Posterior thoracic approach for Pancoast tumour resection

Pancoast tumour is an uncommon presentation of lung cancer. Its specific location and surrounding structures invasion characterizes the Pancoast’s syndrome clinical presentation—shoulder pain, radicular arm affection and Horner’s syndrome. At the same time thoracic outlet location makes it difficult to detect by simple chest X-ray and delays the diagnosis. Pancoast tumour is considered a locally advanced lung cancer. In consequence aggressive staging and accurate surgical planning are mandatory. Induction therapy, although no entirely accepted is used to increase resectability in our centre’s protocol. Anterior and posterior approaches have been described to resect superior sulcus tumours. Selection is normally based on tumour location and peripheral structures involvement as well as surgeon’s personal experience and preferences. In the following text we describe the posterior approach technique for tumour resection and the tricks and tips we learned in our experience to minimize surgical risks. We prefer the posterior approach in those tumours with no major vessel involvement evidence. Anterior chest wall resection and posterior costo-vertebral junction disarticulation are carried out before the lobectomy to achieve a complete en bloc resection. Special care must be taken during the dissection and division of the first rib because of thoracic outlet structures proximity. After resection, we prefer not to reconstruct the wall systematically. It is reserved for selected patients who had a large chest wall resection and have higher risk of complications.