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Ann Thorac Surg 1996;61:1878-1879
© 1996 The Society of Thoracic Surgeons

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Correspondence

En Bloc Resection of Lung Cancer Invading the Spine

Institut Mutualiste Montsouris 6 Place de Port au Prince 75013 Paris, France

To the Editor:

We were very interested by the results reported by Dartevelle and colleagues in an invited commentary about our article entitled ``Total Vertebrectomy for En Bloc Resection of Lung Cancer Invading the Spine'' [1]. Actually their results, not previously published, demonstrate clearly that the philosophical aspect of our approach is quite different. In their commentary, Dartevelle and colleagues never emphasize the critical breakpoint between the surgical approaches proposed for Pancoast's tumors heretofore and our proposition.

The originality of the operation described by Shaw and associates [2] was the en bloc resection of the tumor, the lung, the thoracic wall, and a part of the thoracic vertebrae. Paulson [3] underlined the contraindications for this operation, which were vascular involvement and extensive invasion of the brachial plexus. Dartevelle himself, whose surgical technique has allowed resection of some anteroapical tumors invading vascular structures, stated in 1993 that his approach was ``absolutely contraindicated'' in superior sulcus tumors with vertebral body involvement [4].

Our approach allowed us to resect such tumors, involving vertebral bodies, in an ``en bloc fashion,'' resecting the entire vertebral body, the lung, and the parietal wall without opening the tumor tissue, thus respecting oncologic principles of surgery. Patients' postoperative contraints are obviously greater after total vertebrectomy. Due to the risk of an invaded bone margin, a partial vertebrectomy or even a hemivertebrectomy jeopardizes complete resection in some patients, and therefore would be a carcinologic fault. Our earliest case, presented in our article, had an important vertebral body involvement, as presented in Figure 1, and the resection was only possible through a total vertebrectomy. To date this patient is alive and free of disease 32 months after the vertebral resection. With increasing experience, we believe that the extent of bone resection needed is determined by the extent of the tumor on the vertebral arch analyzed on computed tomography and magnetic resonance imaging transverse view. When the tumor only extends along the vertebral body or just the lateral part of the body, hemivertebrectomy is performed. As soon as the median part of the body is invaded total vertebrectomy is mandatory (Fig 2). Even in cases with hemivertebrectomy, a major oncologic principle, ie, avoiding tumor opening, is always respected.

View larger version (32K): [in this window] [in a new window]   Fig 1. . Magnetic resonance image of the thoracic apex, showing vertebral body involvement of T2 before induction chemotherapy.

View larger version (33K): [in this window] [in a new window]   Fig 2. . Magnetic resonance image (A) and computed tomographic scan (B) of the thoracic apex after three cycles of chemotherapy, showing slight decrease of the tumor size and persistent vertebral body involvement. Note the abnormal bone structure of the body of T2.

We fully agree that small series and short follow-ups for innovative techniques do not allow firm recommendations other than careful and open-minded interest. At present, our updated results may be regarded only as ``rather encouraging.'' We are convinced that continuing constructive efforts to better outline the indications and the technical aspects of this approach will ultimately benefit the patients.

References

1. Grunenwald D, Mazel C, Girard P, Berthiot G, Dromer C, Baldeyrou P. Total vertebrectomy for en bloc resection of lung cancer invading the spine. Ann Thorac Surg 1996;61:723–6.[Abstract/Free Full Text]
2. Shaw RR, Paulson DL, Kee JL Jr. Treatment of the superior sulcus tumor by irradiation followed by resection. Ann Surg 1961;154:29–40.[Medline]
3. Paulson DL. Carcinomas in the superior pulmonary sulcus. J Thorac Cardiovasc Surg 1975;70:1095–104.[Abstract]
4. Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 1993;105:1025–34.[Abstract]

This article has been cited by other articles:

				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. 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]

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dominique Grunenwald Pierre Baldeyrou Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grunenwald, D. Articles by Girard, P. Search for Related Content PubMed PubMed Citation Articles by Grunenwald, D. Articles by Girard, P.