En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina

Objective: In patients with non-small cell lung cancer invading the thoracic inlet, the transcervical approach does not permit removal of tumor in the intervertebral foramina. We report a variant that lifts this limitation. Methods: Through the transcervical approach, resectability was assessed and tumor-bearing structures were removed, leaving tumor-free margins. Standard upper lobectomy was performed, leaving the lobe in place. A posterior midline approach was used for multilevel unilateral laminectomy, nerve root division inside the spinal canal, and vertebral body division along the midline. The tumor was removed en bloc with the lung, ribs, and vessels through the posterior incision. Fixation of the spine was performed. Medical charts of patients treated with this technique between October 1994 and April 2001 were reviewed retrospectively. Results: Seventeen patients (mean age 45 years) were treated. Resection of the upper lobe and T1 root was done in all 17 cases: 3- and 4-level hemivertebrectomies were done in 13 and 3 cases, respectively; 2-level total vertebral body resection and 2-level hemivertebrectomy were done in 1 case; and resections of the phrenic nerve and subclavian artery were done in 7 and 6 patients, respectively. There were no perioperative deaths or residual neurologic impairments. Postoperative complications were pneumonia (n = 6), cerebrospinal fluid leakage (n = 1), wound breakdown (n = 1), and bleeding necessitating reoperation (n = 1). The overall Sand 5-year survivals were 39% and 20%, respectively. Conclusions: Non-small cell lung cancers invading the thoracic inlet and intervertebral foramina can be removed completely through a combined anterior transcervical and posterior midline approach, with good results.