This document discusses the surgical approach for Pancoast tumors, which are lung cancers located in the superior pulmonary sulcus that can invade nearby structures. It covers the anatomy, clinical presentation including Horner's syndrome, diagnosis with biopsy and imaging, staging, and treatment with induction chemoradiation followed by surgical resection. The key surgical techniques described are the Shaw-Paulson posterior approach and Dartevelle transclavicular anterior approach. Post-operative care and follow up are also outlined.

1. SURGICAL APPROACH
TO PANCOAST TUMOR
Dr Mohammad Masoom
Parwez
M Ch Resident
Department of Surgical
Oncology

2. INTRODUCTION
Superior sulcus tumor - 1st described in 1838 - Henry
Pancoast
Earlier believed to arise from embryonal rests of 5th
branchial cleft
Recently, believed to have pulmonary origin
Aka Pancoast tumor, Pancoast-Tobias tumor, Superior sulcus
or Superior pulmonary sulcus tumors
Located at apical pleuro-pulmonary groove, adjacent to
subclavian vessels

3. Ipsilateral
Horner
syndrome
Wasting
of Hand
muscles
Shoulder
/ Arm
Pain
Pancoast syndrome
Pancoas
t tumor
+

4. PULMONARY SULCUS - ANATOMY
Comprises of thoracic costo-vertebral gutter on either side
of vertebral column
Area on the superior surface of lung
Encircled by the 1st rib and spine
Superiorly - Arch of 1st rib
Inferior margin is not well defined

9. CLINICAL MANIFESTATIONS
Shoulder and arm pain (distribution of C8, T1 and T2 dermatomes)
Horner Syndrome (ipsilateral ptosis, miosis, anhidrosis)
Pulmonary symptoms - cough, hemoptysis, dyspnea are uncommon
Shoulder Pain - most common initial symptom (44-96%)
Invasion of brachial plexus, extension into parietal pleura,
endothoracic fascia, 1st and 2nd ribs, or vertebral bodies
Pain can progress and radiate upto head and neck, down to medial
aspect of scapula, axilla, anterior chest, ipsilateral arm (ulnar nv)

12. HORNER SYNDROME
Ipsilateral Ptosis with narrowing of
palpebral fissure
Miosis
Enophthalmos
Anhidrosis
Present in 14-83% of patients
Involvement of paravertebral
sympathetic chain and inferior
cervical (stellate) ganglion

13. HORNER SYNDROME
Ipsilateral flushing and
increased sweating of face -
initial presentation
Irritation of sympathetic chain
by tumor, before frank invasion
Contralateral facial sweating
and flushing with exercise -
excessive response by intact
sympathetic pathway
(HARLEQUIN SIGN)

15. NEUROLOGICAL COMPLICATION
Extension of tumor to C8 and T1 nerve roots
8 - 22% of cases
Weakness and atrophy of intrinsic muscles of hand
Pain and paresthesia of 4th and 5th digit and medial aspect of arm and
forearm
Abnormal sensation and pain in T2 region (axilla and medial aspect of
upper arm)
Loss of triceps reflex
Invasion of intervertebral foramina - 5% cases - spinal cord compression
and paraplegia

16. OTHER FINDINGS
Supraclavicular lymph node enlargement
Prominent weight loss
25-35% cases
Phrenic or recurrent laryngeal neuropathy or SVC syndrome
(5-10% cases)

17. DIAGNOSIS
Core needle biopsy - confirm histology and molecular
markers
Majority diagnosed by percutaneous needle biopsy
Posterior or Cervical approach with help of biplane
fluoroscopy/USG/CT
Diagnostic yields >90%
VATS / thoracotomy - if biopsy is non-diagnostic
Bronchoscopy - low diagnostic yield - peripheral location of
tumor

19. PATHOLOGY
Majority are NSCLC (95%)
However, only 5% of all NSCLC arise in this location
Squamous cell > Adenocarcinoma
Molecular testing for EGFR, ALK, ROS1, PD-1
in stage IV patients
not candidates for local therapies
who recur after definitive local treatment

20. DIFFERENTIAL DIAGNOSIS
Lymphoma
Tuberculosis
Adenoid cystic carcinoma
Hemangiopericytoma
Mesothelioma
Plasmacytoma
Metastatic malignancies from cervix, larynx, liver, bladder, and
thyroid gland
Vascular aneurysms, amyloid nodules, cervical rib syndrome, chronic
infections - can result in Pancoast Syndrome

21. STAGING
Staged same as NSCLC located elsewhere in thorax
Typically T3 or T4 lesions - chest wall/ brachial plexus,
mediastinum, vertebral bodies
In the absence of mets to scalene, SCLN, C/L mediastinal
nodes or distant sites; usually stage IIB (T3N0), IIIA (T3N1 /
T4N0-1), IIIB (T3-4N2)

23. PRE-TREATMENT EVALUATION
Determine patient’s ability to tolerate resection
Cardiovascular and pulmonary risk stratification
Shared decision making discussion about risks and benefits
Complete history, physical examination, blood tests and
imaging
CT chest and upper abdomen - evaluate mediastinum, liver
and adrenals
PET - regional LN mets as well as distent mets

24. INITIAL IMAGING
Radiographic findings - Unilateral apical cap >5mm, assymetry of
bilateral apical caps >5mm, an apical mass, bone destruction
CT - tumor and its extension, satellite pulmonary nodules, parenchymal
disease, hilar / mediastinal LN.
CT however limited for brachial plexus, subclavian vessels, and chest
wall involvement (MRI being more accurate)
MRI - also in evaluating vertebral bodies and spinal canal for tumor
extension
MRA - vascular involvement of subclavian artery

26. MEDIASTINAL EVALUATION
PET-CT more accurate than CT
PET are routinely performed for staging evaluation
Surgical staging of mediastinum - generally undertaken prior to
attempts at curative surgery - even if PET negative
PET also most sensitive test for distant mets in liver, adrenal gland
and other LN
EBUS - useful tool especially with enlarged/PET +ve LN in
mediastinum
N2 or N3 mets on EBUS precludes need for mediastinoscopy

27. BRAIN IMAGING
MRI/CT brain - complementary staging information
Recommendation - Routine preoperative brain MRI for
superior sulcus tumor
High propensity for brain mets from bronchogenic CA in this
location

28. TREATMENT
Resectable - CCRT - initial step followed by surgical
resection and post-operative chemotherapy
Adjuvant Atezolizumab - now used for patients with stage II
- IIIA NSCLC with PDL1 expression >1%
Adjuvant Osimertinib - patients with resected EGFR +ve
NSCLC

29. INDUCTION CHEMOTHERAPY +
SURGERY
Patients with locally advanced, stage III NSCLC, RCTs
demonstrated induction chemo f/b definitive RT improves
survival compared to RT alone
Further studies showed that CCRT - additional survival
advantage over sequential treatment
No RCTs comparing induction chemo with preop RT or
surgery alone in such patients, several studies focussed on
this approach

30. INDUCTION CHEMO RT + SURGERY
A best evidence analysis of literature concluded that induction
chemo RT followed by Sx - survival advantage compared with RT
f/b Sx or Sx alone
North American* prospective study - 111 patients - evaluated
CCRT (2 cycles of CIS + ETO) and thoracic RT (45Gy in 25#) - f/b
sx after 3-5 weeks - and 2 cycles of post-op chemo
Eligible patients with pT3-4,N0-1 NSCLC , post staging
mediastinoscopy
Results: 80% - underwent thoracotomy, 76% complete R0
resection; OS- 44% at 5 yrs
*Induction chemoradiation and surgical resection for NSCLC of superior sulcus: Initial results of SWOG trial 9416 (Intergroup Trial
0160); Rusch VW et al; J Thorac Cardiovasc Surg.2001;121(3):472

31. INDUCTION CHEMO RT + SURGERY
Japanese study* - 2 cycles of chemo with mitomycin,
vindesine, and cisplatin concurrent with split course RT
(45Gy in 25#) - f/b surgery 2-4 weeks later
76 patients enrolled, 57 underwent surgery, 51 had R0
resection. 12 cases of pCR. DFS and OS were 45 and 56%. 3
treatment related deaths
*Phase II Trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus NSCLC: report of Japan
Clinical Oncology Group trial 9806 ; Kunitoh H et al; J Clin Oncol. 2008;26(4):644

32. INDUCTION CHEMO RT + SURGERY
French study* - 107 patients - treated with induction chemoRT
(cisplatin and etoposide)
Patients with bulky N2/N3 disease were excluded
72 had thoracotomy, 21 pneumonectomy performed
pCR in 40% cases
OS was 55 and 40% at 2 and 3 years
Median survival was 26.7 months
*Concurrent Cisplatin/etoposide plus 3D conformal radiotherapy followed by surgery for stage IB superior sulcus T3N0 NSCLC yields a
higher rate of pathological complete response; Pourel N et al; Eur J Cardiothorac Surg.2008;33(5):829

33. CHOICE OF REGIMEN
North America Intergroup study - Concurrent thoracic RT (45
Gy over 5 weeks in daily 1.8 Gy #) and chemotherapy,
consisting of 2 cycles of cisplatin (50mg/m2 on day 1, 8, 29,
and 36) and etoposide (50mg/m2 on days 1-5 and 29-33)
Thoracotomy for tumor resection three to five weeks after
chemoRT
Two additional post-operative courses of chemotherapy with
platinum based doublet

34. ADJUVANT DOCETAXEL
SWOG 9504 - phase II study with consolidation docetaxel after
definitive chemoradiotherapy in stage III NSCLC - with favorable
results
Lung intergroup completed a trial (SWOG-S0220) in patients with
pancoast tumor, single agent docetaxel following surgery was not
feasible.
Another phase III confirmatory trial demonstrated that
consolidation docetaxel did not lead to improved survival and
increased toxicities
Incorporation of immunotherapy in neoadjuvant regimens is not a
standard approach

35. SURGERY
Generally after 3-5 weeks of completion of chemoRT
Typically carried out through en-bloc resection of tumor and
chest wall, depending upon extent of local invasion
May require resection of paravertebral sympathetic chain,
stellate ganglion, lower trunks of brachial plexus, subclavian
artery, or portions of thoracic vertebrae.

36. SHAW-PAULSON POSTERIOR
SURGICAL TECHNIQUE
General anaesthesia
Double lumen endotracheal tube
Lateral decubitus position with an axillary roll
Incision: above angle of scapula, halfway b/w it and spinous
process, angling around the tip inferiorly
Divide subcutaneous tissue, trapezius and rhomboid muscle

37. STEPS
Intercostal muscle incised over 4th rib
Fourth interspace opened and retracted
Tumor palpated and extent is determined, no of ribs
involved and length of ribs to be resected
Larger tumor, lower interspace preferred
Ribs divided anteriorly and posteriorly, superiorly up and
through the 1st rib

39. STEPS
Intercostal bundles cauterized or clipped
Finger palpation both anterior and posteriorly to identify
relationship with c8/t1 nv roots, lower trunk and subclavian
vessels
Scalenus anticus and medius divided – t1 nv root divided
posteriorly, c8 visualised and divided if necessary
Subclavian artery dissected from tumor
If involved, interposition graft (e.g autologous saphenous
vein)

41. STEPS
Lobectomy performed after en bloc chest wall resection
Segmental resection – higher local recurrence
No chest wall reconstruction – scapula covers the defect
If anterior, usually covered with mesh
Wound closed in layers

43. DARTEVELLE TRANSCLAVICULAR
TECHNIQUE
Anterior approach
Supine position, neck hyperextended and turned away from
tumor
Rolled towel under shoulders
Prepped from angle of mandible to below costal margin
c/l mid clavicular line to i/l midaxillary line
Superiorly beyond the shoulder

45. DARTEVELLE TRANSCLAVICULAR
TECHNIQUE
Incision: L-shaped incision along anterior border of scm, a
few cm below and parallel to clavicle into delto-pectoral
groove
Sternal attachment of SCM and upper digitations of pectoral
muscle divided
Medial half of clavicle Removed and thoracic inlet exposed
Omohyoid divided, scalene fat pad removed and checked for
mets
Anterior scalene muscle divided, phrenic nerve preserved

47. DARTEVELLE TRANSCLAVICULAR
TECHNIQUE
Dissection of subclavian artery and its branches to facilitate
mobilization
Middle scalene muscle divided to better expose brachial plexus
Nerve roots divided and roots ligated to prevent CSF leak
Paravertebral muscles along with paravertebral sympathetic chain
and stellate ganglion resected safely
1st rib divided , 2nd and 3rd rib can also be resected en bloc with
tumor if needed
Upper lobectomy performed
Incision closed

49. OSTEOMUSCULAR SPARING
APPROACH
Sternoclavicular joint is preserved
Incision is same, SCM mobilised, pectoral muscles is split
below the clavicle
L shaped incision in manubrium with sternal saw
Proximal internal mammary art ligated and 1st costal
cartilage resected
The clavicle with attached pectoral and SCM muscle elevated
as OM flap

52. OSTEOMUSCULAR SPARING
APPROACH
Rest of steps remain similar
For closure, manubrium reapproximated with two sternal
wire
Aesthetic and functional outcome – superior
Preservation of shoulder girdle architecture
Negative aspect: suboptimal exposure for lobectomy and
vascular dissection more challenging

53. HEMI-CLAMSHELL OR TRAPDOOR
INCISION
Excellent exposure of anterior mediastinum and chest apex
Incision: median sternotomy down to 4th ICS with lateral
extension along intercostals
Mammary artery ligated proximally
Some recommend resection of medial clavicle (Dartevelle)
Posterior thoracic dissection is difficult relatively

55. VASCULAR RESECTION
Artery properly exposed
Vein mobilised and divided proximal and distal to tumor
Artery prepared for proximal and distal control by dividing
scalenus muscles
Phrenic nerve preserved
Internal mammary and ascending cervical artery divided
Vertebral artery sacrificed if involved
Tumor dissected away in sub adventitial plane, if media involved -
resection

56. VASCULAR RESECTION
Systemic heparinization performed with 5000IU iv heparin
Artery clamped proximally and distally and resected en-bloc
Reconstruction done once resection is complete
End to end anastomosis preferred
PTFE graft – alternative
Reversal of heparin - protamine

58. EXTENT OF RESECTION
Determined by the size and location of primary tumor and patient’s
underlying pulmonary function
Lobectomy for lung cancer is preferable procedure over sublobar
resections with fewer local recurrences and better survival
Combined thoracic-neurosurgical approach is necessary for tumors
invading brachial plexus and/or spine
Recent advances in spinal instrumentation have allowed Ro
resections of tumors involving vertebral body

59. COMBINED CHEST WALL
RESECTION WITH
VERTEBRECTOMY AND SPINAL
RECONSTRUCTION

63. CONTRAINDICATIONS

64. POST OPERATIVE CARE
Similar to lung resection
Atelectasis very common
Good post op analgesia, adequate pleural drainage, aggressive
pulmonary toilet
Hourly vascular checks of involved limb
Iv heparin within 4-6 hours, aspirin when ambulatory
Arm elevation and lymphatic massage
Arm sling for 4-6 weeks if clavicle divided

65. FOLLOW UP
After arterial resection- duplex studies at 3 and 6 months
and annually thereafter
Bp measured in both limbs at each visit
Significant stenosis on duplex (>85%) – angiography
In graft occlusion , no intervention needed unless
symptomatic
5 year patency 85%

66. NEUROLOGICAL SEQUELAE
Weakness of intrinsic muscles of hand after T1 nerve root
division
Hand is usually functional
C8 or lower trunk divided, permanent paresis expected
Due to slow growth of tumor, usually other nerve roots
assume function
Surgical morbidity 38%, mortality 5-10%

67. COMPLICATIONS
Extirpation of superior sulcus tumor may result in
Chylothorax
Ulnar nerve palsy secondary to resection of C8 nerve root
Horner syndrome - resection of stellate ganglion and
sympathetic chain
CSF leak and meningitis
Resection of T1 and T2 nerve roots - no major clinical
sequelae
Reported surgical morbidity - 4 - 10%

68. COMPLICATIONS
Irradiation – skin fibrosis, fatigue, esophagitis, radiation
pneumonitis, pulmonary fibrosis, myelitis and brachial
neuritis
Chemo – myelosuppression, increased risk of bleeding and
infection, peripheral or central neuropathy, renal
insufficiency, mucositis, nausea, vomiting, diarrhea

69. CHEMOTHERAPY OR RT ALONE (NO
SX)
Locally advanced, unresectable (N2/N3 disease) and those
medically inoperable - offer ChemoRT
In case of non - Pancoast stage III NSCLC, concurrent
chemoRT has been shown to be superior to RT alone and is
standard of care
Adjuvant Durvalumab for 1 year after ChemoRT - standard
for stage III NSCLC

70. RT ALONE
Suitable for patients with metastatic tumors or poor
performance status
Also palliates pain in upto 90% of patients
Dose of 60-66 Gy generally recommended for definitive
treatment of unresectable disease
Lower dose 30 Gy is reasonable for palliation in those with
distant metastases
5 year OS - upto 40% for radical RT (localised disease*)

71. PROGNOSTIC FACTORS
Presence of Horner syndrome
Extension into base of neck,Vertebral bodies, Great vessels
Involvement of mediastinal LN - all having worse prognosis
Also longer duration of symptoms, poor histological subtype
- bad prognosis
Good PS and weight loss <5% body weight - better survival
Local control by RT / Sx ; pain relief; pCR - better prognosis
and survival

72. POST TREATMENT SURVEILLANCE
Evidence from studies do not establish a clear benefit of
aggressive surveillance following curative treatment
ASCO and NCCN guidelines differ in their use of imaging
studies
Generally a history, physical examination, CT of the chest
every 3-6 monthly for 1st three years
Then every six monthly for two years and annually thereafter

73. SUMMARY AND RECOMMENDATIONS
Distinct constellation of presenting signs and symptoms
Mostly NSCLC
Initial concurrent chemoRT f/b surgical resection (after 3-5 weeks )
f/b two cycles of platinum based doublet chemo
Adjuvant Atezolizumab - resected stage II to IIIa NSCLC with PDL1 +
Adjuvant Osimertinib - EGFR +
Definitive chemoRT and adj Durvalumab x 1yr - medically inoperable
and locally advanced
Distant metastases or poor PS - radical RT
Whenever possible, enroll in prospective clinical trials for optimal
therapy

74. REFERENCES
N. Barbetakis (2012). Pancoast Tumors: Surgical Approaches and Techniques, Topics in
Thoracic Surgery,
Prof. Paulo Cardoso (Ed.), ISBN: 978-953-51-0010-2, InTech, Available from:
http://www.intechopen.com/books/topics-in-thoracic-surgery/pancoast-tumors-surgical-
approaches-andtechniques
Postero-Lateral (Shaw-Paulson) Approach to Pancoast Tumor
Published on CTSNet (https://www.ctsnet.org)
Combined chest wall resection with vertebrectomy and spinal reconstruction for the
treatment of Pancoast tumors J Neurosurg (Spine 1) 91:74–80, 1999
Cervical Approach for Percutaneous Needle Biopsy of Pancoast Tumors Donald L.
Paulson, M.D

75. THANK YOU