As always, a complete history and physical exam should be performed. The usual imaging and cardiopulmonary evaluation are required (Table 35.1). Tissue diagnosis is important to obtain preoperatively; there are reports of lymphoma, metastatic tumors, or mycobacterial infections masquerading as superior sulcus NSCLC.⁶ Percutaneous image-guided biopsy is usually very high yield with these peripherally located tumors, whereas bronchoscopy is rarely helpful for obtaining tissue.

For a multimodality treatment strategy that includes major pulmonary resection with concomitant rib and vertebral resection, patients need to be in optimal condition. Performance status must be satisfactory, and patients must have adequate cardiac, pulmonary, and renal function. Pulmonary complications are the most frequent source of postoperative morbidity; thus, patients with marginal respiratory status preoperatively are unlikely to have a good result. Smoking cessation is also critical to minimize perioperative respiratory events.

Other important factors in patient selection include a thorough assessment of any neurologic deficits. Brachial plexus involvement above the lower trunk of the plexus is likely to lead to significant limb dysfunction with resection, so most surgeons consider this a contraindication to resection. Lower extremity weakness may indicate direct extension of tumor into the spinal cord, or perhaps unstable bony elements of the vertebrae because of tumor destruction. Spinal cord impingement typically causes pain, followed by weakness, and less frequently sensory deficits and bowel or bladder dysfunction.⁷,⁸ Although spinal canal involvement portends a worse prognosis, it is not strictly a contraindication. It is important to query the patient about subtle symptoms, and involve a spine surgeon early on in case impending neurologic damage may ensue. In some instances, these patients may be well palliated by undergoing resection to prevent or limit lower extremity neurologic deficits, even when an R0 resection is not possible.

Neurosurgical or orthopedic spine consultation should be obtained whenever there is suspicion of vertebral involvement.
In some cases, electromyography or nerve conduction studies may be helpful to delineate the extent and reversibility of neurologic dysfunction. Magnetic resonance imaging (MRI) of the chest and spine with contrast usually accurately demonstrates the extent of vertebral body involvement, nerve impingement, vascular invasion, and juxtaposition of the tumor with the thecal sac. Vertebral artery and anterior spinal artery invasion can also be determined with MR angiography, or in some cases, computed tomography (CT) arteriography can be helpful. Brain MRI is highly recommended given the frequency of brain metastases in this population (7% at presentation, up to 25% within 10 months of diagnosis).⁹ For the same reason, fused imaging with positron emission tomography (PET) and CT is also critical to evaluate for metastatic disease.

Brachial plexus involvement should be evaluated clinically and by MRI and CT imaging. It is useful to review the sensory and motor findings expected with invasion of the brachial plexus and lower nerve roots to assist in the preoperative assessment; in addition, these potential neurologic changes should be discussed with patients before resection and possible nerve ligation. The C8 and T1 nerve roots make up the lower trunk of the plexus as it crosses the first rib. The T1 dermatome extends across the upper chest onto the anteromedial aspect of the forearm. The C8 dermatome follows the ulnar nerve distribution along the medial aspect of the arm and the fourth and fifth digits. C7 innervates sensation for the index and middle fingers, C6 for the thumb. A C7 nerve motor function abnormality is manifested by weakness of forearm extension (triceps). C8 motor nerve impingement leads to weakness of finger flexors and wasting of interosseous muscles of the hand.¹⁰ T1 weakness leads to inability to abduct the little finger. If the clinical exam is equivocal, MRI of the brachial plexus as well as nerve conduction studies can be helpful.

Most agree that division of T1 is acceptable with minimal hand and arm morbidity, whereas the ligation of C8 will be associated with hand deformity that is excessive. Uniformly, C7 ligation is not acceptable. The rationale is that it makes little sense to perform an aggressive surgical resection to preserve a functionless upper extremity that is a source of severe pain or is completely insensate. Although it sounds extreme, sometimes forequarter amputation may provide better palliation than preservation of a useless limb.¹¹ Having an experienced neurosurgeon perform plexus neurolysis may allow for resection with nerve preservation in cases of significant brachial plexus displacement or invasion.

Many authors have recognized poor outcomes with N2 or N3 metastases particularly in the setting of T4 primary tumor.¹²,¹³,¹⁴ Thus, invasive mediastinal staging is a necessary step in the preoperative workup, and if mediastinal nodal disease is identified, radical resection should not be offered. The possibility of downstaging these nodes to N0 or N1 with induction chemoradiation with a reasonable long-term result is a subject of debate. N3 status on the basis of ipsilateral supraclavicular nodal metastases (rather than contralateral mediastinal N3) is considered local spread by some authors, analogous to N1 disease with a typical lung primary¹⁵,¹⁶ and not a contraindication to resection, whereas others exclude any N2 or N3 disease from surgical consideration.⁵ Recent series have reinforced the importance of nodal disease as it pertains to curative resection, as outcomes have been uniformly poor with N1, N2, or N3 diseases.⁴

To summarize, contraindications to resection (Table 35.2) include involvement of the anterior spinal artery,¹⁷,¹⁸ brachial plexus compromise at or above C7, poor cardiopulmonary reserve, distant metastases, N3 disease, and persistent N2 disease after preoperative therapy. Relative contraindications are involvement of more than three vertebral bodies, N2 disease prior to induction therapy, and invasion of the C8 nerve root.

For most stage IIIB NSCLC, chemoradiation alone is offered, either concurrently or sequentially, depending on performance status.¹⁹ However, local control rates are only about 17% at 1 year,²⁰ and distant failure more than 50% at 2 years,²¹ prompting interest in trimodality therapy. Several series of locally advanced T4, N0 or N1, NSCLC cases with adjacent structure invasion have been treated aggressively with resection alone, resulting in 5-year survival rates in the 20% to 35% range.²¹ Distant failure is still a problem even after complete resection. Clearly, multidisciplinary care is necessary; questions remain about which chemotherapeutic agents are best, optimal dose of radiation, and the order in which chemotherapy, radiation, and surgery are used. Regardless of these questions, the lessons learned from this aggressive treatment for locally advanced lung cancers are that not all T4 designations are created equal, and most structures deemed unresectable in the last iteration of the lung cancer staging system have indeed been successfully resected with reasonable oncologic and functional outcomes. Surgery alone is almost never going to be adequate treatment, and it must be combined with other therapy. These lessons have been learned over the last 4 to 5 decades for superior sulcus tumors with or without vertebral body invasion.