1. Superior Sulcus Resection G. Alexander Patterson, MD Evarts A. Graham Professor of Surgery Chief, Division of Cardiothoracic Surgery

3. Superior Sulcus Tumors • Evaluated 116 patients • Eligible 101 patients • Completed Induction Rx 93% • Thoractomy 81% • 1 operative mortality SWOG 9416, JTCVS 2001; 121: 472

4. Superior Sulcus Tumors SWOG 9416, JTCVS 2001; 121: 472

5. Requirement for Cure Accurate Staging Localized Disease Complete Resection

6. Surgical Approaches for Superior Sulcus Tumor • Posterolateral (Shaw - Paulson) • Anterior cervicothoracic (Dartevelle) • Hemi-clamshell (Burt) • Anteroposterior “hook” (Niwa) • VATS - Posterior

7. de Perrot, M et al. JTCVS 2012; 144:72-80

11. L. D.Squamous Cell Ca T3 N0

12. Initial thoracotomy determines resectability Anterior rib resection facilitates posterior rib detachment Posterolateral Approach

13. 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

14. Dissection of: Supraclavicular nodes S.C. artery Brachial plexus Scalene muscles Phrenic nerve Determine resectability prior to morbidity of major resection Preliminary Supraclavicular Exploration

15. Anterior Cervicothoracic Approach Excellent Exposure for Anterior Lesions Incision anterior sternomastoid inferior to clavicle into D.P. groove Clavicular resection exposes throacic inlet

16. Hemi-Clamshell Approach Excellent Exposure for Anterior Lesions Initial anterolateral thoracotomy Extension after resectability confirmed

23. T3 Superior Sulcus • Adverse prognostic factors: • Horner’s syndrome • N2, N3 disease • Incomplete resection • 9% 5yr survival Ginsberg, Ann Thor Surg 1994; 57:1440

24. Superior Sulcus Tumors Survival Gomez D, Cancer 2012 38(0) 50, 2012 Jan

25. Summary • Detailed History • Accurate Staging • Neoadjuvant chemorads • Precise Exploration • Complete resection

26. 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

27. All of the following are absolute contraindications to potentially curative resection except: • Extrathoracic metastatic disease • Vertebral column involvement • Tracheal involvement • Brachial plexus invasion

28. 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