Sulcus or Pancoast Tumor with Horner's Syndrome

7/11/2005

Question:  What is the significance of Horner's Syndrome (oculosympathoparesis) in the diagnosis of sulcus or pancoast tumor?

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12703690.ui or 15201002.ui or 14615640.ui or 14605058.ui or 12970029.ui or 12822662.ui or 12527583.ui or 12022545.ui or 11332249.ui or 10343256.ui or 10551556.ui or 9692463.ui or 10813231.ui or 9358132.ui or 2254613.ui or 7425056.ui

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 12703690[PMID] or 15201002[PMID] or 14615640[PMID] or 14605058[PMID] or 12970029[PMID] or 12822662[PMID] or 12527583[PMID] or 12022545[PMID] or 11332249[PMID] or 10343256[PMID] or 10551556[PMID] or 9692463[PMID] or 10813231[PMID] or 9358132[PMID] or 2254613[PMID] or 7425056[PMID]

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<1>

Unique Identifier [PMID]: 12703690

Authors: Patel S. Ilsen PF.

Institution: West Los Angeles VA Health Care Center, California, USA.

Title: Acquired Horner's syndrome: clinical review. [Review] [48 refs]

Source: Optometry (St. Louis, Mo.). 74(4):245-56, 2003 Apr.

Abstract: BACKGROUND: Horner's syndrome results from disruption of the sympathetic innervation to the eye anywhere along its three-neuron circuit. It is essential to be familiar with the oculosympathetic pathway, the structures that are in close proximity to it, and the disease processes that may interrupt it when an evaluation is made of an acquired Horner's syndrome, since it may be a manifestation of a life-threatening condition. CASE REPORTS AND DISCUSSION: Four patients with acquired Horner's syndrome resulting from various etiologies are presented. The first case is that of a 41-year-old man with a history of central retinal artery occlusion and Horner's syndrome caused by an internal carotid dissection. The second patient, a 51-year-old man with a Pancoast tumor, initially went to his chiropractor with sympyoms of weakness and pain in the upper extremity. The third case involves a 49-year-old woman with an enlarged thyroid gland. The fourth patient is a 70-year-old man with a history of a stellate ganglionectomy. The sympathetic pathway to the eye, its anatomical correlates, pharmacologic testing, and the systemic diseases that may cause Horner's syndrome are reviewed. CONCLUSION: Familiarity with the sympathetic pathway to the eye and its anatomical relationships enables one to understand the mechanism by which a Horner's syndrome has developed. [References: 48]

Publication Type: Case Reports. Journal Article. Review. Review, Tutorial.

<2>

Link Directly to Fulltext Article at Science Direct

Unique Identifier [PMID]: 15201002

Authors: Pitz CC. de la Riviere AB. van Swieten HA. Duurkens VA. Lammers JW. van den Bosch JM.

Institution: Department of Pulmonology, Sint Antonius Hospital, 3430 EM Nieuwegein, The Netherlands.

Title: Surgical treatment of Pancoast tumours. [Review] [54 refs]

Source: European Journal of Cardio-Thoracic Surgery. 26(1):202-8, 2004 Jul.

Abstract: Due to its localisation in the apex of the lung with invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, a superior sulcus tumour causes characteristic symptoms, like arm or shoulder pain or Horner's syndrome. If rib invasion is the only feature, lysis of the rib must be evident on the chest radiograph; otherwise the tumour cannot be defined as a Pancoast tumour. It is important to adequately stage the tumour, because staging significantly influences survival. Survival is better for T3 than T4 tumours and mediastinal lymph node involvement has been found to be a negative prognostic factor. Also Horner's syndrome and incompleteness of resection worsen survival. The management of superior sulcus tumours has evolved over the past 50 years. Before 1950 it was considered to be inoperable and uniformly fatal. Shaw and Paulson introduced combined modality treatment and for many years, this combination of radiotherapy and surgery was the treatment of choice with a mean 5-year survival of approximately 30%. Postoperative radiotherapy or brachytherapy does not improve survival in patients with complete or incomplete resection. The tumour can be resected through the classic posterior Shaw-Paulson approach or the newer anterior transcervical approach, introduced by Dartevelle. This method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels. Regarding the extent of pulmonary resection, en bloc resection of the involved ribs with a lobectomy is recommended. Recent multimodality studies, involving chemoradiotherapy and surgical resection, show promising results regarding completeness of resection, local recurrence and survival, provided that appropriate staging has been carried out. However, careful patient selection and adequate perioperative management with protection of the bronchial stump or anastomosis are important to achieve reasonable rates of morbidity and mortality. As brain metastases remain one of the most common forms of relapse, further studies are needed to examine the role of prophylactic cranial irradiation in patients with complete resection. Also the addition of other chemotherapy agents or biologic agents such as angiogenesis inhibitors or tyrosine kinase inhibitors gives a new perspective in the treatment of Pancoast tumours. [References: 54]

Publication Type: Journal Article. Review.

<3>

Link Directly to Fulltext article in Ovid

Unique Identifier [PMID]: 14615640

Authors: Walton KA. Buono LM.

Institution: Neuro-Ophthalmology Servive, Duke University Eye Center, Durham, NC 27710, USA.

Title: Horner syndrome. [Review] [52 refs]

Source: Current Opinion in Ophthalmology. 14(6):357-63, 2003 Dec.

Abstract: Horner syndrome refers to the constellation of signs resulting from the interruption of sympathetic innervation to the eye and ocular adnexae. Classically, the clinical findings include a triad of ipsilateral blepharoptosis, pupillary miosis, and facial anhidrosis. The history, additional clinical examination features, and pharmacologic testing may help localize the lesion and suggest an etiology. An appropriate evaluation of Horner syndrome and a timely elucidation of the etiology may allow for a potentially life-saving intervention. [References: 52]

Publication Type: Journal Article. Review. Review, Tutorial.

<4>

Unique Identifier [PMID]: 14605058

Authors: van Geel AN. Jansen PP. van Klaveren RJ. van der Sijp JR. Rotterdam Oncological Thorax Study Group.

Institution: Department of Surgical Oncology, Erasmus Medical Center/Daniel den Hoed, Rotterdam, The Netherlands. geel@chih.azr.nl

Title: High relapse-free survival after preoperative and intraoperative radiotherapy and resection for sulcus superior tumors.

Source: Chest. 124(5):1841-6, 2003 Nov.

Abstract: STUDY OBJECTIVES: Relapse-free survival in patients with sulcus superior tumors. DESIGN: Prospective registration study. SETTING: Department of surgical oncology of a university hospital. PATIENTS: Twenty-one patients treated with preoperative radiotherapy (46 Gy), lobectomy and chest-wall resection, and intraoperative radiotherapy (10 Gy). RESULTS: After a median follow-up of 18 months, 18 patients (85%) were free from locoregional relapse, while 8 patients were still alive. CONCLUSIONS: The results show that this protocol can achieve excellent local tumor control and can even be used for palliative treatment.

Publication Type: Clinical Trial. Journal Article.

<5>

Link Directly to Fulltext Article at Publisher

Unique Identifier [PMID]: 12970029

Authors: Alifano M. D'Aiuto M. Magdeleinat P. Poupardin E. Chafik A. Strano S. Regnard JF.

Institution: Unite de Chirurgie Thoracique, Hotel-Dieu, AP-HP, 1 Place du Parvis Notre-Dame, 75004 Paris, France.

Title: Surgical treatment of superior sulcus tumors: results and prognostic factors.

Source: Chest. 124(3):996-1003, 2003 Sep.

Abstract: OBJECTIVES: To study the clinical characteristics, treatment modalities, and outcome of patients with superior sulcus tumors who underwent surgery over a 15-year period. DESIGN: Retrospective clinical study. METHODS: Clinical records of all patients operated on for superior sulcus tumors by the same surgical team between 1988 and 2002 were reviewed retrospectively. RESULTS: Sixty-seven patients were operated on in this period. All the patients underwent en bloc lung and chest wall resection. Surgical approaches were as follows: posterolateral thoracotomy according to Paulson (n = 33), combined transcervical and transthoracic approach (n = 33), and isolated transcervical approach (n = 1). Types of pulmonary resection included lobectomies (n = 59), pneumonectomies (n = 2), and wedge resections (n = 6). Pathologic stages were IIB, IIIA, and IIIB in 49 cases, 12 cases, and 6 cases, respectively. Resection was complete in 55 patients (82%). Operative mortality was 8.9% (n = 6). Postoperative treatment was administered in 53 patients (radiotherapy, n = 42; chemoradiotherapy, n = 9; and chemotherapy, n = 2). Overall 2-year and 5-year survival rates were 54.2% and 36.2%, respectively. Five-year survival was significantly higher after complete resection than after incomplete resection (44.9% vs 0%, p = 0.000065). The presence of associated major illness negatively affected the outcome (5-year survival, 16.9% vs 52%; p = 0.043). Age, weight loss, respiratory impairment, tumor size, presence of nodal disease, and histologic type did not influence the long-term outcome. At multivariate analysis, only the completeness of resection and the absence of associated major comorbidities had an independent positive prognostic value. CONCLUSIONS: Superior sulcus tumor remains an extremely severe condition, but long-term survivals may be achieved in a large percentage of cases. The presence of associated major illness and the completeness of resection are the two most important factors affecting the long-term outcome.

Publication Type: Journal Article.

<6>

Unique Identifier [PMID]: 12822662

Authors: Detterbeck FC.

Institution: Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7065, USA. fdetter@med.unc.edu

Title: Changes in the treatment of Pancoast tumors. [Review] [45 refs]

Source: Annals of Thoracic Surgery. 75(6):1990-7, 2003 Jun.

Abstract: Our understanding of superior sulcus tumors has evolved over time. The unique feature of Pancoast tumors is their location, in which the anatomy poses limitations to resection. Many resections are found to be incomplete, and the majority of recurrences have involved local failure. New surgical approaches allow greater flexibility according to tumor location and may improve these outcomes. Furthermore, new approaches permit complete resection of tumors involving vertebral bodies or the neural foramina. Traditionally, preoperative radiotherapy has been used, but a recent prospective phase II study suggests that preoperative concurrent chemoradiotherapy improves the rate of complete resection, local recurrence, and intermediate-term survival. [References: 45]

Publication Type: Journal Article. Review. Review, Tutorial.

<7>

Unique Identifier [PMID]: 12527583

Authors: Detterbeck FC. Jones DR. Kernstine KH. Naunheim KS. American College of Physicians.

Institution: Multidisciplinary Thoracic Oncology Program, Division of Cardiothoracic Surgery, University of North Carolina, CB #7605, 108 Burnett-Womack Building, Chapel Hill, NC 27599-7065, USA. fdetter@med.unc.edu

Title: Lung cancer. Special treatment issues.

Source: Chest. 123(1 Suppl):244S-258S, 2003 Jan.

Abstract: This chapter of the Lung Cancer Guidelines addresses patients with particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLC), and solitary metastases. For patients with a Pancoast tumor, a multimodality approach, involving chemoradiotherapy and surgical resection, appears optimal provided appropriate staging has been carried out. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. When carefully staged and selected, however, such patients appear to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment from what would be dictated by the primary tumor alone. On the other hand, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLC do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and those with a second primary lung cancer, although criteria to distinguish them have not been defined. Finally, some patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit substantially from resection.

Publication Type: Guideline. Journal Article. Practice Guideline.

<8>

Unique Identifier [PMID]: 12022545

Authors: Martinod E. D'Audiffret A. Thomas P. Wurtz AJ. Dahan M. Riquet M. Dujon A. Jancovici R. Giudicelli R. Fuentes P. Azorin JF.

Institution: Department of Thoracic and Vascular Surgery, Hopital Avicenne, Bobigny, France. emartinod@wanadoo.fr

Title: Management of superior sulcus tumors: experience with 139 cases treated by surgical resection.[see comment].

Comments Comment in: Ann Thorac Surg. 2003 Feb;75(2):633-4; author reply 634; PMID: 12607698

Source: Annals of Thoracic Surgery. 73(5):1534-9; discussion 1539-40, 2002 May.

Abstract: BACKGROUND: The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival. METHODS: Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV. RESULTS: The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival. CONCLUSIONS: The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.

Publication Type: Journal Article.

<9>

Unique Identifier [PMID]: 11332249

Authors: Vallieres E. Karmy-Jones R. Mulligan MS. Wood DE.

Institution: Section of General Thoracic Surgery, University of Washington, Seattle, Washington, USA.

Title: Pancoast tumors. [Review] [149 refs]

Source: Current Problems in Surgery. 38(5):293-376, 2001 May.

Publication Type: Journal Article. Review.

<10>

Unique Identifier [PMID]: 10343256

Authors: Hagan MP. Choi NC. Mathisen DJ. Wain JC. Wright CD. Grillo HC.

Institution: Departments of Radiation Oncology and Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.

Title: Superior sulcus lung tumors: impact of local control on survival.

Source: Journal of Thoracic & Cardiovascular Surgery. 117(6):1086-94, 1999 Jun.

Abstract: OBJECTIVES: Our goal was to assess patient survival and response to treatment for superior sulcus tumors treated with combined radiation therapy and surgery when possible, or with radiation alone when surgery was not possible. METHODS: Seventy-three patients were treated for primary non-small cell carcinoma of the superior pulmonary sulcus. Thirty-four patients received combined resection and irradiation. Thirty-nine patients who had extensive primary disease, distant metastases, or who were medically unfit for surgery were treated with radiation alone. Thirty-one patients (91%) assigned to the resection/irradiation group completed treatment. Combined therapy patients routinely received 40 Gy before the operation, with additional postoperative irradiation based on the surgical findings. RESULTS: Overall survival at 5 years was 19% and disease-specific survival was 20% for all patients. Overall survival and disease-specific survival at 5 years for the resection/irradiation group were 33% and 38%, respectively. Significant indicators of poor prognosis included unresected primary disease, low performance score, T4 stage, or positive node status. Eighty-two percent of the patients who received irradiation alone were treated with palliative intent. Freedom from local-regional progression, achieved initially in 66% of these patients, was associated with a median survival of 8 months. Median survival for 7 patients considered for definitive irradiation was 25 months. During the first 18 months, distant failures occurred in approximately 35% of patients in each treatment group. CONCLUSIONS: Selection of medically fit patients with resectable disease for combined surgery and aggressive radiation therapy resulted in a high likelihood of local control. Overall survival for the resection/irradiation group was significantly poorer for patients with T4 stage, nodal disease, or Horner's syndrome. Distant metastases eventually developed in 56% of patients undergoing resection. Median survival in the resection/irradiation group was significantly prolonged for those patients who could tolerate high-dose radiation treatment.

Publication Type: Journal Article.

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Link Directly to Fulltext Article at Publisher

Unique Identifier [PMID]: 10551556

Authors: Dartevelle P. Macchiarini P.

Institution: Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hopital Marie-Lannelongue Paris-Sud University, Le Plessis Robinson, France.

Title: Surgical management of superior sulcus tumors.

Source: Oncologist. 4(5):398-407, 1999.

Abstract: Superior sulcus tumor refers to any primary lung cancer presenting with constant pain in the nerve distribution of the eighth cervical, first and second thoracic nerve roots and Horner's syndrome caused by invasion of the stellate ganglion. The pain is steady, severe, and unrelenting, involving the shoulder, the vertebral margin of the scapula and ulnar distribution of the arm to the elbow and finally to the ulnar surface of the forearm, and the small and ring fingers of the hand (Pancoast-Tobias syndrome). Weakness and atrophy of the hand muscles can also occur as the lesions spreads to involve the first and second ribs and vertebrae. Radiologically, there is a small shadow at the extreme apex of the lung with rib and possible vertebral body invasion. Pulmonary symptoms are less frequent because of the peripheral location of the lesions. Since Shaw and Paulson approached superior sulcus tumors in 1961 by using preoperative radiation-therapy (30 to 45 Gy in four 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 that offered by other treatment modalities. It has now become evident that en bloc resection of the chest wall, involved adjacent structures as well as lobectomy must be considered the standard surgical approach for superior sulcus tumors combined with external radiation (preoperative, postoperative, or both). The goal of the operation is the complete and en bloc resection of the upper lobe in continuity with the invaded ribs, transverse processes, subclavian vessels, T1 nerve root, upper dorsal sympathetic chain and prevertebral muscles.

Publication Type: Journal Article.

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Link Directly to Fulltext Article at Science Direct

Unique Identifier [PMID]: 9692463

Authors: Attar S. Krasna MJ. Sonett JR. Hankins JR. Slawson RG. Suter CM. McLaughlin JS.

Institution: Department of Surgery, University of Maryland Hospital, Baltimore 21201, USA. sattar@surgery1.umaryland.edu

Title: Superior sulcus (Pancoast) tumor: experience with 105 patients.[see comment].

Comments Comment in: Ann Thorac Surg. 1998 Dec;66(6):2160-1; PMID: 9930529

Source: Annals of Thoracic Surgery. 66(1):193-8, 1998 Jul.

Abstract: BACKGROUND: The evolution of therapy in 105 patients with superior sulcus (Pancoast) tumor over the past 42 years was reviewed. METHODS: There were 82 men and 23 women aged 30 to 75 years. Tumor cell types were: squamous, 41 (39%); adenocarcinoma, 23 (21.9%); anaplastic, 14 (13.3%); undetermined, 12 (11.4%); mixed, 9 (8.7%); and large cell 6 (5.7%). Therapy was based on extent of disease and lymph node involvement. There were 5 treatment groups: I, preoperative radiation and operation (n = 28); II, operation and postoperative radiation (n = 16); III, radiation (n = 37); IV, preoperative chemotherapy, radiation, and operation (n = 11); and V, operation (n = 12). RESULTS: The median survival for group I was 21.6 months; group II, 6.9 months; group III, 6 months; and group V, 36.7 months. Median survival for group IV has not yet been reached (estimated at 72% at 5 years). On univariate analysis, mediastinal lymph node involvement, Horner syndrome, TNM classification, and method of therapy affected survival. On multivariate regression analysis, only N2 and N3 disease and method of therapy were significant (p < 0.05). CONCLUSIONS: The optimal treatment for superior sulcus tumor was preoperative radiation and operation. However, triple modality therapy, although promising, requires longer follow-up.

Publication Type: Journal Article.

<13>

Unique Identifier [PMID]: 10813231

Authors: Jones DR. Detterbeck FC.

Institution: Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill 27599-7065, USA.

Title: Pancoast tumors of the lung. [Review] [52 refs]

Source: Current Opinion in Pulmonary Medicine. 4(4):191-7, 1998 Jul.

Abstract: Pancoast or superior pulmonary sulcus tumors are uncommon primary bronchogenic carcinomas that produce a characteristic clinical syndrome of upper extremity pain and Horner's syndrome. Treatment of patients with this malignancy has traditionally involved irradiation alone or preoperative irradiation followed by resection. Recent advances in the management of Pancoast tumors include the importance of mediastinoscopy in staging the tumor before treatment begins. A complete resection should be accomplished including a lobectomy whenever possible. The current treatment protocol involves induction chemoradiotherapy followed by surgery. [References: 52]

Publication Type: Journal Article. Review. Review, Tutorial.

<14>

Unique Identifier [PMID]: 9358132

Authors: Arcasoy SM. Jett JR.

Institution: Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, PA 15261, USA.

Title: Superior pulmonary sulcus tumors and Pancoast's syndrome.[see comment]. [Review] [71 refs]

Comments Comment in: N Engl J Med. 1998 Mar 12;338(11):765-6; PMID: 9499177, Comment in: N Engl J Med. 1998 Mar 12;338(11):765; author reply 766; PMID: 9499175, Comment in: N Engl J Med. 1998 Mar 12;338(11):765; author reply 766; PMID: 9499176

Source: New England Journal of Medicine. 337(19):1370-6, 1997 Nov 6.

Publication Type: Journal Article. Review. Review, Tutorial.

<15>

Link Directly to Fulltext Article at Science Direct

Unique Identifier [PMID]: 2254613

Authors: Harpe KG. Roth RN.

Institution: Craven Regional Medical Center, New Bern, North Carolina.

Title: Horner's syndrome in the emergency department. [Review] [28 refs]

Source: Journal of Emergency Medicine. 8(5):629-34, 1990 Sep-Oct.

Abstract: We present a case of a 47-year-old female who was followed for 7 months with complaints of musculoskeletal pain involving the shoulder and scapula until she presented to the emergency department with Horner's syndrome and was diagnosed as having a superior pulmonary sulcus tumor. A review of the literature shows that although such tumors are a frequent cause of Horner's syndrome there are numerous other benign as well as malignant causes of Horner's syndrome. The differential diagnosis can be significantly narrowed by a knowledge of the anatomy and a careful physical examination. We present the anatomy, pathophysiology, differential diagnosis, and evaluation of patients who present to the emergency department with Horner's syndrome. [References: 28]

Publication Type: Case Reports. Journal Article. Review. Review, Tutorial.

<16>

Unique Identifier [PMID]: 7425056

Authors: Maloney WF. Younge BR. Moyer NJ.

Title: Evaluation of the causes and accuracy of pharmacologic localization in Horner's syndrome.

Source: American Journal of Ophthalmology. 90(3):394-402, 1980 Sep.

Abstract: Of 450 cases of Horner's syndrome examined by pupillography. 13% were caused by tumor but less than 3% were undetected malignant tumors. The largest group of lesions (40%) had an undetermined cause, presumably related to vascular disease. Although the hydroxyamphetamine test usually can differentiate postganglionic from preganglionic lesions, its clinical value and accuracy for this purpose has been overemphasized in previous reports. Of the 13 undetected malignant neoplasms, nine (69%) manifested as Pancoast's syndrome with arm pain, a reliable sign to identify patients with Horner's syndrome caused by undetected malignancy.

Publication Type: Journal Article.