The transmanubrial approach: a new operative approach to cervicothoracic neuroblastoma in children.
BACKGROUND
Cervicothoracic neuroblastoma originates from the cervical sympathetic nerves and ganglia and thus presents a problem when dissecting the vascular and nervous elements of the subclavian region. The standard operation is based on thoracotomy or dual cervicotomy/thoracotomy, but these approaches do not provide optimal control of the subclavian vessels. We report our experience in children with cervicothoracic neuroblastoma by using a technique usually performed for apical lung cancer.


METHODS
Four patients with localized cervicothoracic neuroblastoma with no N-myc amplification were resected after chemotherapy by this approach. The anatomic evaluation was performed preoperatively with angio-magnetic resonance imaging. This transmanubrial approach, performed through a manubrial L-shaped transection and first costal cartilage resection, affords excellent access to the subclavian region with safe control of the vessels and nerves and exposure of the first 4 thoracic intervertebral foramina.


RESULTS
Removal of more than 90% of the tumor was possible in all cases. The postoperative course was uneventful in 3 cases, and the fourth patient with a left-sided tumor had a transient chylothorax. No recurrence occurred with a follow-up period of 8 to 32 months.


CONCLUSIONS
The transmanubrial approach is an osteomuscular-sparing technique that seems particularly suitable for the treatment of these tumors, which require a resection that is as complete as possible to avoid postoperative chemotherapy and tumor relapse.
Sauvat
Frédérique
F
Department of Pediatric Surgery, Necker Enfants-Malades Hospital, 149 rue de Sèvres, 75015 Paris, France. frederique.sauvat@nck.ap-hop-paris.fr
Brisse
Hervé
H
Magdeleinat
Pierre
P
Lopez
Manuel
M
Philippe-Chomette
Pascale
P
Orbach
Daniel
D
Aerts
Isabelle
I
Brugieres
Laurence
L
Revillon
Yann
Y
Sarnacki
Sabine
S
D002574:Cervical Vertebrae; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging; D009423:Nervous System Neoplasms / Q000175:diagnosis / Q000601:surgery*; D009447:Neuroblastoma / Q000175:diagnosis / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000009:adverse effects; D013902:Radiography, Thoracic; D013564:Sympathetic Nervous System; D013904:Thoracic Vertebrae