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.