Pancoast tumor surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Pancoast tumor}} | {{Pancoast tumor}} | ||
{{CMG}}{{AE}}{{Mazia}} | {{CMG}}; {{AE}} {{Mazia}} | ||
==Overview== | ==Overview== | ||
[[Surgery]] is the mainstay of [[therapy]] for early-stage Pancoast tumor. [[Surgical procedure]] selection will depend on the [[histology]], margins, and [[Tumor|size of the tumor]]. Common [[surgical procedures]] for the [[Treatments|treatment]] of Pancoast tumor | [[Surgery]] is the mainstay of [[therapy]] for early-stage Pancoast tumor. [[Surgical procedure]] selection will depend on the [[histology]], margins, and [[Tumor|size of the tumor]]. Common [[surgical procedures]] for the [[Treatments|treatment]] of Pancoast tumor include [[lung]] [[resection]] with [[lobectomy]], [[lung]] [[resection]] with [[pneumonectomy]] with or without [[Lymph nodes|lymph node]] [[dissection]], [[thoracotomy]] with the removal of the entire [[lung]] or [[lobe]] ([[lobectomy]]) along with regional [[lymph nodes]] ([[Peribronchial cuffing|peribronchial]] and perihilar [[lymph node]] [[dissection]]), and [[pathological]] evaluation. If evidence of [[lymph node]] [[extension]] of the [[disease]] is present [[adjuvant chemotherapy]] should be administered. [[Surgical resection]] is not recommended for [[patients]] with advanced or [[metastatic]] [[lung carcinoma]]. [[Surgery|Surgical]] [[Cancer staging|staging]] of the [[mediastinum]] is considered standard if accurate evaluation of the [[Lymph node metastases|nodal status]] is needed to determine [[therapy]]. [[Surgery|Surgical]] [[Treatments|treatment]] consists of a [[thoracotomy]] with removal of the entire [[lung]] or [[lobe]] along with regional [[lymph nodes]] and contiguous structures. [[Pneumonectomy]] is used if the [[tumor]] involves the [[main bronchus]], extends across a [[fissure]] or is located such that [[Excision|wide excision]] is required. Survival following ‘curative’ [[resection]] is approximately 30% at 5 years and 15% at 10 years. The best results are found in [[squamous cell carcinoma]] followed by [[Large-cell lung carcinoma|large-cell carcinoma]] and the [[adenocarcinoma]]. If the [[tumor]] is inoperable, [[Stereotactic radiosurgery|stereotactic ablative radiation therapy]] should be administered. | ||
==Surgery== | ==Surgery== | ||
In [[non-small cell lung cancer]], [[surgical procedure]] selection will depend on the [[histology]], margins, and [[Tumor|size of the tumor]].<ref name="pmid22054885">{{cite journal |vauthors=von Groote-Bidlingmaier F, Koegelenberg CF, Bolliger CT |title=Functional evaluation before lung resection |journal=Clin. Chest Med. |volume=32 |issue=4 |pages=773–82 |year=2011 |pmid=22054885 |doi=10.1016/j.ccm.2011.08.001 |url=}}</ref><ref name="pmid16618956">{{cite journal |vauthors=Smetana GW, Lawrence VA, Cornell JE |title=Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians |journal=Ann. Intern. Med. |volume=144 |issue=8 |pages=581–95 |year=2006 |pmid=16618956 |doi= |url=}}</ref><ref name="surgery">Surgery of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/treatment/surgery/?region=ab</ref> | In [[non-small cell lung cancer]], [[surgical procedure]] selection will depend on the [[histology]], margins, and [[Tumor|size of the tumor]].<ref name="pmid22054885">{{cite journal |vauthors=von Groote-Bidlingmaier F, Koegelenberg CF, Bolliger CT |title=Functional evaluation before lung resection |journal=Clin. Chest Med. |volume=32 |issue=4 |pages=773–82 |year=2011 |pmid=22054885 |doi=10.1016/j.ccm.2011.08.001 |url=}}</ref><ref name="pmid16618956">{{cite journal |vauthors=Smetana GW, Lawrence VA, Cornell JE |title=Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians |journal=Ann. Intern. Med. |volume=144 |issue=8 |pages=581–95 |year=2006 |pmid=16618956 |doi= |url=}}</ref><ref name="surgery">Surgery of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/treatment/surgery/?region=ab</ref><ref name="pmid19010280">{{cite journal |vauthors=Davis GA, Knight SR |title=Pancoast tumors |journal=Neurosurg. Clin. N. Am. |volume=19 |issue=4 |pages=545–57, v–vi |date=October 2008 |pmid=19010280 |doi=10.1016/j.nec.2008.07.002 |url=}}</ref><ref name="pmid27079507">{{cite journal |vauthors=Rosso L, Palleschi A, Mendogni P, Nosotti M |title=Video-assisted pulmonary lobectomy combined with transmanubrial approach for anterior Pancoast tumor resection: case report |journal=J Cardiothorac Surg |volume=11 |issue=1 |pages=65 |date=April 2016 |pmid=27079507 |pmc=4831106 |doi=10.1186/s13019-016-0446-7 |url=}}</ref><ref name="pmid25052071">{{cite journal |vauthors=Caronia FP, Fiorelli A, Ruffini E, Nicolosi M, Santini M, Lo Monte AI |title=A comparative analysis of Pancoast tumour resection performed via video-assisted thoracic surgery versus standard open approaches |journal=Interact Cardiovasc Thorac Surg |volume=19 |issue=3 |pages=426–35 |date=September 2014 |pmid=25052071 |doi=10.1093/icvts/ivu115 |url=}}</ref><ref name="pmid21471804">{{cite journal |vauthors=Hubbard MO, Schroeder C, Linden PA |title=Routine use of staging thoracoscopy for pancoast tumors without overt radiographic chest wall invasion |journal=Surg Laparosc Endosc Percutan Tech |volume=21 |issue=2 |pages=111–5 |date=April 2011 |pmid=21471804 |doi=10.1097/SLE.0b013e31821a3cb0 |url=}}</ref><ref name="pmid19699106">{{cite journal |vauthors=Tamura M, Hoda MA, Klepetko W |title=Current treatment paradigms of superior sulcus tumours |journal=Eur J Cardiothorac Surg |volume=36 |issue=4 |pages=747–53 |date=October 2009 |pmid=19699106 |doi=10.1016/j.ejcts.2009.04.036 |url=}}</ref> | ||
*[[Surgery]] is the mainstay of [[therapy]] for early-stage Pancoast tumor . | *[[Surgery]] is the mainstay of [[therapy]] for early-stage Pancoast tumor. | ||
*Common [[surgical procedures]] for the [[Treatments|treatment]] of Pancoast tumor | *Common [[surgical procedures]] for the [[Treatments|treatment]] of Pancoast tumor include: | ||
:*[[Lung]] [[resection]] with [[lobectomy]] | :*[[Lung]] [[resection]] with [[lobectomy]] | ||
:*[[Lung]] [[resection]] with [[pneumonectomy]] with or without [[lymph node]] [[dissection]] | :*[[Lung]] [[resection]] with [[pneumonectomy]] with or without [[lymph node]] [[dissection]] | ||
:*The preferred [[surgical procedure]] is [[thoracotomy]] with the removal of the entire [[lung]] or [[lobe]] ([[lobectomy]]) along with regional [[lymph nodes]] (peribronchial and perihilar [[lymph node]] dissection) and [[pathological]] evaluation. | :*The preferred [[surgical procedure]] is [[thoracotomy]] with the removal of the entire [[lung]] or [[lobe]] ([[lobectomy]]) along with regional [[lymph nodes]] (peribronchial and perihilar [[lymph node]] dissection) and [[pathological]] evaluation. | ||
*If evidence of [[lymph node]] [[extension]] of the [[disease]] is present [[adjuvant chemotherapy]] should be administered | *If evidence of [[lymph node]] [[extension]] of the [[disease]] is present [[adjuvant chemotherapy]] should be administered. | ||
*[[Surgical resection]] is not recommended for [[patients]] with advanced or [[metastatic]] [[lung carcinoma]] | *[[Surgical resection]] is not recommended for [[patients]] with advanced or [[metastatic]] [[lung carcinoma]]. | ||
*[[Surgery|Surgical staging]] of the [[mediastinum]] is considered standard if accurate evaluation of the [[Lymph node metastases|nodal status]] is needed to determine [[therapy]] | *[[Surgery|Surgical staging]] of the [[mediastinum]] is considered standard if accurate evaluation of the [[Lymph node metastases|nodal status]] is needed to determine [[therapy]]. | ||
*[[Surgeries|Surgical treatment]] consists of a [[thoracotomy]] with removal of the entire [[lung]] or [[lobe]] along with regional [[lymph nodes]] and contiguous structures | *[[Surgeries|Surgical treatment]] consists of a [[thoracotomy]] with removal of the entire [[lung]] or [[lobe]] along with regional [[lymph nodes]] and contiguous structures. | ||
*[[Pneumonectomy]] is used if the [[tumor]] involves the main [[bronchus]], extends across a [[fissure]] or is located such that wide [[excision]] is required. | *[[Pneumonectomy]] is used if the [[tumor]] involves the main [[bronchus]], extends across a [[fissure]] or is located such that wide [[excision]] is required. | ||
*[[Survival analysis|Survival]] following ‘curative’ [[resection]] is approximately 30% at 5 years and 15% at 10 years. | *[[Survival analysis|Survival]] following ‘curative’ [[resection]] is approximately 30% at 5 years and 15% at 10 years. | ||
| Line 30: | Line 30: | ||
::* [[Tumour|Tumours]] are considered unresectable if: | ::* [[Tumour|Tumours]] are considered unresectable if: | ||
:::* They are too large to completely remove | :::* They are too large to completely remove | ||
:::* The [[cancer]] has spread to certain [[mediastinal lymph nodes]], other [[organs]] near the [[lungs]] or to distant sites | :::* The [[cancer]] has spread to certain [[mediastinal lymph nodes]], other [[organs]] near the [[lungs]], or to distant sites | ||
:::* There is [[pleural effusion]] or [[pericardial effusion]] present | :::* There is [[pleural effusion]] or [[pericardial effusion]] present | ||
| Line 68: | Line 68: | ||
'''Extended pulmonary resection''' | '''Extended pulmonary resection''' | ||
* Extended [[pulmonary]] [[resection]] is used to treat [[Tumour|tumours]] that have spread to the [[chest wall]], [[diaphragm]], [[nerves]], [[blood vessels]] or other [[tissues]] near the [[lung]]. During [[surgery]], a complete section (en bloc) of the surrounding [[tissue]] is removed to try to take out as much of the [[cancer]] as possible. | * Extended [[pulmonary]] [[resection]] is used to treat [[Tumour|tumours]] that have spread to the [[chest wall]], [[diaphragm]], [[nerves]], [[blood vessels]], or other [[tissues]] near the [[lung]]. During [[surgery]], a complete section (en bloc) of the surrounding [[tissue]] is removed to try to take out as much of the [[cancer]] as possible. | ||
'''Sleeve resection''' | '''Sleeve resection''' | ||
| Line 121: | Line 121: | ||
[[Surgery]] is usually reserved for [[patients]] with the following characteristics:<ref name="pmid22054885">{{cite journal |vauthors=von Groote-Bidlingmaier F, Koegelenberg CF, Bolliger CT |title=Functional evaluation before lung resection |journal=Clin. Chest Med. |volume=32 |issue=4 |pages=773–82 |year=2011 |pmid=22054885 |doi=10.1016/j.ccm.2011.08.001 |url=}}</ref> | [[Surgery]] is usually reserved for [[patients]] with the following characteristics:<ref name="pmid22054885">{{cite journal |vauthors=von Groote-Bidlingmaier F, Koegelenberg CF, Bolliger CT |title=Functional evaluation before lung resection |journal=Clin. Chest Med. |volume=32 |issue=4 |pages=773–82 |year=2011 |pmid=22054885 |doi=10.1016/j.ccm.2011.08.001 |url=}}</ref> | ||
*[[Pulmonary function testing]] | *[[Pulmonary function testing]] | ||
:*Preoperative assessment of FEV1/DLCO | :*Preoperative assessment of FEV1/[[DLCO]] | ||
:*[[FEV1]] >2 L (or more than 80%) | :*[[FEV1]] >2 L (or more than 80%) | ||
:*[[DLCO]] > 80 | :*[[DLCO]] > 80 | ||
| Line 127: | Line 127: | ||
:*Successful cutoff of 22 m on the stair climbing test | :*Successful cutoff of 22 m on the stair climbing test | ||
*Fitness for [[surgery]] | *Fitness for [[surgery]] | ||
*Evaluation of [[risk factors]], such as: | |||
:*[[Age]] | :*[[Age]] | ||
:*General health status ([[obesity]], Karnofsky scale >70) | :*General health status ([[obesity]], Karnofsky scale >70) | ||
| Line 148: | Line 148: | ||
*[[Hypercapnia]] ([[arterial]] PCO2 greater than 45 mmHg) | *[[Hypercapnia]] ([[arterial]] PCO2 greater than 45 mmHg) | ||
*Inadequate [[exercise]] testing results (22 m on the stair climbing test) | *Inadequate [[exercise]] testing results (22 m on the stair climbing test) | ||
*Presence of oncological emergencies, such as [[superior vena cava syndrome]], [[malignant]] [[pleural effusion]], [[cardiac tamponade]], [[vocal cord]] or [[phrenic nerve]] [[paralysis]] | *Presence of oncological emergencies, such as [[superior vena cava syndrome]], [[malignant]] [[pleural effusion]], [[cardiac tamponade]], [[vocal cord]], or [[phrenic nerve]] [[paralysis]] | ||
==Complications== | ==Complications== | ||
Latest revision as of 18:32, 20 March 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]
Overview
Surgery is the mainstay of therapy for early-stage Pancoast tumor. Surgical procedure selection will depend on the histology, margins, and size of the tumor. Common surgical procedures for the treatment of Pancoast tumor include lung resection with lobectomy, lung resection with pneumonectomy with or without lymph node dissection, thoracotomy with the removal of the entire lung or lobe (lobectomy) along with regional lymph nodes (peribronchial and perihilar lymph node dissection), and pathological evaluation. If evidence of lymph node extension of the disease is present adjuvant chemotherapy should be administered. Surgical resection is not recommended for patients with advanced or metastatic lung carcinoma. Surgical staging of the mediastinum is considered standard if accurate evaluation of the nodal status is needed to determine therapy. Surgical treatment consists of a thoracotomy with removal of the entire lung or lobe along with regional lymph nodes and contiguous structures. Pneumonectomy is used if the tumor involves the main bronchus, extends across a fissure or is located such that wide excision is required. Survival following ‘curative’ resection is approximately 30% at 5 years and 15% at 10 years. The best results are found in squamous cell carcinoma followed by large-cell carcinoma and the adenocarcinoma. If the tumor is inoperable, stereotactic ablative radiation therapy should be administered.
Surgery
In non-small cell lung cancer, surgical procedure selection will depend on the histology, margins, and size of the tumor.[1][2][3][4][5][6][7][8]
- Surgery is the mainstay of therapy for early-stage Pancoast tumor.
- Common surgical procedures for the treatment of Pancoast tumor include:
- Lung resection with lobectomy
- Lung resection with pneumonectomy with or without lymph node dissection
- The preferred surgical procedure is thoracotomy with the removal of the entire lung or lobe (lobectomy) along with regional lymph nodes (peribronchial and perihilar lymph node dissection) and pathological evaluation.
- If evidence of lymph node extension of the disease is present adjuvant chemotherapy should be administered.
- Surgical resection is not recommended for patients with advanced or metastatic lung carcinoma.
- Surgical staging of the mediastinum is considered standard if accurate evaluation of the nodal status is needed to determine therapy.
- Surgical treatment consists of a thoracotomy with removal of the entire lung or lobe along with regional lymph nodes and contiguous structures.
- Pneumonectomy is used if the tumor involves the main bronchus, extends across a fissure or is located such that wide excision is required.
- Survival following ‘curative’ resection is approximately 30% at 5 years and 15% at 10 years.
- The best results are found in squamous cell carcinoma followed by large-cell carcinoma and the adenocarcinoma.
- If the tumor is inoperable, stereotactic ablative radiation therapy should be administered.
Evaluation before surgery
- Resectable
- The tumour can be completely removed (resected) during surgery.
- Tissue around the tumour and nearby lymph nodes may also be removed.
- Unresectable
-
- They are too large to completely remove
- The cancer has spread to certain mediastinal lymph nodes, other organs near the lungs, or to distant sites
- There is pleural effusion or pericardial effusion present
- Because surgery to treat Pancoast tumor is a major operation, the person needs to be in good overall health and be able to tolerate surgery. Lung and heart function tests are done to make sure that people are healthy enough to have surgery and that they will have enough lung function after surgery.
- Surgery is offered to people who have a low risk of developing shortness of breath after surgery.
- Some people are at high risk of poor lung function and shortness of breath after surgery. Before surgery is offered to these people, the healthcare team will discuss the benefits of surgery and quality of life after surgery.
- If the person is not well enough to have surgery, the tumor is considered inoperable.
- Lung surgery is done through an incision between the ribs on the side of the chest (thoracotomy). The ribs are spread so the surgeon can reach the lung.
- The type of surgery done depends on the size and location of a tumour and how far it has spread within the lung. Side effects of surgery depend on the type of surgical procedure.
Wedge or segmental resection
- A wedge or segmental resection removes a tumour along with a margin of healthy lung tissue. A segmental resection removes more tissue than a wedge resection.
- A wedge or segmental resection may be offered for very early stage Pancoast tumor to preserve as much lung function as possible. These procedures may also be done in people with more advanced lung cancer who may have poor lung function after surgery.
- Wedge or segmental resection may also be done for a single tumor that has spread to the lung from other parts of the body (lung metastases).
Lobectomy
- A bilobectomy is the removal of 2 lobes of the right lung, which has 3 lobes. This surgery may be done if the tumour has spread into 2 joining lobes. The upper and middle lobes or the middle and lower lobes may be removed during a bilobectomy.
Pneumonectomy
- A pneumonectomy is the removal of a whole lung during surgery. This surgery is done if the tumour has spread either:
- There are more complications with pneumonectomy when the right lung (the larger lung) is removed.
Extended pulmonary resection
- Extended pulmonary resection is used to treat tumours that have spread to the chest wall, diaphragm, nerves, blood vessels, or other tissues near the lung. During surgery, a complete section (en bloc) of the surrounding tissue is removed to try to take out as much of the cancer as possible.
Sleeve resection
- A sleeve resection is used to treat tumours in the large bronchus of the lung. The tumour is removed from the bronchus, along with a margin of healthy tissue on either side of the tumour. The 2 ends of the bronchus are then joined together (anastomosis).
Lymph node removal
- Lymph nodes play a large part in the staging and prognosis of Pancoast tumor, as well as in planning for surgery. During diagnosis, tests may show if the cancer has spread to certain lymph nodes.
- N1 nodes – Cancer that has spread to these nodes can usually be completely removed with surgery.
- N2 nodes – It may not be possible to completely remove cancer that has spread to these nodes, so surgery may not be an option.
- N3 nodes – Cancer that has spread to these nodes cannot be completely removed with surgery, so surgery is not an option.
Stent placement
- Pancoast tumor can grow into the bronchus, causing breathing problems or pneumonia. A stent is a small metal or plastic tube that is placed into the bronchus during a bronchoscopy. It keeps the airway open and allows air into the lungs.
Chest tube placement
- During surgery, a flexible tube will be inserted through a cut in the skin, between the ribs and into the space between the lungs and the wall of the chest (pleural cavity). The tube is connected to a bottle with sterile water and a suction machine. It may be held in place with stitches or tape.
- A chest tube is used to drain blood, other fluids and air from the space around the lungs (pleural space) after surgery. It is left in place until x-rays show that the blood, fluids or air have been drained and that the lung can fully expand.
Thoracentesis
- A thoracentesis is a procedure in which a hollow needle is inserted through the skin and between the ribs into the space between the lungs and the wall of the chest (pleural cavity). It is used to drain fluid or air from the chest cavity.
- Thoracentesis may be used with lung cancer to treat:
- Air leaking from the lung into the chest, causing the lung to collapse (pneumothorax)
- Bleeding into the chest (hemothorax)
- A buildup of fluid in the pleural cavity (pleural effusion)
Pleurodesis
- Pleurodesis is done to prevent a buildup of fluid in the pleural cavity and pleural effusion. Excess pleural fluid is drained, and then drugs or chemicals, such as sterile talc, are put into the pleural space through a chest tube. Pleurodesis seals the parietal pleura and visceral pleura together so there is no longer a space between them in which fluid could build up.
Surgery for metastatic Pancoast tumor
- Surgery may be done to remove a single metastatic tumour that has spread from the lung to the:
Video-assisted thoracic surgery (VATS)
- Video-assisted thoracic surgery (VATS) is a less invasive type of surgery. It uses a small video camera and surgical tools inserted through several small incisions in the chest wall. The surgeon is guided by an image on a video screen.
- VATS may be used to remove small (3–4 cm) lung cancer tumours from the outer edges (periphery) of the lung. A lobectomy may also be done using VATS.
Indications
Surgery is usually reserved for patients with the following characteristics:[1]
- Successful cutoff of 22 m on the stair climbing test
- Fitness for surgery
- Evaluation of risk factors, such as:
- Age
- General health status (obesity, Karnofsky scale >70)
- COPD/Asthma
- Smoking
- Other conditions: pulmonary hypertension, heart failure, and metabolic factors
Contraindications
Surgery is usually contraindicated in patients with the following characteristics:[2]
- Lung cancer extension past the diaphragm
- Extrathoracic metastases
- Metastases to supraclavicular lymph nodes
- Contralateral mediastinal node metastases
- Involvement of contralateral hemithorax
- Invasion of structures of the mediastinum
- Chest wall invasion
- No fitness for surgery
- Hypercapnia (arterial PCO2 greater than 45 mmHg)
- Inadequate exercise testing results (22 m on the stair climbing test)
- Presence of oncological emergencies, such as superior vena cava syndrome, malignant pleural effusion, cardiac tamponade, vocal cord, or phrenic nerve paralysis
Complications
Common complications of Pancoast tumor surgery, include:[2]
References
- ↑ 1.0 1.1 von Groote-Bidlingmaier F, Koegelenberg CF, Bolliger CT (2011). "Functional evaluation before lung resection". Clin. Chest Med. 32 (4): 773–82. doi:10.1016/j.ccm.2011.08.001. PMID 22054885.
- ↑ 2.0 2.1 2.2 Smetana GW, Lawrence VA, Cornell JE (2006). "Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians". Ann. Intern. Med. 144 (8): 581–95. PMID 16618956.
- ↑ Surgery of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/treatment/surgery/?region=ab
- ↑ Davis GA, Knight SR (October 2008). "Pancoast tumors". Neurosurg. Clin. N. Am. 19 (4): 545–57, v–vi. doi:10.1016/j.nec.2008.07.002. PMID 19010280.
- ↑ Rosso L, Palleschi A, Mendogni P, Nosotti M (April 2016). "Video-assisted pulmonary lobectomy combined with transmanubrial approach for anterior Pancoast tumor resection: case report". J Cardiothorac Surg. 11 (1): 65. doi:10.1186/s13019-016-0446-7. PMC 4831106. PMID 27079507.
- ↑ Caronia FP, Fiorelli A, Ruffini E, Nicolosi M, Santini M, Lo Monte AI (September 2014). "A comparative analysis of Pancoast tumour resection performed via video-assisted thoracic surgery versus standard open approaches". Interact Cardiovasc Thorac Surg. 19 (3): 426–35. doi:10.1093/icvts/ivu115. PMID 25052071.
- ↑ Hubbard MO, Schroeder C, Linden PA (April 2011). "Routine use of staging thoracoscopy for pancoast tumors without overt radiographic chest wall invasion". Surg Laparosc Endosc Percutan Tech. 21 (2): 111–5. doi:10.1097/SLE.0b013e31821a3cb0. PMID 21471804.
- ↑ Tamura M, Hoda MA, Klepetko W (October 2009). "Current treatment paradigms of superior sulcus tumours". Eur J Cardiothorac Surg. 36 (4): 747–53. doi:10.1016/j.ejcts.2009.04.036. PMID 19699106.