Foroulis Christophoros N, Zarogoulidis Paul, Darwiche Kaid, Katsikogiannis Nikolaos, Machairiotis Nikolaos, Karapantzos Ilias, Tsakiridis Kosmas, Huang Haidong, Zarogoulidis Konstantinos
Department of Cardiothoracic Surgery, AHEPA University Hospital, Aristotle University Medical School, Thessaloniki, Greece;
J Thorac Dis. 2013 Sep;5 Suppl 4(Suppl 4):S342-58. doi: 10.3978/j.issn.2072-1439.2013.04.08.
Pancoast tumors account for less than 5% of all bronchogenic carcinomas. These tumors are located in the apex of the lung and involve through tissue contiguity the apical chest wall and/or the structures of the thoracic inlet. The tumors become clinically evident with the characteristic symptoms of the "Pancoast-Tobias syndrome" which includes Claude-Bernard-Horner syndrome, severe pain in the shoulder radiating toward the axilla and/or scapula and along the ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in edema of the upper arm. The diagnosis will be made by the combination of the characteristic clinical symptoms with the radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1(st) and/or 2(nd) ribs. A tissue diagnosis of the tumor via CT-guided FNA/B should always be available before the initiation of treatment. Bronchoscopy, thoracoscopy and biopsy of palpable supraclavicular nodes are alternative ways to obtain a tissue diagnosis. Adenocarcinomas account for 2/3 of all Pancoast tumors, while the rest of the tumors are squamous cell and large cell carcinomas. Magnetic resonance imaging of the thoracic inlet is always recommended to define the exact extent of tumor invasion within the thoracic inlet before surgical intervention. Pancoast tumors are by definition T3 or T4 tumors. Induction chemo-radiotherapy is the standard of care for any potentially resectable Pancoast tumor followed by an attempt to achieve a complete tumor resection. Resection can be made through a variety of anterior and posterior approaches to the thoracic inlet. The choice of the approach depends on the location of the tumor (posterior - middle - anterior compartment of the thoracic inlet) and the depth/extent of invasion. Prognosis depends mainly on T stage of tumor, response to preoperative chemo-radiotherapy and completeness of resection. Resection of the invaded strictures of the thoracic inlet should me made en bloc with pulmonary parenchyma resection, preferably an upper lobectomy. Invasion of the vertebral column is not a contraindication for surgery which, however, should be performed in oncologic centers with experience in spinal surgery. Surgery for Pancoast tumors is associated with 5% mortality rate and the complication rate varies from 7-38%. The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%). The main pattern of recurrence is that of distant metastases, especially in the brain.
肺上沟瘤占所有支气管肺癌的比例不到5%。这些肿瘤位于肺尖，通过组织连续性累及胸壁尖部和/或胸廓入口结构。肿瘤出现“潘科斯特 - 托拜厄斯综合征”的特征性症状时在临床上变得明显，该综合征包括克劳德 - 伯纳德 - 霍纳综合征、肩部向腋窝和/或肩胛骨放射并沿上臂尺侧分布的严重疼痛、手部和手臂肌肉萎缩以及锁骨下静脉阻塞导致上臂水肿。结合特征性临床症状与肺尖部肿块或不透光区浸润第1和/或第2肋骨的影像学表现进行诊断。在开始治疗前，应始终通过CT引导下细针穿刺抽吸/活检获得肿瘤的组织学诊断。支气管镜检查、胸腔镜检查和可触及的锁骨上淋巴结活检是获得组织学诊断的替代方法。腺癌占所有肺上沟瘤的2/3，其余肿瘤为鳞状细胞癌和大细胞癌。在手术干预前，始终建议对胸廓入口进行磁共振成像以确定肿瘤在胸廓入口内的确切侵犯范围。根据定义，肺上沟瘤为T3或T4期肿瘤。诱导放化疗是任何潜在可切除肺上沟瘤的标准治疗方法，随后尝试实现肿瘤的完全切除。可通过多种胸廓入口的前后入路进行切除。入路的选择取决于肿瘤的位置（胸廓入口的后 - 中 - 前区）和侵犯的深度/范围。预后主要取决于肿瘤的T分期、对术前放化疗的反应以及切除的完整性。胸廓入口受侵狭窄的切除应与肺实质切除整块进行，最好是上叶切除。椎体侵犯不是手术的禁忌证，但手术应在有脊柱手术经验的肿瘤中心进行。肺上沟瘤手术的死亡率为5%，并发症发生率在7%至38%之间。诱导放化疗和切除后的总体2年生存率在55%至70%之间，而R0切除的5年生存率相当不错（54%至77%）。复发的主要模式是远处转移，尤其是脑转移。
