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Superior Sulcus Resection. G. Alexander Patterson, MD Evarts A. Graham Professor of Surgery Chief, Division of Cardiothoracic Surgery. Superior Sulcus Tumors. Evaluated 116 patients Eligible 101 patients Completed Induction Rx 93% Thoractomy 81% 1 operative mortality.

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Superior sulcus resection

Superior Sulcus Resection

G. Alexander Patterson, MD

Evarts A. Graham Professor of Surgery

Chief, Division of Cardiothoracic Surgery


Superior Sulcus Tumors

  • Evaluated 116 patients

  • Eligible 101 patients

    • Completed Induction Rx 93%

    • Thoractomy 81%

      • 1 operative mortality

SWOG 9416, JTCVS 2001; 121: 472


Superior Sulcus Tumors

SWOG 9416, JTCVS 2001; 121: 472


Requirement for cure
Requirement for Cure

Accurate Staging

Localized Disease

Complete Resection


Surgical approaches for superior sulcus tumor
Surgical Approaches for Superior Sulcus Tumor

  • Posterolateral (Shaw - Paulson)

  • Anterior cervicothoracic (Dartevelle)

  • Hemi-clamshell (Burt)

  • Anteroposterior “hook” (Niwa)

  • VATS - Posterior



L d squamous cell ca
L. D.Squamous Cell Ca

T3 N0


Posterolateral approach

Initial thoracotomy determines resectability

Anterior rib resection

facilitates posterior rib detachment

Posterolateral Approach


Dissection, resection of involved S.C. artery

Dissection, neurolysis,

resection of involved

T1C8 nerve roots

Posterolateral Approach

Excellent exposure for final stage of chest wall excision


Preliminary supraclavicular exploration

Dissection of:

Supraclavicular nodes

S.C. artery

Brachial plexus

Scalene muscles

Phrenic nerve

Determine resectability prior to morbidity of major resection

Preliminary Supraclavicular Exploration


Anterior cervicothoracic approach
Anterior Cervicothoracic Approach

Excellent Exposure for Anterior Lesions

Incision anterior sternomastoid

inferior to clavicle into D.P. groove

Clavicular resection

exposes throacic inlet


Hemi clamshell approach
Hemi-Clamshell Approach

Excellent Exposure for Anterior Lesions

Initial anterolateral

thoracotomy

Extension after

resectability confirmed


T 3 superior sulcus
T3 Superior Sulcus

  • Adverse prognostic factors:

    • Horner’s syndrome

    • N2, N3 disease

    • Incomplete resection

      • 9% 5yr survival

Ginsberg, Ann Thor Surg 1994; 57:1440


Survival

Superior Sulcus Tumors

Survival

Gomez D, Cancer 2012 38(0) 50, 2012 Jan


Summary
Summary

  • Detailed History

  • Accurate Staging

  • Neoadjuvant chemorads

  • Precise Exploration

  • Complete resection


What treatment regimen provides the best long term survival for resectable superior sulcus tumors
What treatment regimen provides the best long term survival for resectable superior sulcus tumors?

  • Resection + adjuvant radiation

  • Resection + adjuvant chemorads

  • Resection alone

  • Neoadjuvant chemorads + resection

  • Neoadjuvant chemorads + resection + adjuvant chemo


All of the following are absolute contraindications to potentially curative resection except
All of the following are absolute contraindications to potentially curative resection except:

  • Extrathoracic metastatic disease

  • Vertebral column involvement

  • Tracheal involvement

  • Brachial plexus invasion


Which of the following is a recognized complication following resection of superior sulcus tumors
Which of the following is a recognized complication following resection of superior sulcus tumors

  • Horner’s

  • CSF leak

  • Dejerine syndrome

  • All of the above

  • None of the above


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