Transmanubrial osteomuscular sparing approach for lung cancer invading the anterior part of the thoracic inlet

Surgical approach through the anterior scalene muscle resection for invasive tumours in the supraclavicular fossa (with video)

BACKGROUND

The supraclavicular fossa contains many vital organs to be preserved, such as the brachial plexus, subclavian artery and vertebral artery. Various surgical methods have been reported. However, no well-standardized surgical procedure has been established.

METHODS

Between 2010 and 2020, we performed 28 surgical treatments of the superior mediastinum and supraclavicular fossa. Of these, we retrospectively reviewed seven cases of supraclavicular invasion using a unified surgical technique in which the anterior scalene muscle was resected, and the inter-scalene triangle was approached.

RESULTS

We performed claviculectomy in four cases and a transmanubrial approach in three cases. In all cases, by resecting the anterior scalene muscle, the brachial plexus, subclavian artery and vertebral artery were preserved. There were no critical postoperative complications other than tracheostomy and lymphatic leakage. Median bleeding amount and operative time were 438 (range; 76-1144) ml and 328 (range; 246-615) minutes, respectively.

CONCLUSIONS

The anterior scalene muscle resection method might be a safe and standardized method for preserving the brachial plexus, subclavian artery and vertebral artery.

Reverse "L" surgical approach for the management of giant tumors of the cervicothoracic junction

Background

An isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection of tumors of the cervicothoracic junction. This study examines reverse “L” thoracotomy as a surgical approach to these tumors. Additionally, the feasibility, safety, and effectiveness of reverse “L” surgical incision for tumor resection was also analyzed.

Methods

Patients with cervicothoracic tumors were identified from an internal database. Subjects were selected on the basis of undergoing reverse “L” thoracotomy from August 2014 to August 2018. The tumor characteristics, surgical technique, completeness of resection, morbidity, and patient outcome were reviewed.

Results

All patients successfully underwent resection through reverse “L” surgical approach. No patients needed to undergo full sternotomy. There were 6 neurogenic tumors, 4 thyroid adenocarcinomas, 4 bronchogenic tumors, and 7 other cases in the study. The median operative time was 191.0 min (range, 113.0–348.0 min) and postoperative in-hospital stay ranged from 3 to 7 days. Horner syndrome was observed in 1 case. Hoarseness and lymphatic leakage were evident in 3 and 1 case(s), respectively. Hemidiaphragm paralysis was observed in 1 case. Three cases were unsuccessful in achieving R0 resection. The duration of follow-up ranged from 6 to 42 months. Eleven of 13 patients who underwent resection had no evidence of tumor recurrence. Two patients with metastatic disease died of distant progression within 15 months.

Conclusions

Applying reverse “L” surgical approach is safe, feasible, and effective for the resection of giant tumors of the cervicothoracic junction.

Intravenous Lobular Capillary Hemangioma in the Subclavian Vein

We report the case of a 73-year-old man with severe edema of the right upper extremity. Computed tomography, magnetic resonance imaging, and venography revealed an intravenous tumor in the middle portion of the right subclavian vein. The tumor was completely resected, and an accompanying thrombus was also removed using the transmanubrial osteomuscular sparing approach. The patient recovered well without any complications or recurrence. The histopathologic diagnosis was intravenous lobular capillary hemangioma, which is also called pyogenic granuloma. To our knowledge, this is the first reported surgical case involving this type of benign tumor originating in a thoracic vein.

Alveolar rhabdomyosarcoma of the anterior mediastinum with vessel invasion in a 4-month-old boy: a case report

Introduction

Alveolar rhabdomyosarcomas of the mediastinum in children are rarely reported. Multimodality therapy including chemotherapy, surgery and radiotherapy make up the backbone of the treatment of childhood rhabdomyosarcomas. Complete resection whenever achievable is an important prognostic factor. However, complete resection of tumors in the mediastinum often poses a unique challenge to thoracic surgeons due to their close proximity to important neurovascular structures. Complete resection may not always be possible and judicious peri-operative planning and preparation are required to avoid creating unnecessary surgical morbidities resulting in delay of adjuvant therapy.

Case presentation

A 4-month-old Chinese baby boy was presented to our hospital with stridor, shortness of breath and episodes of cyanosis. Imaging studies found an anterior mediastinal mass compressing the trachea and other neurovascular structures and he was diagnosed to have alveolar rhabdomyosarcoma. Our patient received upfront chemotherapy and subsequently open resection of the mass was attempted via median sternotomy. Intraoperatively, the mass had invaded into the great vessels, precluding a complete resection. Debulking surgery was performed instead and our patient received timely postoperative chemoradiotherapy.

Conclusions

We report a rare case of childhood alveolar rhabdomyosarcoma of the mediastinum with vascular invasion treated with chemoradiotherapy and debulking surgery. Complete resection was not possible due to the close proximity to the great vessels. Different surgical approaches to the mediastinum have been reported in adults and children alike. Regardless of the surgical access, the treatment of childhood rhabdomyosarcomas should be individualized, with careful balance between surgical clearance and surgical morbidity.

Transmanubrial approach with video-assisted thoracoscopic surgery for left superior sulcus tumour with dense adhesion after replacement of descending thoracic aorta

There are various surgical approaches to superior sulcus tumours according to the location of the tumour. The chief difficulties in the operation are broadening of the operative field and adhesiolysis. This study presents the case of surgical treatment of superior sulcus tumour following chemoradiation therapy with dense pleural adhesion due to a history of graft replacement of the descending thoracic aorta. The patient underwent left upper lobectomy via a transmanubrial osteomuscular-sparing approach combined with video-assisted thoracoscopic surgery (VATS). Transmanubrial approach combined with VATS offered a good overview during local tumour dissection.