What is a Pancoast tumor (superior sulcus tumor)?

From the Guidelines

Pancoast tumors should be treated with induction chemoradiotherapy followed by surgical resection when possible, as this approach has been shown to improve outcomes and achieve five-year survival rates of 30-50% for patients who can undergo complete resection after induction therapy. The standard chemotherapy regimen often includes platinum-based agents such as cisplatin or carboplatin combined with etoposide or paclitaxel, delivered concurrently with radiation therapy (typically 45-54 Gy) 1. Diagnosis typically involves chest imaging (CT scan, MRI) and tissue biopsy.

Key Considerations

• In patients with a Pancoast tumor, a tissue diagnosis should be obtained prior to the initiation of therapy 1.
• An MRI of the thoracic inlet and brachial plexus is recommended to characterize possible tumor invasion of vascular structures or the extradural space 1.
• Invasive mediastinal staging and extrathoracic imaging are recommended to rule out metastatic disease 1.
• Preoperative concurrent chemoradiotherapy is suggested prior to resection in patients with a potentially resectable Pancoast tumor and good performance status 1.
• Every effort should be made to achieve a complete resection, which should involve at least a lobectomy and the involved chest wall structures 1.

Treatment Approach

• Induction chemoradiotherapy followed by surgical resection is the recommended treatment approach for patients with a resectable Pancoast tumor 1.
• Definitive concurrent chemotherapy and radiotherapy is suggested for patients with an unresectable, but nonmetastatic Pancoast tumor who have good performance status 1.
• Palliative radiotherapy is suggested for patients who are not candidates for curative-intent treatment 1.

Prognosis

• Prognosis depends on tumor stage, involvement of surrounding structures, and whether complete resection is achieved 1.
• Five-year survival rates of 30-50% can be achieved for patients who can undergo complete resection after induction therapy 1.

From the Research

Definition and Treatment of Pancoast Tumors

• Pancoast tumors, also known as superior sulcus tumors, are a complex clinical condition requiring high technical surgical skills within a multimodality treatment approach 2.
• The treatment of Pancoast tumors typically involves a combination of chemotherapy, radiotherapy, and surgery, with surgical resection playing a pivotal role in the multimodality approach 2, 3.

Surgical Approaches

• Various surgical approaches are used to treat Pancoast tumors, including the anterior transclavicular approach, anterior transmanubrial approach, anterior trap-door approach, posterior approach, hemiclamshell approach, and hybrid approaches 2.
• The choice of surgical approach depends on the location and extent of the tumor, as well as the patient's overall clinical condition 2, 4.

Outcomes and Prognostic Factors

• The outcomes of patients with Pancoast tumors have improved in recent years, with 5-year survival rates ranging from 41% to 46% 3, 5.
• Prognostic factors for Pancoast tumors include the presence of a pathological complete response, vertebral and/or vascular infiltration, and the stage of the disease at diagnosis 5, 6.
• Trimodal therapy, which includes induction chemoradiotherapy followed by surgical resection, offers the best short- and long-term outcomes for patients with Pancoast tumors 3, 5, 6.

Challenges and Future Directions

• Despite improvements in treatment outcomes, Pancoast tumors remain a challenging condition to manage, with high rates of recurrence and mortality 2, 3.
• Future studies are needed to define the best surgical approach and the role of mini-invasive surgery in the treatment of Pancoast tumors 4.
• The incorporation of new therapies, such as tyrosine kinase inhibitors and anti-PD1/PD-L1, may improve outcomes for patients with Pancoast tumors 5.