Total vertebrectomy for en bloc resection of lung cancer invading the spine

How I do it: en-bloc thoracic vertebrectomy

BACKGROUND

Some young patients with preserved functional status suffering from aggressive isolated neoplastic disease of the thoracic spine may be eligible from curative en-bloc vertebrectomy surgical treatment.

METHOD

Long-segment posterior pedicle screw fixation is performed. Complete excision of the posterior arch and of ribs posterior aspect is performed. Finger blunt dissection is performed between vertebral body, pleura, and aorta allowing to place a soft abdominal valve and then Gigli saws surrounding the anterior aspect of the spine, in order to saw the upper and the lower discs. Unilateral temporary rod is placed. The vertebral body is dislodged from posterior ligament and then removed by circling laterally around spinal cord. An expandable vertebral implant is placed.

CONCLUSION

Posterior en-bloc thoracic vertebrectomy is a highly technical yet achievable procedure which carries a curative intent for isolated neoplastic spine lesions.

Extended Pulmonary Resection for T4 Non-Small Cell Lung Cancer

T4 non-small cell lung cancer is a locally advanced disease with poor prognosis. The operation can be challenging even for an experienced surgeon. N2 disease has been shown repeatedly as a risk factor for poor outcome, and these patients should not be candidates for surgical treatment. Surgery for locally advanced T4 tumors without mediastinal lymph node involvement (T4N0 and T4N1) has been demonstrated to result in good outcomes in carefully selected patients. Patients with T4N0-1M0 should be rejected for surgery only after consulting an expert surgical center. As with other stages, the decision for resectability and surgery should be made by a multidisciplinary team.

The oncologic efficacy of extended thoracic resections

Locally invasive lung cancers pose unique challenges for management. Surgical resection of these tumors can pose high morbidity due to the invasion into surrounding structures, including the spine, chest wall, and great vessels. With advances in immunotherapy and chemoradiation, the role for radical resection of these malignancies and associated oncologic outcomes is evolving. This article reviews the current literature of extended thoracic resections with a focus on technical approach, functional outcomes, and oncologic efficacy.

Surgical and Oncological Outcomes of En-Bloc Resection for Malignancies Invading the Thoracic Spine

OBJECTIVE(S)

There is still limited data in the literature concerning the survival of patients with tumors of the thoracic spine. In this study, we analyzed clinical features, perioperative and long-term outcomes in patients who underwent vertebrectomy for cancer. Furthermore, we evaluated the survival and surgical complications.

METHODS

We retrospectively reviewed all cases of thoracic spinal tumors treated by the same team between 1998 and 2018. We divided them into three groups according to type of tumor (primary vertebral, primary lung and metastases) and compared outcomes. For each patient, Overall Survival (OS) and Cumulative Incidence of Relapse (CIR) were estimated. Complications and survival were analyzed using a logistic model.

RESULTS

Seventy-two patients underwent thoracic spine surgery (40 in group 1, 16 in each group 2 and 3). Thirty patients died at the end of the observation at a mean follow up time of 60 months (41%). The 5-year overall survival was 72% (95% CI: 0.52-0.84), 20% (95% CI: 0.05-0.43) and 27% (95% CI: 0.05-0.56) for each group, respectively. CIR of group 3 was higher (HR 2.57, 95% CI: 1.22-5.45, p = 0.013). The logistic model revealed that age was related to complications (p = 0.04), while surgery for a type 3 tumor was related to mortality (p = 0.02).

CONCLUSIONS

Although the cohort size was limited, primary vertebral tumors displayed the best 5-y-OS with an acceptable complications rate. The indication of surgery should be advised by a multidisciplinary team and only for selected cases. Finally, the use of a combined approach does not increase the risk of complications.

Long-term outcome after en bloc resection and reconstruction of the spinal column and posterior chest wall in the treatment of malignant tumors

BACKGROUND

Malignant tumors occurring around both the spinal column and posterior chest wall are uncommon. Surgical resection of chest wall tumors adjacent to the spinal column is still challenging due to the surrounding anatomical structures. The purpose of the present study was to evaluate the long-term outcomes of surgical management in malignant tumors involving the spinal column and posterior chest wall.

METHODS

Between 1999 and 2007, 10 consecutive patients underwent en bloc resection combined with the posterior chest wall in the treatment of malignant tumors around the spinal column. There were 6 males and 4 females with a mean age at the surgery of 40.9 years old (range, 14-62 years old). The mean postoperative follow-up period was 159.7 months (range, 84-245 months). The clinical history, physical examination, laboratory data, radiological findings, and operative findings for each patient were retrospectively reviewed.

RESULTS

All surgeries were performed via a combined anterior and posterior approach. The mean numbers of partially resected vertebrae and ribs were 3.1 and 4.1, respectively. Lower or upper lobectomy was performed in four patients, and the diaphragm was partially resected in two patients. The surgical margin was wide in seven patients and marginal in two patients. Although five patients had postoperative respiratory problem, all patients improved immediately without life-threatening complications. There were no patients with respiratory insufficiency after surgery. One patient with osteosarcoma died of lung metastases 99 months after surgery. At the final follow-up, only one patient had local recurrence, five had been continuously disease-free, and three were alive with no evidence of disease.

CONCLUSIONS

En bloc resection and reconstruction in selected patients with malignant tumors involving both the spinal column and posterior chest wall demonstrated good long-term results for local control and the respiratory function.

Evolution of the Surgical Management of Lung Cancer Invading the Spine: A Single Center Experience

For patients with locally advanced non-small cell lung cancer invading the spine, induction chemoradiotherapy combined with radical en bloc resection is the key to obtaining long-term survival. With time, our operative technique evolved to a two-step surgery as we experienced numerous perioperative complications during one step surgery. The aim of our study was to assess postoperative morbimortality and long-term survival of both techniques. We retrospectively reviewed all patients who underwent en bloc resection for lung cancer invading the spine between October 2012 and June 2020. Every patient underwent induction therapy. Sixteen patients were included: nine patients were operated on with one step surgery, seven patients were operated on with two step interventions. Twenty-five percent of patients had major perioperative complications and 56.2% of patients had major post-operative complications. Patients in the “one step” group tended to have more perioperative complications whereas patients in the “two step” group tended to have more post-operative complications. Overall 3-year survival was 40% in the one-step and 86% in the two-step surgery group. Although our practice has been improved by two-step interventions, post-operative morbidity remains significant. As long term survivals are encouraging, this type of treatment should still be proposed for highly selected patients, in specialized centers.

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine

OBJECTIVES

This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC).

METHODS

Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10.

RESULTS

There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence.

CONCLUSIONS

VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.

Use of Navigated Ultrasonic Bone Cutting Tool for En Bloc Resection of Thoracic Chondrosarcoma: Technical Report

BACKGROUND

En bloc surgical resection with wide margins offers the best local control rates for chondrosarcoma of the spine.

OBJECTIVE

To describe the surgical technique for en bloc resection of a large thoracic chondrosarcoma using image guidance for a complex osteotomy with an ultrasonic bone cutting device (Misonix, Farmingdale, New York).

METHODS

A 2-stage procedure was performed for resection of a thoracic chondrosarcoma involving the T3-T7 vertebral bodies. During the first stage, a posterior approach, the ultrasonic bone cutter was precisely navigated to perform an intralaminar osteotomy as well as a multilevel split sagittal osteotomy through the vertebral bodies. In the second stage, a transthoracic approach was used to complete the en bloc resection of the specimen. Intraoperative frozen sections from the surgical margins were negative for tumor.

RESULTS

The ultrasonic bone cutting device was navigated based on coregistration of the intraoperative computed tomography (CT) images and preoperative magnetic resonance imaging (MRI). Real-time navigation using coregistered images enabled identification of tumor margins within the bone and adjacent soft tissue allowing precise execution of the intralaminar and multilevel split sagittal vertebral osteotomies. Surgical video demonstrates the utility of real-time navigation to properly identify the tumor margins and guide the ultrasonic bone cutting tool during the osteotomies.

CONCLUSION

We describe the use of image guidance to navigate an ultrasonic bone cutting tool for a complex en bloc resection of a multilevel thoracic spine chondrosarcoma.

Successful surgical management of periosteal chondroma of the left second rib: a case report

We present a case of successfully resected periosteal chondroma of the left second rib in view of extremely rare occurrence of such cases and the success achieved in its management. A 12-year-old female child presented to our hospital with a swelling in the upper anterolateral aspect of the left chest wall. On chest X-ray and contrast-enhanced computed tomography (CECT), it was diagnosed to be a case of osteochondroma of the second rib. The tumor was approached through a left posterolateral thoracotomy and parts of the first and second ribs were excised along with the tumor. Patient is now on outpatient follow-up and hemodynamically stable with no recurrence of symptoms. The histopathology revealed periosteal chondroma of the second rib with all margins of the resected mass being free of tumor suggesting complete excision. Patient is now on outpatient follow-up and hemodynamically stable with no recurrence of symptoms. Postoperative results were very satisfactory not only in terms of oncological clearance but also from the functional and cosmetic point of view. We believe our case is going to add to the very limited number of such cases available in literature.

Initial extended resection or neoadjuvant therapy for T4 non-small cell lung cancer-What is the evidence?

Locally advanced non-small cell lung cancer (NSCLC) tumors that invade surrounding structures within the chest (T4) are a heterogeneous group, and, as such, there are no straightforward guidelines for their management. Advances in imaging, invasive mediastinal staging, and neoadjuvant therapies have expanded the role of surgery with curative intent for this patient group and have also diminished the rate of explorative thoracotomies. Unlike for T4 superior sulcus tumors, the use of neoadjuvant therapy for central T4 tumors is not clearly defined. The most important determinants of a successful outcome after surgery are achieving an R0 resection and avoiding incidental pathologic N2 disease. Use of neoadjuvant therapy in this setting may yield better outcomes after surgery, as both of these variables can be altered if the tumor responds to neoadjuvant therapy. Moreover, response to induction therapy has been shown to have prognostic value.

Utilizing Stereotactic Spine Navigation for Posterior Partial Vertebrectomy in an En Bloc Resection of a Superior Pulmonary Sulcus Tumor Invading the Thoracic Vertebrae: A Technical Note

Prior to the development of en bloc techniques, vertebral invasion by non-small cell lung cancer (NSCLC) had been considered a relative contraindication to surgical intervention. However, reports in the literature have demonstrated increased progression-free survival with the use of neoadjuvant chemotherapy followed by anterior en bloc resection of the residual tumor. Stereotactic spine navigation has been shown to improve accuracy during complex vertebral osteotomies, improving patient outcomes. We report a 53-year-old woman with an NSCLC in the left upper lobe, a periosteum attachment of the second and third thoracic vertebrae (T2 and T3, respectively), and an infiltration of the corresponding nerve roots. We describe a surgical approach for the resection of NSCLC with vertebral infiltration utilizing stereotactic spine navigation and intraoperative computed tomography (CT) (O-Arm, Medtronic, Minneapolis, Minnesota, US) for a posterior approach laminectomy, osteotomy, and partial vertebrectomy, followed by trans-thoracic en bloc resection of a superior pulmonary sulcus tumor with nerve root infiltration. Posterior approach vertebral osteotomy and en bloc resection for superior sulcus NSCLC infiltrating the vertebrae utilizing stereotactic spine navigation and intraoperative CT (O-Arm) is a viable alternative to the traditional anterior approach.

En Bloc Resection with the Assistance of Video-Assisted Thoracoscopy for Left Lower Lung Cancer Invading Thoracic Vertebrae and Rib: A Case Report

Lung cancer invading the spine was previously considered unresectable and fatal and, consequently, there are few reports focusing on tumors located in the lower lung lobe and invading the spine. With the development of spinal instrumentation and surgical techniques, and wider acceptance of spondylectomy by surgeons, radical surgical resection has become feasible. Here, we present a case of a male patient with a left lower lung cancer invading thoracic vertebrae who underwent complete resection with sagittal en bloc hemivertebrectomy with video-assisted thoracoscopy. A 60-year-old man complained of left chest pain for 3 months. Chest computed tomography and thoracic vertebrae magnetic resonance image revealed that a tumor in the left lower lung lobe had invaded the seventh and eighth thoracic vertebrae and the eighth rib. As no lymph node or distant metastasis was detected by positron emission tomography-computed tomography, the patient was diagnosed with left lower lung cancer directly invading the seventh and eighth thoracic vertebrae and the eighth rib (T4N0M0, stage IIIA) instead of metastasizing to the thoracic vertebrae. An en bloc resection of the lung tumor and the involved vertebrae was performed by a thoracic surgeon and orthopaedic surgeon with video-assisted thoracoscopy. Six months after the operation, there was no evidence of local recurrence, and the patient had recovered well. En Bloc resection with video-assisted thoracoscopy for lung cancer invading thoracic vertebrae is a safe and feasible surgical method. This method can significantly improve the safety and convenience of this type of surgery.

En bloc spondylectomy combined with chest wall excision for spinal tumor via a modified posterior approach: a retrospective study on 21 patients

OBJECTIVE

This study was to investigate the feasibility and efficacy of total en bloc spondylectomy (TES) combined with chest wall excision through a modified posterior approach in treating the patients with thoracic spinal tumor and posterior chest wall invasion.

METHODS

Clinical data of 21 consecutive patients (7 males, 14 females; average age: 41.5, range: 20-69) who underwent the combined TES and chest wall excision through a modified posterior approach from 08/2005 to 01/2014 were retrospectively analyzed. Reconstruction of the spinal defect following TES was accomplished by dorsal stabilization and carbon cage interposition. All resected specimens were examined histologically. Radiotherapy and chemotherapy were performed according to the results of the surgery and histological examination. All patients were followed up on a regular basis.

RESULTS

The surgery was successfully performed in all patients. Histological analysis revealed primary malignant tumors in 16 patients and solitary vertebral metastases in 5 patients. Three patients with preoperative neurologic deficits of Frankel D recovered to Frankel E 1-3 weeks postoperatively. After the mean follow-up of 31 months (9-70), the 16 patients (16/21, 76.2%) with primary bone tumors were free of recurrence and present no evidence of disease. Four cases (4/21, 19%) with metastatic tumor developed recurrence or distant metastases. Three patients presented with cerebrospinal fluid leakage and one patient suffered pneumonia; they were soon recovered after treatment. No other complications were observed.

CONCLUSION

The results suggest that the combined TES with chest wall excision via a modified posterior approach seems feasible and effective for treating patients with thoracic spinal tumor and posterior chest wall invasion.

Management of locally advanced pancoast (superior sulcus) tumors with spine involvement

BACKGROUND

The preferred treatment for locally aggressive lung cancers is triple modality therapy with concurrent and induction chemotherapy with radiation therapy followed by surgery. Patients with locally advanced T4 Pancoast tumors with spine involvement, without mediastinal N2 lymph node involvement and without distant metastases, are appropriate candidates for complete resection with subsequent spine reconstruction. This review addresses the questions of whether triple modality therapy with complete en bloc resection of locally advanced Pancoast tumors offers an advantage in terms of overall survival and complication rates compared with other therapeutic modalities or therapies with incomplete resection.

METHODS

A comprehensive literature search was conducted using common medical databases. Inclusion and exclusion criteria for the articles were prospectively defined. The articles were independently reviewed and a consensus decision was made about each article. Selected papers were graded by level of evidence.

RESULTS

A total of 1,001 abstracts and 93 articles fulfilled the criteria; from these studies, 14 were included in this systematic review. No level 1 study was found in this search. Four level 2 studies and 10 level 3 retrospective case series were found. The overall 5-year survival rate reported in these studies ranged from 37% to 59% and the mortality rate ranged from 0% to 6.9%.

CONCLUSIONS

Evidence suggests that triple modality therapy with complete resection of locally advanced Pancoast tumors with involvement of the spine offers an advantage over other therapeutic modalities or therapies with incomplete resections.

Cervicosternotomy as an anterior approach to the upper thoracic and cervicothoracic spinal junction

Object

The cervicothoracic junction is always a difficult area to approach. When operating on this specific area (for tumor or trauma), the aim is generally to decompress and stabilize the spine. The authors describe an improved median sternotomy method for reaching the anterior aspect of the spine down to T-5.

Methods

Seven patients with a mean age of 40 years (range 17–68 years) were included in this study. The vertebral lesion was due to trauma in 4 cases and tumor in the other 3. A single vertebral body was involved in 2 cases, 2 in 3 cases, and 3 in 2 cases. The vertebra most often involved was T-3 (6 cases), although T-4 was involved in 2 cases, T-5 in 2 cases, and T-1 and T-2 in 1 case each. All patients underwent the same preoperative workup: CT scanning, MR imaging, and CT angiography of the aortic arch.

Results

The median sternotomy made it possible to effectively decompress and stabilize the spinal cord. An anterior screw plate was used in 5 cases. The plate extended from T-2 to T-5 in 3 cases, from T-2 to T-4 in 2 cases, and from C-7 to T-4 in 1 case. The mean duration of surgery was 195 minutes (range 180–240 minutes). No neurological deterioration occurred. The mean hospital stay was 8 days (range 6–15 days). In 2 cases (28.6%), recurrent left nerve palsy was observed postoperatively; the palsy was transient in both of these cases, and full recovery occurred within 3 months. The mean follow-up among this series of patients was 29 months (range 22–38 months).

Conclusions

The median sternotomy provided a good means of reaching the upper thoracic spine (T2–5) and cervicothoracic junction. It enables surgeons to decompress the spinal cord and stabilize the spine.

Cervical and thoracic spine tumor management: surgical indications, techniques, and outcomes

Since the first pioneering work in the area of tumors of the spine, medical professionals have sought to determine the proper role of spine surgery in the management of spinal tumors. Experience has proven that spine surgery is effective in the treatment of spinal cord compression for decreasing pain and improving quality of life with low rates of surgical complications. We use several staging systems to assess the patient's prognosis, to determine the best type of tumoral resection in preoperative surgical planning, and to provide guidance as to the best therapeutic option for the patient. In the surgical treatment of spine tumors, one of two opposing strategies must be chosen: (1) palliative surgery with cord decompression and spine stabilization or (2) curative surgery with en bloc radical resection of the tumor and stabilization. In this article, we describe indications and surgical techniques related to cervical spinal tumors: fixation and laminectomy of the upper and lower cervical spines, corporectomy, and partial and total vertebrectomy. For tumors of the cervicothoracic region, the most frequent level of spine metastasis and thoracic spine tumors, we describe the fixation and laminectomy technique, en bloc tumor resection, and partial and total vertebrectomy. The last part of the article addresses outcomes following spinal surgery, including outcomes related to en bloc Pancoast Tobias tumor resection, malignant dumbbell schwanomas, and metastasis.

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.

Total L-5 spondylectomy and reconstruction of the lumbosacral junction

✓The authors describe a technique for total L-5 spondylectomy and reconstruction of the lumbosacral junction. The technique, which involves separately staged posterior and anterior procedures, is reported in two patients harboring neoplasms that involved the L-5 level. The first stage consisted of a posterior approach with removal of all posterior bone elements of L-5 and radical L4–5 and L5–S1 discectomies. Lumbosacral and lumbopelvic instrumentation included pedicle screws as well as iliac screws or a transiliac rod. The second stage consisted of an anterior approach with mobilization of vascular structures, completion of L4–5 and L5–S1 discectomies, and removal of the L-5 vertebral body. Anterior lumbosacral reconstruction included placement of a distractable cage and tension band between L-4 and S-1. Allograft bone was used for fusion in both stages. No significant complications were encountered. At more than 1 year of follow-up, both patients were independently ambulatory, without evidence of recurrent or metastatic disease, and adequate lumbosacral alignment was maintained. The authors conclude that this technique can be safely performed in appropriately selected patients with neoplasms involving L-5.

Morphometric effects of acute shortening of the spine: the kinking and the sliding of the cord, response of the spinal nerves

Spinal shortening is performed for a wide spectrum of diseases. This study was designed to investigate the morphologic effects of shortening on the spinal cord, to enlighten the amount and direction of the sliding of the cord, the alteration of the angles of the roots, and to identify the appropriate laminectomy length. Total vertebrectomy of T12 was applied to ten sheep models after spinal instrumentation. Gradual shortening was applied to five sheep; then, the degree and direction of the sliding of the spinal cord and the angles of the adjacent roots were measured. On five other sheep, additional sagittal sectioning was performed via excision of the pedicles. Measurements were taken at different laminectomy lengths to record kinking of the spinal cord with gradual shortening. The mean sliding of the spinal cord was 9 mm cranially and 7.8 mm caudally. T11 spinal nerves became more vertical caudally, and T12 spinal nerves achieved an ascending position with gradual shortening. Both T11 and T12 spinal nerves were sharply bent in the foramen and on the pedicle of T13, respectively. In full-length shortening, the mean kink of the spine in the sagittal plane was 92.4 degrees for two levels of hemi-laminectomies, 24.6 degrees for complete laminectomy of T11 with hemilaminectomy of T13, and 20.2 degrees for two levels of complete laminectomies. The slippage of the cord is dominant in the earlier stages and kinking is dominant in later stages of shortening. Increasing the laminectomy length by only a half or one level prevents excessive kinking and compressions at the upper and lower margins of the laminectomy. In the later stages of shortening, the spinal nerves near the vertebrectomy site are at risk because of the sharp bending of the nerves. This study describes the mechanism of the sliding and kinking of the cord due to gradual shortening of the spine, which might be useful in spinal surgery procedures. It also states that it is possible to avoid excessive kinking by planning the appropriate technique of laminectomy style in full-length shortening.

Traitement des tumeurs de l'apex: un modèle de stratégie multimodale dans les cancers bronchiques localement évolués

Superior sulcus tumors have been individualized among other non-small cell lung cancers because of their characteristic clinical presentation in connection with their local extension to the chest wall and the brachial plexus. For a long time considered as marginally resectable, superior sulcus tumors have been treated since the early 1960's, with a combined approach including preoperative radiotherapy and curative-intent surgery. Surgical resection includes both thoracic, cervical and neurosurgical approach, and aims at obtaining complete resection, which has been identified as a determining prognostic factor in most reported series. Two recent phase II trials showed the benefit, both regarding resectability and local control rates, and survival of combined therapeutic strategies including induction platinum-based chemoradiation, extensive surgical resection, and adjuvant chemotherapy. Adjuvant radiotherapy is not recommended at the time, but needs to be re-evaluated regarding its recent technical optimisation. Similarly to other locally advanced non-small cell lung cancers, exclusive chemoradiation is the standard treatment of unresectable superior sulcus tumors. In this way, radiotherapy has shown to offer a prolonged analgesia in more than 75% of cases, and is associated with concurrent or sequential chemotherapy, with comparable results to those observed in stage III lung cancer. These developments make superior sulcus tumors a therapeutic model for locally advanced non-small cell lung cancer, whereby the benefit of combined multimodal strategies including induction chemoradiation and surgical resection are currently evaluated in phase III trials.

Résection vertébrale monobloc pour cancer pulmonaire : 12 ans d'expérience

OBJECTIVES

To report a single-institution retrospective study of radical en bloc resection for lung cancer invading the spine.

METHODS

Between 1993 and 2004, 32 patients underwent partial or total vertebrectomy for non-small cells lung cancer with spinal extension. Twenty-one received induction treatment (chemotherapy, N=16; radiation, N=1 and chemoradiotherapy, N=4). Pneumonectomy was performed in 3 patients, lobectomy in 26 patients and wedge resection in 3 patients. Partial vertebrectomy was performed in 26 patients and total vertebrectomy was performed in 6 patients. Tumor stage was IIb in 9 patients, IIIa in 2 patients and IIIb in 21 patients.

RESULTS

There was no immediate postoperative mortality. Major morbidity was observed in 10 patients (31%), including 4 complications related to spinal surgery. For 28 patients, a completed resection was achieved (87%). 2-years survival was 65% and 5-years survival was 24%. Completed resection and induction chemotherapy appear to be determinant prognostics factors (respectively p=0,01 and p=0,04 in univariate analysis).

CONCLUSION

Radical en bloc resection with vertebrectomy for lung cancer is technically demanding. Encouraging long-term survival suggest that this surgical approach could be a valid option for selected patients with vertebral involvement of lung cancer.

Multimodality therapy for Pancoast tumor

The management of Pancoast tumors has challenged surgeons and radiation and medical oncologists over several decades. Retrospective studies have raised a greater awareness of the importance of positive N2 lymph nodes in terms of prognosis and treatment decision making. While patients with positive N2 lymph nodes have generally been excluded from trials of preoperative chemoradiation for superior sulcus tumors, the potential of surgery for these patients is still being evaluated. The role of PET for initial staging as well as for assessment of disease response to induction therapy continues to evolve. The use of combined treatment modalities has enhanced the progress in successfully treating Pancoast tumors. The historical data showing improved results with a combination of surgery and radiation compared with surgery alone for patients with positive N2 nodes provides the basis for several important clinical trials that integrate the use of chemotherapy into the treatment paradigm. The Southwest Oncology Group and Japanese Clinical Oncology Group have shown dramatic improvements in complete resection rates following a neoadjuvant course of combined chemotherapy and radiation therapy compared with historical series. We discuss relevant ongoing clinical trials that include consolidative taxane-based chemotherapy and the role of prophylactic cranial irradiation in complete responders. Future potential areas of investigation, including the role of surgery for patients with N2-positive disease and the use of imaging to assess response after induction therapy, are discussed.

Thoracic extradural paragangliomas: a case report and review of the literature

STUDY DESIGN

Case report.

OBJECTIVES

To report on a case of paraganglioma presenting in an uncommon extradural thoracic localization.

SETTING

Department of Neurosurgery, Florence, Italy.

CASE REPORT

A 43-year-old woman with a thoracic lesion extending into the extradural space along four levels, T(1)-T(4), presented with sudden spastic incomplete paraplegia and paresthesia at the lower limbs.

RESULTS

The neoplasm was surgically resected 'en bloc' and histological findings corresponded to paraganglioma. One year after surgery, the patient was walking without assistance, a T(3)-T(4) hypoesthesia was still present and an magnetic resonance imaging (MRI) study showed no signs of focal recurrence.

CONCLUSIONS

The imaging features of thoracic paragangliomas may be misleading and an advanced malignant lesion could be primarily suspected; thus, a histological study is always needed. Total resection is the gold standard therapy. Owing to the risk of recurrence or multicentric growth, follow-up must be prolonged and accurate.

Use of "MAPs" for determining the optimal surgical approach to metastatic disease of the thoracolumbar spine: anterior, posterior, or combined. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

The surgical treatment of thoracolumbar metastases is controversial, and various approaches have been described. No single approach, however, is always applicable, and the optimal surgical strategy for any individual is determined by several interrelated factors. The authors have grouped these factors into four preoperative planning considerations that form the mnemonic "MAPS": 1) method of resection; 2) anatomy of spinal disease; 3) patient's level of fitness; and 4) stabilization. The choice of approach is also considered in light of the goals of surgery, including the relief of pain, neurological palliation, spinal stabilization, and oncological control.

Superior Sulcus Tumors: A Mini‐Review

The management and outcome for superior sulcus tumors have remained unchanged for 40 years. The rarity of these tumors has led to varying treatment techniques spanning decades, from which no solid conclusions can be drawn. Recent advances in combined-modality therapy have offered the first inkling that a paradigm shift is on the horizon. Here, we review the history and new advances in treating this challenging pulmonary neoplasm.

Surgical approach in T4N0M0 (vertebral involvement) lung cancer

Approximately 5% of the cancers involve the chest wall and spine by direct extension and remain localized at the time of diagnosis. T4 lesions invading the vertebra are considered inoperable. We reviewed a new evolution in the surgical treatment of lung cancer involving the vertebra (T4N0M0) and report preliminary results of our approach. Four patients with T4N0M0 (vertebral involvement) lung cancer underwent en bloc surgical resection of tumor between 1998 and 2002. Posterior stabilization, hemilaminectomy, and osteotomy of the involved vertebral bodies below the corresponding pedicle were performed in the prone position and then, in the lateral position, en bloc resection was completed along with the lung resection (large wedge resection or lobectomy) and involved vertebral bodies. There was no immediate postoperative mortality. Three patients died during the follow-up period at the 6th, 8th, and 14th postoperative months with a postoperative recognized metastasis. The fourth patient was in follow-up at 20 months. Although T4N0M0 (vertebral involvement) lung cancers are considered inoperable, lung resection with hemivertebrectomy of the involved vertebra after neoadjuvant chemotherapy and radiotherapy is an alternative treatment in this type of lung cancer. Staging should be made meticulously for the expected surveillance.

Posterior cervicothoracic instrumentation in spine tumors

STUDY DESIGN

We retrospectively review 32 patients who underwent posterior fixation for cervicothoracic junctional tumors. All patients possessed unstable or potential after surgery unstable spines as a result of either their tumors or the surgery performed. We examined cervicothoracic spine stability, maintenance of alignment, and associated complications.

OBJECTIVES

To review our experience with 3 different posterior osteosynthesis systems applied to the cervico-thoracic junction for spinal tumors. Our review includes surgical outcomes and complications. The evolution through 3 different systems between 1994 and 1997 reflects our attempts to improve accuracy in light of variable facet and pedicle interspaces. Our goal is not to compare the efficacy of the systems but to assess the efficiency of cervicothoracic facet and transpedicular screw and plate or rod fixation. However, we will comment on why the evolution occurred. The 3 different systems share a similar characteristic. Each system employs posterior cervical facet screw fixation and thoracic trans-pedicular screw fixation.

SUMMARY OF BACKGROUND DATA

Spinal disorders involving the cervicothoracic junction and specific instrumentation to this region have been sparsely described in the literature.

METHODS

Between June 1994 and June 2000, 32 patients underwent surgery for spinal tumors involving the cervicothoracic junction at our institution. There were 27 males and 5 females. The ages ranged from 17 to 72 years with a mean age of 52 years. A total of 32 cervicothoracic instrumentations were performed. We used the R. Roy-Camille thoracolumbar plate in 20 patients, the cervico-thoracic plate in 8, and the Agora rod system in 4. In all, 96 lateral mass screws were implanted from C4 to C6, 54 into C7, and 180 pedicle screws from T1 to T8. Nineteen patients had lung cancer with vertebral body invasion (Pancoast tumors), 11 had metastasis to the cervicothoracic junction, 1 had a chondrosarcoma, and 1 had myeloma. In a first group consisting of 19 patients, a combination of anterior and extended posterior surgical approaches allowed complete en bloc resection of the tumors, including all invaded vertebrae. Four total vertebrectomies and 15 partial vertebrectomies were performed. A second group of 13 patients had only posterior palliative stabilizing procedures with laminectomy and cervicothoracic fixation.

RESULTS

The follow-up period varied from 3 to 54 months, average 15 months. The average duration of survival for patients who underwent partial or total vertebrectomy was 16 months (range 3-54 months). The average duration of survival for patients who underwent palliative decompression and stabilization was 11 months (range 5-19 months). No changes in the sagittal alignment occurred during the immediate postoperative period for 30 patients. However, 2 mechanical failures occurred. Two patients experienced a clinically significant early increase in thoracic kyphosis and required revision of the posterior instrumentation. A 21-month minimum follow-up was available for 6 patients, in whom all implants were stable. We noted no screw, plate, or rod breakage in this series. No neurologic complications, including root impingement or spinal cord injury, or vertebral artery injury occurred related to screw insertion into either the thoracic pedicles (180 screws) or the cervical lateral masses (96 screws in C4-C5-C6 and 54 screws in C7).

CONCLUSIONS

Posterior plate or rod and screw fixation is a good method of treatment for cervicothoracic instability in spine tumors. Facet screw fixation in the cervical spine with Roy-Camille drilling technique and transpedicular screw fixation in the thoracic spine provides an efficacious means by which to stabilize the cervicothoracic junction. This stabilization technique was effective even in cases of high postoperative instability, such as with partial or total vertebrectomy. This screw-type stabilization is clinically effective and well documented. The evolution through 3 different systems reflects our attempts to improve accuracy in light of variable facet and pedicle interspaces. Importantly, posterior instrumentation will not interfere with subsequent laminectomy or more extreme surgical procedures.

Vertebral body resection

Vertebral body resection for locally advanced lung cancer can be performed with acceptable morbidity and mortality rates, and with improved long-term survival, when combined with chemotherapy and radiation. A consensus has not been reached on either the optimal extent of vertebral resection or the optimal treatment regimen. Should total vertebrectomies be the standard of care for all patients, even those with minimal spine involvement? Can the extended operative times and multiple incisions and anatomic limitations that place some of the mediastinal organs at risk be justified for potential improvement in local control, or are the quicker and potentially safer endolesional resections appropriate for these tumors? Is local control, and ultimately survival, improved when additional chemotherapy and radiation therapy is given up front, or is an uninterrupted course of a higher dose of concurrent chemotherapy and radiation therapy following surgery preferred? Ideally, these questions will be answered by means of prospective randomized trials; however, because of the small number of patients who actually present with vertebral body involvement by lung cancer, physicians may have to rely on phase 2 studies and series reports from high-volume institutions to guide their treatment algorithms in the future.

Total spondylectomy for en bloc resection of lung cancer invading the chest wall and thoracic spine. Case report

Lung cancers invading the chest wall and spinal column are often considered unresectable, and consequently there are few reports describing resection of invasive vertebral lesions. The authors developed a new anterior approach procedure for the en bloc resection of primary lung adenocarcinoma invading the thoracic spine and chest wall, in which the primary tumor does not need to be separated from the vertebrae. The authors describe a total spondylectomy for the en bloc resection of lung cancer invading the spine. A combination of surgical techniques was required, including resection of the osseous elements T-2 and T-3 (the pedicles were excised using a thread saw), anterolateral thoracotomy, apical lobectomy, chest wall resection, vertebrectomy, anterior spinal column reconstruction with a titanium mesh cage containing bioactive glass ceramic, and placement of anterior and posterior spinal instrumentation. At 46 months after surgery, there is no evidence of local recurrence or distant metastasis, and the patient continues to improve. This new procedure allows for the en bloc resection of primary lung tumors and adherent vertebral invasion without separation of the lesion from the vertebra. Thus, surgical management by complete excision of Pancoast tumors can achieve longer-term survival rates without sequelae.

Intensity-modulated Stereotactic Radiotherapy of Paraspinal Tumors: A Preliminary Report

OBJECTIVE

Radioresistant paraspinal tumors may benefit from conformal treatment techniques such as intensity-modulated radiotherapy (IMRT). Local tumor control and long-term palliation for both primary and metastatic tumors may be achieved with IMRT while reducing the risk of spinal cord toxicity associated with conventional radiotherapy techniques. In this article, we report our initial clinical experience in treating 16 paraspinal tumors with IMRT in which the planning target volume was 2 mm or greater from the spinal cord.

METHODS

IMRT was administered by using a linear accelerator mounted with a multileaf collimator. Two immobilization body frames developed at Memorial Sloan-Kettering Cancer Center were used for patients with and without spinal implants. During a 30-month period, 16 patients underwent IMRT for metastatic and primary tumors. Eleven patients were treated for symptomatic recurrences after undergoing surgery and prior external beam radiotherapy, and one patient was treated after undergoing radiotherapy for a metastatic pancreatic gastrinoma with overlapping ports to the spine. Four patients with primary tumors were treated after primary resection that resulted in positive histological margins. Twelve patients were symptomatic with pain, functional radiculopathy, or both. Tumoral doses were determined on the basis of the relative radiosensitivity of tumors. Patients with metastatic tumors were administered a median tumoral dose of 20 Gy in four to five fractions and a spinal cord maximum dose of 6.0 Gy in addition to the full tolerance dose administered in previous radiation treatments. The primary tumors were delivered a median dose of 70 Gy in 33 to 37 fractions and a spinal cord maximum dose of 16 Gy. The median tumoral volume was 7.8 cm3.

RESULTS

Of the 15 patients who underwent radiographic follow-up, 13 demonstrated either no interval growth or a reduction in tumor size in a median follow-up period of 12 months (range, 2–23 mo). Two patients, one with a thoracic chondrosarcoma and one with a chordoma, showed tumor progression 1 year after undergoing IMRT. Pain symptoms improved in 11 of 11 patients, and 4 of 4 patients had significant improvement in their functionally significant radiculopathy and/or plexopathy. Pain relief was durable in all patients except the two with tumor progression. No patient showed signs or symptoms of radiation-induced myelopathy, radiculopathy, or plexopathy, including 12 patients with a median follow-up of 18 months.

CONCLUSION

IMRT was effective for treating pain and improving functional radiculopathy in patients with metastatic and primary tumors. Although long-term tumor control is not established in this study, high-dose tumoral irradiation can be performed without causing radiation myelopathy in more than 1 year of follow-up.

Surgery for locally advanced non-small cell lung cancer

Advanced stage non-small lung cancers are currently considered unresectable. However numerous series on patients with locally advanced disease treated by surgery have been published. Surgery alone or induction treatments followed by surgery achieve long-term outcomes in an encouraging proportion of selected patients with T4 disease, despite the high rate of morbidity associated with technically demanding procedures.

Contemporary management of superior pulmonary sulcus (Pancoast) lung tumors

For more than three decades following the initial report by Shaw et al. in 1961, the standard treatment of Pancoast lung tumors consisted of induction radiotherapy followed by en bloc resection through a posterolateral thoracotomy. Overall 5-year survival rates with this regime were typically 30 to 40%, with poor prognosis in patients with positive mediastinal lymph nodes, T4 involvement, or incomplete resection. During the past decade, advancements in surgical technique and adjuvant therapy have improved the safety and completeness of resection as well as the probability of long-term survival. Alternative surgical approaches have been developed to facilitate more complete resection of tumors involving subclavian vessels and brachial plexus, and aggressive vertebral body resection has been performed in conjunction with neurosurgeons. Arguably the most important advance in the treatment of Pancoast tumors has been the recognition that induction chemoradiation substantially improves both the rate of complete resection and medium-term survival.

Changes in the treatment of Pancoast tumors

Our understanding of superior sulcus tumors has evolved over time. The unique feature of Pancoast tumors is their location, in which the anatomy poses limitations to resection. Many resections are found to be incomplete, and the majority of recurrences have involved local failure. New surgical approaches allow greater flexibility according to tumor location and may improve these outcomes. Furthermore, new approaches permit complete resection of tumors involving vertebral bodies or the neural foramina. Traditionally, preoperative radiotherapy has been used, but a recent prospective phase II study suggests that preoperative concurrent chemoradiotherapy improves the rate of complete resection, local recurrence, and intermediate-term survival.

Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases

STUDY DESIGN

A new surgical technique for en bloc resection of posterior mediastinum tumors invading the spine is described.

OBJECTIVE

To demonstrate that major soft tissue tumors of the thoracic apex (Pancoast Tobias syndrome) or posterior mediastinum tumors can be removed en bloc even though the vertebral body or the foramina are invaded.

SUMMARY OF BACKGROUND DATA

En bloc surgery of tumor is accepted today as being the goal of carcinologic surgery with the best results for survival. Until now, no surgical technique has been described for radical excision of soft tissue tumors invading the thoracic spine adjacent to the ribs and lung. We reviewed our 8 years' experience of 36 such cases and report outcome and survival rates.

METHOD

The authors have joined their abilities and technique to enable complete en bloc extratumoral resections of lung tumors or posterior mediastinum tumors invading the adjacent soft tissue and spine. The surgical technique recommended by the authors is different at the cervicothoracic and medium thoracic level. At the cervicothoracic level, the authors first perform an anterior approach with dislocation of the sternoclavicular joint and dissection of the subclavian vessels with exposure of the brachial plexus. Dissection of the tumor from the anterior soft tissues is then performed but is kept attached to the adjacent spine. Dissection of lung hilum and its division are done through the same approach. At the thoracic level, the authors perform a posterior lateral thoracotomy for dissection of lung hilum and division of its elements. The lung and the adjacent tumoral ribs are not removed but are carefully kept undissected against the spine. Thoracoscopy can replace the open thoracotomy in small and medium-sized tumors. En bloc extratumoral resection is the second step performed through a median posterior cervicothoracic or thoracic approach. Vertebrectomy is complete or partial depending on the type of extension against or inside the vertebrae.

RESULTS

Thirty-six cases have been operated on with this technique. Vertebrectomy was complete in seven cases and partial in 29. Follow-up ranges from 6 days to 7.2 years (average, 23.3 months). One patient died 1 year postoperatively from an unrelated cause. Only 35 patients are available for follow-up analysis. Twenty-one patients (60%) are dead, with an average survival of 16.7 months 8 days to 44 months. The 14 others (40%) are alive (average, 38.26 months; range, 8-87 months).

CONCLUSIONS

Even though a learning curve is necessary to achieve this extreme type of surgery, selective preoperative screening of patients is mandatory. Interesting results today confirm the feasibility of possible treatment of tumors still considered unresectable.

Effectiveness of radical resections in malignant dumbbell tumors of the thoracic spine: review of three cases

We report postoperative evolution and prognosis after radical resection of three dumbbell-shaped neurogenic tumors. It was a malignant schwannoma in all cases. Patients were observed from 8 to 27 months postoperatively. All tumors were completely excised, with histologically controlled extratumoral resection limits. The surgical technique used is the one developed by the authors for extended Pancoast Tobias resections. The patients had been operated on previously with possible local contamination, and the previous surgical wound needed to be excised with the tumor The patients died 8, 12, and 27 months postoperatively. This short series of three malignant dumbbell tumors dramatically shows that prognosis is undoubtedly more related to inadequate previous resection and to the tumor malignancy than to the surgical technique itself. The authors consider that the combined anteroposterior approach is the most efficient technique with minimum complications, even in major multilevel resections. Indications for such extended surgery include the inability to use adjuvant therapy and impending neurologic deficit.

Surgical treatment of superior sulcus tumors with spinal and brachial plexus involvement

OBJECT

Non-small cell lung carcinomas with spinal and brachial plexus involvement have traditionally been considered to be Stage IIIb lesions and therefore unresectable. Advances in spinal surgery, the application of magnetic resonance (MR) imaging, and improvements in neoadjuvant therapy require a reassessment of the potential for complete resection.

METHODS

The authors conducted a retrospective review of all procedures involving the resection of superior sulcus tumors with spinal or brachial plexus involvement performed between 1985 and 1999. Assessment or resectability and operative planning were based on an MR imaging classification scheme in which the extent of spinal involvement was considered. Class A tumors involved the periosteum of the vertebral body (VB) (16 patients); Class B, distal neural foramen without epidural compression (eight patients); Class C, proximal neural foramen with epidural compression (four patients); and Class D, bone involvement (VB or posterior elements) with or without epidural involvement (14 patients). Brachial plexus involvement was present in 21 patients, including 17 with T-1 nerve root only and four with C-8 or lower-trunk infiltration. Complete tumor resection was achieved in 27 patients and incomplete resection in 15. Complications occurred in 14 patients, two of which were related to instrumentation failures. The overall median survival was 1.44 years. The median survival for the complete and incomplete resection groups were 2.84 and 0.79 years, respectively (p = 0.0001). There was no statistical difference in survival among classification groups.

CONCLUSIONS

Complete tumor resection of superior sulcus tumors is possible in selected patients in whom involvement of the spinal column and/or brachial plexus is present. Preoperative MR imaging is essential for evaluation of the spine and surgical planning. Survival and cure are dependent on complete resection, regardless of the extent of spinal involvement.

Incidental surgical findings of a phase I trial of weekly gemcitabine and concurrent radiotherapy in patients with unresectable non-small cell lung cancer

OBJECTIVE

to report the surgical facts of unresectable patients with locally advanced non-small cell lung cancer (NSCLC) treated in a phase I trial with concurrent weekly gemcitabine and radiotherapy who achieved a clinical downstaging so as to re-enter resectability.

MATERIALS AND METHODS

from 3/99 to 11/00, 30 patients (ten stage IIIa, 16 IIIb and four IV) with histologically proven, unresectable NSCLC, were enrolled in this phase I trial. Gemcitabine was given weekly for 5 consecutive weeks as a 30-min intravenous infusion, at least 4 h before radiotherapy. Starting dose: 100 mg/m(2). Maximum tolerated dose (MTD): 350 mg/m(2). Radiotherapy total dose: 50.4 Gy (1.8 Gy/day) on primitive tumour and involved lymph nodes.

RESULTS

27 out of 30 patients (90%) were evaluable for clinical restaging (three patients who decided to continue their treatment elsewhere have been excluded). A major clinical response (partial+complete response) was observed in 17 out of 27 cases (62.9%). Clinical complete response rate was 3.7% (1/27) while partial response rate was 59.2% (16/27). Nine patients (33.4%) showed a clinical stable disease and one a disease progression (3.7%). Fourteen patients re-entered resectability and were operated upon: seven lobectomies; four bilobectomies; two pneumonectomies and one explorative thoracotomy. Mean operation duration time was 112 min; mean blood loss was 390 cc. Thirty-day morbidity and mortality were nil. Mean post-operative hospital stay was 6.8 days. A slight increase in operational technical difficulty was encountered. Definitive histology showed a pathologic downstaging of 71.4% (10/14). In four patients, only microscopic neoplastic remnants were found.

CONCLUSIONS

combined treatment with weekly gemcitabine and concurrent radiotherapy is feasible. In patients with advanced NSCLC who achieved a good clinical response and therefore were judged to be resectable, surgery was possible without any increase in thirty-day morbidity and mortality. Satisfactory pathologic results were obtained.