Dr. Eric Vallieres, thoracic surgeon, introduces us to and provides a brief history for the special case in lung cancer of a "Pancoast Tumor", along with how its optimal treatment has evolved over several decades.
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So, there’s a particular tumor called Pancoast tumor, or superior sulcus tumor. Pancoast was the name of a radiologist from Philadelphia who in 1932, and this is way before we had CAT scans, so this is on a plain chest x-ray, described individuals who showed up with enormous pain around their shoulder and down their arm, sometimes some changes in their facial expression, who had, on x-ray, a tumor at the top of their lung. Basically what it means is a tumor that’s not only involving the lung, but involving the structures at the top of the lung, which happen to be the ribs and the nerves that come out of your neck and go down into your arm, and also some vessels that come out. So, it’s a very busy area up here, a very tight area – there’s not a lot of room for growth there. And so that’s what these Pancoast tumors or superior sulcus tumors are — they are tumors, regular lung cancers, but it’s their location that defines that we call them that way, and the fact that they are invading these structures.
Back in the ‘50s, those tumors were considered 100% fatal — there was no survivor anywhere with those tumors. And then, there was a first survivor who was treated with radiation alone — survivor at three years. And then, in the late ‘50s, accidentally, there is a patient who had received some radiation therapy, and had a beautiful response, and that is, the pain all went away, and he’d heard of some surgeons in Dallas, thoracic surgeons, who were quite good and aggressive, and he went to visit them and asked if he could have surgery, and they said sure. And the time that had elapsed, by the time he had finished his radiation, to the time he showed up in Dallas, was three weeks. So, it was radiation to 30 Gray, three weeks traveling and getting there, and then he had surgery. The surgery went much better than anticipated — the surgeons comments were, “this operation was easier than what we’ve seen in the past,” and what they found is that, the periphery of tumor was dead, but at the middle of the tumor there was still some cancer, and patients did well and recovered and lived. And as a result of that, they adopted this protocol, which we call the Paulson protocol, Paulson being one of the surgeons on the team, and that’s how we treated Pancoast tumors for years — 3,000 Gray, three weeks, surgery.
Until in the ‘90s, mid ‘90s, the Southwest Oncology Group (SWOG) ran a trial where, in addition to the radiation therapy, we added some chemotherapy at the same time, so a so-called concurrent chemo and radiation therapy, and then we took these patients to surgery afterwards. The results of that trial were so far better than anything else that we had seen before, that that has become the standard of care for the treatment of the Pancoast tumors — chemoradiation therapy, the dose of radiation being around 45 Gray, and then recovery, and then resection.
There’s also a study that was done in Japan about a few years later — very similar concept, different chemotherapy drugs, but very similar concept of concurrent chemoradiation therapy, recovery, and resection that showed identical results to those of the Southwest Oncology Group, and those two trials have established what we considered to be the standard of care for the resection of these Pancoast tumors.
Now, the operation is tricky because you just don’t remove lung — remember, those tumors are invading into the ribcage and the nerve structures at the inlet. So these operation can be very tricky, and may either involve a very high incision in the back, if the tumor is dominantly in the back, or if the tumor is more in the front, where the vessels are running, the incisions will be in the front. Again, those operations are — we do very few of those, in centers of excellence, and probably should be done by surgeons who have that experience.
So, basically we went, before 1954, to a disease that was considered 100% fatal, now, in 2015, for individuals that we commit to this chemoradiation therapy and a resection, we’re looking at about a 60%, 4 to 5 year survival. That’s a major shift, a major improvement, in a relatively short period of time.
The other improvement is that historically we considered individuals where their tumor was invading the spine, the vertebral column, not spinal cord, but the bones in which the cord is running — that used to be considered non-surgical. Today, because of advances in spinal surgery, we can combine these operations where we have a tumor that’s invading into the spine, going back to the descriptor, that’s considered a T4, because historically it was considered non-surgical, but today we can remove the spine and the lung altogether, and the reconstruction of the spinal column by the spine surgeon is quite amazing, how they do things, and we can achieve very, very good results.
Now, some of those are also Pancoast, if they are in the spine, high up in the chest, but that concept applies to tumors all along the chest and the spine itself. That’s another major improvement in that arena, and we’re lucky here to have the spinal expertise where we can offer that to our patients.