Pathologic complete response after neoadjuvant tislelizumab and chemotherapy for Pancoast tumor: A case report.

A 60-year-old man was hospitalized because of numbness and weakness in the right upper limb. Magnetic resonance imaging revealed a large mass in the right upper lobe invading the right eighth cervical and first thoracic nerve root. Biopsy pathology confirmed primary lung adenocarcinoma with a clinical stage of cT4N0M0 IIIA, negative for anaplastic lymphoma kinase fusion gene and epidermal growth factor receptor mutations but positive for programmed death ligand 1 (3%). Neoadjuvant tislelizumab and chemotherapy were offered to this patient with Pancoast tumor, and tumor shrinkage of 71% was achieved. After the operation, surgical pathology indicated pathologic complete response (pCR). Circulating tumor cells testing was negative after the first adjuvant treatment. In this case, we provide real-world evidence of encouraging pCR with neoadjuvant tislelizumab and chemotherapy for a patient with Pancoast tumor.

A case of pulmonary mucormycosis presented as Pancoast syndrome and bone destruction in an immunocompetent adult mimicking lung carcinoma.

Pulmonary mucormycosis is a rare opportunistic infection caused by Mucormycosis. This fungal infection is uncommon in immunocompetent individuals. Because of its various clinical and imaging manifestations, it is a diagnostic challenge to distinguish pulmonary mucormycosis from other pulmonary diseases, such as carcinoma. Herein, we report a case of pulmonary mucormycosis presenting as Pancoast syndrome and bone destruction of ribs. A 46-year-old Chinese woman was admitted due to pain in chest, right neck and arm for four months and hoarseness for one week. The pre-admission diagnosis via chest CT was pulmonary carcinoma. The subsequent bronchoalveolar lavage fluid analysis and bronchoscopic biopsy were negative for malignant cells, except chronic inflammation. Imaging-guided percutaneous biopsies were carried out after admission and the final pathological diagnosis was pulmonary mucormycosis. Although the patient was started on oral posaconazole of 400mg bid, the disease condition continued to deteriorate. She finally died of respiratory failure.

Conservative Management of Neuropathic Pain in a Patient With Pancoast-Tobias Syndrome: A Case Report.

Pancoast-Tobias syndrome characterizes the signs and symptoms of a superior pulmonary sulcus tumor, and includes arm and shoulder pain, atrophy of intrinsic hand muscles, and ipsilateral Horner syndrome. The rarity and overall poor prognosis of patients with superior pulmonary sulcus tumors associated with Pancoast-Tobias syndrome has led to few reports detailing pain management strategies with adjunctive therapies, such as continuous infusions of ketamine and lidocaine, chemotherapy, radiation, and multimodal oral medication regimens. This case highlights the diagnosis and treatment of pain in a patient with Pancoast-Tobias syndrome.

Does induction chemoradiotherapy increase survival in patients with Pancoast tumour?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether induction (neoadjuvant) chemoradiotherapy (iCRT) compared with other therapeutic strategies improves survival in patients with Pancoast tumours. Altogether 248 papers were identified using the below-mentioned search. Ten of them represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. Four studies were retrospective comparative studies of induction chemoradiotherapy and surgery (trimodal therapy) versus other therapeutic strategies. Two studies were retrospective and four were prospective investigating trimodal therapy. These papers comprised a total of 550 patients. The overall survival was better with trimodal therapy compared with RT (radiotherapy) followed by surgery group in all three comparative studies. The 2-year survival varied in the trimodal therapy group from 70 to 93%, in comparison to RT group where variation was from 22 to 49%. Five-year survival for trimodal therapy varied between 36.4 and 84% in the results of two comparative studies, compared with 11 and 49% for RT and surgery, respectively. One paper looked at survival in patients who underwent surgery alone [30% at 2-year and 20% at 4-year overall survival (OS)]. The 5-year OS in the retrospective group varied between 38 and 59%. Similar results were reported for the prospective group with 5-year OS between 44 and 56%. Despite a large variation in pCR (complete pathological response) (15-93%) and R0 (77-100%) reported, both represented a positive prognostic factor for survival. Three papers looked at the impact of staging following induction chemoradiotherapy. The majority of patients had T3 disease. An advantage in survival was seen in patients with early disease compared with advanced stage. No randomized controlled trials were identified. All the 10 articles suggested there was a benefit in trimodal therapy with improvement in overall survival. We conclude that combining induction chemoradiotherapy with surgery for Pancoast tumour may offer a survival benefit compared with radiotherapy with surgery or surgery alone.

VATS lobectomy combined with limited Shaw-Paulson thoracotomy for posterolateral Pancoast tumor.

PURPOSE: Several techniques have been proposed for the challenging surgical resection of Pancoast tumors. We describe a hybrid approach that combines video-assisted thoracic surgery (VATS) lobectomy and limited Shaw-Paulson thoracotomy. METHODS: We report a case of Pancoast tumor in a 57-year-old man, staged as cT3N0M0, that was treated with induction chemoradiotherapy prior to the hybrid surgical approach. After thoracoscopic pleural cavity inspection, an upper right VATS lobectomy by a 3-port standard approach was performed. The chest wall was resected through a limited paravertebral incision, allowing the extraction of the lobe together with the rib segments. The posterior chest wall defect was repaired with a synthetic patch. RESULTS: The postoperative period was uneventful and the pain never exceed a score of 3 on a visual analogue scale. Pathological examination revealed nonvital tumor cells in the specimen (ypT0N0M0). The patient is disease free at 6 months' follow-up. CONCLUSIONS: With this approach we experienced excellent access to both the apical and hilar structures. Further experiences are needed to validate the role of VATS lobectomy in the multidisciplinary management of posterior Pancoast tumor.

[Safety of reintroduction of erlotinib at low doses following hand-foot syndrome induced by erlotinib treatment for a Pancoast-Tobias tumour]. / Sécurité de la réintroduction de l'erlotinib à faible posologie après un syndrome main-pied induit par l'erlotinib dans une tumeur de Pancoast-Tobias.

INTRODUCTION: Erlotinib, an epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), is a targeted therapy used in first, second or third line treatment of non-small cell lung carcinoma. Several cutaneous toxicities after the use of EGFR-TKI are well-described. OBSERVATION: After 13 days of erlotinib treatment, an 82-year-old man, diagnosed with squamous cell lung carcinoma, developed an acneiform rash in parallel with hand-foot syndrome (HFS). This led to the interruption of his treatment because of the patient's distress. However, for the first time and after a total recovery of the toxidermia, we reintroduced the therapy at very low doses without any HFS recurrence being observed. DISCUSSION: The HFS is a dose-dependent toxidermia appearing within the first week following administration of the triggering cytotoxic agents (chemotherapies or target therapies). It appears that a specific pathogenic mechanism exists for each cytotoxic agent triggering the skin damage, resulting in different clinical presentations. A major aspect of HFS treatment involves the reduction or withdrawal of the treatment. CONCLUSIONS: We describe what is to our knowledge, the third case of erlotinib-induced HFS, a new secondary undesirable skin pathology for which, currently, exist few direct causal explanations or drug monitoring. This observation highlights the importance of broadening our knowledge of the exact mechanisms linking EGFR-TKI to the appearance of HFS in order to optimize treatment.

Atraumatic tooth extraction in patients taking bisphosphonates: a review of literature and experience with three cases.

PURPOSE: Regev et al. first re-introduced the method of atraumatic tooth extraction with orthodontic elastics in 2008. Since then, the method has been mentioned regularly in literature. Nevertheless, the need for additional more detailed information remains. METHODS: We present a review of literature and a retrospective analysis of our three patients receiving bisphosphonate medication. Two of our patients suffered from bisphosphonate-related osteonecrosis of the jaw (BRONJ). All three patients underwent atraumatic tooth extraction, which we describe in detail. RESULTS: Regev et al. reported satisfactory results using the novel method. We removed six teeth in two patients with continued chemotherapy or bisphosphonate therapy in a time span of 26.2 ± 16.4 weeks successfully. None of the patients developed exposed bone in the follow-up (7.4 ± 0.2 months). In one case, the technique had to be discontinued due to increasing tooth soreness. CONCLUSIONS: Atraumatic tooth extraction seems to be a safe method to prevent bone exposure, even in cases with BRONJ. The time required of our patients for exfoliation exceeded the time mentioned in literature considerably. This proved to be a major limitation. Our cases showed that patients with good compliance, no sore teeth, or painful BRONJ lesions, benefited from atraumatic tooth extraction. One of the method's major advantages might be the possibility to continue chemotherapy and bisphosphonate therapy throughout the treatment.

[Treatment and prognosis of superior sulcus tumours]. / Behandeling en prognose van sulcus-superiortumoren.

Superior sulcus tumours (or Pancoast tumours) are non-small-cell lung carcinomas presenting with specific symptoms and requiring a specific approach to treatment due to their location in the pulmonary apex. Early recognition is rare as a result of the low incidence and the relatively late occurrence of symptoms .Shoulder pain, with or without radiation to the ipsilateral arm or hand, and Horner's syndrome are often presenting symptoms. The current standard of care for patients with resectable tumours is pre-operative chemoradiotherapy, followed by resection of the tumour and affected surrounding structures. This is associated with 5-year survival rates of more than 50%. Invasion of local structures, the presence of mediastinal lymph node metastases and, in a select group of patients, distant metastasis, are not necessarily contra-indications for surgical resection. Patients who have undergone complete resection, or demonstrate a pathologically complete response after induction therapy, have significantly higher survival rates. Treatment of superior sulcus tumours requires a multidisciplinary approach; considering the complexity of the treatment, patients should be referred to a specialised centre.

[Single French centre retrospective analysis of local control after high dose radiotherapy with or without chemotherapy and local control for Pancoast tumours]. / Analyse rétrospective monocentrique française du contrôle local des cancers bronchiques non à petites cellules de l'apex après radiothérapie de haute dose avec ou sans chimiothérapie.

PURPOSE: Superior sulcus non-small cell lung cancer represents less than 5% of all lung cancers and is a challenge for the physicians because of clinical presentation, treatments related toxicities and poor prognosis. The aim of this preliminary retrospective report is to present outcomes of patients affected by a superior sulcus non-small cell lung cancer, treated by high dose radiotherapy (>60 Gy) with or with our chemotherapy. PATIENTS AND METHODS: All adult inoperable or unresectable patients (≥18 years) with a clinical and radiological diagnosis of superior sulcus non-small cell lung cancer treated in our department by radiotherapy with or without chemotherapy were retrospectively analysed. Primary endpoint was the local control. Overall survival, metastasis free survival and toxicity rates were also analysed and reported. RESULTS: From January 1999 to June 2009, 12 patients were treated by exclusive high-dose radiochemotherapy. Median age was 53 years (range: 33-64 years); mean follow-up time was 20 months (range: 2-75 months). Mean local control, overall survival and metastasis free survival were 20.2, 22 and 20 months, respectively. At the time of this analysis, seven patients died of cancer and three of them presented only a metastatic disease progression. One patient died of acute cardiac failure 36 months after the end of radiochemotherapy and was disease free. Treatment was well tolerated and any acute and/or late G3-4 toxicity was recorded (NCI-CTC v 3.0 score). CONCLUSION: This analysis confirms the interest of exclusive high-dose radiochemotherapy in treating inoperable superior sulcus non-small cell lung cancer patients, in achieving good local control and overall survival rates.

[Chest wall surgery]. / Cirugía de la pared torácica.

Despite the numerous differences among the distinct diseases of the chest wall, the surgery of this area shows certain common features. Treatment has progressively changed in the last few years due to advances in diagnostic techniques, minimally invasive procedures and reconstruction materials, and especially due to the multidisciplinary management of many diseases. Nuss' minimally invasive correction of pectus excavatum has gained devotees, although open approaches are performed with increasingly small incisions, almost comparable to the lateral incisions in Nuss' technique. Surgeons supporting the open approach also cite the evident disadvantages of the need for a steel implant for 2 or 3 years and for a second intervention to remove this implant. En-bloc resections with reconstruction using materials, which are increasingly better and covered by myocutaneous grafts in collaboration with plastic surgery departments, constitute a major advance in the treatment of chest wall tumors. Trimodal therapy for Pancoast tumors, consisting of induction chemotherapy and radiotherapy and subsequent surgical treatment of the tumor, currently provides the best results in terms of resectability and survival.

Definitive radiotherapy plus regional hyperthermia with or without chemotherapy for superior sulcus tumors: a 20-year, single center experience.

PURPOSE: To assess the efficacy and toxicity of definitive radiotherapy (RT) plus regional hyperthermia (HT) in treating superior sulcus tumors (SSTs), and to identify predictors of positive outcomes. METHODS AND MATERIALS: Twenty-four patients with SSTs treated with definitive RT plus regional HT were retrospectively analyzed. The median total dose of RT was 70 Gy. All patients were treated with an 8-MHz RF-capacitive heating device. Twelve of 24 (50%) patients also underwent chemotherapy. Those with either subcutaneous fat measuring 2.5 cm or greater, or any other serious complications did not undergo this therapy. RESULTS: Overall survival, local control, and distant metastasis-free survival rates at 3 years were 47%, 55%, and 71%, respectively. Chemotherapy and younger age (<65 years) were significant predictors of the overall survival rate. Clinical stage (IIB) was a statistically significant prognostic indicator for local control survival rate. Toxicities were mild, with Grade 3 dermatitis seen in one patient. CONCLUSIONS: Definitive RT plus regional HT with chemotherapy may be a promising treatment for SSTs. The results justify further evaluation with detailed treatment protocols in a large number of patients.

[A case of lung adenocarcinoma of pancoast type successfully treated with concurrent chemoradiotherapy].

We reported a case of lung adenocarcinoma of Pancoast type that was successfully treated with chemoradiotherapy. A 66-year-old man was admitted to our hospital because of back pain. Chest computed tomography (CT) showed a Pancoast tumor on the left side. Using transbronchial needle aspiration, we diagnosed lung adenocarcinoma (cT3N0M0). The patient received chemoradiotherapy simultaneously(carboplatin AUC5 and irinotecan 60 mg/m2). There are no findings of tumor recurrence 8 years after chemoradiotherapy. This patient was successfully treated with concurrent chemoradiotherapy, which is suggested to be a useful therapy for Pancoast tumor.

Tumor de Pancoast con lesión hipofísiaria sincrónica / Pancoast tumor with synchronous hypofisiary lesion

Pancoast tumors represent a rare presentation of lung cancer. Their particular location delays diagnosis and makes resection difficult. Nevertheless recent advances in surgical techniques and multi-modality therapy (chemo-radiation followed by surgery) had increased resection rates and achieved long term survival. We present the case of a 62-year-old woman with an extensive Pancoast tumor and a synchronous hypofisiary lesion. We carried out an exhaustive staging workout determining that the infratentorial lesion was a hypofisiary adenoma. She underwent induction chemo-radiotherapy and posterior surgery. A complete resection was possible with prolonged survival and minimal functional disability. We present the evolution in management of Pancoast tumors and our approach to patients with suspicious metastases in potentially resectable tumors.

Los tumores de Pancoast representan una presentación poco frecuente de los cánceres pulmonares. Su particular localización retrasa el diagnóstico y dificulta su resección. En los últimos años se han realizado importantes avances en las técnicas quirúrgicas y se ha consolidado la terapia tri-modal en el manejo de estos pacientes mejorando su sobrevida. Presentamos el caso de una mujer de 62 años con un extenso tumor de Pancoast y una lesión sincrónica hipofísiaria. Un exhaustivo estudio de diseminación permitió determinar que esta lesión era un adenoma hipofisiario. Se realizó quimio y radioterapia de inducción y posteriormente una resección completa del tumor, con una sobrevida prolongada sin secuelas funcionales. Se presenta la evolución del manejo de estos tumores y nuestra conducta en el enfrentamiento de posibles metástasis en tumores potencialmente curables.

Pulmonary leiomyosarcoma presenting as a pancoast tumor.

A patient presenting with Pancoast syndrome was definitely diagnosed to have pulmonary leiomyosarcoma. The patient underwent a right upper lobectomy combined with resection of the chest wall, including the 1st to 3rd ribs. The disease recurred rapidly at the local and distant sites. No previous reports about pulmonary sarcoma presenting as a Pancoast tumor were found in the literature. The possibility of primary pulmonary leiomyosarcoma should be considered, and early detection and surgical resection are necessary when a round or oval tumor with necrosis is observed in the apex of the lung.

[Complete resection of Pancoast tumor while receiving preoperative concurrent chemoradiotherapy (CCRT) as an induction therapy--report of a case].

A 60-year-old man complaining of right shoulder pain and numbness of right arm was diagnosed with Pancoast tumor (invasive right apical lung cancer). Chest CT scan showed a tumor, 5 cm in diameter, in the right apex invading the right posterior chest wall. The patient received preoperative CCRT (RT: 40 Gy/20 Fr, cisplatin: CDDP and etoposide: ETP), resulting in tumor regression (PR). The patient underwent right upper lobectomy (ND 2a), partial resection of the 1st-3rd ribs and Th 1 nerve. Pathological examination demonstrated no live cancer cells and organization of necrotic tissue in the lung and intercostal region (Ef. 3). The patient received postoperative chemotherapy (CDDP+ETP) and was discharged. He did well without any tumor recurrence for 1 year postoperatively. CCRT seems effective and is one of the standard treatments for Pancoast tumor.

Multimodality therapy for Pancoast tumor.

The management of Pancoast tumors has challenged surgeons and radiation and medical oncologists over several decades. Retrospective studies have raised a greater awareness of the importance of positive N2 lymph nodes in terms of prognosis and treatment decision making. While patients with positive N2 lymph nodes have generally been excluded from trials of preoperative chemoradiation for superior sulcus tumors, the potential of surgery for these patients is still being evaluated. The role of PET for initial staging as well as for assessment of disease response to induction therapy continues to evolve. The use of combined treatment modalities has enhanced the progress in successfully treating Pancoast tumors. The historical data showing improved results with a combination of surgery and radiation compared with surgery alone for patients with positive N2 nodes provides the basis for several important clinical trials that integrate the use of chemotherapy into the treatment paradigm. The Southwest Oncology Group and Japanese Clinical Oncology Group have shown dramatic improvements in complete resection rates following a neoadjuvant course of combined chemotherapy and radiation therapy compared with historical series. We discuss relevant ongoing clinical trials that include consolidative taxane-based chemotherapy and the role of prophylactic cranial irradiation in complete responders. Future potential areas of investigation, including the role of surgery for patients with N2-positive disease and the use of imaging to assess response after induction therapy, are discussed.