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En bloc total vertebrectomy for lung cancer invading the spine
Lung Cancer (2008) 61, 137—139
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/lungcan
CASE REPORT
En bloc total vertebrectomy for lung cancer invading the spine Fengshi Chen a, Ayuko Takahashi a, Mitsugu Omasa a, Masashi Neo b, Shunsuke Fujibayashi b, Hiromi Wada a, Toru Bando a,∗ a b
Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
Received 4 November 2007; received in revised form 27 November 2007; accepted 2 December 2007
KEYWORDS Chest wall; En bloc resection; Lung cancer; Lung cancer surgery; Total spondylectomy; Vertebral invasion
Summary Introduction of spinal surgery into lung cancer operations has made extensive operations feasible with an acceptable long-term survival. We report our successful experience of en bloc total vertebrectomy for lung cancer invading the spine. A 49-year-old man was found to have squamous cell carcinoma of the posterior apex of the right lung with an invasion of the body of the second and third thoracic vertebra. After induction chemoradiotherapy, we performed en bloc resection through thoracotomy and posterior median approach. Vertebral stabilization was achieved with a rod fixation and a placement of titanium mesh cage packed with autogenous bone chips. © 2007 Elsevier Ireland Ltd. All rights reserved.
It is generally accepted that locally advanced resectable non-small cell lung cancer (NSCLC) should be resected; however, the treatment of patients for NSCLC with vertebral body invasion remains challenging. The introduction of spinal surgery into lung cancer operations has made extensive operations for NSCLC feasible with an acceptable long-term survival [1]. Herein, we report our experience of en bloc total vertebrectomy for lung cancer invading the spine. A 49-year-old man was found to have squamous cell carcinoma of the posterior apex of the right lung with an invasion of the body of the second and third thoracic vertebra and adjacent rib, as shown on chest computed
∗ Corresponding author. Tel.: +81 75 751 4975; fax: +81 75 751 4974. E-mail address: [email protected] (T. Bando).
tomographic scan (Fig. 1A). Pretreatment TNM staging was IIIb (T4N0M0). Induction chemoradiotherapy with two cycles of carboplatin and paclitaxel and a dose of 64 Gy obtained a moderate decrease in tumor size (Fig. 1B). After restaging confirmed a persistent T4N0M0 tumor, an en bloc resection was planned. The surgical procedure included three steps. Firstly, the patient was placed in a left decubitus position. A long posterior thoracotomy incision was made. It started superiorly midway between the spinous process of the seventh cervical vertebra and the posterior aspect of the scapula, described a gentle arc between the thoracic spinous processes and the medial margin of the scapula, extended downward 2 cm below the inferior angle of the scapula, and curved up anteriorly to the anterior axillary line. This incision allowed the section of the chest wall in tumor-free margins. At thoracotomy, a right fourth rib was resected and preserved for bone grafting for vertebral body reconstruc-
0169-5002/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2007.12.004
138
F. Chen et al.
Fig. 2 Through median posterior approach, laminectomy from T1 to T4 was performed. Pedicle screws were inserted bilaterally at C7, T1, T5 and T6 on the right (arrows). The dura mater can be seen (arrowheads).
Fig. 1 (A) Chest computed tomography on admission revealed the tumor invading into the second and third thoracic vertebra. (B) Chest computed tomography after induction chemoradiotherapy showed that tumor decreased in size, but that it still invaded into the thoracic vertebra.
tion. Vessels for right upper lobe and right upper bronchus were dissected. The prevertebral plane at the upper thoracic level was separated from the posterior mediastinum (esophagus). Intervertebal discs of T1/2 and T3/4 were curetted as best as possible. Mediastinal lymph node dissection was also performed. The thoracotomy was temporarily closed. Second, the patient was placed in a prone position with a Mayfield head clamp and median posterior incision from the level of C5 to that of T7 was performed. Pedicle screws were inserted bilaterally at C7, T1, T5, and T6 using a computerassisted navigation system, and laminectomy from T1 to T4 was performed (Fig. 2). On the left side, transverse processes and pedicles from T2 to T4 were resected, and the costovertebral joints were disarticulated (T2—T4), which allowed us to reach the anterior aspect of the vertebrae. On the right side, the same procedure was performed except T2/3 level, to preserve the vertebrae—tumor—third rib complex intact. Then the bilateral T2 and T3 roots were dissected, and the T1/2 and 3/4 discs were cut using a thread saw. After right unilateral rod fixation was performed, the surgical specimen including vertebral bodies (T2 and T3), the attached tumor, lung, and right chest wall was translated forward, then rotated around the cord, and extracted en bloc (Fig. 3). After the removal of the tumor block, a contralateral rod fixation completed stabilization of the spine and spinal cord. Vertebral body reconstruction was achieved with a placement of titanium mesh cage packed with bone
chips made of an autogenous fourth rib which was resected at thoracotomy. The posterior wound was closed. Lastly, the patient was placed in a left decubitus position again. The last step was to reconfirm the hemostasis and close the thoracotomy. Pathologic examination confirmed the complete resection of a squamous cell carcinoma invading the body of the second and third thoracic vertebra (Fig. 4). There was no lymph node involvement. His postoperative course was without problems, and he was discharged home almost 1 month after surgery. He had not shown any findings indicating recurrence, but he died 1-year postoperatively from sepsis at a regional hospital.
Fig. 3 After right unilateral rod fixation was performed, the surgical specimen including vertebral bodies, right upper lobe with the tumor, and right chest wall was extracted en bloc. After the removal of the tumor block, a contralateral rod fixation was under way to complete stabilization of the spine and spinal cord. The right thorax (arrow) and the dura mater (arrowheads) can be seen.
Total vertebrectomy for lung cancer
139 posterior median approach. Several approaches have been reported [3—5], but posterior approach in addition to thoracotomy is necessary even when partial vertebrectomy is considered, since only this approach allows safe section of the vertebral body and nerve roots [5]. In such challenging tumors, complete resection with negative margin is the most important factor for the long-term survival [3—5]. In our patient, the tumor was completely resected with negative margins. In conclusion, although our patient died of an unrelated cause 1 year after surgery, we could successfully perform en bloc resection of lung cancer invading the spine after induction chemoradiotherapy.
Conflict of interest Fig. 4 En bloc resected specimen including the body of the second (II) and third (III) thoracic vertebra, the attached tumor, right upper lobe (RUL), and right chest wall.
1. Discussion NSCLC with substantial invasion of vertebral bodies was usually considered a contraindication to operation due to poor long-term survival [2], but nowadays there are several reports indicating that an aggressive multidisciplinary approach to NSCLC with vertebral invasion can lead to longterm survival with acceptable morbidity [3—5]. The recent advances in chemotherapy and/or radiotherapy have made it possible to control distant metastasis or local recurrence. Furthermore, the recent evolution of sophisticated spinal stabilization techniques has allowed larger portions of the vertebral body to be resected successfully and safely [1]. As a result, if complete surgical resection is possible with or without induction therapy, then surgery itself will be the therapy of choice for NSCLC with vertebral invasion. In our patient, we performed en bloc resection of NSCLC fixed to the vertebral column through thoracotomy and
None.
References [1] Mazel Ch, Grunenwald D, Laudrin P, Marmorat JL. Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases. Spine 2003;28:782—92. [2] Ginsberg RJ, Martini N, Zaman M, Armstrong JG, Bains MS, Burt ME, et al. Influence of surgical resection and brachytherapy in the management of superior sulcus tumor. Ann Thorac Surg 1994;57:1440—5. [3] Grunenwald DH, Mazel C, Giard P, Veronesi G, Spaggiari L, Gossot D, et al. Radical en bloc resection for lung cancer invading the spine. J Thorac Cardiovasc Surg 2002;123:271—9. [4] Gandhi S, Walsh GL, Komaki R, Gokaslan ZL, Nesbitt JC, Putnam Jr JB, et al. A multidisciplinary surgical approach to superior sulcus tumors with vertebral invasion. Ann Thorac Surg 1999;68:1778—85. [5] Yokomise H, Gotoh M, Okamoto T, Yamamoto Y, Ishikawa S, Liu D, et al. En bloc vertebrectomy for lung cancer invading the spine after induction chemotherapy. Eur J Cardiothorac Surg 2007;31:788—90.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/lungcan
CASE REPORT
En bloc total vertebrectomy for lung cancer invading the spine Fengshi Chen a, Ayuko Takahashi a, Mitsugu Omasa a, Masashi Neo b, Shunsuke Fujibayashi b, Hiromi Wada a, Toru Bando a,∗ a b
Department of Thoracic Surgery, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
Received 4 November 2007; received in revised form 27 November 2007; accepted 2 December 2007
KEYWORDS Chest wall; En bloc resection; Lung cancer; Lung cancer surgery; Total spondylectomy; Vertebral invasion
Summary Introduction of spinal surgery into lung cancer operations has made extensive operations feasible with an acceptable long-term survival. We report our successful experience of en bloc total vertebrectomy for lung cancer invading the spine. A 49-year-old man was found to have squamous cell carcinoma of the posterior apex of the right lung with an invasion of the body of the second and third thoracic vertebra. After induction chemoradiotherapy, we performed en bloc resection through thoracotomy and posterior median approach. Vertebral stabilization was achieved with a rod fixation and a placement of titanium mesh cage packed with autogenous bone chips. © 2007 Elsevier Ireland Ltd. All rights reserved.
It is generally accepted that locally advanced resectable non-small cell lung cancer (NSCLC) should be resected; however, the treatment of patients for NSCLC with vertebral body invasion remains challenging. The introduction of spinal surgery into lung cancer operations has made extensive operations for NSCLC feasible with an acceptable long-term survival [1]. Herein, we report our experience of en bloc total vertebrectomy for lung cancer invading the spine. A 49-year-old man was found to have squamous cell carcinoma of the posterior apex of the right lung with an invasion of the body of the second and third thoracic vertebra and adjacent rib, as shown on chest computed
∗ Corresponding author. Tel.: +81 75 751 4975; fax: +81 75 751 4974. E-mail address: [email protected] (T. Bando).
tomographic scan (Fig. 1A). Pretreatment TNM staging was IIIb (T4N0M0). Induction chemoradiotherapy with two cycles of carboplatin and paclitaxel and a dose of 64 Gy obtained a moderate decrease in tumor size (Fig. 1B). After restaging confirmed a persistent T4N0M0 tumor, an en bloc resection was planned. The surgical procedure included three steps. Firstly, the patient was placed in a left decubitus position. A long posterior thoracotomy incision was made. It started superiorly midway between the spinous process of the seventh cervical vertebra and the posterior aspect of the scapula, described a gentle arc between the thoracic spinous processes and the medial margin of the scapula, extended downward 2 cm below the inferior angle of the scapula, and curved up anteriorly to the anterior axillary line. This incision allowed the section of the chest wall in tumor-free margins. At thoracotomy, a right fourth rib was resected and preserved for bone grafting for vertebral body reconstruc-
0169-5002/$ — see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2007.12.004
138
F. Chen et al.
Fig. 2 Through median posterior approach, laminectomy from T1 to T4 was performed. Pedicle screws were inserted bilaterally at C7, T1, T5 and T6 on the right (arrows). The dura mater can be seen (arrowheads).
Fig. 1 (A) Chest computed tomography on admission revealed the tumor invading into the second and third thoracic vertebra. (B) Chest computed tomography after induction chemoradiotherapy showed that tumor decreased in size, but that it still invaded into the thoracic vertebra.
tion. Vessels for right upper lobe and right upper bronchus were dissected. The prevertebral plane at the upper thoracic level was separated from the posterior mediastinum (esophagus). Intervertebal discs of T1/2 and T3/4 were curetted as best as possible. Mediastinal lymph node dissection was also performed. The thoracotomy was temporarily closed. Second, the patient was placed in a prone position with a Mayfield head clamp and median posterior incision from the level of C5 to that of T7 was performed. Pedicle screws were inserted bilaterally at C7, T1, T5, and T6 using a computerassisted navigation system, and laminectomy from T1 to T4 was performed (Fig. 2). On the left side, transverse processes and pedicles from T2 to T4 were resected, and the costovertebral joints were disarticulated (T2—T4), which allowed us to reach the anterior aspect of the vertebrae. On the right side, the same procedure was performed except T2/3 level, to preserve the vertebrae—tumor—third rib complex intact. Then the bilateral T2 and T3 roots were dissected, and the T1/2 and 3/4 discs were cut using a thread saw. After right unilateral rod fixation was performed, the surgical specimen including vertebral bodies (T2 and T3), the attached tumor, lung, and right chest wall was translated forward, then rotated around the cord, and extracted en bloc (Fig. 3). After the removal of the tumor block, a contralateral rod fixation completed stabilization of the spine and spinal cord. Vertebral body reconstruction was achieved with a placement of titanium mesh cage packed with bone
chips made of an autogenous fourth rib which was resected at thoracotomy. The posterior wound was closed. Lastly, the patient was placed in a left decubitus position again. The last step was to reconfirm the hemostasis and close the thoracotomy. Pathologic examination confirmed the complete resection of a squamous cell carcinoma invading the body of the second and third thoracic vertebra (Fig. 4). There was no lymph node involvement. His postoperative course was without problems, and he was discharged home almost 1 month after surgery. He had not shown any findings indicating recurrence, but he died 1-year postoperatively from sepsis at a regional hospital.
Fig. 3 After right unilateral rod fixation was performed, the surgical specimen including vertebral bodies, right upper lobe with the tumor, and right chest wall was extracted en bloc. After the removal of the tumor block, a contralateral rod fixation was under way to complete stabilization of the spine and spinal cord. The right thorax (arrow) and the dura mater (arrowheads) can be seen.
Total vertebrectomy for lung cancer
139 posterior median approach. Several approaches have been reported [3—5], but posterior approach in addition to thoracotomy is necessary even when partial vertebrectomy is considered, since only this approach allows safe section of the vertebral body and nerve roots [5]. In such challenging tumors, complete resection with negative margin is the most important factor for the long-term survival [3—5]. In our patient, the tumor was completely resected with negative margins. In conclusion, although our patient died of an unrelated cause 1 year after surgery, we could successfully perform en bloc resection of lung cancer invading the spine after induction chemoradiotherapy.
Conflict of interest Fig. 4 En bloc resected specimen including the body of the second (II) and third (III) thoracic vertebra, the attached tumor, right upper lobe (RUL), and right chest wall.
1. Discussion NSCLC with substantial invasion of vertebral bodies was usually considered a contraindication to operation due to poor long-term survival [2], but nowadays there are several reports indicating that an aggressive multidisciplinary approach to NSCLC with vertebral invasion can lead to longterm survival with acceptable morbidity [3—5]. The recent advances in chemotherapy and/or radiotherapy have made it possible to control distant metastasis or local recurrence. Furthermore, the recent evolution of sophisticated spinal stabilization techniques has allowed larger portions of the vertebral body to be resected successfully and safely [1]. As a result, if complete surgical resection is possible with or without induction therapy, then surgery itself will be the therapy of choice for NSCLC with vertebral invasion. In our patient, we performed en bloc resection of NSCLC fixed to the vertebral column through thoracotomy and
None.
References [1] Mazel Ch, Grunenwald D, Laudrin P, Marmorat JL. Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases. Spine 2003;28:782—92. [2] Ginsberg RJ, Martini N, Zaman M, Armstrong JG, Bains MS, Burt ME, et al. Influence of surgical resection and brachytherapy in the management of superior sulcus tumor. Ann Thorac Surg 1994;57:1440—5. [3] Grunenwald DH, Mazel C, Giard P, Veronesi G, Spaggiari L, Gossot D, et al. Radical en bloc resection for lung cancer invading the spine. J Thorac Cardiovasc Surg 2002;123:271—9. [4] Gandhi S, Walsh GL, Komaki R, Gokaslan ZL, Nesbitt JC, Putnam Jr JB, et al. A multidisciplinary surgical approach to superior sulcus tumors with vertebral invasion. Ann Thorac Surg 1999;68:1778—85. [5] Yokomise H, Gotoh M, Okamoto T, Yamamoto Y, Ishikawa S, Liu D, et al. En bloc vertebrectomy for lung cancer invading the spine after induction chemotherapy. Eur J Cardiothorac Surg 2007;31:788—90.