Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases.
METHODS
A new surgical technique for en bloc resection of posterior mediastinum tumors invading the spine is described.


OBJECTIVE
To demonstrate that major soft tissue tumors of the thoracic apex (Pancoast Tobias syndrome) or posterior mediastinum tumors can be removed en bloc even though the vertebral body or the foramina are invaded.


BACKGROUND
En bloc surgery of tumor is accepted today as being the goal of carcinologic surgery with the best results for survival. Until now, no surgical technique has been described for radical excision of soft tissue tumors invading the thoracic spine adjacent to the ribs and lung. We reviewed our 8 years' experience of 36 such cases and report outcome and survival rates.


METHODS
The authors have joined their abilities and technique to enable complete en bloc extratumoral resections of lung tumors or posterior mediastinum tumors invading the adjacent soft tissue and spine. The surgical technique recommended by the authors is different at the cervicothoracic and medium thoracic level. At the cervicothoracic level, the authors first perform an anterior approach with dislocation of the sternoclavicular joint and dissection of the subclavian vessels with exposure of the brachial plexus. Dissection of the tumor from the anterior soft tissues is then performed but is kept attached to the adjacent spine. Dissection of lung hilum and its division are done through the same approach. At the thoracic level, the authors perform a posterior lateral thoracotomy for dissection of lung hilum and division of its elements. The lung and the adjacent tumoral ribs are not removed but are carefully kept undissected against the spine. Thoracoscopy can replace the open thoracotomy in small and medium-sized tumors. En bloc extratumoral resection is the second step performed through a median posterior cervicothoracic or thoracic approach. Vertebrectomy is complete or partial depending on the type of extension against or inside the vertebrae.


RESULTS
Thirty-six cases have been operated on with this technique. Vertebrectomy was complete in seven cases and partial in 29. Follow-up ranges from 6 days to 7.2 years (average, 23.3 months). One patient died 1 year postoperatively from an unrelated cause. Only 35 patients are available for follow-up analysis. Twenty-one patients (60%) are dead, with an average survival of 16.7 months 8 days to 44 months. The 14 others (40%) are alive (average, 38.26 months; range, 8-87 months).


CONCLUSIONS
Even though a learning curve is necessary to achieve this extreme type of surgery, selective preoperative screening of patients is mandatory. Interesting results today confirm the feasibility of possible treatment of tumors still considered unresectable.
Mazel
Ch
Ch
Orthopaedic Department, Institut Mutualiste Montsouris, Paris, France. Christian.Mazel@imm.fr
Grunenwald
D
D
Laudrin
P
P
Marmorat
J L
JL
D000293:Adolescent; D000328:Adult; D000368:Aged; D002277:Carcinoma / Q000556:secondary / Q000601:surgery*; D000075202:Contraindications; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008479:Mediastinal Neoplasms / Q000601:surgery*; D008875:Middle Aged; D009442:Neurilemmoma / Q000556:secondary / Q000601:surgery*; D010178:Pancoast Syndrome / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D012086:Reoperation; D012509:Sarcoma / Q000556:secondary / Q000601:surgery*; D013125:Spinal Neoplasms / Q000556:secondary / Q000601:surgery*; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000379:methods*; D015996:Survival Rate; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome