Is there a standard of care for the radical management of non-small cell lung cancer involving the apical chest wall (Pancoast tumours)?

The term Pancoast tumour encompasses a wide range of tumours that invade the apical chest wall. Although less than 5% of non-small cell lung cancers are Pancoast tumours, they still account for most cases. They often pose a formidable challenge to the multidisciplinary lung cancer team due to their relative rarity, anatomical proximity to vital structures, differing stages of presentation, and their association with smoking-related illnesses. A lack of clinical trials makes comparisons between different treatment modalities very difficult and the management of Pancoast tumours has been largely based on the published retrospective experience of large single institutions. The bimodality approach of induction radiotherapy followed by surgical resection has been the accepted standard of care for the last 50 years, with reported 5-year survival rates of 30% in selected patients. However, two recent prospective multicentre phase II studies using a trimodality approach of induction concurrent chemoradiotherapy followed by surgical resection (followed by two further cycles of adjuvant chemotherapy in one of the studies), have reported 5-year survival rates of 44-56%. This has led to some authorities advocating the trimodality approach as the new standard of care for the management of Pancoast tumours. In this overview, the historical evolution of the management of Pancoast tumours and recent published studies on the trimodality approach are discussed. This is followed by a discussion of whether the trimodality approach should be seen as a new standard of care. Finally, other potential treatment options and the possibilities for future research are deliberated.

The effectiveness of an informal teaching programme for junior doctors identifying pleural effusions using ultrasound at the bedside.

OBJECTIVES: The use of bedside ultrasound to localise pleural effusions has gained in popularity in recent years. We investigated whether or not junior doctors could accurately identify thoracic anatomical structures and localise pleural effusions using bedside ultrasound. METHODS: Junior doctors were instructed by a consultant chest physician in the theory and practice of using ultrasound to localise pleural effusions, and then instructed in the method of inserting a Seldinger chest drain. Juniors were instructed to record a scan picture, including labelling of relevant structures. We then conducted a review of 52 images, noting indications, complications and the grade of doctor performing the scan. A consultant radiologist reviewed the scan pictures to confirm that the anatomy was correctly identified. RESULTS: Fifty out of 52 images (96%) were of diagnostic quality, with the anatomy correctly identified. The complication rate from chest drain insertion was 3.85%. CONCLUSIONS: With instruction, junior doctors can competently utilise basic chest ultrasound, obtain useful images, identify relevant thoracic anatomy and insert chest drains by the Seldinger technique with a low rate of complications. We suggest thoracic ultrasound should be more widely taught to junior doctors.