title: Surgical approaches to apical thoracic malignancies.
abstract: OBJECTIVE
  Several surgical approaches have been described to access apical thoracic malignancies extending into the thoracic inlet. However, most publications have focused on a specific approach and considered the thoracic inlet as 1 entity. In the present analysis, we divided the thoracic inlet into 5 different zones requiring specific surgical considerations to identify the best approach for each zone.
  
  
  METHODS
  A review of 22 consecutive patients undergoing surgery for apical thoracic malignancies extending into the thoracic inlet from January 2005 to November 2011 was performed.
  
  
  RESULTS
  Different surgical approaches were used for each zone. The first (anterolateral) zone required a subclavicular approach to open the costoclavicular space and expose the subclavian vein with or without elevating or removing the clavicle (n = 4). The second (anterocentral) zone required a transverse supraclavicular approach with or without extension to a partial (trapdoor) or full sternotomy (n = 10). The third (posterosuperior) zone located between the top of the subclavian artery and the T1 vertebra along the posterior superior border of the first rib was the most difficult area to access (n = 5). The transclavicular approach was ideally suited to expose this zone in our experience. The fourth (posteroinferior) zone and fifth (inferolateral) zone located posteriorly and laterally along the inferior border of the first rib were accessed using a posterolateral and posterotransaxillary approach, respectively (n = 3).
  
  
  CONCLUSIONS
  The thoracic inlet could be divided into 5 zones requiring specific surgical considerations and different approaches. Division of the thoracic inlet into these zones could provide more clarity and guidance for thoracic surgeons to select the correct surgical approach.
authors.affiliation: Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada. marc.deperrot@uhn.on.ca
authors.forename: Marc
authors.initials: M
authors.lastname: de Perrot
authors.forename: Raja
authors.initials: R
authors.lastname: Rampersaud
mesh_terms: D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D013899:Thoracic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D019616:Thoracic Surgical Procedures / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome