title: The transmanubrial approach: a new operative approach to cervicothoracic neuroblastoma in children.
abstract: 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.
authors.affiliation: Department of Pediatric Surgery, Necker Enfants-Malades Hospital, 149 rue de Sèvres, 75015 Paris, France. frederique.sauvat@nck.ap-hop-paris.fr
authors.forename: Frédérique
authors.initials: F
authors.lastname: Sauvat
authors.forename: Hervé
authors.initials: H
authors.lastname: Brisse
authors.forename: Pierre
authors.initials: P
authors.lastname: Magdeleinat
authors.forename: Manuel
authors.initials: M
authors.lastname: Lopez
authors.forename: Pascale
authors.initials: P
authors.lastname: Philippe-Chomette
authors.forename: Daniel
authors.initials: D
authors.lastname: Orbach
authors.forename: Isabelle
authors.initials: I
authors.lastname: Aerts
authors.forename: Laurence
authors.initials: L
authors.lastname: Brugieres
authors.forename: Yann
authors.initials: Y
authors.lastname: Revillon
authors.forename: Sabine
authors.initials: S
authors.lastname: Sarnacki
mesh_terms: 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