PRESENTATION

Superior sulcus lesions of non–small cell histology account for less than 5% of all bronchial carcinomas, as reported by Ginsberg and associates.⁵ These tumors may arise from either upper lobe and tend to invade parietal pleura, endothoracic fascia, subclavian vessels, brachial plexus, vertebral bodies, or the first rib. However, their clinical features are influenced by their location.

Tumors located anterior to the anterior scalene muscle may invade the platysma and sternocleidomastoid muscles, the external and anterior jugular veins, the inferior belly of the omohyoid muscle, the subclavian and internal jugular veins including major branches, and the scalene fat pad (Fig. 21-1). They invade the first intercostal nerve and the first rib more frequently than the phrenic nerve or superior vena cava. Patients usually complain of pain distributed to the upper anterior chest wall.

Figure 21–1 CT scan showing a right superior sulcus bronchial carcinoma invading the anterior thoracic inlet, including the subclavian vein.

Tumors located between the anterior and middle scalene muscles may invade the anterior scalene muscle (phrenic nerve lying on its anterior aspect); the subclavian artery including primary branches, except the posterior scapular artery; and the trunks of the brachial plexus and middle scalene muscle (Fig. 21-2). These tumors manifest with signs and symptoms related to the compression or infiltration of the middle and lower trunks of the brachial plexus (e.g., pain and paresthesia radiating to the shoulder and upper limb).

Figure 21–2 MR image showing a left superior sulcus bronchial carcinoma invading the middle thoracic inlet, including the subclavian artery.

Tumors lying posterior to the middle scalene muscles are usually located in the costovertebral groove and invade the nerve roots of T1, the posterior aspect of the subclavian and vertebral arteries, the paravertebral sympathetic chain, the inferior cervical (stellate) ganglion, and the prevertebral muscles. Some of these posterior tumors can invade transverse processes (Fig. 21-3) or extend to the vertebral bodies (only those abutting the costovertebral angle or extending into the intraspinal foramen without intraspinal extension may be resected).

Figure 21–3 CT scan showing a right superior sulcus bronchial carcinoma invading the posterior arch and the transverse process of the first rib and abutting the costovertebral angle.

Because of the peripheral location of these lesions, pulmonary symptoms, such as cough, hemoptysis, and dyspnea, are uncommon in the initial stages of the disease. Abnormal sensation and pain in the axilla and medial aspect of the upper arm in the distribution of the intercostobrachial (T2) nerve are more frequently observed in the early stage of the disease process. With further tumor growth, patients may present with overt Pancoast’s syndrome.

PREOPERATIVE STUDIES

Any patient presenting with signs and symptoms that suggest the involvement of the thoracic inlet should undergo a detailed preoperative evaluation to establish the diagnosis of bronchial carcinoma and to assess for operability. These patients usually present with small apical tumors that are hidden behind the clavicle and the first rib on routine chest radiographs. The diagnosis is established by history and physical examination, biochemical profile, chest radiographs, bronchoscopy with sputum cytology, fine-needle transthoracic or transcutaneous biopsy, and computed tomography of the chest. A tissue diagnosis via video-assisted thoracoscopy may be indicated when other investigations are negative and to eliminate the possibility of pleural metastatic disease. If there is evidence of mediastinal adenopathy on computed tomographic scanning, mediastinoscopy is mandatory because patients with clinical N2 disease are not operative candidates.

Neurologic examination, magnetic resonance imaging (MRI), or electromyography may delineate the tumor’s extension to the brachial plexus, phrenic nerve, or epidural space. Vascular invasion is evaluated by venous angiography, subclavian arteriography, Doppler ultrasonography (cerebrovascular disorders may contraindicate resection of the vertebral artery), or MRI (Fig. 21-4). Additional MRI is mandatory if the workup suggests tumor encroachment into the intervertebral foramina, to rule out invasion of the extradural space (Fig. 21-5).

Figure 21–4 Angiography illustrating a massive tumoral invasion of the intrascalenic left subclavian artery.

Figure 21–5 MR image that rules out invasion of the intervertebral foramina by the tumor.

The initial evaluation also includes routine cardiopulmonary function tests and investigative procedures (e.g., positron emission tomography) to identify the presence of any metastatic disease. Extrathoracic metastases are rare.

TREATMENT

Tumors of the superior sulcus are deemed universally and rapidly fatal lesions. For many years, it was believed that these tumors were not amenable to surgery, until Chardack and MacCallum⁶ successfully performed a lobectomy and chest wall excision followed by radiation therapy. Five years later, Shaw and colleagues⁷ approached superior sulcus tumors with preoperative radiation therapy (30 to 45 Gy in 4 weeks, including the primary tumor, mediastinum, and supraclavicular region) followed by surgical resection. This radiosurgical approach shortly became the standard treatment, yielding better disease control and survival than other treatments. More recently, Ginsberg and colleagues⁵ provided evidence that en bloc resection of the tumor combined with external radiation (preoperative, postoperative, or both) must be considered the standard therapeutic approach for superior sulcus tumors. The goal of resection is the complete removal of the upper lobe in continuity with the invaded ribs, transverse processes, subclavian vessels, T1 nerve root, upper dorsal sympathetic chain, and prevertebral muscles.

In 1999, we reviewed various surgical approaches for treating superior sulcus lesions.⁸ In general, superior sulcus lesions not invading the thoracic inlet are completely resectable through the classic posterior approach of Shaw and colleagues.⁷ However, the posterior approach does not allow direct, safe visualization, manipulation, or complete oncologic clearance of all anatomic structures of the thoracic inlet. Superior sulcus lesions extending to the thoracic inlet should be resected by an anterior transcervical approach according to our previous description.⁹

This operation has been increasingly accepted as a standard approach for all benign and malignant lesions of the thoracic inlet. Additionally, this approach facilitates exposure of the anterolateral aspects of the upper thoracic vertebrae. Contraindications to this approach include extrathoracic metastasis, invasion of the brachial plexus above the T1 nerve root, invasion of the vertebral canal or sheath of the medulla, massive invasion of the scalene muscles or extrathoracic muscles, mediastinal lymph node involvement, and advanced cardiopulmonary disease.

ANTERIOR TRANSCERVICAL TECHNIQUE

One-lung anesthesia with measurements of urine output and body temperature are necessary. An arterial line opposite to the primary lesion, and at least two venous lines for volume expansion should be used. The patient is supine with the neck hyperextended and the head turned away from the involved side. A bolster behind the shoulder elevates the operative field. The skin preparation extends from the mastoid downward to the xiphoid process and from the midaxillary line laterally to the contralateral midclavicular line medially. An L-shaped cervicotomy incision is made, including a vertical pre-sternocleidomastoid incision carried horizontally below the clavicle up to the deltopectoral groove (Fig. 21-6). To increase the exposure, the interception between the vertical and horizontal branches of the L-shaped incision is lowered to the level of the second or third intercostal space, depending on tumor extent. The incision is then deepened with cautery. The sternal attachment of the sternocleidomastoid muscle is divided. The cleidomastoid muscle, along with the upper digitations of the ipsilateral pectoralis major muscle, is scraped from the clavicle. A myocutaneous flap is then folded back, providing full exposure of the neck and cervicothoracic junction.

Figure 21–6 Anterior transcervical approach.

(As described in Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993;105:1025.)