EN BLOC RESECTION OF THE LUNG APEX CANCERS WITH INVASION OF THE INTERVERTEBRAL FORAMEN: TECHNIQUE AND RESULTS

Abstract

Purpose: En bloc resection can be proposed for lung cancer involving the apex with invasion of the ribs or the transverse process using a transcervical anterior approach. Cancers invading the intervertebral foramen cannot be resected via this approach despite the classical indication for surgical resection. We report results of a novel surgical technique allowing cancerological resection of these tumours.

Material and methods: Fifteen patients with the same grade of cancer were operated using the same surgical technique. The first operative time included: superior lobectomy via anterior cervicothoracic access (without removal of the lobe), dissection of the subclavian vessels and the brachial plexus, section of the ribs and the T1 root, spinal exposure from C6 to T5, hemi-disectomy C7-T1 and discectomy at the level below the invaded foramen, medial vertebral groove, closure. The second operative time included: posterior access, extended instrumentation of the spine, hemi-laminectomy C7 extended as needed, section of the roots (depending on the level of the resection) within the canal, oblique posterior vertebral osteotomy along the medial border of the pedicle terminating in the anterior groove. Finally en bloc ablation via the posterior access of the surgical piece including the lung, the ribs and the hemi-vertebrae.

Results: Three- and four-level hemivertebrectomy was performed in eleven and three patients respectively. One patient had two hemivertebrectomies associated with one vertebrectomy. There were six resections (with repair) of the subclavian vessels for tumour invasion. Peroperative mortality was zero. Mean blood loss was 3000 ml. There were no neurological complications. There were eight postoperative complications: pneumonia five patients, cerebrospinal fluid fistula one patient, skin dehiscence one patient, haemorrhage one patient requiring reoperation. All patients were given postoperative radiotherapy. Three- and five-year survival was 36% and 27% respectively. Among the nine deaths, three had local relapse and six had general relapse.

Discussion: This techniques enables resection of tumours considered to be inextirpable using other techniques. Survival was the same as for tumours of the apex without invasion of the foramen and better than without surgery. This major surgery requires a well-trained multidisciplinary team (thoracic and vascular surgeons, spinal surgeon, anaesthesiologists, intensive care specialists). Contraindications for this type of surgery are invasion of the spinal canal, the brachial plexus and the vertebral body as well as the presence of a spinal artery entering the foramen to be resected.