Individualized surgical treatment for patients with tumours of the cervicothoracic junction

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Abstract

OBJECTIVES

The cervicothoracic junction is a special section that connects the neck, thoracic cavity, mediastinum and axilla. Tumours in the region often invade or compress surrounding tissues and organs, which makes the surgical treatment difficult.

METHODS

A retrospective analysis involving 69 patients with tumours at the cervicothoracic junction. Clinical data with regard to manifestation, surgical approach, resection degree, outcome and pathological types were collected.

RESULTS

A total of 48 cases of asymptomatic patients and 21 cases of patients with ≥1 clinical manifestation were enrolled in the study. Twenty-seven patients received radical resection with video-assisted thoracoscopic surgery. Anterior approach was the predominant treatment method in open surgery (25 cases, 36.2%), while the anterolateral approach was used in 8 cases (6 cases of hemiclamshell incisions and 2 cases of trap-door incisions). In addition, we observed 1 case of posterior approach, 2 cases of posterolateral approach and 1 case of supraclavicular approach combined with posterolateral approach. Pathological examination results revealed 67 cases of radical resection and 2 cases of microscopic residual. Neurilemmoma was the most widespread pathological type (30 cases, 43.5%), followed by tumour originating from fibrous tissues (5 cases, 7.2%). A 3-year overall survival rate of the 69 patients was 89.9%, while a 5-year overall survival rate was 85.5%.

CONCLUSIONS

Tumours associated with the cervicothoracic junction are characterized by their unique location, complex anatomy and various histopathological subtypes. An individualized approach during surgery enhances safety and standardized of treatments for patients with tumours located at the cervicothoracic junction.

Abstract

The cervicothoracic junction, which is low in the front and high in the back, is a narrow region extending from the C7–T4 bilateral transverse processes to the first rib and the sternum [1].

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Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet.

Philippe Dartevelle, Alain R Chapelier, Paolo Macchiarini … (1993)

We describe an original anterior transcervical-thoracic approach required for a safe exposure and radical resection of non-small-cell lung cancer that has invaded the cervical structures of the thoracic inlet. Through a large L-shaped anterior cervical incision, after the removal of the internal half of the clavicle, the following steps may be performed: (1) dissection or resection of the subclavian vein; (2) section of the anterior scalenus muscle and resection of the cervical portion of the phrenic nerve, if invaded; (3) exposure of the subclavian and vertebral arteries; (4) dissection of the brachial plexus up to the spinal foramen; (5) section of invaded ribs; and (6) en bloc removal of chest wall and lung tumor, either directly or through an extension of the cervical incision into the deltopectoral groove. An additional posterior thoracotomy may be required for resection of the chest wall below the second rib. Between 1980 and 1991, 29 patients underwent radical en bloc resection of the inlet tumor, chest wall (ribs 1 and 2), and underlying lung, either through the anterior transcervical approach alone (n = 9) or with an additional posterior thoracotomy (n = 20). The inferior root of the brachial plexus, either alone (n = 11) or with the phrenic nerve (n = 4), was involved and resected in 15 patients (52%). Twelve patients (41%) had a vascular involvement that included the subclavian artery alone (n = 3); subclavian artery and subclavian vein (n = 3); subclavian artery, subclavian vein, and vertebral artery (n = 2); subclavian artery and vertebral artery (n = 1); subclavian vein alone (n = 1); vertebral artery alone (n = 1), or subclavian artery and vertebral artery (n = 1). The subclavian artery was revascularized either with a prosthetic replacement (n = 7) or an end-to-end anastomosis (n = 2), and the median graft patency was 18.5 months (range, 6 to more than 73 months); only 1 patient had postradiotherapy graft occlusion in the revascularized artery 6 months after operation. We performed 14 wedge resections, 14 lobectomies, and 1 pneumonectomy. There were no operative or hospital deaths. Postoperative radiotherapy (median, 56 Gy) was given to 25 (86%) patients, either alone (n = 14) or in combination with adjuvant systemic chemotherapy (n = 11). With a median follow-up time of 2.5 years, overall 2- and 5-year survivals were 50% and 31%, respectively. This transcervical-thoracic approach affords a safe exposure and radical resection of non-small-cell lung cancer involving the thoracic inlet and results in encouraging long-term survival.

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Superior sulcus tumors (Pancoast tumors).

Giuseppe Marulli, Lucia Battistella, Marco Mammana … (2016)

Superior Sulcus Tumors, frequently termed as Pancoast tumors, are a wide range of tumors invading the apical chest wall. Due to its localization in the apex of the lung, with the potential invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, the superior sulcus tumors cause characteristic symptoms, like arm or shoulder pain or Horner's syndrome. The management of superior sulcus tumors has dramatically evolved over the past 50 years. Originally deemed universally fatal, in 1956, Shaw and Paulson introduced a new treatment paradigm with combined radiotherapy and surgery ensuring 5-year survival of approximately 30%. During the 1990s, following the need to improve systemic as well as local control, a trimodality approach including induction concurrent chemoradiotherapy followed by surgical resection was introduced, reaching 5-year survival rates up to 44% and becoming the standard of care. Many efforts have been persecuted, also, to obtain higher complete resection rates using appropriate surgical approaches and involving multidisciplinary team including spine surgeon or vascular surgeon. Other potential treatment options are under consideration like prophylactic cranial irradiation or the addition of other chemotherapy agents or biologic agents to the trimodality approach.

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Surgical management of cervical myelopathy dealing with the cervical-thoracic junction.

Samir Lapsiwala, Edward Benzel (2016)

The treatment of compressive cervical myelopathy is, in general, a surgical endeavor. Surgery involves decompression, often with an accompanying fusion with stabilization. The length of the fusion can vary and the decision regarding length of fusion is not always clear. This study explores the fundamental principles regarding the length of fusion at the cervicothoracic junction. A review of the literature regarding the anatomy and biomechanics of the cervicothoracic region is provided. Surgical approaches and indications for cervicothoracic junction region fusions are discussed. Fundamental guidelines for the decision-making process are provided. The cervicothoracic region is a biomechanically complex region. Although there is little biomechanical data indicating the appropriate length of fusion, several fundamental guidelines may be followed to reduce the incidence of construct failure. A long fusion should not end at an apical vertebra nor at the cervicothoracic junction. Long cervical fusions should be extended to traverse the cervicothoracic junction to a neutral vertebra.

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Author and article information

Journal

Journal ID (nlm-ta): Interact Cardiovasc Thorac Surg

Journal ID (iso-abbrev): Interact Cardiovasc Thorac Surg

Journal ID (publisher-id): icvts

Title: Interactive Cardiovascular and Thoracic Surgery

Publisher: Oxford University Press

ISSN (Print): 1569-9293

ISSN (Electronic): 1569-9285

Publication date Collection: June 2022

Publication date (Electronic): 26 November 2021

Publication date PMC-release: 26 November 2021

Volume: 34

Issue: 6

Pages: 1024-1030

Affiliations

[1 ] Department of Thoracic Surgery, Zhongshan Hospital, Fudan University , Shanghai, China

[2 ] Department of Thoracic Surgery, Affiliated Hospital of Hebei University , Baoding, China

[3 ] Basic Research Key Laboratory of General Surgery for Digital Medicine , Baoding, China

[4 ] Institute of Life Science and Green Development, Hebei University , Baoding, China

[5 ] Department of Plastic Surgery, Zhongshan Hospital, Fudan University , Shanghai, China

[6 ] Department of Vascular Surgery, Zhongshan Hospital, Fudan University , Shanghai, China

[7 ] Department of Orthopedic Surgery, Zhongshan Hospital, Fudan University , Shanghai, China

Author notes

Shuai Wang, Zhencong Chen and Ke Zhang authors contributed equally to this work.

Corresponding author. Department of Thoracic Surgery, Zhongshan Hospital of Fudan University, No. 180, Fenglin Road, Shanghai 200032, China. Tel: 86-21-64041990; e-mail: jiang.wei1@ 123456zs-hospital.sh.cn (W. Jiang).

Author information

Qun Wang https://orcid.org/0000-0003-4853-1727

Article

Publisher ID: ivab297

DOI: 10.1093/icvts/ivab297

PMC ID: 9159439

PubMed ID: 34849938

SO-VID: a1900e2b-bfbd-44c6-b998-dfb54c187387

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 01 June 2021

Date revision received : 24 August 2021

Date accepted : 26 September 2021

Page count

Pages: 7

Funding

Funded by: Clinical Research Plan of SHDC;

Award ID: SHDC2020CR310B

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Individualized surgical treatment for patients with tumours of the cervicothoracic junction

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Abstract

OBJECTIVES

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RESULTS

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Abstract

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Most cited references 10

Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet.

Superior sulcus tumors (Pancoast tumors).

Surgical management of cervical myelopathy dealing with the cervical-thoracic junction.

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