Anterior Approach to Superior Sulcus Lesions

Historical Note

Henry K. Pancoast, a radiologist at the University of Pennsylvania, described a patient afflicted with a carcinoma of uncertain histologic origin occupying the extreme apex of the chest, associated with shoulder and arm pain, atrophy of the hand muscles, and Horner syndrome. This clinical entity has become known as Pancoast syndrome. Unknown to Pancoast, Tobias had already characterized the anatomic and clinical aspects of this lesion, correctly recognizing that the tumor was a peripheral lung cancer. Anatomically, the pulmonary sulcus refers to the costovertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus lies at the uppermost extent of this recess, as reviewed by Teixeira. Generally, it is understood that non–small cell lung carcinomas of this region are termed Pancoast tumors, and we refer to this association throughout the chapter. However, the term superior sulcus lesion encompasses other, more diverse causes, both benign and malignant. Furthermore, this definition has been expanded to include patients who do not have evidence of brachial plexus or stellate ganglion involvement. Chest wall involvement in this region might be restricted to involvement of the parietal pleura or could extend deeper to the upper ribs, vertebral bodies, or subclavian vessels, according to Detterbeck. Invasion of the chest wall at or lower than the level of the second rib, or of the visceral pleura only, does not meet the criteria for a superior sulcus lesion. Additionally, Macchiarini and colleagues reported that a wide variety of superior sulcus lesions can result in Pancoast syndrome ( Box 21-1 ); thus, a histologic diagnosis is mandatory when the syndrome is encountered.