The transmanubrial osteomuscular-sparing approach: a valuable adjunct to the head and neck surgical armamentarium

PURPOSE OF REVIEW

To describe and popularize the transmanubrial osteomuscular-sparing approach (TOSA) outside its original thoracic surgical field of application, based on the consideration that it could be of interest for the management of a number of head and neck cases in both elective and emergent scenarios.

RECENT FINDINGS

The main advantages of TOSA compared with transclavicular techniques are its superb exposure of anatomic structures located at the level of the cervicothoracic junction, and superior postoperative aesthetic and functional outcomes. Recently, a number of studies have described the association of TOSA with other minimally invasive approaches, such as video-assisted thoracoscopic surgery and robotic hybrid approaches, with the aim of avoiding association of the transmanubrial route with anterior/posterior thoracotomies, or more extended surgeries, such as the trapdoor or hemiclamshell procedures.

SUMMARY

TOSA, even though originally conceived to reduce the morbidity ensuing from classic transclavicular approaches for management of Pancoast tumors, may well play an important role in a number of head and neck surgical conditions, including those related to mediastinal goiter and thyroid cancer, management of stenosis and lesions of the thoracic trachea and esophagus, treatment of the junction between innominate, internal jugular, and subclavian veins, epiaortic arteries, thoracic duct, brachial plexus, and low sympathetic chain. Whenever comprehensive control of vascular and nonvascular structures of the upper mediastinal inlet is required, TOSA should be planned and performed by combining the expertise of cooperating professionals.

Transmanubrial Approach for Removing a Head and Neck Tumor Located at the Upper Lateral Mediastinum

Background

When a head and neck tumor invades the upper lateral mediastinum, the transmanubrial approach (TMA), in which the sternoclavicular joint is temporary mobilized and replaced back to the physiological position, appears to be an excellent method. However, there have been only a few reports about the application of this approach to head and neck tumors.

Materials and Methods

We recently adopted this technique for the removal of 2 head and neck tumors that required handling of the subclavian and innominate veins around the venus angle.

Results

We could safely remove the tumors under good surgical view and obtained excellent cosmetic and functional results.

Conclusions

TMA is a useful technique for the removal of head and neck tumors, which invade the upper lateral mediastinum. More frequent applications of this method are encouraged in combination with head and neck tumor surgery.

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.

Successful multimodality treatment for locally advanced primary thymic adenocarcinoma: report of a case

Although the optimal treatment strategy for locally advanced thymic carcinomas has yet to be determined, complete resection of the tumor after induction chemoradiotherapy (CRT) can sometimes provide a good chance of being cured. A 61-year-old woman was diagnosed with locally advanced primary thymic carcinoma, which invaded bilateral brachiocephalic veins and superior vena cava with intraluminal tumor thrombus. Induction CRT was performed, and a partial response to the treatment was achieved. Subsequent radical surgery was successfully performed by the median full sternotomy with a right transmanubrial osteomuscular sparing approach (TMA). The patient is currently alive and has remained disease-free for a year. The TMA is useful for extensive surgery of locally advanced thymic carcinoma because it can provide good exposure of the operative field without post-operative functional limitation of upper limbs.

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

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