EN BLOC RESECTION OF PRIMARY BRONCHOGENIC TUMOURS WITH DIRECT SPINAL COLUMN INVASION WITH A MINIMUM 12 MONTHS FOLLOW-UP

Abstract

Study Design: A retrospective analysis of prospectively collected data on 18 consecutive patients undergoing en bloc resection of primary bronchogenic tumours that locally invaded the adjacent spinal column with a minimum of 12 months follow-up.

Objectives: To report on operative details, outcome scores, survival and satisfaction in this group of patients.

Summary of Background: Primary thoracic tumours with direct spinal extension have traditionally been regarded as being unresectable and thus, associated with a poor prognosis. However, en bloc surgery is now emerging as being the goal of primary tumor surgery offering the best results for survival.

Methods: We reviewed 18 consecutive patients undergoing concomitant lung and vertebral resection performed by a combined team of an orthopedic surgeon and a thoracic surgeon during 2002–2006. All patients had negative staging for systemic disease (T4 N0 M0).

Results: Mean age of patients was 62.5 +/−11.6 years (33–76 years) with a mean follow-up of 26.1 months (13–60 months). Seven patients had a one-stage procedure and 11 had en bloc resections in two stages. Mean length of operation was 995.8 minutes (280–1965 minutes). Mean estimated blood loss was 5425.8 mls (1430–12830 mls). Mean length of hospital stay was 31 days (range 9–122 days). In total, an average of 3.0 (range 2–4) vertebrae were resected – two patients had a partial vertebrectomy, 10 had a hemivertebrectomy, 2 had a total vertebrectomy and 4 had a combination. Three patients had a ‘palliative’ procedure as a result of local tumour invasion (around the great vessels and dura). The remaining 15 patients were operated with ‘curative’ intent.

The ODI (Oswestry Disability Index) score was 27.4 (+/−13) preoperatively and 42.2 (+/−10.9) post operatively (p=0.004). The scores for SF-36 (Short Form-36) were 34.0 (+/−10.9) preoperatively and 29.7 (+/−6.3) post-operatively (physical component summary; p=0.3); 39.2 (+/−7.9) preoperative and 40.6 (+/− 14.9) postoperative (mental component summary; p=0.85).

There were 6 major complications (1- wound break-down, 3 – required extended respiratory support of which 1 required thoracotomy for lung re-expansion, 1- developed severe distal junctional kyphosis requiring revision, 1 – recurrent laryngeal palsy needing thoraco-plasty) and 3 minor (2- dural tears, 1-chyle leak).

The survival in the ‘curative’ group was 10/15 (67%) with a mean follow-up of 27.3 months; five patients died at a mean of 115 days (86–129 days) due to respiratory complications. All ten surviving patients reported that they were satisfied/very satisfied with surgery. The survival in the ‘palliative’ group was 192 days (48–360).

Conclusions: There is a significant complication rate following en-bloc tumour surgery (> 50%), but curative resections are achievable at the expense of pain and function.