Completely portal robotic Pancoast tumour resection with en bloc resection of the left upper lobe and chest wall.

The current gold standard for the treatment of Pancoast tumours is considered to be neoadjuvant chemoradiation followed by radical resection of the affected upper lobe en bloc with resection of the chest wall. Shaw and Paulson first described the most commonly used approach in 1961 via an extended posterolateral thoracotomy. However, because this approach comes with significant soft tissue damage and occasionally provides only suboptimal exposure, especially for anterior superior sulcus tumours, other approaches have been published in recent years, including open anterior approaches (Dartevelle and Gruenenwald) in addition to rare case reports of minimally invasive assisted hybrid procedures. Because we routinely perform robotic anatomical lung resections as well as three-port robotic first rib resections for thoracic inlet/outlet syndrome in our department, combining both techniques with our accumulated experience seemed to be the next logical step. We describe step-by-step what is (to our knowledge) one of the first reported cases of a fully portal robotic-assisted Pancoast tumour resection consisting of a left upper lobe resection en bloc with the first rib after neoadjuvant chemoradiation therapy. This approach proved to be safe and allowed for excellent exposure, especially of the thoracic outlet.

Pancoast Tumor With Cardiac Metastases and Intracardiac Thrombosis.

Pancoast tumor is a rare and aggressive form of lung cancer; cardiac metastasis is very uncommon. We present a case of advanced Pancoast tumor, with extensive cardiac metastases and intracardiac thrombosis in a woman presenting with dyspnea, shoulder pain, and weight loss. A contrast-enhanced chest computed tomographic scan revealed an apical mass, metastatic thoracic nodes, and filling defects within both ventricles. Further imaging with cardiac magnetic resonance imaging revealed 2 left ventricular masses infiltrating into the myocardium suggestive of metastatic disease, and a multilobulated mass within the right ventricle suggestive of intracardiac thrombus. She was initiated on anticoagulation for intracardiac thrombosis. Surgical pathology of biopsied tissue samples was consistent with advanced metastatic lung adenocarcinoma. She was a poor candidate for surgical intervention. Given the patient's goals of care, she was ultimately transitioned to comfort care.

Influence of anterior tumor location on survival after resection of lung cancer invading the thoracic inlet (Pancoast tumors).

OBJECTIVE: Superior sulcus tumors are a challenging subset of non-small cell lung carcinomas invading the thoracic inlet. In this study, we determined whether the location of the tumor along the first rib had an influence on survival. METHODS: We performed a review of 92 consecutive patients undergoing surgery for non-small cell lung carcinomas invading the thoracic inlet between January 1996 and June 2021. Tumor location was categorized into anterior and posterior based on predefined zones. RESULTS: In total, 21 tumors were located anteriorly (23%) and 71 posteriorly (77%). The rate of R0 resection (81% vs 87%; P = .4) and pathological complete response to induction therapy (33% vs 37%; P = .8) were similar between locations. After a median follow-up of 5.8 years (range, 0.8-24 years), 49 patients died for an overall survival of 48% (95% CI, 38%-59%) at 5 years. The 5-year survival was favorably influenced by R0 (vs R1) resection (51% vs 29%; P = .02), pathological complete response (vs no pathological complete response) (69% vs 31%; P = .03), posterior (vs anterior) location (56% vs 22%; P = .01), and ≤60 (vs >60) years of age (61% vs 37%; P = .007). Compared with posterior tumors, anterior tumors were associated with higher risk of systemic recurrence and significantly greater survival benefit from pathological complete response. Anterior tumors remained an independent predictor of worse survival in multivariate analysis (hazard ratio, 2.3; 95% CI, 1.2-4.5; P = .01). CONCLUSIONS: The anatomical location of the tumor affects survival after resection of non-small cell lung carcinomas invading the thoracic inlet. Anterior tumors have greater propensity to metastasize and may derive greater benefit from optimal systemic therapy than posterior tumors.

Clinicopathological analysis of a superior sulcus tumor treated by salvage surgery after concurrent definitive chemoradiotherapy followed by durvalumab: A case report.

Surgical treatment of superior sulcus tumors (SSTs) is clinically challenging. Definitive chemoradiotherapy (CRT) is a standard treatment for SST. In operable cases, multimodal therapy (CRT followed by surgery) is another option, at least for experienced institutions. Immune checkpoint inhibitors (ICIs) have recently been developed, and several clinical trials have investigated definitive CRT followed by ICIs for consolidation or maintenance therapy of unresectable local advanced non-small cell lung cancer (NSCLC), including SSTs. Clinical studies of salvage surgery after CRT followed by ICIs are also ongoing. However, the clinical outcomes of salvage surgery after multimodal therapies and histopathological analyses of surgical specimens after such treatments remain unclear. Here, we report the case of a patient with SST comprising squamous cell carcinoma with invasion of the second to third rib and vertebrae who underwent salvage surgery after concurrent definitive CRT followed by the ICI durvalumab, and show the results of clinicopathological analyses of the resected specimen.

[Thoracoscopic Surgery for Lung Cancer Invading the Superior Chest Wall].

We herein report a case of a 73-year-old man with lung cancer who underwent thoracoscopic right upper lobectomy with combined resection of the superior chest wall. His tumor was 48 mm in diameter and located in the posterior right lung apex involving the chest wall between ribs 1 and 3. The anterior aspects of the ribs 2 and 3 were separated using forceps under thoracoscopic vision. The first rib could be released from the tumor by peeling off the parietal pleura. An 8 cm incision was made posteriorly between the scapula and vertebrae to obtain the posterior aspect of the ribs 2 and 3. After separating the pulmonary vessels and bronchus, en bloc resection of the superior sulcus tumor was completed. Thoracoscopic chest wall resection of the superior sulcus tumor can be an alternative to the Paulson posterolateral-paravertebral thoracotomy approach, which can cause severe postoperative pain and limited range of motion of the shoulder joint.

Pancoast Tumor Presenting as Neck Pain in the Chiropractic Office: A Case Report and Literature Review.

BACKGROUND Pancoast tumors, also called superior sulcus tumors, are a rare type of cancer affecting the lung apex. These tumors can spread to the brachial plexus and spine and present with symptoms that appear to be of musculoskeletal origin. CASE REPORT A 59-year-old Asian man presented to a chiropractor in Hong Kong with a 1-month history of neck and shoulder pain and numbness that had been treated unsuccessfully with exercise, medications, and acupuncture. He had an active history of tuberculosis, which was currently treated with antibiotics, and a 50-pack-year history of smoking. Cervical magnetic resonance imaging (MRI) was performed urgently, revealing a small cervical disc herniation thought to correspond with radicular symptoms. However, as the patient did not respond to a brief trial of care, a thoracic MRI was urgently ordered, revealing a large superior sulcus tumor invading the upper to mid-thoracic spine. The patient was referred for medical care and received radiotherapy and chemotherapy with a positive outcome. A literature review identified 6 previously published cases in which a patient presented to a chiropractor with an undiagnosed Pancoast tumor. All patients had shoulder, spine, and/or upper extremity pain. CONCLUSIONS Patients with a previously undiagnosed Pancoast tumor can present to chiropractors given that these tumors may invade the brachial plexus and spine, causing shoulder, spine, and/or upper extremity pain. Chiropractors should be aware of the clinical features and risk factors of Pancoast tumors to readily identify them and refer such patients for medical care.

Small Cell Lung Carcinoma with Pancoast Syndrome: A Case Report.

Small cell lung cancer mostly arises centrally in the large bronchi. The literature search revealed very limited cases of small cell lung cancer arising at the upper part of the pulmonary sulcus near the thoracic inlet as superior sulcus tumor and also manifesting with typical Pancoast syndrome. We report a case of a 71 years old male patient, presenting with features of Pancoast syndrome including Horner's syndrome with completed three cycles of chemotherapy resulting in partial response which concludes that small cell lung carcinoma has to be considered despite the clinical findings like pancoast syndrome.

Pathologic complete response after neoadjuvant tislelizumab and chemotherapy for Pancoast tumor: A case report.

A 60-year-old man was hospitalized because of numbness and weakness in the right upper limb. Magnetic resonance imaging revealed a large mass in the right upper lobe invading the right eighth cervical and first thoracic nerve root. Biopsy pathology confirmed primary lung adenocarcinoma with a clinical stage of cT4N0M0 IIIA, negative for anaplastic lymphoma kinase fusion gene and epidermal growth factor receptor mutations but positive for programmed death ligand 1 (3%). Neoadjuvant tislelizumab and chemotherapy were offered to this patient with Pancoast tumor, and tumor shrinkage of 71% was achieved. After the operation, surgical pathology indicated pathologic complete response (pCR). Circulating tumor cells testing was negative after the first adjuvant treatment. In this case, we provide real-world evidence of encouraging pCR with neoadjuvant tislelizumab and chemotherapy for a patient with Pancoast tumor.

Pancoast tumour presenting as shoulder pain with Horner's syndrome.

A 54-year-old man presented to the emergency department with a 4-week history of right shoulder pain radiating down his arm, with some associated sensory loss. Further questioning and examination in the department revealed a classical Horner's syndrome; miosis, partial ptosis and hemifacial anhidrosis. An initial chest X-ray was deemed to be unremarkable; however, further review by a radiologist noted asymmetrical right apical thickening. A subsequent high-resolution CT scan of the chest revealed a right-sided Pancoast tumour. This case highlights the importance of a thorough history and examination in identifying a rare cause of shoulder and/or back pain.

Pancoast's syndrome caused by lymph node metastasis from breast cancer.

Pancoast's syndrome may be the result of neoplastic, inflammatory or infectious disease. We report an unusual case of Pancoast's syndrome in a patient with metastatic breast cancer. A 54-year-old woman, affected by metastatic breast cancer, presented for severe shoulder pain, paraesthesia and numbness in the right arm. Despite further multiple lines of systemic chemotherapy, she developed a progressive enlargement of retropectoral, supraclavicular and infraclavicular lymph node metastases, which involved brachial plexus, apex of lung and anterior mediastinum. Physical examination revealed severe weakness of proximal muscles of the right arm. Neuropathic pain was managed with pharmacological treatment. Lastly, the patient has been treated with intrathecal analgesia with morphine and ziconotide with a good control of pain. The patient died after 3 months.

[Modern Management of Pancoast Tumour]. / 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.

Less Invasive Approach to Pancoast Tumor in a Partitioned Incision.

We describe our approach to resect a Pancoast tumor with thoracoscopic assistance in a partitioned incision. We used the LigaSure vessel-sealing system under thoracoscopy in chest wall resection for Pancoast tumor. This approach is of great utility: easy-to use and less invasive for Pancoast tumor resection.

Trimodality therapy for Pancoast tumors: T4 is not a contraindication to radical surgery.

OBJECTIVE: This study aims to evaluate the impact of T stage and extended surgery on the outcome of patients with Pancoast tumors after induction chemoradiation therapy. METHODS: Forty-six consecutive patients who underwent chemoradiation therapy (platin-based, 45-66 Gy) followed by surgery between 1998 and 2013 were retrospectively reviewed and analyzed. RESULTS: In 28 (61%) patients with T4 tumors, extended procedures (more than rib resection) were performed. There were 37 (80%) lobectomies, 6 (13%) pneumonectomies, and 3 (7%) sublobar resections. A total of 44 (96%) patients had R0 resection. About 30-day mortality was 0%, major surgical complications occurred in 9 (19.6%) patients. Overall survival (OS) at 5-years was 63%. Disease-free survival (DFS) at 5-years was 45%. At multivariate cox regression analysis adjusted for clinical factors, T factor (T3/T4) and extended surgical procedures did not impact survival. However, pathological positive N stage had a negative impact on OS and lack of pathological response negatively impacted both OS and DFS. CONCLUSION: Trimodality treatment including radical resection for Pancoast tumors provides good surgical outcome and favorable long-term results. Survival of patients with T4 tumors and extended surgical procedures comparable to that of patients with T3 tumors undergoing rib resection only.

Management of Lung Cancer Invading the Superior Sulcus.

Superior sulcus tumors have posed a formidable therapeutic challenge since their original description by Pancoast and Tobias in the early twentieth century. Initial therapeutic efforts with radiotherapy were associated with high rates of relapse and mortality. Bimodality therapy with complete surgical resection in the 1960s paved the way for trimodality therapy as the current standard of care in the treatment of superior sulcus tumors. The evolution of treatment approaches over time has provided outcomes that come increasingly closer to rivaling those of similarly staged nonapical lung cancer.

A rare presentation of myxofibrosarcoma as a Pancoast tumor: a case report.

BACKGROUND: Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor. CASE PRESENTATION: A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable. Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma. CONCLUSIONS: Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner's syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature.