Fig. 53: Computed tomographic scan of the chest shows a large mass in the right paratracheal area obstructing the superior vena cava. The azygous vein (white arrow) is also obstructed and multiple small vessels are seen on the left side of the mediastinum (white arrowheads); the internal mammary veins are also prominent (black arrows), T4 N2 M0, stage IIIB.

Involvement of the Vertebral Body
In most patients with superior sulcus or Pancoast's tumors with clinical evidence of vertebral body invasion this extension of the disease indicates unresectability and a poor prognosis. There are reports of patients who have undergone successful resection for tumors with localized invasion of a specific area of the vertebral body who have a better prognosis than that anticipated for patients with unresectable disease. There are investigational surgical programs, usually multidisciplinary efforts undertaken by thoracic and neurosurgeons, that address removal of part or all of the vertebra. Although a few patients may be found at operation to have resectable tumor invading the vertebral body, clinical evidence of this extent of disease is generally associated with non-surgical treatment options and a prognosis consistent with the T4 category.

A tumor arising in the superior sulcus of the lung with evidence for a true Pancoast's syndrome, that is, a Horner's syndrome and brachial plexus involvement, should be classified T4, whether or not vertebral body invasion is present.