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Thoracic Surgery: Answers

249

term

survivors (approximately 5%). However, many of these series

have included patients

with advanced-stage tumors. Among studies

that have involved primarily patients who had a

reasonable chance

of cure, the average median survival time was 16 months and

the average

5-year survival was 20% (range, 15 to 23%).

Treatment with preoperative radiation and resection has resulted

in an average median

survival time of 22 months and a 5-year

survival of 27%. In these series, approximately one

third

of patients underwent an incomplete (R1 or R2) resection, and

approximately one third

of the resections involved only a limited

resection of the affected lobe of the lung.

Retrospective

analysis found that a complete resection with negative margins

(R0) and a

pulmonary resection involving at least a lobectomy

are major factors associated with better

survival. Furthermore,

N2,3 lymph node involvement is a major negative prognostic factor

and should generally be considered a contraindication to surgery.

Patients with vertebral body

or subclavian vessel involvement

have traditionally not been consider for resection, but it

seems

that with improved surgical approaches to these structures,

a few experienced centers

have been able to achieve reasonable

survival in such patients. The presence of Horner

syndrome is

also associated with poor survival.

A large phase II study of preoperative chemoradiotherapy in

patients with Pancoast

tumors showed a complete resection rate

of 92% and a good 2-year survival rate compared

with historical

controls of radiotherapy followed by surgery. Furthermore, local

recurrences

were seen in only 33% of patients with a recurrence,

whereas in series involving preoperative

radiotherapy alone,

the majority of recurrences involved the tumor bed. These data,

combination with the data for non-Pancoast stage III NSCLC,

suggest that preoperative

chemoradiotherapy is a significant

improvement over preoperative radiotherapy, particularly

light of the fact that there are insufficient numbers of patients

with a Pancoast tumor to be

able to complete a randomized comparison.

The Southwest Oncology Group is accruing

patients with Pancoast

tumors into a phase II study of induction chemotherapy with

cisplatin/etoposide and concurrent radiation followed by surgical

resection, followed by

consolidation docetaxel (S0220).

A single-institution, retrospective report using high-dose

three-dimensional radiation as

part of induction chemotherapy

and radiation therapy followed by surgery strategy showed

that

doses up to 60 Gy could be tolerated by most patients without

any significant increase in

postoperative complications. In

37 patients with pretreatment Pancoast tumors stages IIB to

IV, the authors reported a complete resection rate of 97.3%,

with a complete response rate of

40.5%. Overall median survival

time was 2.6 years, and 7.8 years in the group with a

pathologic

complete response. The overall recurrence rate was higher than

most other series at

50%, with 50% of those being in the brain.

References

Shen KR, Meyers BF, Larner JM, et al. Special treatment issues in lung cancer: ACCP

evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3

Suppl):290S-305S.

Komaki R, Roh J, Cox JD, et al. Superior sulcus tumors: results of irradiation of 36 patients.

Cancer. 1981;48,1563-1568.

Millar J, Ball D, Worotniuk V, et al. Radiation treatment of superior sulcus lung carcinoma.

Australas Radiol. 1996;40,55-60.

Shahzad G. Raja

250

Ginsberg RJ, Martini N, Zaman M, et al. Influence of surgical resection and brachytherapy in

the management of superior sulcus tumor. Ann Thorac Surg. 1994;57,1440-1445.

Gandhi S, Walsh GL, Komaki R, et al. A multidisciplinary surgical approach to superior

sulcus tumors with vertebral invasion. Ann Thorac Surg. 1999;68,1778-1785.

Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach

for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc

Surg. 1993;105,1025-1034.

Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for

non-small cell lung carcinomas of the superior sulcus: initial results of Southwest

Oncology Group Trial 9416 (Intergroup Trial 0160). J Thorac Cardiovasc Surg.

2001;121,472-483.

Kwong, K, Edelman MJ, Suntharalingam M, et al. High-dose radiotherapy in trimodality

treatment of Pancoast tumors results in high pathologic complete response rates and

excellent long-term survival. J Thorac Cardiovasc Surg. 2005;129,1250-1257.

Shaw RR, Paulson DL, Kee JL. Treatment of the superior sulcus tumor by irradiation

followed by resection. Ann Surg. 1961;154,29-40.

3.50 Answer: B

In the context of surgical management of superior sulcus tumors, it is useful to

conceptualize the anatomy of the superior sulcus as being divided into anterior, middle, and

posterior compartments by the scalene muscles. The anterior compartment contains the

subclavian vein; the middle compartment (interscalene triangle) contains the subclavian artery

and its branches, as well as the trunks of the brachial plexus; and the posterior compartment

contains the costovertebral groove, the roots of the brachial plexus, and the stellate ganglion.

The superior sulcus is more clearly divided by the scalene muscles into anterior, middle

(interscalene), and posterior compartments. The subclavian vein is anterior to the anterior

scalene muscle. The interscalene compartment contains, from the most superior to the most

inferior level, the trunks of the brachial plexus (superior, middle, and inferior), the subclavian

artery, the Sibson fascia, and the apical pleura. The dorsal scapular artery is present superior

to the subclavian artery and between the inferior and middle trunks of the brachial plexus. A

thin sliver of fat normally separates the apical pleura from the T1 nerve root medially and the

subclavian artery laterally. ObLation of this fat plane typically signifies tumor invasion of the

soft tissues of the superior sulcus and the possibility of tumor involvement of the T1 nerve

root and subclavian artery. However, because the brachial plexus is surrounded by a

connective-tissue sheath, a tumor may indent the brachial plexus and displace the nerve roots

or trunks superiorly without actually invading them. Sensory dysfunction may occur merely

because of extrinsic nerve compression, whereas a loss of motor function is more likely to be

indicative of frank invasion of the nerve.

Lateral to the costal insertion sites of the scalene muscles, the subclavian vessels pass

over the first rib and enter the retropectoral space to become the axillary vessels. The trunks

of the brachial plexus divide as they exit the interscalene compartment and then re-form at a

location superior to the axillary artery as the lateral, posterior, and medial cords of the

brachial plexus. The cords are named with respect to their relationship to the axillary artery.

Thoracic Surgery: Answers

251

References

Bruzzi JF, Komaki R, Walsh GL, et al. Imaging of non-small cell lung cancer of the superior

sulcus: part 1: anatomy, clinical manifestations, and management. Radiographics.

2008;28:551-60.

Komaki R, Putnam JB Jr, Walsh G, et al. The management of superior sulcus tumors. Semin

Surg Oncol. 2000;18 :152-164.

3.51 Answer: E

Absolute contraindications to surgery (Table) include invasion of the brachial plexus

roots or trunks at levels above T1, invasion of more than 50% of a vertebral body, and

invasion of the esophagus or trachea. In addition, N2 (mediastinal) or N3 (contralateral

supraclavicular) nodal metastases and distant metastatic disease are absolute contraindications

to surgery.

The presence of nodal metastases (N1–N3) is associated with a much poorer survival

than is nonmetastatic (N0) disease.Mediastinal lymph node metastases are reported to occur

in up to 20% of patients with superior sulcus tumors, and, accordingly, mediastinoscopy is

advisable in all potential surgical candidates before treatment, both for staging purposes and

for determining the extent of lymph node dissection at the time of surgery. However, whereas

mediastinal (N2) and contralateral supraclavicular (N3) nodal metastases represent absolute

contraindications to surgery, hilar (N1) and ipsilateral supraclavicular (N3) nodal metastases

constitute relative contraindications, because both can be successfully resected with the

primary tumor and do not necessarily preclude long-term survival. PET/CT may usefully

complement mediastinoscopy by depicting unsuspected nodal metastases in sites that are not

accessible with a transcervical approach; in such patients, anterior mediastinoscopy, video-

assisted thoracoscopic surgery, or endobronchial ultra-sonographically guided biopsy may be

necessary to determine nodal status.

Table. Contraindications to surgery in superior sulcus tumors

Absolute contraindications

 N2 (mediastinal) or N3 (contralateral supraclavicular) nodal metastases

 Vertebral body invasion > 50%

 Brachial plexus invasion at a level above the T1 nerve

 Distant metastases

Relative contraindications

 N1 (ipsilateral hilar) or N3 (ipsilateral supraclavicular) nodal metastases

 Vertebral body invasion < 50%

 Intraforaminal extension

 Invasion of the subclavian artery

 Invasion of the common carotid or vertebral artery

Other relative contraindications include invasion of the subclavian vessels, which is often

difficult to establish at imaging prior to surgery. If the subclavian vein is involved, it can be

ligated and resected easily along with the tumor, since collateral venous pathways usually

have developed by the time of diagnosis. Tumors that have invaded the subclavian artery are

Shahzad G. Raja

252

also technically resectable, but resection must be accompanied by vascular reconstruction

with a polytetrafluoroethylene graft. A tumor with intraforaminal extension is potentially

resectable unless there is an anterior spinal artery that enters the spinal canal at that level.

Similarly, tumors that have invaded less than 50% of a vertebral body may be resectable, but

their resection often requires a combined thoracic and neurosurgical approach. Last, invasion

of the common carotid artery or vertebral artery represents another relative contraindication to

surgery. These vessels often have to be ligated to achieve complete resection of a locally

invasive carcinoma. However, if there is significant atherosclerotic disease of the

contralateral vessels, resection may not be feasible. In such instances, CT or MR imaging

may be the first examination that alerts the surgeon to the presence of contralateral

atherosclerosis.

References

Dartevelle

P, Macchiarini P. Surgical management of superior sulcus tumors. Oncologist 1999;4:398-

407.

Rusch

VW, Parekh KR, Leon L, et al. Factors determining outcome after surgical resection of T3

and T4 lung cancers of the superior sulcus. J Thorac Cardiovasc Surg 2000;119: 1147-

1153.

Bruzzi JF, Komaki R, Walsh GL, et al. Imaging of non-small cell lung cancer of the superior

sulcus: part 2: initial staging and assessment of resectability and therapeutic response.

Radiographics 2008;28:561-72.

3.52 Answer: E

Surgical resection of a superior sulcus tumor is most commonly performed via a

posterolateral thoracotomy, also known as the Shaw-Paulson approach. This approach

requires an incision that extends inferiorly between the posterior spinous processes and the

medial aspect of the scapula and then laterally to a point approximately 2 cm below and

lateral to the angle of the scapula. This method allows the en bloc resection of a posteriorly

located tumor and the involved portion of the chest wall as well as a pulmonary lobar

resection or pneumonectomy. A complete resection requires the removal of all ribs that have

been invaded by the tumor and of one uninvolved rib below the inferior margin of the tumor.

CT and MR imaging are useful for planning the extent of the chest wall resection. Although a

posterolateral thoracotomy allows the resection of posteriorly located tumors that have not

invaded the thoracic inlet structures, it provides only limited access to the middle and anterior

compartments of the thoracic inlet, making it more difficult to safely excise a tumor that has

involved the trunks of the brachial plexus or the subclavian vessels. An alternative approach

involves the creation of an L-shaped incision in the anterior chest wall. The first leg of the L

proceeds downward from the midcervical level, anterior and parallel to the

sternocleidomastoid muscle. The second leg extends laterally, parallel to the clavicle in the

intercostal space below the first uninvolved rib. The ribs above this level are excised, along

with the involved portion of the chest wall and the medial portion of the clavicle. The anterior

approach allows greater access to the subclavian vessels and brachial plexus and easier

clearance of supraclavicular lymph nodes; however, pulmonary lobectomy or

pneumonectomy through the resultant chest wall defect may be technically more challenging.

Thoracic Surgery: Answers

253

In addition, resection of the medial portion of the clavicle may result in glenohumeral

instability and functional discomfort. Alternative approaches in which the sternoclavicular

joint is preserved include the transmanubrial approach (extended cervico-sterno-thoracotomy)

and the hemi-clamshell approach. The combined use of both an anterior and a posterolateral

approach has been associated with a higher mortality than the use of either approach alone.

References

Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach

for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc

Surg 1993;105:1025-1034.

Alifano M, D'Aiuto M, Magdeleinat P, et al. Surgical treatment of superior sulcus tumors:

results and prognostic factors. Chest 2003;124: 996-1003.

Bruzzi JF, Komaki R, Walsh GL, et al. Imaging of non-small cell lung cancer of the superior

sulcus: part 1: anatomy, clinical manifestations, and management. Radiographics

2008;28:551-60.

3.53 Answer: D

White light bronchoscopy (WLB) is one of the most commonly used

diagnostic tools for

obtaining a definitive diagnosis of lung

cancer. However, WLB is limited in its ability to

detect small

intraepithelial and microinvasive preinvasive lesions, which

may be only a few

cells thick and might only have a surface

diameter of a few millimeters. Autofluorescence

bronchoscopy

(AFB) was developed to address this limitation by WLB in detecting

intraepithelial and microinvasive or preinvasive lung cancer

lesions. AFB is now an

established technique that has been shown

to be a far more sensitive method of detecting these

lesions

than WLB.

All studies appear to show a lower specificity with AFB compared

to WLB at the expense

of higher sensitivity. Although low specificity

is seen for most screening technologies, such

as mammography

and prostate-specific antigen, lower specificity with AFB is

somewhat

problematic because it might result in more biopsy

specimens with AFB and there is a greater

cost with AFB than

with a minimally invasive screening diagnostic procedure. However,

data

regarding lesions that are positive on autofluorescence

but negative on pathology (false-

positive findings) suggest

that these lesions are not entirely normal. Increased amounts

chromosomal aberration have been found, suggesting that these

lesions may have potential for

progression and therefore may

not truly be benign lesions. The presence of

multiple areas of

abnormal autofluorescence, notwithstanding

the histopathology grade, appears to be a risk

factor for subsequent

development of lung cancer. Pasic et al. evaluated a group

of 46 subjects

with either previous aerodigestive cancer or

sputum atypia and reported that the presence of

two areas of

abnormal autofluorescence increased the risk of subsequent lung

cancer over the

next 4 years compared to subjects with only

one suspicious area (50% vs 8%). Therefore, the

presence of

autofluorescence abnormalities alone may be an indicator of

cancer risk and field

carcinogenesis.

Photodynamic therapy (PDT) is based on the interaction of a photosensitizer with light

narrow bandwidth. In the presence of oxygen, tumor death

occurs by several mechanisms

including vascular shutdown, cell

cycle apoptosis, and direct singlet oxygen membrane injury.

The majority of clinical data using PDT in early lung cancer

have been for treatment of

patients who were deemed nonsurgical

candidates. The greatest experience has emerged from

Shahzad G. Raja

254

Japan in

the past 2 decades. One hundred forty-five

patients with 191 early NSCLCs have

been treated with PDT since

1980. This includes 99 patients with stage 0 and 56 patients

with

stage IA disease. There were 141 men and 4 women. The majority

of cases (98%) were

squamous cell carcinoma (SqCC). Complete response was achieved in

86% of lesions, with a

recurrence rate of 13%, thereby resulting

in a long-term response of 75%. When success of

treatment was

evaluated according to lesion size, lesions < 1.0 cm had

a complete response of

95%, and lesions ≥2 cm had a complete

response of only 46%. Treatment success was also

related to

whether the distal margin of the tumor could be clearly seen

bronchoscopically. If

the margin were visible, a complete response

rate of 92% was achieved, compared to 67% if

the margins were

not visible. If the lesion was < 1.0 cm and the margins were

visible,

complete response was achieved in 98% of cases.

Imamura et al. studied 29 patients (39 cancers) and achieved

complete response in 64% of

lesions. Recurrence occurred in

36%, giving a long-term response of 41%. On evaluation of

lesion

size, 72% of lesions that were < 3 cm

achieved a complete

response. Ono et al. studied

36 patients (39 cancers) and achieved

a complete response rate of only 31%, with a recurrence

in 33%.

Therefore, the long-term response was only 21%. A number of

smaller studies from

Europe and Canada reported complete

response rates of 62 to 91%. A multicenter

investigator-initiated

experience was collated and presented to the Food and Drug

Administration for approval of porfimer sodium in the treatment

of early superficial SqCC. A

total of 102 patients with radiologically

occult (stages 0, IA, and IB) SqCC were treated. An

overall

immediate complete response rate of 78% was achieved (95% confidence

interval, 7 to

87%). Forty-four percent of the patients had

recurrent tumor on follow-up, giving a long-term

response rate

of 43%. The median time to tumor recurrence was 2.8 years (range,

0.1 to 10

years). Analysis of the subgroup of the 24 inoperable

patients revealed a complete response of

92% (95% confidence

interval, 81 to 100%). A similar recurrence rate of 46%, a long-term

response rate of 50%, and a median time to tumor recurrence

of 2.7 years were observed.

The Mayo Clinic has reported treatment of 58 nonsurgical patients

with early lung cancer.

An 84% complete response

rate was achieved after one treatment. Nineteen patients (39%)

recurred and had a second PDT treatment. The median time to

tumor recurrence after the first

treatment was 4.1 years. After

the second treatment, 11 patients (22%) had recurrence. The

long-term complete response rate was 66%. PDT as an alternative

to surgical resection was

studied in 21 patients with small

bronchial cancers. A 71% complete response (15 of 21

patients)

was achieved, with 11 patients (52%) maintaining a complete

response > 12 months.

Patients who did not respond or recurred

were offered surgery. Of the 10 patients who

underwent surgery,

3 were found to have N1 disease. Two patients refused surgery.

A total of

nine patients (43%) were spared surgery.

In summary, PDT is effective in managing small

superficial SqCC.

The worldwide data showed that patients with early lung cancer

treated

with PDT achieve a complete response in approximately

75% cases, with a recurrence rate of

approximately 30%. Complete

response rates > 90% can be achieved when lesions are small

(< 1 cm in diameter), superficial, and all margins can be

visualized. Experience remains

limited using PDT for patients

who are surgical candidates.

References

Kennedy TC, McWilliams A, Edell E, et al. Bronchial intraepithelial neoplasia/early central

airways lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).

Chest. 2007;132(3 Suppl):221S-233S.

Thoracic Surgery: Answers

255

Helfritzsch H, Junker K, Bartel M, et al. Differentiation of positive autofluorescence

bronchoscopy findings by comparative genomic hybridization. Oncol Rep. 2002;9,697-

701.

Pasic A, Vonk-Noordegraaf A, Risse EK, et al. Multiple suspicious lesions detected by

autofluorescence bronchoscopy predict malignant development in the bronchial mucosa

in high risk patients. Lung Cancer. 2003;41,295-301.

Kato H. Photodynamic therapy for lung cancer: a review of 19 years‘ experience. J

Photochem Photobiol B Biol. 1998;42,96-99.

3.54 Answer: E

Bronchial sleeve lobectomy was first introduced by Sir Clement Price-Thomas in 1947 as

a means of parenchymal sparing surgery and in 1954, Allison performed the first sleeve

lobectomy for a bronchogenic carcinoma. While bronchoplastic procedures were initially

utilized in patients with impaired pulmonary function, are currently the procedures of choice

in anatomically suitable patients regardless of whether they would tolerate a larger resection.

A recent meta-analysis comparing the results of sleeve lobectomy and pneumonectomy has

concluded that sleeve lobectomy offers better long-term survival and quality of life than does

pneumonectomy and is more cost effective.

There have been many retrospective analyses of the operative mortality and morbidity of

sleeve lobectomy and pneumonectomy for non-small cell lung cancer. Tedder et al. reported

that 30-day mortality was 5.5%; however in a recent meta-analysis, Ferguson and Lehman

reported that the weighted mean operative mortality was 4.1% (confidence interval [CI], 2.3–

5.9%). On the other hand, the mortality after pneumonectomy was reported as 6.0%

(confidence interval, 1–11%), that is significantly higher than sleeve lobectomy . Deslauriers

et al. reported an operative mortality four times more important after pneumonectomy (5.3%

vs 1.3%, p = 0.036).

More than 20% of early deaths are attributable to respiratory failure. Cardiac events cause

19.8% of early deaths and consist of myocardial infarction, congestive heart failure, and

malignant dysrhythmias. Pulmonary embolism causes 14.3% of deaths. Bronchopleural and

bronchovascular fistulas represent 8.8% and 8.5% of the early deaths, respectively. Death

from empyema occurs only in 2% of bronchoplastic procedures.

References

Yildizeli B, Fadel E, Mussot S, et al. Morbidity, mortality, and long-term survival after sleeve

lobectomy for non-small cell lung cancer. Eur J Cardiothorac Surg. 2007;31:95-102.

Deslauriers J. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative

analysis of survival and sites or recurrences. Ann Thorac Surg. 2004;77:1152-6

Ferguson MK, Lehman AG. Sleeve lobectomy or pneumonectomy: optimal management

strategy using decision analysis techniques. Ann Thorac Surg. 2003;76:1782-8.

Tedder M, Anstadt MP, Tedder SD, Lowe JE. Current morbidity, mortality, and survival after

bronchoplastic procedures for malignancy. Ann Thorac Surg. 1992;54:387-91.

3.55 Answer: B

Hemoptysis after a sleeve lobectomy is an ominous sign and should be taken seriously. It

may represent a herald bleed that is indicative of a bronchovascular fistula between the

airway anastomosis and the adjacent pulmonary artery. A bronchovascular fistula may result

Shahzad G. Raja

256

from excessive dissection of the bronchial ends, excessive tension of the suture line, poor

quality tissues (post irradiation), or technical errors. At the initial operation wrapping the

bronchial anastomosis with pleura, a pericardial fat pad, or muscle may decrease the

incidence of postoperative anastomotic complications.

The patient described in this vignette should be taken to the operating room for a more

careful bronchoscopy. In the presence of anastomotic dehiscence, the airway should not be

disturbed bronchoscopically. The patient must undergo immediate redo thoracotomy and a

completion pneumonectomy performed to avoid the fatal consequences of a bronchovascular

fistula.