Microsurgical DREZotomy for pain related to Pancoast-Tobias syndrome: how I do it?

BACKGROUND: Neuralgic pain related to Pancoast-Tobias syndrome can be difficult to treat. An invasive but effective option for management is open cervical DREZotomy. METHOD: This procedure involves the interruption of the dorsal root entry zone (A delta and C fibers) that sustains the nociceptive pathways. After dura opening, the microsurgical steps are micro incisions of the pia mater under each dorsolateral rootlets and contiguous microcoagulations in the posterolateral sulcus downward to the posterior horn. CONCLUSION: When properly performed in a well-selected patient, DREZotomy is a safe and effective procedure for treating devastating pain related to Pancoast-Tobias syndrome.

Study protocol for JCOG1807C (DEEP OCEAN): a interventional prospective trial to evaluate the efficacy and safety of durvalumab before and after operation or durvalumab as maintenance therapy after chemoradiotherapy against superior sulcus non-small cell lung cancer.

BACKGROUND: Superior sulcus tumours (SSTs) are relatively uncommon and one of the most intractable lung cancers among non-small cell lung cancer (NSCLC). We planned a multicenter, single-arm confirmatory trial of new multidisciplinary treatment using immune-checkpoint inhibitor. The aim is to evaluate the safety and efficacy of new multidisciplinary treatment with perioperative durvalumab after chemoradiotherapy (CRT). METHODS: The primary endpoint is 3-year overall survival. Patients receive induction CRT with sequential two courses of durvalumab, followed by surgical resection for resectable SST. The regimen for CRT is two courses of cisplatin and S-1, and concurrent radiotherapy (66 Gy/33 Fr). After surgery, 22 courses of post-operative durvalumab therapy are administered. For unresectable SST, an additional 22 courses of durvalumab are administered after induction durvalumab. RESULTS: In two cases as a safety cohort, the safety of intervention treatment up to 30 days after surgery was examined, and there were no special safety signals. Patient enrollment has now resumed in the main cohort. CONCLUSIONS: The results of this study may contribute to the establishment of a new standard of care for SST, which is an intractable NSCLC.

Can MRI differentiate surrounding vertebral invasion from reactive inflammatory changes in superior sulcus tumor?

OBJECTIVES: Vertebral invasion is a key prognostic factor and a critical aspect of surgical planning for superior sulcus tumors. This study aims to further evaluate MRI features of vertebral invasion in order to distinguish it from reactive inflammatory changes. METHODS: Between 2000 and 2016, a retrospective study was performed at a single institution. All patients with superior sulcus tumors undergoing surgery, including at least two partial vertebrectomies, were included. An expert radiologist evaluated qualitative and quantitative MRI signal intensity characteristics (contrast-to-noise ratio [CNR]) of suspected involved and non-involved vertebrae. A comparison of CNR of invaded and sane vertebrae was performed using non-parametric tests. Imaging data were correlated with pathological findings. RESULTS: A total of 92 surgical samples of vertebrectomy were analyzed. The most specific sequences for invasion were T1 and T2 weighted (92% and 97%, respectively). The most sensitive sequences were contrast enhanced T1 weighted fat suppressed and T2 weighted fat suppressed (100% and 80%). Loss of extrapleural paravertebral fat on the T1-weighted sequence was highly sensitive (100%) but not specific (63%). Using quantitative analysis, the optimum cut-off (p < 0.05) to distinguish invasion from reactive inflammatory changes was CNR > 11 for the T2-weighted fat-sat sequence (sensitivity 100%), CNR > 9 for contrast-enhanced T1-weighted fat-suppressed sequence (sensitivity 100%), and CNR < - 30 for the T1-weighted sequence (specificity 97%). Combining these criteria, 23 partial vertebrectomies could have been avoided in our cohort. CONCLUSION: Qualitative and quantitative MRI analyses are useful to discriminate vertebral invasion from reactive inflammatory changes. KEY POINTS: • Abnormal signal intensity in a vertebral body adjacent to a superior sulcus tumor may be secondary to direct invasion or reactive inflammatory changes. • Accurate differentiation between invasion and reactive inflammatory changes significantly impacts surgical planning. T1w and T2w are the best sequences to differentiate malignant versus benign bone marrow changes. The use of quantitative analysis improves MRI specificity. • Using contrast media improves the sensitivity for the detection of tumor invasion.

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

BACKGROUND: Pancoast 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 REPORT: We 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.

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.

The Pennsylvania Anatomy Act of 1883: Weighing the Roles of Professor William Smith Forbes and Senator William James McKnight.

Effective Anatomical Acts transformed medical education and curtailed grave-robbing. William S. Forbes, Demonstrator of Anatomy at Jefferson Medical College in Philadelphia, authored the Pennsylvania Anatomy Act of 1867, but it was ineffective. In December of 1882, Forbes and accomplices were charged with grave-robbing. Forbes was acquitted in early 1883, but his accomplices were all convicted; nevertheless, these events precipitated a strengthened Anatomy Act in 1883. Forbes was crowned the Father of the Pennsylvania Anatomy Act and was revered by the Philadelphia medical community for his personal sacrifices for medical education; they even paid his legal fees. Over the remainder of his life, Forbes received many honors. However, there was a second major player, rural doctor William J. McKnight, a convicted grave-robber and State Senator. The evidence shows that Forbes precipitated the crisis, which was a racial powder keg, and then primarily focused on his trial, while McKnight, creatively working behind the scenes in collaboration with Jefferson, Anatomy Professor William H. Pancoast, used the crisis to draft and pass transformative legislation enabling anatomical dissection at Pennsylvania medical schools. While not minimizing Forbes suffering throughout these events, McKnight should be appropriately recognized for his initiative and contributions, which far exceeded those of Forbes.

Superior sulcus non-small cell lung carcinoma: A comparison of IMRT and 3D-RT dosimetry.

AIM: A dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC). BACKGROUND: IMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated. MATERIAL AND METHODS: A dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation. RESULTS: In the patients who received at least 66 Gy, the mean V95% was significantly better with IMRT than 3D-RT (p = 0.043). IMRT delivered a lower D2% compared to 3D-RT (p = 0.043). The IH was significantly better with IMRT (p = 0.043). The lung V 5 Gy and V 13 Gy were significantly higher in IMRT than 3D-RT (p = 0.043), while the maximal dose (D max) to the spinal cord was significantly lower in IMRT (p = 0.043). The brachial plexus D max was significantly lower in IMRT than 3D-RT (p = 0.048). For patients treated with 46 Gy, no significant differences were found. CONCLUSION: Our study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose.

Chest wall reconstruction after en bloc Pancoast tumour resection with the use of MatrixRib and SILC fixation systems: technical note.

STUDY DESIGN: Technical note. OBJECTIVE: In cases in which partial resection of the rib cage is accomplished with vertebrectomy, reconstruction of the chest wall may be challenging. That is because of lack of the anchor point which normally would be a proximal end of a rib or transverse process. We report a straightforward technique for chest wall reconstruction with the novel use of two systems of fixation commonly applied in spinal practice. METHODS: The operation of a squamous cell carcinoma (Pancoast tumour) of the right lung infiltrating T2, T3 and T4 vertebrae was performed though T4 lateral thoracotomy. Posterior instrumentation with transpedicular screws T1-3-5 on the left and T1-5 on the right side was followed with the right upper lobectomy and hemivertebrectomy. The laminae and facet joints of T2-T4 vertebrae were removed on the side of the tumour. An osteotomy was performed medial to the pedicle at the lateral aspect of the dural sac on the side of the tumour. Proximal parts of four adjacent ribs were removed allowing radical en bloc resection with tumour-free margins. The distal end of each of four rib plates used (MatrixRib Precontoured Plate system) was attached to the proximal end of the rib. The proximal end of the plate was then attached to the rod of posterior fixation construct with the use of a flexible polyethylene terephthalate (PeT) band of the SILC™ fixation system. The other end of the PeT band was then passed through the top-loading clamp subsequently attached to the rod of the posterior fixation. RESULTS: The patient did not require additional procedures for chest wall reconstruction. On the 7-month follow-up, in chest CT he was found with satisfactory expansion of the remaining lung tissue with proper spinal alignment and anatomical shape of the rib cage. CONCLUSIONS: The reported technique can be applied for chest wall reconstruction in cases of total or subtotal vertebrectomy accomplished with the resection extending towards rib cage. It appears to be straightforward, safe and effective allowing good cosmetic and functional outcome.

Deciphering the enigmatic symptoms of Pancoast tumors: Navigating the complex landscape of pain management-A case report.

Pancoast tumors, also known as superior sulcus tumors, encompass a diverse spectrum of neoplasms that infiltrate the apex of the chest wall, yielding distinctive clinical presentations. One of the earliest signs of tumor growth is pain radiating to the upper limb, stemming from peripheral nerve involvement, which can mimic joint pain or spinal radicular irritation. In this case report, we present the clinical history of a 64-year-old female smoker who had previously been recommended for orthopedic elbow surgery due to epicondylitis. Subsequent to the development of additional symptoms and rigorous investigation, a Pancoast tumor was diagnosed. Furthermore, we discuss the characteristic treatment modalities available for Pancoast tumors, including pharmacological pain management and interventional strategies such as spinal cordotomy and spinal alcoholysis. This case underscores the significance of recognizing atypical presentations and emphasizes the importance of comprehensive evaluation in the diagnosis and management of Pancoast tumors.

Chest wall resection with robotic-assisted thoracoscopic surgery for a Pancoast tumour: a case report.

We describe a rare procedure involving near-total robotic-assisted thoracoscopic surgery resection of a right posterior Pancoast tumour. Four ports and an assistant port were used. The DaVinci X system was used. The lobectomy was performed first to allow for adequate exposure to the apex and spine. The lateral aspect of ribs 1 to 4 was resected next, and the extrathoracic space was entered. Dissection proceeded through this space superiorly up to the level of the scapula and then posteriorly towards the spine. The second to the fifth ribs were dissected off the chest wall and resected medially off the spine at the rib heads. Further postero-superior exploration revealed the tumour to be invading the transverse process of the second rib, with ill-defined margins. Because of this development, and with the support of the spinal surgeons, a small high posterior thoracotomy was performed to complete the procedure and remove the specimen en bloc. The postoperative recovery was uneventful, and the patient was discharged on post-operative day 5. The final histological report confirmed a squamous non-small-cell lung cancer (pT3N0M0) with negative margins (R0). Asymptomatic recurrence was noted near the margin of the second rib resection posteriorly 1 year postoperatively and was successfully treated with radiotherapy.

Chest wall resections for sulcus superior tumors.

Chemoradiotherapy followed by surgical resection (trimodality therapy) is a guideline recommended treatment for sulcus superior tumors (SST). By definition, SSTs invade the chest wall and therefore require en-bloc chest wall resection with the upper lung lobe or segments. The addition of a chest wall resection, potentially results in higher morbidity and mortality rates when compared to standard anatomical pulmonary resection. This, together with their anatomical location in the thoracic outlet, and varying grades of fibrosis and adhesions resulting from induction chemoradiotherapy in the operation field, make surgery challenging. Depending on the exact location of the tumor and extent to which it invades the surrounding structures, the preferred surgical approach may vary, e.g., anterior, posterolateral, hemi-clamshell, or combined approach; all with their own potential advantages and morbidities. Careful patient selection, adequate staging and discussion in a multidisciplinary tumor board in a center experienced in complex thoracic oncology leads to the best long-term survival outcomes with the least morbidity and mortality. Enhanced recovery guidelines are now available for thoracic surgery, promoting faster recovery and helping to minimize complications and morbidity, including infections and thoracotomy pain. Although minimally invasive surgery can enhance recovery and reduce chest wall morbidity, and is in widespread use in thoracic oncology, its use for SST has been limited. However, this is an evolving area and hybrid surgical approaches (including use of the robot) are being reported. Chest wall reconstruction is rarely necessary, but if so, the prosthetic materials are preferably radiolucent/non-scattering, rigid enough while still being somewhat flexible, and inert, providing structural support, allowing chest wall movement, and closing defects, while inciting a limited inflammatory response. New techniques such as 3D image reconstructions/volume rendering, 3D-printing, and virtual reality modules may help pre-operative planning and informed patient consent.

Durable complete response to PET-CT driven stereotactic radiation therapy plus pembrolizumab for pleomorphic Pancoast cancer: Case report and literature review.

PET-driven SBRT plus pembrolizumab as first-line therapy against pleomorphic Pancoast cancer appears beneficial, probably due to high equivalent doses of SBRT on photopenic necrotic core and synergic immune system stimulation of immunoradiotherapy.

Treatment patterns and outcomes in patients with Pancoast tumors: a national cancer database analysis.

Background: Pancoast tumors represent 5% of non-small cell lung cancers. Complete surgical resection and no lymph node involvement are important positive prognostic factors. Previous literature has identified neoadjuvant chemoradiation treatment, followed by surgical resection, as the standard of care. But many institutions choose upfront surgery. Our goal was to identify the treatment patterns and outcomes in patients with node-negative Pancoast tumors using the National Cancer Database (NCDB). Methods: The NCDB was queried from 2004 through 2017 to identify all patients who had undergone surgery for a Pancoast tumor. Treatment patterns, including the percentage of patients who received neoadjuvant treatment, were recorded. Logistic regression and survival analyses were used to determine outcomes based on different treatment patterns. Secondary analyses were performed on the cohort who received upfront surgery. Results: A total of 2,910 patients were included in the study. Overall 30- and 90-day mortality were 3% and 7% respectively. Only 25% (717/2,910) of the group received neoadjuvant chemoradiation treatment prior to surgery. Patients who received neoadjuvant chemoradiation treatment experienced significantly improved 90-day survival (P<0.01) and overall survival (P<0.01). When analyzing the cohort who received upfront surgery, there was a statistically significant difference in survival based on adjuvant treatment pattern (P<0.01). Patients in this group who received adjuvant chemoradiation had the best survival, whereas patients who received adjuvant radiation only or no treatment had the worst outcomes. Conclusions: Patients with Pancoast tumors receive neoadjuvant chemoradiation treatment in only a quarter of cases nationally. Patients who received neoadjuvant chemoradiation treatment had improved survival compared to patients who had upfront surgery. Similarly, when surgery is performed first, adjuvant chemoradiation treatment improved survival compared to other adjuvant strategies. These results suggest underutilization of neoadjuvant treatment for patients with node-negative Pancoast tumors. Future studies with a more clearly defined cohort are needed to assess the treatment patterns being utilized on patients with node-negative Pancoast tumors. It will be beneficial to see whether neoadjuvant treatment for Pancoast tumors has increased in recent years.

Superior sulcus non-small cell lung cancers (Pancoast tumors): Current outcomes after multidisciplinary management.

OBJECTIVE: Despite neoadjuvant chemoradiotherapy, Pancoast tumors still present surgical and oncologic challenges. To optimize outcomes, we used a multidisciplinary care paradigm with medical and radiation oncology, and involvement of spine neurosurgery for most T3 and all T4 tumors. Spine neurosurgery permitted resection of transverse process for T3 and vertebral body resection for T4 tumors. METHODS: Retrospective analysis of single institution, prospective database of patients undergoing resection for cT3 4M0 Pancoast tumors. Patients were grouped as cT3 with combined resection with spine neurosurgery (T3 Neuro), cT3 without spine neurosurgery (T3 NoNeuro), and cT4. Overall survival, progression-free survival were analyzed by Kaplan-Meier and compared between groups using log-rank test. Cumulative incidence of local-regional and distant recurrence were compared using Gray test. P value <.05 was considered significant. RESULTS: From 2000 to 2021, 155 patients underwent surgery: median age was 58 years, and 81 were (52%) men. Most patients received neoadjuvant platinum-based neoadjuvant chemoradiotherapy (n = 127 [82%]). Operations were 48 cT3 Neuro, 41 cT3 NoNeuro, 66 cT4. R0 resection was achieved in 49 (94%) cT3 NoNeuro, 35 (85%) cT3 Neuro, and 57 (86%) cT4 patients (P = .4). Complete or major pathologic response occurred in 71 (55%) patients. Lower local-regional cumulative incidence was seen in cT3 Neuro versus cT3 NoNeuro (P = .05) and after major pathologic response. Overall survival and progression-free survival were associated with complete response, pathologic stage, and nodal status but not cT category. CONCLUSIONS: This treatment paradigm was associated with a high frequency of R0 resection, complete response, and major pathologic response. cT3 and cT4 tumors had similar outcomes. Novel therapies are needed to improve complete response.

Anatomic evaluation of Pancoast tumors using three-dimensional models for surgical strategy development.

OBJECTIVE: Pancoast tumor resection planning requires precise interpretation of 2-dimensional images. We hypothesized that patient-specific 3-dimensional reconstructions, providing intuitive views of anatomy, would enable superior anatomic assessment. METHODS: Cross-sectional images from 9 patients with representative Pancoast tumors, selected from an institutional database, were randomly assigned to presentation as 2-dimensional images, 3-dimensional virtual reconstruction, or 3-dimensional physical reconstruction. Thoracic surgeons (n = 15) completed questionnaires on the tumor extent and a zone-based algorithmic surgical approach for each patient. Responses were compared with surgical pathology, documented surgical approach, and the optimal "zone-specific" approach. A 5-point Likert scale assessed participants' opinions regarding data presentation and potential benefits of patient-specific 3-dimensional models. RESULTS: Identification of tumor invasion of segmented neurovascular structures was more accurate with 3-dimensional physical reconstruction (2-dimensional 65.56%, 3-dimensional virtual reconstruction 58.52%, 3-dimensional physical reconstruction 87.50%, P < .001); there was no difference for unsegmented structures. Classification of assessed zonal invasion was better with 3-dimensional physical reconstruction (2-dimensional 67.41%, 3-dimensional virtual reconstruction 77.04%, 3-dimensional physical reconstruction 86.67%; P = .001). However, selected surgical approaches were often discordant from documented (2-dimensional 23.81%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .084) and "zone-specific" approaches (2-dimensional 33.33%, 3-dimensional virtual reconstruction 42.86%, 3-dimensional physical reconstruction 45.24%, P = .501). All surgeons agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction benefit surgical planning. Most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction would facilitate patient and interdisciplinary communication. Finally, most surgeons (14/15) agreed that 3-dimensional virtual reconstruction and 3-dimensional physical reconstruction's benefits outweighed potential delays in care for model construction. CONCLUSIONS: Although a consistent effect on surgical strategy was not identified, patient-specific 3-dimensional Pancoast tumor models provided accurate and user-friendly overviews of critical thoracic structures with perceived benefits for surgeons' clinical practices.

Pancoast tumor mimicking lung tuberculosis, a case report.

It is well-recognized that tuberculosis (TB) can mimic several clinical diseases, particularly cancer. On several occasions, lung TB can be misdiagnosed as cancer, particularly in developed countries with a rare case of TB and high incidence of lung cancer, and vice versa- in which Indonesia, with a high incidence of TB, lung cancer may be mistakenly identified as TB, delaying the initiation of definitive therapy and causing unnecessary diagnostic and treatment procedures. We reported a 59-year-old male who complained of right upper chest pain, accompanied by chronic cough and weight loss, with a history of 6-month treatment with a TB regimen without resolution of his symptoms. Core biopsy CT guiding pathology anatomy revealed atypical adenocarcinoma. All patients seeking medical attention must be treated carefully, avoiding diagnostic procedures that can result in a delay in definitive therapy.

Erector Spinae Plane Block for the Treatment of Intractable Pain in a Patient with Pancoast Tumor: A Case Report.

Introduction: The erector spinae plane (ESP) block is a regional anesthetic technique that involves injecting a local anesthetic below the erector spinae muscle in an interfascial plane. Case Presentation: We report a case of a 66-year-old man with cervicothoracic junction pain caused by an advanced Pancoast tumor. The administration of ESP block at the T2-T3 level led to pain relief of more than 50% in this patient after two sessions. Conclusions: Therefore, the application of this method of regional analgesia is both convenient and safe and reduces opioid consumption. Further studies are needed to evaluate the safety and effectiveness of continuous blocks in outpatient settings.

A Patient With Pancoast Tumor Presenting With Cervical Radiculopathy: A Case Report.

Objective: The purpose of this report was to describe a patient with a Pancoast tumor who presented for chiropractic care with neck and arm pain. Clinical Features: A 52-year-old male patient with right-sided cervicothoracic pain and numbness in the right upper extremity presented to a chiropractic office for care. The patient reported an occupational history of repetitive lifting motions and overuse injuries. The patient denied history of smoking at the time of presentation. Intervention and Outcome: Radiographic imaging revealed tracheal deviation. A chest computed tomography image demonstrated a large lesion in the apex of the right lung, suggestive of bronchogenic carcinoma. The patient was referred to an oncology clinic, where he admitted to having a 20-year history of smoking. The diagnosis of adenocarcinoma was made via biopsy, and the oncologist's evaluation confirmed the cancer to be stage IIIC. The patient received palliative care treatments, as the advanced state of his condition determined that he was not a candidate for surgical intervention. Conclusion: Chiropractors and other first-contact health care providers must keep in mind unusual presentations masquerading as common conditions. This case demonstrates the importance of including apical lung tumors in the differential diagnosis of unilateral arm and neck pain and neurologic deficits of the upper extremity. This case demonstrates the importance of thorough follow-up on images ordered, including the ordering clinicians viewing the images themselves.

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.

Genomic profile of Pancoast syndrome due to hepatocellular carcinoma: A case report.

Hepatocellular carcinoma (HCC) is a common cancer and is frequently diagnosed at a late and unresectable stage with limited effective treatment options. Here, we present the fifth reported case of a 77 year-old male with metastatic HCC presenting as a symptomatic superior sulcus lung tumor and discuss the genomic profile of this rare presentation of HCC for the first time, which included multiple classic mutations in HCC such as TERT, TP53, and WNT/ß-catenin signaling as well as in the DNA repair gene ATM. The patient was treated with palliative radiotherapy to the Pancoast tumor followed by atezolizumab plus bevacizumab and passed away 6 months after diagnosis. This rare case highlights the need for effective treatment in aggressive and unresectable HCC and the utility of early genomic studies to allow for targeted therapy such as poly (ADP-ribose) polymerase (PARP)-inhibitors.