Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet

Three-dimensional multidetector computed tomography may aid preoperative planning of the transmanubrial osteomuscular-sparing approach to completely resect superior sulcus tumor

The anterior transcervical-thoracic approach clearly exposes the subclavian vessels and brachial plexus. We believe that this approach is optimal when a superior sulcus tumor (SST) invades the anterior part of the thoracic inlet. However, this approach is not yet widely applied because anatomical relationships in this procedure are difficult to visualize. Three-dimensional tomography can considerably improve preoperative planning, enhance the surgeon's skill and simplify the approach to complex surgical procedures. We applied preoperative 3-dimensional multidetector computed tomography to a case where an SST had invaded the anterior part of the thoracic inlet including the clavicle, sternoclavicular joint, first rib, subclavian vessels and brachial plexus. After the patient underwent induction chemotherapy, we performed the transmanubrial osteomuscular-sparing approach and added a third anterolateral thoracotomy with a hemi-clamshell incision and completely resected the tumor.

Anterior approach for Pancoast tumor resection

Tumors arising anteriorly in the apex of the chest were long considered unresectable because of early invasion of vascular structures limiting radical resection through the conventional Paulson approach. These tumors became operable in 1993 when Dartevelle popularized the cervico-thoracic transclavicular technique for resecting these neoplasms. Since then several different surgical approaches to anterior Pancoast tumors have been proposed, drastically improving the rate of radical resections of these tumors. However, there is no consensus on which anterior surgical approach provides the best access to all of the apical non-small cell lung cancers of the thoracic inlet. Moreover, it is still unclear if integrated neoadjuvant and adjuvant treatments can improve the rates of complete resection, local recurrence and long-term survival.

Manubrial-clavicular-chest wall explantation to expose the anterior thoracic inlet

The anterior thoracic inlet is difficult to access surgically because of the overlying pectoral-shoulder girdle, clavicle, and manubrium. With both the Dartevelle and Grunenwald approaches, retraction of an osteomuscular flap is required, and patients may be left with the functional and aesthetic implications of partial clavicular resection. We describe a novel technique involving manubrial-clavicular-chest wall explantation with preservation and reimplantation. Manubrial and clavicular plating is performed to stabilize the anterior chest wall and clavicle after reimplantation. This approach represents an alternative technique that provides excellent visualization of the entire anterior thoracic inlet.

"Trap-door" and "clamshell" surgical approaches for the management of pediatric tumors of the cervicothoracic junction and mediastinum

BACKGROUND/PURPOSE

For pediatric tumors of the cervicothoracic junction, an isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection. We retrospectively examined "trap-door" and "clamshell" pediatric thoracotomies as a surgical approach to these tumors.

METHODS

We searched our database for pediatric patients with cervicothoracic tumors who underwent clamshell or trap-door thoracotomy between 1991 and 2013, reviewing tumor characteristics, surgical technique, completeness of resection, morbidity, and outcome.

RESULTS

Trap-door (n=13) and clamshell (n=4) thoracotomies were performed for neuroblastoma (n=9), non-rhabdomyosarcoma soft tissue sarcoma (n=4), germ cell tumor (n=2), rhabdomyosarcoma (n=1), and neuroendocrine small cell carcinoma (n=1). Fourteen of these cervicothoracic tumors were primary, and three were metastatic. Gross total resection was achieved in 15 patients (94%). Operative complications included vocal cord paralysis (n=2), mild upper-extremity neuropraxia (n=2), and hemidiaphragm paralysis (n=1), All but one involved encased nerves. Overall survival was 61% for the series and 80% for patients with primary tumors. Eleven (73%) of 15 patients who underwent gross total resection had no evidence of recurrence. Three patients with metastatic disease died of distant progression within 1.3years.

CONCLUSIONS

Gross total resection of primary cervicothoracic tumors can be accomplished with specialized exposure in pediatric patients with minimal morbidity.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Management of tumors involving the chest wall including pancoast tumors and tumors invading the spine

Bronchogenic carcinomas involving the chest wall include tumors invading the ribs and spine, as well as Pancoast tumors. In the past, such neoplasms were considered to be incurable, but with new multimodality regimens, including induction chemoradiation followed by surgery, they can now be completely resected and patients can benefit from prolonged survival. The most important prognostic factors are the completeness of resection and the pathologic nodal status.

Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy

Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.

The use of the trapdoor incision for access to thoracic inlet pathology in children

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.

Cervical approach to the thoracic inlet in paediatric patients with broncho-pulmonary foregut malformations

Lesions of the thoracic inlet present a significant challenge to the surgeon due to the difficulty of access and proximity to important neurovascular structures within the region. We describe two cases of benign disease of the thoracic inlet in children, one bronchogenic cyst and an esophageal duplication, and report the cervical approach used to manage them. Both lesions extended from the neck through the thoracic inlet, but demonstrate how benign lesions in this area can be delivered up into a cervical incision, negating the need for the more invasive modified thoracotomies. A cervical approach can be safely and successfully used to approach benign pathology, such as bronchogenic cysts and oesophageal duplications of the thoracic inlet. Careful multidisciplinary planning is required for such procedures.

Analysis of the surgical treatment for superior sulcus tumors

PURPOSE

This study was undertaken to assess the mortality, complication, and major morbidity rates of surgical treatment for superior sulcus tumors (SSTs), and to estimate the significance of prognostic factors.

METHODS

We retrospectively reviewed the hospital records of 50 consecutive patients undergoing surgical treatment for SSTs between 1992 and 2007. The significance of risk factors for an adverse outcome was investigated.

RESULTS

Both the thirty-day and in-hospital mortality rates were 0 %. Complications developed in 18.0 % (9/50) of the patients. The overall 5-year survival was 32.7 %. Pathological T4 and N1 or more were the risk factors predicting an adverse outcome. Survival was not significantly influenced by the preoperative symptoms, the histological type, the invaded organ or the curability.

CONCLUSION

Surgical treatment for SSTs is associated with acceptable overall morbidity and mortality rates. However, special care must be taken for the patients with pathological T4 and N1 or higher tumors. Preoperative chemoradiotherapy followed by surgical treatment has become a logical strategy for SSTs. Preoperative chemoradiotherapy for SSTs may yield better results than surgery alone.

The surgical approach for cervicothoracic masses in children

BACKGROUND

The surgical approach to masses located in the cervicothoracic juncton represents a challenge for surgeons. Many techniques have been described with good results.

METHODS

We analyzed and compared the results obtained in 2 Italian pediatric surgery centers using 2 different techniques in patients with tumors of the thoracic inlet: center 1, using anterior cervical transsternal approach on 7 patients, and center 2, applying "trap-door" technique on 5 patients.

RESULTS

Excision was incomplete in 5 patients and complete in 7 patients. Histologic examination revealed 5 patients with neuroblastoma; 3, ganglioneuroblastoma; 1, mixoid liposarcoma; 1, desmoid fibromatosis; 1, Castleman disease; and 1, Schwann cell tumor. The median duration of the procedure was 345 minutes in center 1 and 245 minutes in center 2. The median blood loss was 200 mL in both centers. The median hospital stay was 11 days in center 1 and 9 days in center 2. Globally, 5 patients developed postoperative complications. No significant differences were encountered comparing the main surgical outcome parameters between the 2 approaches.

CONCLUSIONS

Both techniques resulted in valid options to achieve a safe excision of thoracic inlet masses with a manageable complication rate and acceptable hospital stay. Surgical risk factors should be carefully investigated preoperatively. Postoperative pain control is important to guarantee early recovery.

Completely resected superior sulcus tumor and vascular reconstruction of vertebral and subclavian arteries

A 62-year-old man was pointed out the superior sulcus tumor of the left lung invading to the subclavian artery and the vertebral artery. Bronchoscopic brushing cytology of the tumor showed Class V large cell carcinoma. The patient was diagnosed as clinical stage IIIA(cT4N0M0). After concurrent chemoradiotherapy, we performed left-upper lobectomy and reconstructions of left subclavian and vertebral arteries through modified transmanubrial approach. Surgeons of three different departments took part in the operation. Cooperative works were the key for the complete resection of such an advanced superior sulcus tumor.

Ministernotomy with subclavian extension for the management of a large intrathoracic pseudoaneurysm

We report on the management of a large intrathoracic subclavian pseudoaneurysm treated using an upper J ministernotomy with subclavian extension. This approach allows exposure of the supraaortic vessels and upper portion of the thoracic cavity and may be of help in selected cases.

Resection of the entire first rib for fibrous dysplasia using a combined posterior-transmanubrial approach

A 27-year-old woman presented with pain of the left anterior chest of 2-year duration. Chest X-ray revealed a mass in the upper-left lung field and chest computed tomography (CT) a 6-cm first-rib tumor. CT-guided biopsy was performed and the tumor diagnosed as fibrous dysplasia. Because of continued pain, surgery was deemed necessary. Surgery began with the use of the posterior approach in the prone position to expose the first thoracic vertebra and detach the first rib at the costotransverse joint. After transitioning to the spine position, the transmanubrial approach was used to resect the tumor en bloc with the left first rib. Histological examination revealed the tumor to be fibrous dysplasia. Postoperative recovery was uneventful. The outcomes of this case suggest that the combined posterior-transmanubrial approach described here is a safe, successful approach for first-rib resection of a space-occupying tumor that yields good cosmetic results.

Technical aspects of the anterior transmanubrial approach in thoracic inlet tumor surgery

Surgical treatment of thoracic inlet tumors represents a challenge to the surgeon due to its location and anatomical elements contained in that region. Several surgical approaches have been proposed, each of them showing some advantages but drawbacks as well. In our opinion, the anterior transmanubrial approach described in 1997 is one of the most convenient. The objective of this paper is to describe and comment on some technical aspects of the procedure in order to aid surgeons who intend to perform this surgical approach. Moreover, we show our results in five patients and also comment on other approaches in this pathology.

Intrathoracic ganglioneuroma surrounding left vertebral and subclavian arteries successfully resected by modified trapdoor thoracotomy

Neurogenic tumors are derived from tissue of the neural crest. Most of the mediastinal neurogenic tumors occur in the posterior compartment. Extension to the cervical area and the surrounding major arteries is rare. We report a patient with a ganglioneuroma arising from the brachial plexus, extending into the cervical region, and surrounding the left vertebral and subclavian arteries. The patient underwent successful resection by modified trapdoor thoracotomy.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

[Chest wall surgery]

Despite the numerous differences among the distinct diseases of the chest wall, the surgery of this area shows certain common features. Treatment has progressively changed in the last few years due to advances in diagnostic techniques, minimally invasive procedures and reconstruction materials, and especially due to the multidisciplinary management of many diseases. Nuss' minimally invasive correction of pectus excavatum has gained devotees, although open approaches are performed with increasingly small incisions, almost comparable to the lateral incisions in Nuss' technique. Surgeons supporting the open approach also cite the evident disadvantages of the need for a steel implant for 2 or 3 years and for a second intervention to remove this implant. En-bloc resections with reconstruction using materials, which are increasingly better and covered by myocutaneous grafts in collaboration with plastic surgery departments, constitute a major advance in the treatment of chest wall tumors. Trimodal therapy for Pancoast tumors, consisting of induction chemotherapy and radiotherapy and subsequent surgical treatment of the tumor, currently provides the best results in terms of resectability and survival.

[Incisions and routes of surgical access]

The correct choice of the incision to the chest is essential for surgical success and a favorable postoperative course. The route of access to the thorax must be adapted both to the disease and to the thoracic surgeon's experience, striking a balance between aggressiveness and the safety of the technique. This article describes the characteristics of surgical incisions, including classical thoracotomy, sternotomy and its variants, thoracoscopy and minimally-invasive surgery. The distinct techniques used to explore mediastinal lymphatic areas, including video-assisted mediastinal lymphadenectomy and transcervical extended mediastinal lymphadenectomy, are also described.

Treatment of pancoast tumors from the surgeons prospective: re-appraisal of the anterior-manubrial sternal approach

Pancoast tumours are now amenable to multimodality treatment with an acceptable survival. This is because trimodality treatment improves tumor sterilization and hence outcome. Moreover the development of an anterior approach to access the tumor, further improved the technical challenges for a sound resection.The Anterior-manubrial sternal approach was described more than a decade ago and although this method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels, its popularity has not reached high levels. We felt that by re-addressing this topic we would stimulate reconsideration of the anterior approach.

Resection of apical lung carcinoma involving the vertebral artery

We report a patient with left apical lung carcinoma involving the left subclavian artery with the origin of the vertebral artery who had hypoplasia of the right vertebral artery and the bilateral posterior communicating arteries. After induction chemoradiotherapy, a vein graft was used to create a bypass between the left common carotid artery and the vertebral artery, followed by a successful left upper lobectomy with combined resection of the subclavian artery together with the left vertebral artery. Because anatomic variations of vertebral arteries and cerebral arterial circle are known, preoperative evaluation of the cerebral blood flow should be performed and a relevant reconstruction considered.

Open approaches to posterior mediastinal tumor in adults

Thoracic surgeons must be familiar with available surgical approaches for posterior mediastinal tumors in order to choose the approach that will contribute to better prognosis and patient quality of life. An open surgical approach should be decided on based on the tumor size, location, and pathology. This article discusses the indications for the open approach in adults and outlines the surgical procedure.

Anterior minithoracotomy: a direct approach to the difficult hilum for upper lobectomy, pneumonectomy, and sleeve lobectomy

BACKGROUND

Central lung cancers with pulmonary hilar involvement can pose a technical challenge when a lateral thoracotomy is used. Proximal vascular control and pulmonary vascular dissection from this approach can be challenging and potentially dangerous. We describe the use of a Chamberlain anterior minithoracotomy as an alternative approach for safe and reliable access to the pulmonary hilum.

METHODS

One hundred two consecutive patients undergoing the Chamberlain approach were identified through retrospective chart review from 2002 to 2009. The supine position was used, thus reducing the likelihood of down-lung syndrome. An 8-cm anterior thoracotomy was performed over the second interspace along the line of the pectoral fibers, with preservation of the mammary artery medially and the thoracoacromial neurovascular bundle laterally. Primary outcome variables included hospital course, complications, and mortality rate.

RESULTS

The mean age was 64.8 years (range, 20-89 years). Sex ratio (female:male) was 44:58. Neoadjuvant therapy was used in 43 patients (42.2%). Proposed resections were successful in 101 (99%) of 102 patients. Conversion to hemiclamshell was required in 1 patient for vascular control. Three perioperative deaths (2.9%; two pneumonectomies, one lobectomy) occurred.

CONCLUSIONS

The Chamberlain mini anterior thoracotomy provides direct access to the pulmonary hilum, facilitating dissection and vascular control for large and central tumors. Reduced perioperative pain and down-lung syndrome compared to lateral approaches can be achieved. Muscle function is preserved, and intrapericardial/hilar access is expeditious. This approach enhances hilar access and avoids the vascular control and hilar exposure challenges inherent with lateral thoracotomy.

The hemiclamshell approach in thoracic surgery: indications and associated morbidity in 50 patients

This retrospective study was carried out to evaluate the indications for and outcomes of the hemiclamshell (HCS) approach (longitudinal partial sternotomy with antero-lateral thoracotomy) in patients undergoing mass resection in thoracic surgery. All patients (50) who underwent a HCS procedure in our department, between July 1996 and July 2005, were studied retrospectively, analyzing the indications, morbidity and outcome (pain, neurological or shoulder defects, mortality) at one month and one year. The main indications were apical tumours (38%), tumours of the cervicothoracic junction (46%) and chest wall (10%), and 'bulky' tumours (6%). One-month mortality was 6%. Two patients suffered from a chylothorax and one from phrenic paralysis. The postoperative analgesic requirements were similar to those after other thoracic surgery approaches. Twelve percent of patients suffered pain at one month and 6% at one year. Shoulder dysfunction was observed in 10% of patients at one month and 6% at one year. In conclusion, the HCS surgical approach was associated with an uncomplicated postoperative course. This anterior approach is suitable for apical tumours, tumours of the cervicothoracic junction and 'bulky' lung tumours, providing good access for control of the large vessels and radical mediastinal clearance.

What is the role for surgery in patients with stage III non-small cell lung cancer?

PURPOSE OF REVIEW

Locally advanced non-small cell lung cancer (NSCLC) represents a therapeutic challenge. Although combined modality has become the standard treatment in stage III NSCLC, the role of surgery in it remains controversial. This review will address recent evidence on the potential role of surgery in either superior sulcus tumors, T4N0-1 tumors with central extension multifocal tumors with nodule(s) in the same lobe, or stage III disease with mediastinal lymph node involvement.

RECENT FINDINGS

Two recent phase 2 trials, exploring surgical resection preceded by induction chemoradiotherapy for tumors of the superior sulcus, have reported an impressive survival with acceptable mortality rate. They confirm the outcome observed in other prospective and retrospective series for T3-4N0-1. For subsets of T4 NSCLC with central extension or with satellite nodule(s) in the primary lobe, cumulative data suggest that these tumors behave differently than other stage IIIB tumors and might benefit from upfront surgery, possibly followed by postoperative chemotherapy and/or radiotherapy. Whenever clinical mediastinal lymph node invasion is present, surgery after induction treatment is not proven superior to radiotherapy, and is best restricted to clinical trials.

SUMMARY

Combined modality treatment is the standard of care for locally advanced NSCLC and the optimal role for surgery remains a challenging issue for the clinicians.

Preoperative concomitant chemo-radiotherapy in superior sulcus tumour: A mono-institutional experience

Superior sulcus tumour (SST) is an uncommon neoplasia whose optimal treatment remains controversial. Usually resected after induction RT or treated with definitive chemo-radiotherapy, it has recently aroused more interest because of preoperative chemo-radiotherapy. Treatment consisted of a platinum-based chemotherapy: carboplatin AUC 5 on days 1 and 22, combined with mitomycin-C 8 mg/m(2) on days 1 and 22, and vinblastine 4 mg/m(2) on days 1, 8, 22 and 29 (MVC) from 1994 to 1999, or combined with navelbine 25mg/m(2) on days 1, 8, 22 and 29 (NC), from 2000 to 2007. Radiotherapy was administered 5 days/week, 30 Gy in 10 fractions on days 22-35 (from 1994 to 1996), or 44 Gy in 22 fractions on days 22-52 (from 1997 to 2007). SURGERY was planned after 2-3 weeks since the completion of radiotherapy. Since 1994, 37 pts were treated with induction chemo-radiotherapy, 1 with induction radiotherapy only. Induction chemotherapy: 16 pts had MVC (43%) and 21 NC (57%); induction radiotherapy: 7 patients treated with MVC had 30 Gy/10F, 9 had 44 Gy/22F; all the patients treated with NC had 44 Gy/22F, but 2 of them did not complete radiotherapy because of early death (after 16 Gy/8F) and toxicity (after 38 Gy/19F). Grade 3-4 haematological toxicity of induction chemo-radiotherapy was found in 13 patients (35%); the most frequent non-haematological toxicities were constipation and oesophagitis. One complete, 18 partial and 8 minimal responses/stable disease were observed. Moreover, 1 progression disease and 1 early death occurred.

SURGERY

30 upper lobectomies (17 right, 13 left) and 4 segmentectomies, with chest wall resections, were performed (89% resection rate); 4 pts were not operated. Radical resections were achieved in 74% of the patients, with 5 pathologic complete remissions at resection. Twenty-seven patients (71%) had improvement of shoulder/arm pain. Median progression-free survival was 64 weeks and median survival was 148 weeks. The 5-year overall and progression-free survivals were 40% and 29%, respectively. In the multimodality treatment of SST, concurrent carboplatin-based chemotherapy plus radiotherapy were active and feasible without major toxicities. This resulted in high resectability rate and favourable progression-free and overall survival rates.

Temporary claviculectomy approach for plexiform neurofibroma of the first intercostal nerve

Plexiform neurofibroma at the thoracic inlet has rarely been reported and to our knowledge, the use of a temporary middle claviculectomy approach for thoracic inlet tumors has never been reported. We report a case of plexiform neurofibroma of the first intercostal nerve resected using a temporary claviculectomy approach. An abnormal shadow detected radiographically in a 16-year-old boy led to a diagnosis of neurofibromatosis 1 (NF-1) with a chest wall tumor at the thoracic inlet. The patient underwent resection of the tumor with the right first rib. The resected clavicle was reapproximated with a plate and postoperative shoulder function was satisfactory. The tumor was diagnosed pathologically as a plexiform neurofibroma and the patient's postoperative course was uneventful. The temporary middle claviculectomy approach provides excellent exposure of the subclavian vessels and brachial plexus before resection of the tumor. We recommend this approach for tumors of the anterior thoracic inlet.

Complete resection of pulmonary inflammatory pseudotumors has excellent long-term prognosis

OBJECTIVE

Pulmonary inflammatory pseudotumor is an uncommon disease, often with a benign presentation. However, invasion of adjacent thoracic organs, local recurrence, and distant metastases have been described, and the best management strategy remains unclear. We present a single large institutional experience in patients with pulmonary inflammatory pseudotumor and propose guidelines for treatment of this patient population.

METHODS

A retrospective study was performed to review all patients who underwent resection for pulmonary inflammatory pseudotumor between 1974 and 2007.

RESULTS

A total of 25 patients were treated with pulmonary inflammatory pseudotumor at the Marie Lannelongue Hospital. The mean age was 33 years. Two patients were referred after an incomplete resection. One patient presented with cerebral metastasis. We performed a complete resection in all patients: wedge resection (n = 7), lobectomy (n = 6), sleeve arterial lobectomy (n = 1), lobectomy with thoracic inlet exenteration (n = 2), bilobectomy (n = 2), pneumonectomy with brain metastasectomy (n = 1), sleeve pneumonectomy (n = 2), sleeve main bronchus or tracheal resection (n = 2), wedge with sleeve main pulmonary artery resections (n = 1), and sleeve pneumonectomy with esophageal, aortic arch, and right pulmonary artery resection (n = 1). No adjuvant therapy was given to any patients. Postoperative 30-day mortality and morbidity rates were 4% and 8%, respectively. With a mean follow-up of 80 months (range 4-369 months, 100% follow-up), actuarial 10-year survival was 89%. One patient died of an extensive sarcomatous recurrence 2 years after surgery.

CONCLUSION

Pulmonary inflammatory pseudotumor is a malignant disease affecting young patients with local invasion, distant metastasis, local recurrence, and sarcomatous degeneration. A complete resection should always be performed at initial presentation because of its high likelihood of cure with aggressive management.

Posterior midline approach for single-stage en bloc resection and circumferential spinal stabilization for locally advanced Pancoast tumors

The treatment of Pancoast (superior sulcus) tumors that extensively invade the vertebral column remains controversial. Different surgical approaches involving multistage resection techniques have been previously described for superior sulcus tumors that invade the chest wall and spinal column. Typically a posterior approach to stabilize the spine is followed by a second-stage thoracotomy (posterolateral or trap door) for definitive en bloc resection of stage T4 Pancoast tumors. The authors report and elaborate on a surgical technique successfully used for an en bloc resection as well as spinal stabilization through a single-stage posterior approach without any added morbidity.

Two patients with histologically proven Pancoast tumors were treated by single-stage resection and stabilization through a posterior approach at the H. Lee Moffitt Cancer Center. A wedge lung resection or lobectomy was performed by the chest surgeon utilizing the chest wall defect. Placement of an anterior cage (in one case) and posterior cervicothoracic spinal instrumentation (in both cases) was performed during the same operation. Average blood loss was 675 ml and surgical time was 7 hours. The median hospital stay was 9 days (range 7–11 days). Both patients did well postoperatively and were free of recurrence at the 2-year follow-up.

Radical resection of Pancoast tumors including lobectomy, chest wall resection, costotransversectomy, and partial or complete vertebrectomy with simultaneous instrumentation for spinal stabilization can be performed through a posterior single-stage approach.