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

Supraclavicular-median sternotomy approach for a large neurilemmoma invading the thoracic outlet: a case report and review of the literature

BACKGROUND

Large mediastinum tumors invading the thoracic outlet have consistently been a challenge in thoracic surgery. Due to the large size of the tumor and its proximity to many important tissues, appropriate surgical approaches are crucial for a successful surgery.

CASE PRESENTATIONS

Here, we present a case of a large neurilemmoma that invaded the thoracic outlet that was resected by a supraclavicular-median sternotomy approach. The case was a 58-year-old woman with a large mass in the right chest cavity that had invaded the thoracic outlet. The preoperative biopsy showed a blood clot with a few fibrous connective tissues covered by a single layer of flat epithelium. There was insufficient evidence to diagnose the mass as a tumor, and imaging examinations suggested a diagnosis of solitary pleural fibroma. For good exposure of the cranial and caudal aspects of the large mass, we devised a median sternotomy combined with a supraclavicular approach and safely achieved complete resection. The patient recovered well and experienced no severe complications or functional restrictions of the upper extremity. The postoperative pathology diagnosis was a neurilemmoma.

CONCLUSIONS

The supraclavicular-median sternotomy approach could be an optional approach for the complete resection of large mediastinal tumors invading the thoracic outlet.

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.

Trap-Door Thoracotomy and Clamshell Thoracotomy as Surgical Approaches for Neuroblastoma and Other Thoracic Tumors in Children

Solid tumors of the cervicothoracic junction, the posterior mediastinum, or bilateral dorsal thoracic tumors represent a challenge in pediatric surgical oncology. The aim of this study was to evaluate trap-door thoracotomy and clamshell thoracotomy as surgical approaches. A single-center retrospective study of children with solid tumors in these specific localizations was performed. From 2015 to 2023, 26 children (17 girls; 9 boys) were treated at a median age of 54 months (range 8-229). Tumor resection was performed for neuroblastoma (n = 11); metastatic disease (n = 7); malignant rhabdoid tumor (n = 4); Ewing sarcoma (n = 1); inflammatory myofibroblastic tumor (n = 1); rhabdomyosarcoma (n = 1); and neurofibroma (n = 1). The surgical goal of macroscopic complete excision was achieved in all of the 14 children who underwent trap-door thoracotomy and in 11 of the 12 children who underwent clamshell thoracotomy. There were no major complications. At a median follow-up of 8 months (range 0-60), the disease was under local control or in complete remission in 66.7% of the children. In conclusion, surgical resection of solid tumors of the cervicothoracic junction in children can be performed safely and successfully with trap-door thoracotomy and with clamshell thoracotomy for posterior mediastinal or bilateral dorsal thoracic tumors.

Modified transmanubrial approach for complicated type 1 cervical rib resection requiring subclavian artery reconstruction

The transmanubrial musculoskeletal sparing approach (TMA) is commonly used for resecting apical lung tumours with vascular involvement. Non-neoplastic conditions which might require surgical exploration of the thoracic outlet include the 'cervical rib', a clinical condition consisting of an additional rib forming above the first rib and growing from the base of the neck just above the clavicle. Type 1 cervical rib-when a complete cervical rib articulates with the first rib or manubrium of the sternum-is the most challenging scenario where the subclavian artery can be damaged by continuous compression due to the narrow space between clavicle, first rib and supernumerary cervical rib, requiring prosthetic reconstruction of the involved tract. Here, we describe a modified TMA in which the incision in the neck is conducted posteriorly to the sternocleidomastoid muscle, thus allowing safe dissection of the superior and middle trunk of the brachial plexus.

Superior sulcus non-small cell lung cancers (Pancoast tumors): Current outcomes after multidisciplinary management

OBJECTIVE

Despite neoadjuvant chemoradiotherapy, Pancoast tumors still present surgical and oncologic challenges. To optimize outcomes, we used a multidisciplinary care paradigm with medical and radiation oncology, and involvement of spine neurosurgery for most T3 and all T4 tumors. Spine neurosurgery permitted resection of transverse process for T3 and vertebral body resection for T4 tumors.

METHODS

Retrospective analysis of single institution, prospective database of patients undergoing resection for cT3 4M0 Pancoast tumors. Patients were grouped as cT3 with combined resection with spine neurosurgery (T3 Neuro), cT3 without spine neurosurgery (T3 NoNeuro), and cT4. Overall survival, progression-free survival were analyzed by Kaplan-Meier and compared between groups using log-rank test. Cumulative incidence of local-regional and distant recurrence were compared using Gray test. P value <.05 was considered significant.

RESULTS

From 2000 to 2021, 155 patients underwent surgery: median age was 58 years, and 81 were (52%) men. Most patients received neoadjuvant platinum-based neoadjuvant chemoradiotherapy (n = 127 [82%]). Operations were 48 cT3 Neuro, 41 cT3 NoNeuro, 66 cT4. R0 resection was achieved in 49 (94%) cT3 NoNeuro, 35 (85%) cT3 Neuro, and 57 (86%) cT4 patients (P = .4). Complete or major pathologic response occurred in 71 (55%) patients. Lower local-regional cumulative incidence was seen in cT3 Neuro versus cT3 NoNeuro (P = .05) and after major pathologic response. Overall survival and progression-free survival were associated with complete response, pathologic stage, and nodal status but not cT category.

CONCLUSIONS

This treatment paradigm was associated with a high frequency of R0 resection, complete response, and major pathologic response. cT3 and cT4 tumors had similar outcomes. Novel therapies are needed to improve complete response.

Surgical Approaches to Pancoast Tumors

Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated multimodality treatment. The morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively, and the 5-year survival rate has significantly improved in recent years thanks to the advancement of treatments. Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Surgical resection still plays a pivotal role within the multimodality approach. Here, we focus on surgical approaches to both anterior and posterior Pancoast tumors: the anterior transclavicular approach (Dartevelle); the anterior transmanubrial approach (Grunenwald-Spaggiari); the anterior trap-door approach (Masaoka, Nomori); the posterior approach (Shaw-Paulson); the hemiclamshell approach; and hybrid approaches. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario.

The oncologic efficacy of extended resections for lung cancer

Extended lung resections for T3-T4 non-small-cell lung cancer remain challenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.

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.

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.

Hemi-Clamshell Approach for Fetal Lung Interstitial Tumor Resection in a Neonate: A Case Report

Fetal lung interstitial tumor (FLIT) is a rare primary lung mass in neonates. Classical incisions, such as posterolateral thoracotomy or median sternotomy, do not provide optimal exposure of the operative field for the resection of pediatric thoracic giant tumors. Herein, we report a rare case of a FLIT in a full-term male neonate, with complete resection achieved using a hemi-clamshell approach, which provided the required visualization of the operative field. The neonate was transferred to our hospital because of mild respiratory distress, which developed 18-hour after normal vaginal delivery. A mass in his right chest, without a midline shift, was observed on chest radiographs. Computed tomography showed a well-circumscribed solid anterior cervicothoracic mass, with a uniform density and no apparent cysts, diagnosed as a primary thoracic giant tumor. Once the patient was clinically stabilized, we proceeded with right upper lobectomy, using a hemi-clamshell approach, full sternotomy, and anterolateral thoracotomy, on postnatal day 22.

Histopathologic examination revealed an 8.5 × 6.5 × 4.0 cm solid mass within the right upper lobe, which was diagnosed as a FLIT. His postoperative recovery was uneventful. The patient was followed up for 1 year, with no complaints or symptoms and no postoperative shoulder dysfunction. Gross total resection of primary thoracic giant tumors can be accomplished in neonates with optimal exposure of the chest cavity using a hemi-clamshell approach.

Individualized surgical treatment for patients with tumours of the cervicothoracic junction

OBJECTIVES

The cervicothoracic junction is a special section that connects the neck, thoracic cavity, mediastinum and axilla. Tumours in the region often invade or compress surrounding tissues and organs, which makes the surgical treatment difficult.

METHODS

A retrospective analysis involving 69 patients with tumours at the cervicothoracic junction. Clinical data with regard to manifestation, surgical approach, resection degree, outcome and pathological types were collected.

RESULTS

A total of 48 cases of asymptomatic patients and 21 cases of patients with ≥1 clinical manifestation were enrolled in the study. Twenty-seven patients received radical resection with video-assisted thoracoscopic surgery. Anterior approach was the predominant treatment method in open surgery (25 cases, 36.2%), while the anterolateral approach was used in 8 cases (6 cases of hemiclamshell incisions and 2 cases of trap-door incisions). In addition, we observed 1 case of posterior approach, 2 cases of posterolateral approach and 1 case of supraclavicular approach combined with posterolateral approach. Pathological examination results revealed 67 cases of radical resection and 2 cases of microscopic residual. Neurilemmoma was the most widespread pathological type (30 cases, 43.5%), followed by tumour originating from fibrous tissues (5 cases, 7.2%). A 3-year overall survival rate of the 69 patients was 89.9%, while a 5-year overall survival rate was 85.5%.

CONCLUSIONS

Tumours associated with the cervicothoracic junction are characterized by their unique location, complex anatomy and various histopathological subtypes. An individualized approach during surgery enhances safety and standardized of treatments for patients with tumours located at the cervicothoracic junction.

[Partial cervicosternotomy for resection of non-bronchogenic tumors of the thoracic outlet]

OBJECTIVE

To improve the results of surgical treatment of cervico-mediastinal tumors by using of partial upper cervicosternotomy.

MATERIAL AND METHODS

A retrospective analysis included 24 patients who underwent resection of cervico-mediastinal tumors via partial upper cervicosternotomy for the period from January 2002 to December 2019. Immediate and intermediate postoperative outcomes were analyzed.

RESULTS

Mean surgery time was 282.7 min, intraoperative blood loss - 325.0 ml. Duration of pleural cavity (mediastinum) drainage was 3 days, hospital-stay - 14 days. Major postoperative complications developed in 3 (12.5%) patients. No 90-day mortality was observed. No local relapses were detected throughout the follow-up period (median 36.1 months).

CONCLUSION

Partial cervicosternotomy is a safe and effective approach ensuring adequate visualization and reliable control of great vessels of the upper mediastinum and neck. This access is valuable for en-bloc resection of cervico-mediastinal tumors located in anterior and posterior parts of the thoracic inlet.

Superior vena cava prosthetic replacement for non-small cell lung cancer: is it worthwhile?

OBJECTIVES

Direct involvement of the superior vena cava (SVC) by non-small cell lung cancer (NSCLC) requires en-bloc tumour resection with complete vascular clamping and prosthetic replacement. We report the outcomes of this highly demanding procedure in the largest patient cohort to date.

METHODS

We searched our institution's database for patients who underwent complete en-bloc resection of NSCLC invading the SVC followed by prosthetic SVC replacement, between 1980 and 2018. Patients with cN2, cN3 or distant metastases were not eligible.

RESULTS

We identified 48 patients (38 males, 10 females; mean age of 57 years; tumour size, 1.9-17 cm). Neoadjuvant therapy was administered to 17 and adjuvant therapy to 31 patients. R0 resection was achieved in 41 (85%) patients; lymph node involvement was pN0 in 8, pN1 in 23, pN2 in 14 and pN3 in 3 patients. Five patients died within 30 days of surgery. Right pneumonectomy was significantly associated with postoperative death (P = 0.02). Postoperative complications developed in 13 other patients. No neurologic events related to SVC clamping occurred. Graft thrombosis developed in 2 patients. Median survival was 24 months; 3-, 5- and 10-year survival rates were 45%, 40% and 35%, respectively; and corresponding disease-free survival rates were 37%, 37% and 30%, respectively. By univariable analysis, only margin-free (R0) resection was associated with better survival (P = 0.02).

CONCLUSIONS

In highly selected patients with NSCLC involving the SVC, mortality is acceptable after complete en-bloc resection and prosthetic replacement done in an expert centre. SVC involvement should not preclude consideration of curative resection in selected patients.

Cloward’s approach for Pancoast neurogenic tumors: illustrative cases

BACKGROUND

Pancoast tumors are a wide range of tumors located in the apex of the lung. Traditional surgery for Pancoast neurogenic tumors frequently involves extensive approaches, whether anterior or posterior or a combination, in which osteotomies are sometimes required. In this study, the authors proposed a less invasive surgical strategy using the standard Cloward’s approach for complete resection of a schwannoma arising from the T1 nerve root.

OBSERVATIONS

Two patients, each harboring a large T1 tumor, one on each side, underwent Cloward’s approach with and without thoracoscopic surgery. Both patients had complete resection of the tumor. Considering the benign and encapsulated nature of neurogenic tumors, Cloward’s approach under neuromonitoring, which is a common procedure for anterior cervical discectomy for most neurosurgeons, is a safe and less invasive alternative for Pancoast neurogenic tumors. For patients whose tumor cannot be removed completely via Cloward’s approach, video-assisted thoracoscopic surgery is a viable backup plan with minimal invasiveness.

LESSONS

Cloward’s approach is a viable option for Pancoast neurogenic tumors.

Extended sternotomy with lateral neck incision: An alternative approach for children with large apical chest masses with thoracic inlet involvement

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors - including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).

Extrapleural cervico-manubriotomy and clavicular swing for the management of a mesenchymal tumour of the middle scalenus: an adapted anterior thoracic inlet approach

Surgical approach for resection of tumours involving the thoracic inlet has largely been developed in the context of lung cancer of the superior sulcus. Therefore, initial anterior approaches included a thoracotomy associated with a longitudinal cervicotomy. Here, we describe a variation of the previously described anterior surgical approaches of the thoracic inlet that we performed for the resection of a primary mesenchymal tumour of the left middle scalenus muscle secreting fibroblast growth factor-23 responsible for tumour-induced osteomalacia. This approach allowed a safe control of the great vessels phrenic nerve and brachial plexus as well as a comfortable access to the middle scalenus muscle through an L-shaped incision with a cervico-manubriotomy without thoracotomy. The tumour was resected entirely with the middle scalenus. After 3 months of follow-up, the symptoms resolved entirely.

Surgical Management of Giant Thoracic Paraspinal Schwannomas

BACKGROUND

Giant paraspinal thoracic schwannomas (GPTSs) are benign, slow-growing, encapsulated lesions. They can be intracanalicular, span more than 2 vertebral bodies, and/or have a foraminal component with extraspinal extension >2.5 cm. They pose surgical challenges because of the often unfamiliar complex regional anatomy. We report the largest series of GPTSs and discuss regional surgical strategies for tumors in the thoracic spine.

METHODS

We conducted a retrospective review of GPTSs operated at a national spinal referral center between December 2008 and October 2019. Inclusion criteria included World Health Organization grade 1 GPTS. Patient demographics, clinical features, radiology, and histopathology were assessed.

RESULTS

Seventeen patients (12 females, 5 males) had a mean age of 48.1 years (range 21-65 years). Five GPTS (29%) were located at T1-T3, 6 (35%) at T4-6, and 6 (35%) below T6. The mean maximum diameter was 58.5 ± 19.1 mm (range 30-91 mm). Mean volume was 90.9 cm³ (range 19.1-350.6 cm³). Twelve (70%) had a fluorodeoxyglucose positron emission tomography scan showing low (25%) or moderate to high (75%) uptake. Six patients (35%) had preoperative computed tomography-guided biopsy. Surgical approaches included 1) manubriotomy and variations (4/17); 2) high lateral thoracotomy (4/17); 3) posterior parascapular (1/17); 4) standard lateral thoracotomy (3/16); 5) posterior/posterolateral (2/17); and 6) combined posterior and thoracotomy (3/17). All patients had gross total resection and were grade 1 cellular schwannomas. No recurrence at final follow-up (mean 36.1 months, range 8-130 months).

CONCLUSIONS

A number of approaches are available to resect GPST in specific locations in the thoracic spine. Total resection is achievable despite complex regional anatomy, location, and tumor extension but often requires anterior or combined approaches.

Trimodality therapy for superior sulcus tumour: experience of a single institution over 19 years

OBJECTIVES

Induction chemoradiotherapy followed by surgery is the standard treatment for superior sulcus tumours (SSTs). However, the protocols, chemotherapy agents and cycles used as well as the mode and intensity of radiotherapy vary between institutions. Thus, the objective of the study was to investigate the effects of trimodality therapy on the outcomes of patients with SSTs.

METHODS

Sixty patients with SSTs were enrolled between January 1999 and December 2017. Induction therapy consisted primarily of 2 cycles of mitomycin-vindesine-cisplatin or cisplatin-vinorelbine delivered concurrently to the tumour with 40-45 Gy of radiation. Surgery was performed 2-6 weeks after completion of induction therapy.

RESULTS

Fifty-four (90%) patients underwent radical surgical resection. Complete pathological resection was achieved in 44 patients (81%). There was no 30-day mortality. After a median follow-up of 57.0 months, 19 (35%) patients experienced recurrence, and 8 (15%) patients showed brain metastasis. A pathological complete response (PCR) was observed in 12 (22%) patients. The 5-year survival rate for the entire population (n = 54) was 69% (95% confidence interval 55-81%). The survival rate was better for patients who underwent complete resection than for those who underwent incomplete resection (73% vs 51%, P = 0.46). A better survival rate was evident in patients with PCR than in those without PCR (92% vs 62%, P = 0.12).

CONCLUSIONS

Trimodality therapy for SSTs was efficacious and associated with favourable outcomes, with acceptable morbidity and mortality. PCR in patients with resected SSTs reveals promising long-term survival prospects with the trimodality therapy.

Trapdoor anterior thoracotomy for cervicothoracic and apical thoracic neuroblastoma in children

PURPOSE

Cervicothoracic and apical thoracic neuroblastoma pose unique surgical challenges. We report our experience with the trapdoor anterior thoracotomy (TAT) approach to overcome these difficulties.

METHODS

Retrospective review of our centre's neuroblastoma database was conducted. Patients who underwent TAT at our centre were included, their demographic data and clinical reports were analyzed.

RESULTS

A total of 21 patients underwent TAT for neuroblastoma, mean age at surgery of 3.5 (0.3-7.9) years, male to female ratio was 11:10. Fifteen patients had cervicothoracic tumors while 6 had apical thoracic tumors. All except 2 were primary tumors. They were stage M (n = 12), MS (n = 1), and L2 (n = 8). At pre-operative assessment, 19 patients had image-defined risk factor (IDRF), including dual compartmental involvement (n = 15), trachea/bronchus compression (n = 4), encasement of carotid (n = 5), subclavian (n = 11), and vertebral arteries (n = 6). Four underwent upfront surgery while 17 received pre-operative chemotherapy of 2-8 (mean 3.9) cycles. All patients accomplished gross total resection. None had MYCN amplification. The postoperative complications included Horner's syndrome (n = 21), Klumpke's palsy (n = 1), winged scapula (n = 1), phrenic nerve palsy (n = 1), and bronchomalacia (n = 2).

CONCLUSION

Gross total resection of cervicothoracic and apical thoracic neuroblastoma can be accomplished by TAT with minimal morbidity.

Soft-Tissue Reconstruction after Composite Vertebrectomy and Chest Wall Resection for Spinal Tumors

BACKGROUND

Oncologic resections involving both the spine and chest wall commonly require immediate soft-tissue reconstruction. The authors hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone.

METHODS

The authors performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft-tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine and those who required a composite resection involving the chest wall.

RESULTS

One hundred patients were included. Composite resection patients had larger defects, as indicated by a greater incidence of multilevel vertebrectomies (70.2 percent versus 17 percent; p = 0.001). Thoracic spine patients were older (58.2 ± 10.4 years versus 48.6 ± 13.9 years; p < 0.001) and had a greater incidence of metastatic disease (88.7 percent versus 38.3 percent; p = 0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of composite resection subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (OR, 0.22; 95 percent CI, 0.05 to 0.81; p = 0.03).

CONCLUSIONS

Despite the large defect size in composite resection patients, there was no increase in complications compared to thoracic spine patients. In composite resection patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Surgical strategies for primary malignant tumors of the thoracic and lumbar spine

BACKGROUND

Primary malignant tumors of the thoracic and lumbar spine are rare. They are mainly hematologic malignancies and more rarely sarcomas or chordomas. Giant-cell tumors and osteoblastomas, while benign, are locally very aggressive and their excision should be discussed as an option. Other possibilities are tumors from nearby organs invading the spine, which are actually carcinomas, but may benefit from radical excision in select cases.

METHODS

Excision of these tumors is complex and must be integrated in the diagnostic and therapeutic strategy established by a specific multidisciplinary tumor board at a designated cancer center. Surgical resection must combine tumor excision with long-lasting reconstruction of the spine and neighboring soft tissues. The initial excision must be as complete as possible as the possibilities of repeat excision are nearly impossible if the first resection is not complete.

RESULTS

An exhaustive preoperative imaging workup is essential for determining the tumor's spread and for determining the best surgical strategy. This will often require participation of other surgical specialties, which are well versed in teamwork. Thanks to this multidisciplinary care, especially the participation of thoracic and plastic surgeons, significant progress has been made recently. The first is the possibility of doing very extensive tumor excisions at the spine and in the neighboring organs, thus expanding the surgical indications to patients who were previously considered as being inoperable. We will discuss the surgical strategy and surgical approaches by spine level. Bone and soft tissue reconstruction is more effective thanks to the introduction of new spinal instrumentation and coverage flaps, which have drastically reduced the intra- and postoperative complications. Lastly, the risk factors for neurological complications are better understood, making them easier to prevent and to treat, if they were to occur.

CONCLUSION

These advances have translated to better cancer outcomes, especially better control of the tumor with neoadjuvant therapies (targeted chemotherapy) and preoperative conformal radiotherapy.

En Bloc Resection of Thoracic Tumors Invading the Spine: A Single-Center Experience

BACKGROUND

Vertebral involvement by a thoracic tumor has long been considered as a limit to surgical treatment, and despite advances, such an invasive operation remains controversial. The aim of this study was to characterize a single-center cohort and to evaluate the outcome, focusing on survival and complications.

METHODS

We retrospectively reviewed the data of all patients operated on for tumors involving the thoracic spine in an 8-year period. En bloc resection was generally performed by a double team involving thoracic and orthopedic surgeons. Distant follow-up was recorded for oncologic and functional analysis.

RESULTS

There were 31 patients operated on. An induction therapy was administered in 20 patients. Spinal resection (mostly including ≥2 vertebral levels) was combined with lobectomy in 48.3% of the patients, and osteosynthesis was required in 22 patients. We observed no in-hospital death and a major complications rate of 32.3%, including 5 patients with early neurologic complications. There were 61.3% primary lung carcinomas, 12.9% extrapulmonary primaries, 9.7% metastases, and 16.1% benign tumors. Mean follow-up was 32.1 months. The 5-year overall survival rate was 81.3% in the entire cohort and 75.0% in patients with a malignant tumor. Occurrence of an early postoperative major complication was the only factor significantly associated with shorter overall survival (p = 0.03). The 5-year disease-free survival rate was 37.0% in malignancies. Delayed complications occurred in 35.5% of patients, including persistent neurologic deficit in 12.9%, instrumentation migration in 19.4%, and local infection in 12.9%.

CONCLUSIONS

En bloc resection of spinal thoracic tumors offers long-term survival and few recurrences in highly selected patients but is associated with significant delayed mechanical or infectious complications.

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.

Left Single Lung Transplantation Through Left Anterolateral Thoracotomy With Longitudinal Partial Sternotomy (Hemiclamshell): An Innovative Surgical Resource

INTRODUCTION

Pulmonary fibrosis (PF) is one of the main indications for lung transplantation among end-stage respiratory diseases. PF represents a surgical challenge due to the pulmonary retraction, reduction of pleural space, and limitation for access of the lung hilum by elevation, specifically on the left lung. Unilateral sternothoracotomy, or hemiclamshell (HCS) approach, is the anterolateral thoracotomy with longitudinal partial sternotomy with possibility of cervical extension. This was initially described as a surgical approach for resection of lung apex tumors and of the cervicothoracic region, excision of mediastinal and thoracic wall tumors, and as an urgent incision for the repair of mediastinal and cervicothoracic vascular lesions. HCS is not usually described for liver transplantation.

CASE

A 62-year-old man who was a nonsmoker was diagnosed with idiopathic PF. After 3 years of medical management and follow-up, the patient was referred to us for a pretransplantation study. He presented with dyspnea grade III according to the Medical Research Council. In the radiograph of the chest and computed tomography of the thorax showed signs of pulmonary fibrosis predominantly left-lung associated with loss of volume and alteration of respiratory function tests. We performed left single lung transplantation through a left HCS approach. During implantation we converted the superior pulmonary vein into "neo-atrium" for the atrial anastomosis. The patient presented excellent evolution and was discharged from the hospital at 26 days.

CONCLUSION

We present a case of left single lung transplantation by PF through an HCS approach as novel and effective resource for this type of procedure.

Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man's land

PURPOSE

Cervicothoracic paravertebral neoplasms extending into the mediastinum pose a surgical challenge due the complex regional anatomy, their biological nature, rarity and surgeon's unfamiliarity with the region. We aim to define a surgical access framework addressing the aforementioned complexities whilst achieving oncological clearance.

METHODS

We carried out a retrospective review of 28 consecutive patients operated in two tertiary referral centres between 1998 and 2015. Pathology was located paravertebrally from C6 to T4 with superior mediastinum invasion. Patients were operated jointly by a spinal and a thoracic surgeon.

RESULTS

Tumours were classified according to subclavian fossa involvement as anteromedial, anterolateral and posterior and according to histology in benign nerve sheath tumour group (n = 10) and malignant bone or soft tissue tumours (n = 18). Three surgical routes were utilised: (1) median sternotomy (n = 11), (2) anterior cervical transsternal approach (n = 7) and (3) high posterolateral thoracotomy (n = 10). Resection was en bloc with wide margins in 22 cases, marginally complete in 3 and incomplete in 3. Complications included Horner's syndrome (n = 3), infection (n = 2) and transient neurological deficit (n = 4). In the nerve sheath tumour group, no recurrence or reoperation took place with a median follow-up of 4.5 years. In the malignant bone and soft tissue group, 96% of the patients were alive at 1 year, 67% at 2 years and 33% at 5 years. No vascular injuries or operative related deaths were observed.

CONCLUSIONS

Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relationship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides minimal morbidity/maximum resection and satisfactory oncological outcomes. These slides can be retrieved under Electronic Supplementary Material.

Long-term results of the transmanubrial osteomuscular-sparing approach for pediatric tumors

BACKGROUND

The complete and safe resection of pediatric cervicothoracic tumors, mostly represented by neurogenic tumors, remains a surgical challenge because of the complex anatomy of this region. The transmanubrial osteomuscular-sparing approach (TOSA) is an alternative to isolated or combined cervical and thoracic approaches enabling the control of supra-aortic vessels and nerves through the thoracic inlet.

METHODS

We retrospectively reviewed the tumor characteristics, completeness of resection, morbidity, and long-term outcome of patients with cervicothoracic tumors removed by TOSA between 2000 and 2012 in our institution.

RESULTS

Thirteen patients (7 males, 6 females) underwent surgery at a median age of 72 months (4-188) for neuroblastoma (n = 6), ganglioneuroblastoma (n = 3), rhabdoid tumor (n = 1), melanotic schwannoma (n = 1), chordoma (n = 1), and malignant peripheral nerve sheath tumor in one patient with type 1 neurofibromatosis. The median duration of the procedure was 215 minutes (110-315). Two children presented with postoperative chylothorax that resolved spontaneously. The median duration of hospitalization was 7 days (4-22). At a median follow-up of 39 months (2-159), four patients had died of metastatic relapse (n = 2), locoregional progression (n = 1), and chemotoxicity (n = 1). The patient with melanotic schwannoma was lost to follow-up after a local relapse at 5 months. Long-term morbidity revealed homolateral Claude-Bernard Horner sign and upper limb vasomotor dysfunction in disease-free patients due to mandatory resection of the stellate ganglia.

CONCLUSIONS

TOSA is a valuable surgical approach for all cervicothoracic tumors with acceptable long-term morbidity when compared with its complexity. We can therefore recommend TOSA for tumors involving the thoracic inlet.

Management of Lung Cancer Invading the Superior Sulcus

Superior sulcus tumors have posed a formidable therapeutic challenge since their original description by Pancoast and Tobias in the early twentieth century. Initial therapeutic efforts with radiotherapy were associated with high rates of relapse and mortality. Bimodality therapy with complete surgical resection in the 1960s paved the way for trimodality therapy as the current standard of care in the treatment of superior sulcus tumors. The evolution of treatment approaches over time has provided outcomes that come increasingly closer to rivaling those of similarly staged nonapical lung cancer.

Surgical Management of Lung Cancer Involving the Chest Wall

The prevalence of chest wall invasion by non-small cell lung cancer is < 10% in published surgical series. The role of radiation or chemotherapy around the complete resection of lung cancer invading the chest wall, excluding the superior sulcus of the chest, is poorly defined. Survival of patients with lung cancer invading the chest wall is dependent on lymph node involvement and completeness of en-bloc resection. In some patients harboring T3N0 disease, 5-year survival in excess of 50% can be achieved. Offering en-bloc resection of lung cancer invading chest wall to patients with T3N1 or T3N2 disease is controversial.

Surgical Treatment of Superior Sulcus Tumors: A 15-Year Single-center Experience

This paper reports on the characteristics, treatment modalities, and outcomes of patients with superior sulcus tumors who underwent surgery over a period of 15 years in 1 institution. Clinical records of 94 consecutive patients operated on by the same surgical team for non-small cell lung cancer between July 1998 and December 2013 were retrospectively reviewed. All patients received lung and chest wall en bloc resection. Forty-eight (51%) received induction treatments. Surgery was an anterior approach in 46 patients (48.9%), Paulson incision in 35 (37.2%), and a combined approach in 13 (13.8%). Lung resections were 78 lobectomies (83%), 3 were pneumonectomies (3.2%), 6 were bronchoplastic reconstructions (6.4%), and 7 were wedge resections (7.4%). Nodal dissection was systematic in 96% of patients. The median number of resected ribs was 2 (1-5), chest wall residual defect was reconstructed in 42 patients (44.7%), and 21 patients had an associated vascular resection (22.3%). Resection was radical in 85 patients (90.4%). Overall 90-day mortality was 9.6%. After a median follow-up of 1.9 years, 5-year and 10-year overall survival rates were 35% and 23%, respectively. A lower 5-year survival was observed in patients with nodal disease (48% in N0 vs 18% in N+; P < 0.0001), incomplete resection (21% for incomplete vs 37% for complete resection; P = 0.15), and anteriorly located tumor (anterior vs posterior: 26% vs 50%; P = 0.05). Pancoast tumor is a severe condition, but long-term survival may be achieved in selected cases. Nodal involvement, completeness of resection, and vascular invasion are the most important prognostic factors, and induction treatment may play a role.

Single Posterior Approach for En-Bloc Resection and Stabilization for Locally Advanced Pancoast Tumors Involving the Spine: Single Centre Experience

STUDY DESIGN

Monocentric prospective study.

PURPOSE

To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors.

OVERVIEW OF LITERATURE

In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach.

METHODS

We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation.

RESULTS

Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment.

CONCLUSIONS

The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Case Report: En Bloc Resection of Pancoast Tumor with Adjuvant Aortic Endograft and Chemoradiation

"Pancoast" tumors frequently require a multidisciplinary approach to therapy and are still associated with high morbidity and mortality. Due to their sensitive anatomic location, complex resections and chemoradiation regimens are typically required for treatment. Those with signs of aortic invasion pose an even greater challenge, given the added risks of cardiopulmonary bypass for aortic resection and interposition. Placement of an aortic endograft can facilitate resection if the tumor is in close proximity to or is invading the aorta. Prophylactic endografting to prevent radiation-associated aortic rupture has also been described. This case describes a 60-year-old female who presented with a stage IIIa left upper lobe undifferentiated non-small-cell carcinoma encasing the subclavian artery with thoracic aorta and bony invasion. Following carotid-subclavian bypass with Dacron, en bloc resection of the affected lung, ribs, and vertebral bodies was performed. The aorta was prophylactically reinforced with a Gore TAG thoracic endograft prior to adjuvant chemoradiation. The patient remains disease-free at more than 5 years follow-up after completing her treatment course. Endovascular stenting with subsequent chemoradiation may prove to be a viable alternative to palliation or open operative management and prevention of aortic injury during tumor resection and/or adjuvant therapy in select patients with aortic involvement.

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.

Results of surgical resection after induction chemoradiation for Pancoast tumours †

OBJECTIVES

Pancoast tumour is a rare neoplasia in which the optimal therapeutic management is still controversial. The traditional treatment of Pancoast tumour (surgery, radiotherapy or a combination of both) have led to an unsatisfactory outcome due to the high rate of incomplete resection and the lack of local and systemic control. The aim of the study was to determine the efficacy of the trimodality approach.

METHODS

Fifty-six patients (male/female ratio: 47/9, median age: 64 years) in stage IIB to IIIB were treated during a period between 1994 and 2013. Induction therapy consisted of 2-3 cycles of a platinum-based chemotherapy associated with radiotherapy (30-44 Gy). After restaging, eligible patients underwent surgery 2 to 4-week post-radiation.

RESULTS

Thirty-two (57.1%) patients were cT3 and 24 (42.9%) cT4, 47 (83.9%) were N0 and 9 (16.1%) N+. Forty-eight (85.7%) patients underwent R0 resection and 10 (17.9%) had a complete pathological response (CPR). Thirty-day mortality rate was 5.4%, major surgical complications occurred in 6 (10.7%) patients. At the end of the follow-up, 17 (30.4%) patients were alive and 39 (69.6%) died (29 for cancer-related causes), with an overall 5-year survival of 38%. At statistical analysis, stage IIB (P = 0.003), R0 resection (P = 0.03), T3 tumour (P = 0.002) and CPR (P = 0.01) were significant independent predictors of better prognosis.

CONCLUSIONS

This combined approach is feasible, and allows for a good rate of complete resection. Long-term survival rates are acceptable, especially for early stage tumours radically resected. Systemic control of disease still remains poor, with distant recurrence being the most common cause of death.

Surgical management with radiation therapy for metastatic spinal tumors located on cervicothoracic junction : a single center study

Objective

The cervicothoracic junction (CTJ) is a biomechanically and anatomically complex region that has traditionally posed problems for surgical access. In this retrospective study, we describe our clinical experiences of the treatment of metastatic spinal tumors at the CTJ and the results.

Methods

From June 2006 to December 2011, 23 patients who underwent surgery for spinal tumors involving the CTJ were enrolled in our study. All of the patients were operated on through the posterior approach, and extent of resection was classified as radical, debulking, and simple neural decompression. Adjuvant radiation therapy (RT) was also considered. Visual analog scale score for pain assessment and Medical Research Council (MRC) grade for motor weakness were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG).

Results

Almost all of the patients were operated using palliative surgical methods (91.3%, 21/23). Ten complications following surgery occurred and revision was performed in four patients. Of the 23 patients of this study, 22 showed significant pain relief according to their visual analogue scale scores. Concerning the aspect of neurological and functional recovery, mean MRC grade and ECOG score was significantly improved after surgery (p<0.05). In terms of survival, radiation therapy had a significant role. Median overall survival was 124 days after surgery, and the adjuvant-RT group (median 214 days) had longer survival times than prior-RT (63 days) group.

Conclusion

Although surgical procedure in CTJ may be difficult, we expect good clinical results by adopting a palliative posterior surgical method with appropriate preoperative preparation and postoperative treatment.

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.

Thoracoscopic transclavicular approach for a large thoracic inlet tumor

Large lesions of the thoracic inlet represent a significant challenge to surgeons due to their close relationship with important adjacent neurovascular structures. We report a case of neurofibromatosis type 1 presented with a large neurofibroma located in the right thoracic inlet, and a malignant peripheral nerve sheath tumor in the right clavicle and treated with a hybrid thoracoscopic anterior transclavicular approach to remove the tumors. Combination of thoracoscopic and minimal chest wall resection may serve as a feasible option for resection of the large and benign thoracic inlet tumor in a way of minimal invasiveness and safety.

Combined operative technique with anterior surgical approach and video-assisted thoracoscopic surgical lobectomy for anterior superior sulcus tumours

Video-assisted thoracoscopic surgery (VATS) has been widely used, but surgical resections of superior sulcus tumours remain challenging because of their anatomical location. For such cases, less-invasive procedures, such as the anterior transcervical-thoracic and transmanubrial approaches, have been widely performed because of their excellent visualization of the subclavian vessels. Recently, a combined operative technique with an anterior surgical approach and VATS for anterior superior sulcus tumours has been introduced. Herein, we report three cases of anterior superior sulcus tumours successfully resected by surgical approaches combined with a VATS-based lobectomy. In all cases, operability was confirmed by VATS, and upper lobectomies with hilar and mediastinal lymph node dissections were performed. Subsequently, dissections of the anterior inlet of the tumours were performed using the transmanubrial approach in two patients and the anterior trans-cervical-thoracic approach in one patient. Both approaches provided excellent access to the anterior inlet of the tumour and exposure of the subclavian vessels, resulting in radical resection of the tumour with concomitant resection of the surrounding anatomical structures, including the chest wall and vessels. In conclusion, VATS lobectomy combined with the anterior surgical approach might be an excellent procedure for the resection of anterior superior sulcus tumours.

Outcome and morbidity of surgical resection of primary cervical and cervicothoracic neuroblastoma in children: a comparative analysis

INTRODUCTION

Primary cervical (CN) and cervicothoracic neuroblastoma (CTN) is generally associated with good outcome; however, surgical resection can be challenging and not without morbidity. The aim of this study is to assess the overall outcome and compare the clinico-radiological features, treatment, and complications of CN and CTN.

MATERIALS AND METHODS

Sixteen consecutive patients, (CN = 9, CTN = 7) treated between November 2006 and December 2012 were selected from the prospective database for this analysis.

RESULTS

The 2-year overall and event-free survival of entire cohort is 100 and 72 %, respectively. Respiratory symptoms due to compression of airway and intraspinal extension were common in CTN. Gross total resection was feasible in all patients with CN; in contrast, incomplete excision along with significantly longer duration of surgery and more blood loss occurred in CTN. Postoperative morbidity was seen in three patients with CN and only one patient with CTN. The extent of surgery did not affect the overall and event-free survival of CTN (p = NS).

CONCLUSION

CN and CTN have characteristic clinico-radiological presentation and surgical specification. However, both have a favorable outcome, even though with a distinct but acceptable morbidity. The favorable outcome in CTN is unrelated to the extent of surgical excision.