Surgery for Pancoast tumors—the role of combined approaches

Francesco Puma, Alessio Gili, Lucio Cagini, Damiano Vinci, Alberto Matricardi, Valeria Berti, Alberto Italiani, Rossella Potenza, Silvia Ceccarelli


Background: The surgical techniques for Pancoast tumors are as variable as the clinical pictures. Involved structures and location/size of the tumor deeply affect the choice of technique and surgical approaches.
Methods: Results of the surgical therapy in 23 consecutive patients with Pancoast tumor over an eighteen-year period was reviewed. Disease free survival (DFS) and overall survival (OS) were calculated by the Kaplan-Meier method.
Results: Clinical stage was cT3N0M0 in 17 patients, cT3N1M0 in 2 and cT4N0M0 in 4. No cN2 patients were considered for surgery. Eighteen patients underwent induction chemoradiotherapy. The posterior approach was performed in 61%, the transmanubrial approach in 22% and an original “double step” approach in 17% of patients. A combined approach was performed in 39.1% of patients, mostly through an additional thoracotomy; a combined VATS approach was chosen just in one patient. The prosthetic stabilization of the chest wall was performed in 5 cases. No postoperative mortality was observed with a total complication rate of 48%. The type of approach did not influence the complication rate. Median follow-up was 52.24 months with IQR 13.16–85.39 months (range, 1.48–164.7 months). Median OS was 62.3 months (95% CI, 18.39–104.21 months). The 5-year OS was 55.6% (95% CI, 31.7–74.1%). Median DFS was 65.9 months (95% CI, 12.1–104.2 months); 5-year DFS was 51.5% (95% CI, 28.2–70.7%). Patients with R1 resection had a median OS of 13.1 months (95% CI, 12.2–18.4 months).
Conclusions: Complete resection of the tumor represents one of the strongest prognostic factors of OS and DFS, along with T status and complete pathological response to therapy. Every effort should be made to obtain pathologic negative margin and combined approaches may facilitate this goal in anterior Pancoast tumors.