Posterior Approach to the Cervicothoracic Junction (Pancoast Tumor Surgery)

Published on 02/04/2015 by admin

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Last modified 02/04/2015

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Chapter 22 Posterior Approach to the Cervicothoracic Junction (Pancoast Tumor Surgery)

INTRODUCTION

Primary carcinomas arising in the apex of the lung (Pancoast tumors) can extend into the chest wall and the brachial plexus, causing the characteristic Pancoast syndrome (Fig. 22-1). The classic Pancoast syndrome of rib erosion, shoulder pain radiating down the arm, and Horner’s syndrome results from destruction of the first rib extending typically to involve the T1 nerve root and stellate ganglion of the brachial plexus (Fig. 22-2).1

Factors that affect local tumor control and survival are the completeness of tumor resection, TNM (tumor size, node status, metastatic disease) status, and possibly the extent of lung resection.24 The completeness of tumor resection is often limited by the degree of spinal and brachial plexus involvement. In the past, spinal involvement was not a surgical indication. However, advanced surgical techniques and magnetic resonance imaging (MRI) for spine and brachial plexus tumors have led to a reassessment of their respectability. Recently, induction chemoradiation protocols have resulted in an improved ability to achieve pathologically complete histological tumor responses, which may ultimately improve the rates of complete resection and long-term survival.

PREOPERATIVE EVALUATION

RADIOLOGICAL EVALUATION

A preoperative MRI classification scheme was devised to assess the degree of spinal element involvement and the type and extent of operation required for tumor resection. MRI findings are divided into four classes based on the degree of involvement of the spinal column and neural structures (Table 22-1).5 Class A tumors involve the vertebral body (VB) periosteum only, and Class B tumors involve the proximal rib head and distal neural foramen without epidural involvement (Fig. 22-3). Class C and D tumors often are not amenable to en bloc resection in which gross-total resection can be achieved. Class C tumors extend through the neural foramen with minimal or no vertebral body involvement but with unilateral epidural compression. Class D tumors involve the vertebral column (vertebral body and/or lamina) with or without epidural compression (Fig. 22-4).

Table 22-1 Radiological evaluation

Magnetic Resonance Imaging Staging System
Class Description
A Vertebral body periosteum only
B Extension of tumor into distal neural foramen
C Extension of tumor into proximal neural foramen and/or epidural space
D Vertebral body or posterior element infiltration with our without epidural tumor

SURGICAL TECHNIQUE

CLASS A AND B LESIONS