'Pippa Bacca‘ Giuseppina Pasqualino di Marineo

1. Surgical Outcomes of Superior Sulcus TumorsBedrettin YILDIZELİMARMARA UNIVERSITY HOSPITALDEPARTMENT OF THORACIC SURGERYİSTANBUL, TURKEY

2. 'Pippa Bacca‘ Giuseppina Pasqualino di Marineo Perdonaci Pippa Siamo Addolorati

3. Technical challenges

5. Posterior (Paulson and Shaw) The transmanubrial osteomuscular-sparing (Grunenwald) Transclavicular (Dartevelle) Surgical approach The tans-sternal (Masoaka) The trans-scapular (Tatsumara) Hemiclamshell and trap-door incisions

7. Issues • Definition • Complete resection • Neoadjuvant chemotherapy • Lobectomy vs wedge resection • N disease • Vertebral invasion • Vascular invasion • Brachial plexus involvement • Local control • Tumor relapse, at a distant site

8. Frank C. DetterbeckChanges in the treatment of Pancoast tumors Ann Thorac Surg 2003;75:1990-1997 T3 ? the apex of thelung The chest wall involvement invasion of the parietal pleura, or the periostium or the bone of the upper ribs or apicalvertebral bodies, or the subclavianvesselsor the nerve roots of the brachial plexus, or the stellateganglion T4

9. Induction Chemoradiation and Surgical Resection forSuperior Sulcus NSCLC: Long-Term Results of SWOG Trial 9416 (Intergroup Trial 0160), Valerie W. Rusch et al.Journal of Clinical Oncology, Vol 25, No 3 (January 20), 2007: pp. 313-318

10. Complete resection • complete resection rate (n=225)1 • 64% in T3 N0 • 39% in T4 N0 1 Rusch VW, Parekh KR, Leon L, et al: Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus. J Thorac Cardiovasc Surg 119:1147-1153, 2000.

11. Lobectomy vs wedge resection • Lobectomy is associated with a betteroverall survival than limited pulmonary resection 1 1Ginsberg RJ, Martini N, Zaman M, et al: Influence of surgical resection and brachytherapy in the management of superior sulcus tumor. Ann Thorac Surg 57:1440-1445, 1994

12. Tumor relapse, at a distant site • Radiation Therapy Oncology Group • RTOG 0214 • phase III study • Prophylactic Cranial Irridation vs observationin stage IIIA and IIIB NSCLC

13. Aggressive surgery Multimodality therapy

14. Induction chemotherapy WHY IT IS NECESSARY? WHY IT IS NOT? High incomplete resection Local recurrence Necrosis of tumor is significantly associated with a better outcome only 75% 1 68% underwent surgery2 Mortality 3% Complete resection 76% Local recurrence 20% 1 Rusch et al. J Clin Oncol 2007 2 Pourel et al. J Cardiothorac Surg 2008

15. Oncologic Contraindications for Surgery • Presence of extrathoracic metastases • mediastinal or supraclavicular lymph node involvement • Invasion of the brachial plexus above its lower trunk (C8) • Total venous obstruction • Invasion of the spinal canal • if > 4 vertebral bodies must be resected

16. Transclavicular approach for resecting tumors invading the « thoracic inlet »  n=126(including 28combined “en bloc” resection of the first thoracic vertebrae with spinal fixation) Dartevelle P, Yıldızeli B, Fadel E, Mussot S, Chapelier A. Results of Primary Surgery in 271 Patients With T4 Non-Small Cell Lung Cancer Over a 25 Year Period in a Single Center: The Benefit is Worth the Risk Society of Thoracic Surgeons (STS) 2008 Annual Meeting January 26-30, 2008 Ft Lauderdale, Florida, USA

17. Surgicalapproach n=126 Transcervical Alone 66 Transcervical plus 32 a)Posterior Thoracotomy b)Midline Spinal Incision 28 (Hemivertebrectomy & Spinal fixation)

18. Tumor extension Bone: 53/ 73 First 2 vs. First 4 ribs 25 Intervertebral Foramen (T1-T2) Nerves: Phrenic Nerve 42 Nerve Roots 1 / 82 C8 vs. T1 Vessels: Subclavian artery (19 PTFE; 30 EE) 49 Subclavian Vein (24 ligation; 1 plasty) 25 Vertebral/Carotid Artery 20/2

19. Tumor extension Lung : Wedge Resection 24 Upper Lobectomy 99 Cervical approach 61 Thoracic approach 38 Pneumonectomy 3

20. LymphNodesStaging 95 N0 N1 12 7 N2 12 N3 (ipsilateral scalene nodes)

21. Complications # Deaths • Cerebrospinal fluid leakage 1 • Hemothorax 6 • Chylothorax 4 • Respiratory 21 • Others 26 1 Mortality 0.8%

22. OverallSurvival(n=126) Recurence n=81 Local n=18 Systemic n=55 Both n=8 Death n=88 Alive n=38 1 ,8 36.6% ,6 Survival ,4 25.9% ,2 Median survival 28 months 0 Months after surgery 0 12 24 36 48 60 72 84 96 108 120 Patients 126 94 66 44 40 33 28 21 16 12 10 at risk

23. Thoracic InletNSCLCSurvival According to Vertebral Invasion 1 Sup Sulcus Tm n=98 5 year survival 37.8% ,8 Median survival31 months ,6 Sup Sulcus Tm+Vertebrae n=28 Survival ,4 5 year survival 28.6% ,2 Median survival 20 months p=0.38 0 Months 0 12 24 36 48 60 72 84 96 108 120 Patients 98 73 53 34 32 24 22 16 13 10 9 at risk 28 21 13 10 10 9 7 5 3 2 1

24. Vertebral Invasion Failure n =16 (57%) 5 local recurrence 10 distant recurrence 1 both 1 ,8 ,6 Survival 28.6% ,4 ,2 Median survival 20 months 0 Time (months) 0 12 24 36 48 60 72 84 96 108 120

25. 1 Complete Resection (R0) ,8 Incomplete Resection (R1) ,6 Survival ,4 ,2 0 0 10 20 30 40 50 60 70 80 90 100 110 120 Times (months) Survival according to R0 resection 40.4% 15.9%

26. Survival according to N disease 1 N0-1; n=107 ,8 38.5% ,6 Survival N2+; n=19 ,4 17.1% p = 0.01 ,2 0 Time (months) 0 12 24 36 48 60 72 84 96 108 120

27. Conclusions • Complete resection is must • Invasion of subclavian or mediastinal vessels, T1 nerve root, vertebrae or intervertebral foraminae are not a contraindication to surgery • low mortality rate even when associated with hemivertebrectomies and spinal fixation • 5yr survival rate is 36.6 %

28. Thank you very much for your attention