radiologic findings. A 64-year-old man with a two-month history of left shoulder pain and left arm numbness at the medial aspect of the hand and forearm presented for electrodiagnostic examination, and a severe C8 radiculopathy was documented. Subsequent radiologic evaluation (myelogram and routine chest x-ray) yielded the diagnosis of left apical lung tumor (Pancoast tumor), eroding through the C7 and T1 pedicles and T1 vertebral body, with cut-off of the left C8 nerve root. Pancoast tumor has long been implicated as a cause of brachial plexopathy. The EMG presentation of isolated cervical radiculopathy, however, has not been previously reported, despite the tumor's known tendency for local invasion which may include the nerve roots and even the spinal canal in its advanced stages. This patient's normal sensory studies argue against any significant coexisting lower brachial plexopathy. The possibility of Pancoast lesion should be considered not only in the presence of brachial plexopathy, but also when C8 or T1 radiculopathy is found.

Success in surgery may not require cutting the tracts.

Two patients are described in whom surgical intervention was terminated prior to the lesioning of any pathways relevant to pain and yet the surgery relieved the chronic severe pain.

Therapeutic approach to the Pancoast pain syndrome.

The incidence of the Pancoast syndrome ranges from 2 to 5% of patients with lung cancer. We treated 20 cases between 1979 and 1984 with 29 procedures including percutaneous cordotomy, selective posterior radiculotomy, decompressive laminectomy, central administration of opiates, and TENS. Selective posterior radiculotomy gave the best pain relief.

[Pancoast's syndrome from the analgesic viewpoint. Our current orientation]. / La sindrome di Pancoast Tobias dal punto di vista antalgico. Nostro attuale orientamento.

Based on the neuroanatomic and physiologic characteristics, the pain from the Pancoast's syndrome is distinguished in cervical-brachial and thoracic-scapular. Two new surgical methods are described for the antalgic treatment of this syndrome: release of the brachial plexus, dissection of the over-scapular nerve and removal of the stellate ganglion, in the first case; dissection of the first two (or three) intercostal nerves and subsequent removal together with their thoracic ganglions, in the second case. The advantages of the above methods and the results reached are discussed.