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Principles and Practice of Anesthesia for Thoracic Surgery pp 597–607Cite as

Pancoast Tumors and Combined Spinal Resections

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Abstract

Pancoast tumors, properly known as superior sulcus carcinomas, are a particularly challenging form of non-small cell lung cancer (NSCLC) to treat surgically because they commonly invade vital structures within and near the thoracic inlet. Invasion of the brachial plexus, subclavian vessels, and spine by direct tumor extension necessitates careful preoperative planning by surgeons and anesthesiologists. Originally described in 1924 (Pancoast HK, J Am Med Assoc 83:1407–11, 1924) and again in 1932, (Pancoast HK, J Am Med Assoc 99:1391-6, 1932) by Henry K. Pancoast, a radiologist at the University of Pennsylvania, this subset of NSCLC was considered inoperable, and thus fatal, for nearly two decades until the late 1950s when the combination of radiotherapy and surgery offered some curative hope. Pancoast’s description of an apical chest tumor associated with shoulder and arm pain, a Horner’s syndrome, and atrophy of the hand muscles describes the constellation of signs and symptoms of the syndrome that has come to bear his name.

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Author information

Authors and Affiliations

  1. Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Valerie W. Rusch

  2. Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Ilya Laufer & Mark Bilsky

  3. Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Alexandra Lewis

  4. Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    David Amar

Authors
  1. Valerie W. Rusch
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  2. Ilya Laufer
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  3. Mark Bilsky
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  4. Alexandra Lewis
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  5. David Amar
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Corresponding author

Correspondence to Valerie W. Rusch .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

Case: A 50-year-old man with a recent history of dyspnea on exertion and recurrent pneumonias for the past year is scheduled for surgical resection of a large apical right lung mass (Fig. 37.4a). He is a former 40 pack-year smoker. He has moderately severe but clinically stable multiple sclerosis. He reports pain in his shoulder radiating down his arm but has normal strength and function in his right hand. CT scan, PET scan, and MRI have been done and suggest no evidence of metastatic disease but extension into the paravertebral area and spine.

Questions

  1. 1.

    What position(s) will the patient be in for resection?

  2. 2.

    What is your plan for intravascular monitoring and access?

  3. 3.

    Do you think a chest wall reconstruction will be necessary?

  4. 4.

    If the vertebral bodies are involved, what other exposure is necessary?

  5. 5.

    What strategy do you have for fluid management and postoperative pain control?

Discussion

Based on the history and preoperative imaging, this patient has a superior sulcus tumor or Pancoast tumor, involving vital structures in the thoracic inlet and spine. A combined posterior and anterior approach will be necessary for complete resection (see description in text). The patient will be placed prone for the spine resection and stabilization. Once that is completed, the patient will be rotated into the lateral decubitus position and a posterolateral thoracotomy performed to complete the lobectomy and chest wall resection and reconstruction.

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Rusch, V.W., Laufer, I., Bilsky, M., Lewis, A., Amar, D. (2019). Pancoast Tumors and Combined Spinal Resections. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_37

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_37

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-00858-1

  • Online ISBN: 978-3-030-00859-8

  • eBook Packages: MedicineMedicine (R0)

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