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{{Pancoast tumor}}
{{Pancoast tumor}}
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==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 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==
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>


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*[[Surgery]] is the mainstay of [[therapy]] for early-stage Pancoast tumor.
*Common [[surgical procedures]] for the [[Treatments|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]].
*[[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. 
*[[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.
*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.
 
'''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
::* The [[tumour]] cannot be removed by [[surgery]].
::* [[Tumour|Tumours]] are considered unresectable if:
:::* 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 tests|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 tests|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 [[Wedges|wedge]] or segmental [[resection]] removes a [[tumour]] along with a margin of healthy [[lung]] [[tissue]]. A segmental [[resection]] removes more [[Tissue (biology)|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 (biology)|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 [[lobectomy]] is the removal of the [[lobe]] of the [[lung]] that has a [[tumour]].
 
* 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:
 
:* Across both [[lobes]] of the left [[lung]]
:* To the [[hilum]] of the [[lung]]
 
* 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 [[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'''
 
* A sleeve [[resection]] is used to treat [[Tumour|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 [[Cancer staging|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 [[Lymph node|nodes]] – [[Cancer]] that has spread to these [[Lymph node|nodes]] can usually be completely removed with [[surgery]].
:* N2 [[Lymph node|nodes]] – It may not be possible to completely remove [[cancer]] that has spread to these [[Lymph node|nodes]], so [[surgery]] may not be an option.
:* N3 [[Lymph node|nodes]] – [[Cancer]] that has spread to these [[Lymph node|nodes]] cannot be completely removed with [[surgery]], so [[surgery]] is not an option.
 
'''Stent placement'''
 
* Pancoast tumor can grow into the [[bronchus]], causing [[Breathing|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 [[Chest wall|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 [[Chest wall|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:
 
:* [[Brain]]
:* [[Adrenal gland]]
 
'''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 [[Incision|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]] [[Tumour|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:<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]]
:*Preoperative assessment of FEV1/[[DLCO]]
:*[[FEV1]] >2 L (or more than 80%)
:*[[DLCO]] > 80
*[[Exercise]] [[testing]]
:*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|metabolic factors]]
 
==Contraindications==
[[Surgery]] is usually contraindicated in patients with the following characteristics:<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>
 
*[[Lung cancer]] [[extension]] past the [[diaphragm]]
:*Extrathoracic [[metastases]]
:*[[Metastases]] to [[supraclavicular lymph nodes]]
:*Contralateral [[Mediastinal|mediastinal node]] [[metastases]]
*Involvement of contralateral hemithorax
*Invasion of structures of the [[mediastinum]]
:*Involvement of the main [[pulmonary]] [[artery]]
*[[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:<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>
 
*[[Atelectasis]]
*[[Infection]]
:*[[Nosocomial pneumonia]]
*Prolonged [[mechanical ventilation]]
*[[Respiratory failure]]
*[[Bronchospasm]]
*[[Pulmonary embolism]]


==References==
==References==

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]

Evaluation before surgery

  • Resectable
  • Unresectable
  • 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.
  • 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 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.

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

Extended pulmonary resection

Sleeve resection

Lymph node removal

Stent placement

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.

Thoracentesis

Pleurodesis

Surgery for metastatic Pancoast tumor

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.

Indications

Surgery is usually reserved for patients with the following characteristics:[1]

  • Preoperative assessment of FEV1/DLCO
  • FEV1 >2 L (or more than 80%)
  • DLCO > 80
  • Successful cutoff of 22 m on the stair climbing test

Contraindications

Surgery is usually contraindicated in patients with the following characteristics:[2]

  • Involvement of contralateral hemithorax
  • Invasion of structures of the mediastinum

Complications

Common complications of Pancoast tumor surgery, include:[2]

References

  1. ↑ 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. ↑ 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.
  3. ↑ Surgery of non–small cell lung cancer. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/lung/treatment/surgery/?region=ab
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.

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