Treatment of pancoast tumors from the surgeons prospective: re-appraisal of the anterior-manubrial sternal approach

Abstract

Pancoast tumours are now amenable to multimodality treatment with an acceptable survival. This is because trimodality treatment improves tumor sterilization and hence outcome. Moreover the development of an anterior approach to access the tumor, further improved the technical challenges for a sound resection.The Anterior-manubrial sternal approach was described more than a decade ago and although this method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels, its popularity has not reached high levels. We felt that by re-addressing this topic we would stimulate reconsideration of the anterior approach.

Figure 1

CXR, CT Chest imaging, MRI and bone scan of a Pancoast tumor of a 47 yrs old female, Ex smoker (25 cigs per day up to 13 years ago). Six weeks history of shoulder pain radiating to the median aspect of the right arm. CXR mass at apex of right chest. Percutanteous Biopsy NSCLC. PMH: Hysterectomy for Ca cervix 1996 - no evidence of recurrence. Clinical examination fullness in right supra-clavicular fossa

Figure 2

Staging algorithm for patients prior to resection of a Pancoast Tumor. MRI of the thoracic inlet may yield further information's on the status of vertebra involvement

Figure 3

Root of neck anatomy, depicting carefully the relationship of the most important neurovascular structures to the scalene musculature and the first rib.

Figure 4

Step by step resection of a Pancoast tumor through an Antero-cervical approach. Incision at the anterior edge of Sterno-cleido-mastoid (a). Division of the upper sternum extended into 2^nd intercostal space(b). Mobilisation-Excision of supraclavicular fat pad (c). Exposure of the structures at the thoracic inlet by dividing the subclavius, omohyoid with preservation of the accessory nerve. Division of the Scalenus anterior with preservation of the phrenic nerve (d) & (e). Right upper Lobectomy (f): can be performed through the neck incision or a posterolateral thoracotomy.