Pancoast tumor surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]

Overview

Surgery is the mainstay of therapy for early-stage Pancoast tumor. Surgical procedure selection will depend on the histology, margins, and size of the tumor. Common surgical procedures for the treatment of Pancoast tumor, include lung resection with lobectomy, lung resection with pneumonectomy with or without lymph node dissection, thoracotomy with the removal of the entire lung or lobe (lobectomy) along with regional lymph nodes (peribronchial and perihilar lymph node dissection) and pathological evaluation. If evidence of lymph node extension of the disease is present adjuvant chemotherapy should be administered. Surgical resection is not recommended for patients with advanced or metastatic lung carcinoma. Surgical staging of the mediastinum is considered standard if accurate evaluation of the nodal status is needed to determine therapy. Surgical treatment consists of a thoracotomy with removal of the entire lung or lobe along with regional lymph nodes and contiguous structures. Pneumonectomy is used if the tumor involves the main bronchus, extends across a fissure or is located such that wide excision is required. Survival following ‘curative’ resection is approximately 30% at 5 years and 15% at 10 years. The best results are found in squamous cell carcinoma followed by large-cell carcinoma and the adenocarcinoma. If the tumor is inoperable, stereotactic ablative radiation therapy should be administered.

Surgery

In non-small cell lung cancer, surgical procedure selection will depend on the histology, margins, and size of the tumor.

• Surgery is the mainstay of therapy for early-stage Pancoast tumor .
• Common surgical procedures for the treatment of Pancoast tumor, include:

• Lung resection with lobectomy
• Lung resection with pneumonectomy with or without lymph node dissection
• The preferred surgical procedure is thoracotomy with the removal of the entire lung or lobe (lobectomy) along with regional lymph nodes (peribronchial and perihilar lymph node dissection) and pathological evaluation.

• If evidence of lymph node extension of the disease is present adjuvant chemotherapy should be administered
• Surgical resection is not recommended for patients with advanced or metastatic lung carcinoma
• Surgical staging of the mediastinum is considered standard if accurate evaluation of the nodal status is needed to determine therapy
• Surgical treatment consists of a thoracotomy with removal of the entire lung or lobe along with regional lymph nodes and contiguous structures
• Pneumonectomy is used if the tumor involves the main bronchus, extends across a fissure or is located such that wide excision is required.
• Survival following ‘curative’ resection is approximately 30% at 5 years and 15% at 10 years.
• The best results are found in squamous cell carcinoma followed by large-cell carcinoma and the adenocarcinoma.
• If the tumor is inoperable, stereotactic ablative radiation therapy should be administered.

Evaluation before surgery

• Resectable

• The tumour can be completely removed (resected) during surgery.
• Tissue around the tumour and nearby lymph nodes may also be removed.

• Unresectable

• The tumour cannot be removed by surgery.
• Tumours are considered unresectable if:

• They are too large to completely remove
• The cancer has spread to certain mediastinal lymph nodes, other organs near the lungs or to distant sites
• There is pleural effusion or pericardial effusion present

• Because surgery to treat Pancoast tumor is a major operation, the person needs to be in good overall health and be able to tolerate surgery. Lung and heart function tests are done to make sure that people are healthy enough to have surgery and that they will have enough lung function after surgery.

• Surgery is offered to people who have a low risk of developing shortness of breath after surgery.
• Some people are at high risk of poor lung function and shortness of breath after surgery. Before surgery is offered to these people, the healthcare team will discuss the benefits of surgery and quality of life after surgery.
• If the person is not well enough to have surgery, the tumor is considered inoperable.

• Lung surgery is done through an incision between the ribs on the side of the chest (thoracotomy). The ribs are spread so the surgeon can reach the lung.

• The type of surgery done depends on the size and location of a tumour and how far it has spread within the lung. Side effects of surgery depend on the type of surgical procedure.

Wedge or segmental resection

• A wedge or segmental resection removes a tumour along with a margin of healthy lung tissue. A segmental resection removes more tissue than a wedge resection.

• A wedge or segmental resection may be offered for very early stage Pancoast tumor to preserve as much lung function as possible. These procedures may also be done in people with more advanced lung cancer who may have poor lung function after surgery.

• Wedge or segmental resection may also be done for a single tumor that has spread to the lung from other parts of the body (lung metastases).

Lobectomy

• A lobectomy is the removal of the lobe of the lung that has a tumour.

• A bilobectomy is the removal of 2 lobes of the right lung, which has 3 lobes. This surgery may be done if the tumour has spread into 2 joining lobes. The upper and middle lobes or the middle and lower lobes may be removed during a bilobectomy.

Pneumonectomy

• A pneumonectomy is the removal of a whole lung during surgery. This surgery is done if the tumour has spread either:

• Across both lobes of the left lung
• To the hilum of the lung

• There are more complications with pneumonectomy when the right lung (the larger lung) is removed.

Extended pulmonary resection

• Extended pulmonary resection is used to treat tumours that have spread to the chest wall, diaphragm, nerves, blood vessels or other tissues near the lung. During surgery, a complete section (en bloc) of the surrounding tissue is removed to try to take out as much of the cancer as possible.

Sleeve resection

• A sleeve resection is used to treat tumours in the large bronchus of the lung. The tumour is removed from the bronchus, along with a margin of healthy tissue on either side of the tumour. The 2 ends of the bronchus are then joined together (anastomosis).

Lymph node removal

• Lymph nodes play a large part in the staging and prognosis of Pancoast tumor, as well as in planning for surgery. During diagnosis, tests may show if the cancer has spread to certain lymph nodes.

• N1 nodes – Cancer that has spread to these nodes can usually be completely removed with surgery.
• N2 nodes – It may not be possible to completely remove cancer that has spread to these nodes, so surgery may not be an option.
• N3 nodes – Cancer that has spread to these nodes cannot be completely removed with surgery, so surgery is not an option.

Stent placement

• Pancoast tumor can grow into the bronchus, causing breathing problems or pneumonia. A stent is a small metal or plastic tube that is placed into the bronchus during a bronchoscopy. It keeps the airway open and allows air into the lungs.

Chest tube placement

• During surgery, a flexible tube will be inserted through a cut in the skin, between the ribs and into the space between the lungs and the wall of the chest (pleural cavity). The tube is connected to a bottle with sterile water and a suction machine. It may be held in place with stitches or tape.

• A chest tube is used to drain blood, other fluids and air from the space around the lungs (pleural space) after surgery. It is left in place until x-rays show that the blood, fluids or air have been drained and that the lung can fully expand.

Thoracentesis

• A thoracentesis is a procedure in which a hollow needle is inserted through the skin and between the ribs into the space between the lungs and the wall of the chest (pleural cavity). It is used to drain fluid or air from the chest cavity.

• Thoracentesis may be used with lung cancer to treat:

• Air leaking from the lung into the chest, causing the lung to collapse (pneumothorax)
• Bleeding into the chest (hemothorax)
• A buildup of fluid in the pleural cavity (pleural effusion)

Pleurodesis

• Pleurodesis is done to prevent a buildup of fluid in the pleural cavity and pleural effusion. Excess pleural fluid is drained, and then drugs or chemicals, such as sterile talc, are put into the pleural space through a chest tube. Pleurodesis seals the parietal pleura and visceral pleura together so there is no longer a space between them in which fluid could build up.

Surgery for metastatic Pancoast tumor

• Surgery may be done to remove a single metastatic tumour that has spread from the lung to the:

• Brain
• Adrenal gland

Video-assisted thoracic surgery (VATS)

• Video-assisted thoracic surgery (VATS) is a less invasive type of surgery. It uses a small video camera and surgical tools inserted through several small incisions in the chest wall. The surgeon is guided by an image on a video screen.

• VATS may be used to remove small (3–4 cm) lung cancer tumours from the outer edges (periphery) of the lung. A lobectomy may also be done using VATS.

Indications

Surgery is usually reserved for patients with the following characteristics:

• Pulmonary function testing

• Preoperative assessment of FEV1/DLCO
• FEV1 >2 L (or more than 80%)
• DLCO > 80

• Exercise testing

• Successful cutoff of 22 m on the stair climbing test

• Fitness for surgery

• Evaluation of risk factors, such as:
• Age
• General health status (obesity, Karnofsky scale >70)
• COPD/Asthma
• Smoking
• Other conditions: pulmonary hypertension, heart failure, and metabolic factors

Contraindications

Surgery is usually contraindicated in patients with the following characteristics:

• Lung cancer extension past the diaphragm

• Extrathoracic metastases
• Metastases to supraclavicular lymph nodes
• Contralateral mediastinal node metastases

• Involvement of contralateral hemithorax
• Invasion of structures of the mediastinum

• Involvement of the main pulmonary artery

• Chest wall invasion
• No fitness for surgery
• Hypercapnia (arterial PCO2 greater than 45 mmHg)
• Inadequate exercise testing results (22 m on the stair climbing test)
• Presence of oncological emergencies, such as superior vena cava syndrome, malignant pleural effusion, cardiac tamponade, vocal cord or phrenic nerve paralysis

Complications

Common complications of Pancoast tumor surgery, include:

• Atelectasis
• Infection

• Nosocomial pneumonia

• Prolonged mechanical ventilation
• Respiratory failure
• Bronchospasm
• Pulmonary embolism