Choice of exposure route for surgical excision of superior sulcus lung tumors depends on involvement at the thoracic inlet. From December 1985 to September 1999, we performed surgical treatment of superior sulcus tumors in 42 patients, including 22 with vascular involvement. Various exposure techniques were used, including a novel technique combining transverse supraclavicular cervicotomy and posterolateral thoracotomy in 11 cases, anterior transclavicular cervicothoracotomy in 7 cases, isolated posterolateral thoracotomy in 3 cases, and cervicosternotomy in 1 case. Vascular procedures consisted of subadventitial dissection of the subclavian artery in 5 patients, arterial resection-anastomosis in 7, and prosthetic bypass in 10. Postoperative mortality was 11.9% in the overall series of 42 patients (n = 5) and 9% (n = 2) in the subgroup of patients with vascular involvement. During follow-up, 13 patients died of tumor recurrence and 1 patient died of respiratory insufficiency. Actuarial 5-year survival was 22.7 +/- 17.5% overall and 18 +/- 17.9% in the subgroup of patients with vascular involvement. This study indicates that the combined exposure route with transverse supraclavicular cervicotomy and posterolateral thoracotomy was useful for treatment of superior sulcus lung tumors requiring lobectomy and pneumonectomy.