Key Points

• History and physical examination are the most important components of the workup.
• CT, MRI, and CT/PET are essential and routinely used for all radiographic workups and surgical planning.
• Mediastinoscopy or EBUS is required to rule out N2 disease before proceeding with resection.
• N3 disease, including ipsilateral supraclavicular and scalene lymph nodes, behaves biologically like N1 disease and is considered locoregional resectable disease.
• T3 and T4 superior sulcus tumors are considered resectable.

Superior sulcus tumors are bronchogenic carcinomas, usually of non-small cell histology, that typically produce unrelenting pain in the distribution of the eighth cervical and first and second thoracic nerve roots and are associated with Horner’s syndrome (ptosis, miosis, and anhidrosis) and motor deficits of the intrinsic hand muscles. This compilation of symptoms is known as Pancoast’s syndrome. The apical location of these tumors, tendency to cause severe pain, and functional deficits from their locally invasive nature and distant metastases make these lesions complex surgical challenges for evaluation and management.

For the patient with a superior sulcus tumor, the treatment options vary depending on the anatomic site of the lesion, involvement of surrounding thoracic inlet structures, and the presence or absence of distant metastases. Complete surgical resection with negative margins is the goal in these patients. However, these tumors are more often found at a locally advanced stage or have invaded contiguous structures, such as vertebrae, subclavian vessels, or the chest wall. Although radiation and chemotherapeutic agents continue to be mainstay treatments for unresectable disease, these two treatments are now used in tandem with surgical resection to address the more locally invasive and destructive tumors. Perioperative radiation, chemotherapy, and aggressive surgical resections have changed the previously defined parameters of resectability. For instance, induction chemoradiotherapy can now be used to reduce tumor burden in patients with T3-T4 N0-N1 disease. Subsequently, responding tumors can be resected with a high likelihood of negative margins. The focus in this chapter is on superior sulcus tumors, which by definition are T3 or T4 lesions by virtue of their chest wall or vertebral body invasion, and on the outcomes and controversies of multimodality treatment options. The chapter will highlight the posterior approach to superior sulcus tumors, whereas the anterior approach is most useful in case of axillary or subclavian vessel invasion.