SUPERIOR SULCUS TUMOR

DEFINITION

  • Superior sulcus tumor is a cancer located at the apex of the lung (above the subclavian arterial groove).

TYPES OF SUPERIOR SULCUS TUMOR

It may be divided the the structures invaded

  • Medial: invades the Brachial plexus
    • Brachial plexus is formed by the union of the ventral rami of c5 to c8 and T1.
    • ulnar nerve roots are more typically involved by the tumor C7, C8, T1
  • Anterior: invades the Subclavian artery or a rib
  • Posterior: invades the vertebral body

Horner’s syndrome

  • Tumor invades the Sympathetic Plexus
    • myosis – small pupil (the opposite is mydriasis)
    • anhidrosis - absence of sweating.
    • ptosis - (drooping) of the upper eyelid.

Pancoast’s tumor

  • Tumor invades both the brachial plexus and sympathetic plexus

TREATMENT

Neoadjuvant

  • Pre-operative concurrent chemoradiation
    • → aggressive surgical resection, including resection of all involved structures
    • 45 Gy + EP → ? Surgery (Rusch 2001)
    • 65% complete response rate at surgical resection
    • 70% 2-OS for complete resection
    • 55% 2-OS for all patients
  • Pre-operative RT alone: 30 Gy in 10 fractions with 5-year survival was 6%.
  • induction chemotherapy  surgery  and PORT

Unresectable tumors

  • can be definitively treated with 61.20 Gy chemoradiation.

Post-operative RT

  • Hilaris compared pre-op RT with post-op RT with 5-year survival at 20% for the latter

T alone: Komaki (1990) showed 5-year survival at 23% and LC was 52%. Neal (UF 1990) showed no survival advantage between the 2 groups but increased toxicity with combined treatment (21% versus 3%).

RT technique

  • Use AP: PA fields with wedges.
  • The superior border should be at the thyroid notch,
  • laterally cover entire SCV fossa with 3cm border on gross disease,
  • medially 2cm beyond the contralateral border of the vertebrae,
  • and inferiorly, just below the carina.
  • If proceeding with RT alone limit cord dose to 45-50Gy and then go higher.
  • Post-operative dose of 5040cGy.
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