J Thorac Cardiovasc Surg 1999;117:1042-1044
© 1999 Mosby, Inc.
Anterior approach to the superior sulcus tumors: The transmanubrial osteomuscular sparing approach
Lorenzo Spaggiari, MD, PhD,
Ugo Pastorino, MD
Department of Thoracic Surgery
European Institute of Oncology
Via Ripamonti 435
Milan 20141, Italy
Anterior approach to the superior sulcus tumors: The transmanubrial osteomuscular sparing approach
To the Editor:
We read with great interest the brief communication by Onuki and associates
1 concerning a new modification of the anterior approach to superior sulcus tumors. The surgical treatment of cervicothoracic tumors has long been a challenge for thoracic surgeons, and the search of the "ideal" approach has influenced the development of different proposals. All the same, the treatment of apical chest tumors presents two series of problems: (1) dissection of the neoplasm from the cervicothoracic structures and (2) pulmonary hilar and lymph node dissection.
Concerning the first problem, three main approaches are available: the hemi-clamshell and Masaoka techniques, the anterior transcervical approach, and finally the transmanubrial osteomuscular sparing approach (TMA). The advantages and limits of each type have been widely reported and discussed elsewhere, 2-4 and each new proposal should be compared with these documented approaches.
Theoretically, the ideal approach for the treatment of lung cancer should reach the following oncologic and functional targets: (1) wide exposure of the thoracic inlet and outlet, allowing the control of the vessels arising from the subclavian artery as well as the control of the axillary and innominate arteries in case of subclavian artery en bloc resection, (2) the possibility to dissect the brachial plexus, (3) the complete resection of cervical lymph nodes, (4) the posterior resection or disarticulation of the first and second ribs when infiltrated, (5) the possibility to preserve the muscular insertions of the cervicothoracic muscles to improve cervical and chest wall stability, and finally (6) the maintenance of the integrity of the clavicle with its articulation with the manubrium and its muscular insertions (sternocleidomastoid and major pectoral muscles).
Onuki and colleagues 1 again propose that the clavicle be sectioned, a procedure that has repeatedly been demonstrated to be unnecessary. 2-4 In fact, sacrificing the clavicle contributes to shoulder instability, weakness, and deformity, mainly when a large chest wall resection or vertebrectomy is associated. In any case, even when reinstalled, fixation of the sternoclavicle articulation can lead to shoulder immobility or, more frequently, to painful pseudoarthrosis. Besides, Onuki has clearly confirmed in his series that fixing the two stumps of the clavicle with wires of plates is frequently insufficient and associated with late fracture, mainly in patients who underwent preoperative radiotherapy. The results of this series are paradigmatic; 60% (3/5) of the patients had late insufficient fixation or fracture of the reinstalled clavicle. 1 In conclusion, even reimplantation of the clavicle can be associated with important disadvantages for the patient. This is clearly one of the reasons for the increased popularity of the TMA. 3,4 With this approach the operative cervicothoracic field is wide (Fig. 1), permitting subclavian artery resection 5 but respecting osteoarticular and muscular components.
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Fig 1. Operative photograph. This patient underwent the TMA for an apical non–small cell lung carcinoma invading the anterior part of the first and second ribs.
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The second problem concerning lung resection and hilar lymph nodes dissection can be solved by a further posterolateral thoracotomy, a median sternotomy, or by resecting the third and fourth cartilages during the TMA. The possibility to modulate the thoracic approach according to the pulmonary resection required and the surgeon's preference is another important advantage of the TMA.
For apical non–small cell lung carcinoma without vertebral invasion, we have recently been combining TMA plus anterolateral muscle sparing thoracotomy, which does not necessitate changing the patient's position on the operating table. This approach is excellent in terms of lung resection and radical lymph node dissection (Figs. 1
to 3). At present our experience includes 13 cases of TMA performed for different cervicothoracic tumors (8 cases of apical non–small cell lung carcinoma). In this series, early and late functional and aesthetic results of the cervicothoracic approach were excellent.
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Fig 2. Operative photograph of the same patient shown in Fig 1. An upper right lobectomy with radical lymph node dissection was performed through the anterior muscle sparing thoracotomy. The analysis of the specimen showed a pT3 pN0 non–small cell lung carcinoma.
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Even though the choice among the different approaches still depends on surgeon preference, in recent years TMA has been progressively adopted by several European thoracic surgeons, mainly because it provides wider exposure combined with less invasiveness for the patient.
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References
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Onuki T, Murasugi M, Mae M, Sone Y, Kei J, Nitta S. Modification of anterior approach to superior sulcus tumor. J Thorac Cardiovasc Surg 1998;116:663-4. [Free Full Text]
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Korst RJ, Burt ME. Cervicothoracic tumors: results of resection by the "hemi-clamshell" approach. J Thorac Cardiovasc Surg 1998;115:286-95. [Abstract/Free Full Text]
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Grunenwald D, Spaggiari L. Transmanubrial osteomuscular sparing approach for apical chest tumor. Ann Thorac Surg 1997;63:563-6. [Abstract/Free Full Text]
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Grunenwald D, Spaggiari L, Girard P, Baldeyrou P. Transmanubrial approach to the thoracic inlet. J Thorac Cardiovasc Surg 1997;113:958-9. [Free Full Text]
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Spaggiari L, Pastorino U. Subclavian artery involvement by apical chest tumors: a specific indication for the transmanubrial approach [letter]. J Thorac Cardiovasc Surg 1999;117:627.
