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Multidisciplinary approach to Pancoast tumors

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1 Multidisciplinary approach to Pancoast tumors
D. Amoroso Dip. Di Oncologia Medica Ospedale Versilia Lido di Camaiore (Lu)

2 La vostra definizione di Tumore di Pancoast
Tumore del solco polmonare superiore che può determinare la sindrome di Pancoast Tumore polmonare caratterizzato dalla sindrome di Pancoast Tumore che origina al di fuori del polmone da residui epiteliali del V arco branchiale Tumore polmonare che determina miosi Tumore polmonare che insorge solo nei fumatori Cross-tab label 23 / 30

3 Introduction Henry Pancoast: early 20th century Tobias JW

4 Introduction Henry Pancoast: early 20th century One region…Many names


6 Arcasoy et al. NEJM 1997

7 Bruzzi et al RG 2008


9 Terminology

10 Clinical Presentation
Arm/shoulder pain Horner’s syndrome Weakness/atrophy or hand muscles Pancoast’s Syndrome

11 Clinical Presentation
Most common initial symptom is shoulder pain, produced by neoplastic involvement of the brachial plexus, parietal pleura, endothoracic fascia, vertebral bodies, and 1st, 2nd, 3rd ribs Treatment for presumed cervical osteoarthritis, or bursitis of the shoulder is not uncommon A delay of months in the correct diagnosis has been reported

12 Horner’s Syndrome Anisocoria, miosis and left-sided ptosis, anhydrosis

13 Differential Diagnosis
Malignant Tumor Pancoast’s Tumor Mesothelioma Lymphoma Metastatic Disease Benign Tumor (most commonly Neurofibroma Pleural Thickening Status post radiation Infection (i.e. TB, fungi, hydatid cysts) Pleural effusion (loculated at apex) Hematoma Extrapleural from aortic rupture Vascular aneurysms Iatrogenic (i.e. after attempted CVC placement) Associated with rib or vertebral fracture

14 La diagnosi, secondo voi
Solo radiologica è sufficiente Si ottiene soprattutto con agobiopsia percutanea Occorre la broncoscopia, la citologia dell’escreato e la RMN E’ clinica e radiologica Va fatta con la PET Cross-tab label 24 / 30

15 Staging/Preoperative Assessment
Limited involvement of the lower trunk or roots (C8 and T1 nerves) of the brachial plexus is regarded as T3 disease Extensive invasion of the brachial plexus trunk or roots (C5 through C7 nerves), subclavian vessels, vertebral bodies, spinal cord, trachea, or esophagus constitutes T4 disease

16 Radiographic findings
X-Ray Unilateral cap > 5mm Asymmetry of bilateral caps > 5 mm Apical mass Bone destruction CT Presence of satellite nodules, parenchymal disease, mediastinal lymphadenopathy MRI Evaluation of brachial plexus, subclavian vessels, vertebral bodies, spinal canal, and chest wall involvement

17 X-Rays findings

18 CT findings

19 MRI scans of tumor of superior sulcus




23 PET scan


25 Diagnostic Work-Up Sputum cytology (10-20%) Bronchoscopy (30-40%)
Percutaneous needle biopsy (90%) VATS Thoracotomy

26 Pathology The most common causes are bronchogenic carcinomas
< 5% of these involve the superior sulcus NSCLC (Squamous & Adeno) predominate Small cell is rare (< 5%)

27 La migliore strategia terapeutica, secondo voi
Consiste nella sola chemioterapia Consiste in un trattamento integrato di chemio-radioterapia preoperatoria e chirurgia Consiste nella sola radioterapia Consiste nella radioterapia seguita da chirurgia Consiste nella chirurgia d’embleè Cross-tab label 24 / 30

28 Treatment Surgery alone Radiotherapy alone Surgery and Radiotherapy
RT followed by en bloc extended surgical resection Chemotherapy/chemoradiotherapy plus surgery

29 Multimodality treatment

30 Marra et al Eur Respir J 2007

31 Marra et al Eur Respir J 2007

32 Surgery

33 Surgery Shaw-Paulson’s thoracotomy (posterior approach)

34 Surgery Anterior transcervical–thoracic and cervicothoracic transmanubrial incisions 34

35 Surgery The transmanubrial (TMA) approach 35

36 Surgery Surgical complications can be summarized as follows:
Mortality rate (approximately 3-5%) Atelectasis Severe chest pain Air leaks Spinal fluid leaks Horner syndrome Pain 36


38 Prognosis Overall 5-year survival rates with preoperative RT and surgical resection: 30% Patients with uninvolved lymph nodes: 30-40% Patients with incomplete resection, mediastinal nodal involvement, or T4 vertebral body invasions: <10% 2/3 patients will have recurrent disease Poor prognostic factors: Presence of Horner’s syndrome Extension of tumor into the base of the neck, great vessels, or vertebral bodies Involvement of mediastinal lymph nodes

39 Rusch et al JCO 2007

40 pCR 29%

41 Rusch et al JCO 2007

42 Rusch et al JCO 2007

43 Rusch et al JCO 2007

44 Rusch, V. W. et al. J Clin Oncol; 25:313-318 2007


46 Fig A1. Study schema of Japan Clinical Oncology Group 9806, with the number of patients who actually received each of the protocol therapy Kunitoh, H. et al. J Clin Oncol; 26:

47 Fig A2. Overall survival according to clinical T stage
Kunitoh, H. et al. J Clin Oncol; 26:

48 Fig A6. Overall survival of patients undergoing surgical resection, with and without pathologic complete response (p-CR) Kunitoh, H. et al. J Clin Oncol; 26:



51 Back up slides


53 Rush VW Lancet Oncology 2006

54 2006

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