Current status and future directions of multimodality therapy for non-small cell lung cancer of the superior sulcus

Non-small cell lung cancer (NSCLC) tumors originating in the superior sulcus have undergone a significant evolution in terms of both therapy and prognosis over the course of the last 80 years. Initially thought to portend universal mortality, the Pancoast tumor and syndrome, with its characteristic refractory pain and neurologic dysfunction resultant from significant local invasion, was met with a sense of helplessness. The transition from palliative to neoadjuvant radiation, and ultimately to trimodality therapy with neoadjuvant chemoradiation and surgical resection, has dramatically altered the outlook in terms of longevity and quality of life for patients with Pancoast tumors. Combined-modality chemoradiation, followed by surgical resection, has now improved the survival for Pancoast tumors to have a better prognosis than comparatively-staged NSCLC originating in other locations within the lung parenchyma. Problems with local control have largely become supplanted by the most common cause of mortality for NSCLC of all stages: distant failure rates. Ongoing efforts to improve the resectability and to decrease the occurrence of distant metastatic disease will need to be the focus of future clinical trials. The application of improved radiotherapeutic technology, as well as the development of systemically active molecularly targeted agents with lower toxicity profiles than standard cytotoxic chemotherapy, may help guide the next steps in improving the outcomes for superior sulcus tumors.