| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1996;61:723-725
© 1996 The Society of Thoracic Surgeons
Departments of Thoracic Surgery and Orthopedic Surgery, Institut Mutualiste Montsouris Choisy, Paris, France
Accepted for publication July 18, 1995.
 |
Abstract |
|---|
 TopFootnotes Abstract IntroductionCommentReferences |
|---|
|
Introduction |
|---|
|
TopFootnotesAbstractIntroductionCommentReferences |
|---|
It is generally accepted that locally advanced resectable non–small cell lung cancer should be resected [1–4]. However, lung cancer with substantial invasion of vertebral bodies is usually considered a contraindication to operation [1, 5], mainly because a complete en bloc resection is considered unfeasible. We report here a patient with lung cancer with vertebral body invasion in whom a combination of surgical approaches allowed complete en bloc resection of the tumor, including the entire invaded vertebra, and we also briefly describe 6 additional patients who underwent a similar approach at our institution.
A 52-year-old man was found to have adenocarcinoma of the posterior apex of the left lung with an invasion of the body of the second thoracic vertebra and adjacent rib, as shown by x-ray films and confirmed by computed tomographic scan and magnetic resonance imaging. Pretreatment TNM staging was IIIb (T4 N0 M0). Induction chemotherapy with cisplatin and etoposide (three cycles) obtained a slight decrease in tumor size and incomplete pain relief. After restaging confirmed a persistent T4 N0 M0 tumor, an en bloc resection was planned, after cord arteriography [6].
The surgical procedure included three steps. First, an anterior cervical approach allowed the dissection of cervical structures in tumor-free margins [3]. The prevertebral plane at the upper thoracic level was separated from the posterior mediastinum (esophagus), and the cervical incision was closed.
Second, a classic posterolateral thoracotomy allowed the section of the chest wall in tumor-free margins, together with a wedge resection in the left upper lobe. The ``resected'' lung was left attached to the chest wall and spine in the pleural cavity. A complementary dissection to free the posterior mediastinum from the spine was also performed, and the thoracotomy was closed.
The last step to a complete en bloc resection was vertebrectomy through an enlarged posterior approach (6) (Fig 1
). Briefly, the first stage is a laminectomy at the level of the lesion (Fig 1b), extended one level above and one level below. Laterally, the laminectomy is extended on the facets and includes the resection of pedicles and adjacent ribs except on the invaded side, where the dissection reaches the section of the chest wall performed at thoracotomy and cervicotomy (Fig 1c). The lateral aspects of the vertebral bodies are liberated from the surrounding soft tissues by blunt finger dissection up to the prevertebral plane. Unilateral transpedicular plate stabilization is performed before transection of the spine is achieved by vertebral end plate cutting using a Gigli saw. The vertebral bodies (and the attached tumor, lung, and chest wall) are then pushed sideways and removed en bloc (Fig 1d).
|
), anterior column reconstruction was achieved with the autogenous clavicle graft resected at cervicotomy, and a second posterior transpedicular plate was implanted (Fig 3).
|
|
The main clinical characteristics of all 7 patients who have undergone a combined thoracic and enlarged vertebral approach for tumors invading the vertebral bodies or the costovertebral angle at our institution are summarized in Table 1.
|
|
Comment |
|---|
|
TopFootnotesAbstractIntroductionCommentReferences |
|---|
DeMeester and associates [5] described a technique of resection for lung tumors ``adherent'' to the vertebral column through an enlarged posterolateral thoracotomy. However, this technique included only a tangential osteotomy of the vertebral body through the costotransverse foramen (see Fig 1
), and DeMeester and associates indicated that this approach was inadequate in patients with roentgenographic destruction of vertebral bodies [5] such as the patient in this report (see Fig 2). Only an enlarged posterior approach including a laminectomy allows extended en bloc resections, provided that both laminae and pedicle opposite the tumor are not invaded (see Fig 1) [6]. Furthermore, we favor the posterior approach even when partial vertebrectomy is considered, because only this approach allows safe section of the nerve roots (close to the cord) on the invaded side, safe section of the vertebral body up to the prevertebral plane (by using hand control from the noninvaded side) [6], and adequate spine stabilization.
Both the long-term efficacy and the actual morbidity rate of the technique cannot be extrapolated from these preliminary results. However, if the favorable prognostic influence of complete resection in locally advanced non–small cell lung cancer is confirmed [1–4], and if the morbidity and mortality rates of operation prove to be low, this combined approach by two surgical teams might open promising perspectives in the treatment of tumors that are usually considered unresectable.
|
Footnotes |
|---|
|
TopFootnotesAbstractIntroductionCommentReferences |
|---|
|
References |
|---|
|
TopFootnotesAbstractIntroductionCommentReferences |
|---|
Related Article
This article has been cited by other articles:
|
|
 |
|
  D. H. Grunenwald Editorial comment: En bloc vertebrectomy for lung cancer invading the spine: surgical serenity and optimism warrant innovation Eur J Cardiothorac Surg, September 1, 2011; 40(3): 654 - 655. [Full Text] [PDF]
|
|
|
|
 |
|
 W. D. Bolton, D. C. Rice, A. Goodyear, A. M. Correa, J. Erasmus, W. Hofstetter, R. Komaki, R. Mehran, K. Pisters, J. A. Roth, et al. Superior sulcus tumors with vertebral body involvement: A multimodality approach. J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1379 - 1387. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Stoelben and C. Ludwig Chest wall resection for lung cancer: indications and techniques Eur J Cardiothorac Surg, March 1, 2009; 35(3): 450 - 456. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Anraku, T. K. Waddell, M. de Perrot, S. J. Lewis, A. F. Pierre, G. E. Darling, M. R. Johnston, R. E. Zener, Y. R. Rampersaud, F. A. Shepherd, et al. Induction chemoradiotherapy facilitates radical resection of T4 non-small cell lung cancer invading the spine. J. Thorac. Cardiovasc. Surg., February 1, 2009; 137(2): 441 - 447.e1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. C. Archie and C. R. Thomas Jr. Superior Sulcus Tumors: A Mini-Review Oncologist, September 1, 2004; 9(5): 550 - 555. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. C. Detterbeck Changes in the treatment of Pancoast tumors Ann. Thorac. Surg., June 1, 2003; 75(6): 1990 - 1997. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Paci, G. Sgarbi, G. Ferrari, S. De Franco, and V. Annessi Controversies Over UICC-TNM Classification of Non-small Cell Lung Cancer : Model for a Diagnostic Path Chest, August 1, 2002; 122(2): 754 - 754. [Full Text] [PDF]
|
|
|
|
|
|
E. Fadel, G. Missenard, A. Chapelier, S. Mussot, F. Leroy-Ladurie, J. Cerrina, and P. Dartevelle En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina J. Thorac. Cardiovasc. Surg., April 1, 2002; 123(4): 676 - 685. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. H. Grunenwald, C. Mazel, P. Girard, G. Veronesi, L. Spaggiari, D. Gossot, D. Debrosse, R. Caliandro, J.-L. Le Guillou, and T. Le Chevalier Radical en bloc resection for lung cancer invading the spine J. Thorac. Cardiovasc. Surg., February 1, 2002; 123(2): 271 - 279. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Deslauriers Current surgical treatment of nonsmall cell lung cancer 2001 Eur. Respir. J., February 1, 2002; 19(35_suppl): 61S - 70s. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 British Thoracic Society, Society of Cardiothoracic Surgeons of Great Britai, and Ireland Working Party Guidelines on the selection of patients with lung cancer for surgery Thorax, February 1, 2001; 56(2): 89 - 108. [Full Text]
|
|
|
|
|
|
S. Gandhi, G. L. Walsh, R. Komaki, Z. L. Gokaslan, J. C. Nesbitt, J. B. Putnam Jr, J. A. Roth, K. W. Merriman, I. E. McCutcheon, R. F. Munden, et al. A multidisciplinary surgical approach to superior sulcus tumors with vertebral invasion Ann. Thorac. Surg., November 1, 1999; 68(5): 1778 - 1784. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Spaggiari, M. Rusca, P. Carbognani, and P. Solli Hemivertebrectomy for Apical Chest Tumors: Is the Risk Justified by the Outcome? Ann. Thorac. Surg., May 1, 1998; 65(5): 1515 - 1517. [Full Text] [PDF]
|
|
|
|
|
|
D. H. Grunenwald Reply Ann. Thorac. Surg., May 1, 1998; 65(5): 1516 - 1517. [Full Text] [PDF]
|
|
|
|
|
|
P. Noirhomme, Y. d'Udekem, E. Munting, G. El Khoury, Y. Humblet, and R. A. Dion Resection of a Chest Chondrosarcoma Invading the Spine and the Aorta Ann. Thorac. Surg., February 1, 1998; 65(2): 534 - 534. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Grunenwald and L. Spaggiari Transmanubrial Osteomuscular Sparing Approach for Apical Chest Tumors Ann. Thorac. Surg., February 1, 1997; 63(2): 563 - 566. [Abstract] [Full Text]
|
|
|
|
|
|
D. Grunenwald, C. Mazel, P. Baldeyrou, and P. Girard En Bloc Resection of Lung Cancer Invading the Spine Ann. Thorac. Surg., June 1, 1996; 61(6): 1878 - 1879. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
