Ann Thorac Surg 2001;72:629-631
© 2001 The Society of Thoracic Surgeons
How to do it
Double transmanubrial approach and sternotomy for resection of a giant thymic carcinoid tumor
Lorenzo Spaggiari, MD, PhDa,
Ugo Pastorino, MDa
a Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy
Accepted for publication March 27, 2001.
Address reprint requests to Dr Spaggiari, Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
e-mail: lorenzo.spaggiari{at}ieo.it
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Abstract
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The transmanubrial approach allows excellent unilateral exposure of the thoracic outlet. However, selected patients may require a bilateral cervicomediastinal exposure to completely resect the neoplasm. We report the use of a "double" transmanubrial approach for the resection of a giant mediastinal mass requiring bilateral vascular dissection and superior vena cava system resection and replacement.
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Introduction
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Transmanubrial osteomuscular sparing approach (TMA) may expand the possibility of complete resection of neoplasms involving the thoracic outlet [1]. Vascular axes as well as brachial plexus and cervicothoracic trachea can be safely resected through the opening created by the TMA sparing the clavicle and without any osteomuscular sacrifices [1, 2].
However, some giant mediastinal tumors might require a bilateral outlet vascular dissection and control to perform en bloc tumor resection, and in these cases, unilateral cervicothoracic approaches (TMA, transclavicular, etc), even those associated with sternotomy, might be insufficient.
Recently, we treated a large mediastinal tumor requiring bilateral cervicothoracic vascular control and dissection and superior vena cava system resection with graft replacement. The operation was done by means of a "double" TMA and sternotomy; this approach allowed excellent operative field exposure with safe complete resection of the mass.
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Technique
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A 74-year-old man underwent left anterior mediastinotomy in January 2000 for tissue diagnosis of a mediastinal mass discovered after a chest radiograph for dyspnea and sporadic arrhythmia. Pathology assessment showed an atypical thymic carcinoid tumor (grade II neuroendocrine carcinoma). No extrathoracic deposits were found at clinical staging.
Three cycles of chemotherapy with ifosfamide, carboplatinum, and etoposide were done, but no signs of response to chemotherapy were observed. Thus, the patient remained critically symptomatic because of the mediastinal compression (Fig 1), and salvage surgery was planned.
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Fig 1. Preoperative computed tomographic thoracic scan after chemotherapy. Note the mediastinal dislocation and vascular compression.
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The patient was placed in the supine position on the operating table with the right arm abducted 90 degrees, and a H-shaped cervicotomy was done (Figs 2, 3). The anterior border of both sternomastoid muscles was dissected, and the clavicle insertions of both major pectoral muscles were separated from the sternal ones. The manubrium was divided in two parts from the sternum by a reverse T section (Fig 4). As described in the "monolateral" TMA [1], the first cartilages were resected bilaterally, and both costoclavicular ligaments were sectioned. Thus, bilateral osteomuscular flaps (half part of the manubrium, clavicle, sternomastoid muscle, and clavicle part of the major pectoral muscle) were lifted (Fig 4). This allowed isolation and bilateral dissection of the upper part of the superior vena cava system. A median sternotomy was then performed to expose the lower part of the tumor. With the opening of the pericardium, the intrapericardial origin of the superior vena cava was controlled. Dissection of the tumor was done en bloc with pericardium, left phrenic nerve, and a wedge resection of left lung. The neoplasm totally involved the left brachiocephalic vein. The superior vena cava was tangentially clamped at the confluence with the left brachiocephalic vein, and both (superior vena cava and left brachiocephalic vein) were resected en bloc with the neoplasm. The superior vena cava system was revascularized using a ringed polytetrafluoroethylene prosthesis (No. 10) by an end to lateral anastomosis between the left jugular/subclavian veins confluence and superior vena cava, 2 cm above the right atrium. The final sternal and manubrium osteosynthesis was done as previously reported, using polyglyconate monofilament [2, 3] (Fig 5).
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Fig 2. The planned skin incision. Right anterior thoracotomy was prepared in case of difficulties in removing the mass, but it was not used.
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Fig 4. Schematic representation of double transmanubrial osteomuscular sparing approach. (A) The continuous lines indicate the resection of the manubrium and of the first cartilage to lift the osteomuscular flaps. The dashed lines indicate the planned associated approaches. (B) The retraction of the osteomuscular flaps allows the opening of the space between the clavicle and the first rib and the safe control of the subclavian vessels.
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Fig 5. (A) Schematic representation of Figure 5B. (B) The sternum is closed as reported in the text by using absorbable suture. The manubrium will be fixed with the same material.
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The analysis of the specimen showed an atypical thymic carcinoid tumor (grade II neuroendocrine carcinoma), with extensive nodal involvement (20:29).
The postoperative period was complicated by several episodes of ventricular arrhythmia, which were successfully medically cured, and respiratory insufficiency, which was treated by temporary tracheostomy and respiratory assistance. The patient was maintained 26 days in the intensive care unit and was discharged 30 days after the operation. Postoperative mediastinal radiotherapy was done.
At the follow-up (10 months after surgery) the patient was in good status performance and was disease free. No signs of shoulder anatomical deformities or functional scapular girdle alteration were present (Fig 6). Chest computed tomographic scan showed full graft patency.
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Fig 6. Follow-up at 6 months. Note the absence of shoulder anatomical alterations; note the correct position of the sternomastoid muscles as well as of both clavicles.
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This extended cervicomediastinal approach (the "double" transmanubrial approach) was recently used in another patient with thyroid cancer and bilateral mediastinal lymph node involvement. The opening created by the double TMA allowed a safe and complete cervical and mediastinal resection of the tumor with excellent postoperative results.
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Comment
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Thymic carcinoid tumors are rare neoplasms with very poor prognosis, especially when extrathymic invasion or lymph node metastases have occurred, and complete surgical resection is the only potentially curative treatment [4, 5]. The prognosis seems to be correlated with histologic degree of differentiation and with the completeness of resection (including mediastinal radical lymph node dissection), whereas sex, age, associated clinical manifestations, and, more important, size of the tumor when completely resected do not influence survival [6].
Chemotherapy and radiotherapy have not been shown to be useful; besides, preoperative chemotherapy has rarely been reported. In our case no signs of response were observed after induction of chemotherapy. For these reasons, the possibility of performing extended resections even in the case of a giant tumor involving mediastinal structures might influence survival.
These giant mediastinal masses are a surgical challenge, mainly because of the need for vascular control. Cervicothoracic approaches (such as "transclavicular," TMA, hemiclamshell, etc) have in most instances solved the problem, allowing a safe vascular control and resection when necessary. However, in some cases, resection may require a bilateral vascular dissection. In such a situation, sternotomy associated with a "simple" cervicotomy or a unilateral transclavicular or transmanubrial approach may prove insufficient.
In the present case, the size and the volume of the tumor required a bilateral exposure of cervical as well as thoracic compartments. This double TMA approach, to our knowledge performed for the first time, allowed bilateral dissection of the subclavian and brachiocephalic veins with replacement of the left venous system and complete excision of the tumor.
We believe that this technique may be useful in selected cases to achieve bilateral cervicomediastinal vascular exposure, with excellent aesthetic and functional results in term of scapular girdle mobility and chest wall stabilization.
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References
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Grunenwald D., Spaggiari L. Transmanubrial osteomuscular sparing approach for apical chest tumors. Ann Thorac Surg 1997;63:563-566.[Abstract/Free Full Text]
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Spaggiari L., Pastorino U. Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor. Ann Thorac Surg 1999;68:590-593.[Abstract/Free Full Text]
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Pastorino U., Muscolino G., Valente M., et al. Safety of absorbable suture for sternal closure after pulmonary or mediastinal resection. J Thorac Cardiovasc Surg 1994;107:596-599.[Abstract/Free Full Text]
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Economopoulos G.C., Lewis J.W., Lee M.W., Silverman N.A. Carcinoid tumors of the thymus. Ann Thorac Surg 1990;50:58-61.[Abstract]
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De Montpreville V.T., Macchiarini P., Dulmet E. Thymic neuroendocrine carcinoma (carcinoid): a clinicopathologic study of fourteen cases. J Thorac Cardiovasc Surg 1996;111:134-141.[Abstract/Free Full Text]
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Moran C.A., Suster S. Neuroendocrine carcinomas (carcinoid tumor) of the thymus. Am J Clin Pathol 2000;114:100-110.[Abstract/Free Full Text]
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Abstract
Introduction
