ANTERIOR TRANSCERVICAL-THORACIC APPROACH FOR RADICAL RESECTION OF LUNG-TUMORS INVADING THE THORACIC INLET

We describe an original anterior transcervical-thoracic approach requi red for a safe exposure and radical resection of non-small-cell lung c ancer 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 perf ormed: (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 sp inal 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 pos terior thoracotomy may be required for resection of the chest wall bel ow the second rib. Between 1980 and 1991, 29 patients underwent radica l en bloc resection of the inlet tumor, chest wall (ribs 1 and 2), and underlying lung, either through the anterior transcervical approach a lone (n = 9) or with an additional posterior thoracotomy (n = 20). The inferior root of the brachial plexus, either alone (n = 11) or with t he phrenic nerve (n = 4), was involved and resected in 15 patients (52 %). Twelve patients (41 %) had a vascular involvement that included th e subclavian artery alone (n = 3); subclavian artery and subclavian ve in (n = 3); subclavian artery, subclavian vein, and vertebral artery ( n = 2); subclavian artery and vertebral artery (n = 1); subclavian vei n 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 anastom osis (n = 2), and the median graft patency was 18.5 months (range, 6 t o more than 73 months); only 1 patient had postradiotherapy graft occl usion in the revascularized artery 6 months after operation. We perfor med 14 wedge resections, 14 lobectomies, and 1 pneumonectomy. There we re no operative or hospital deaths. Postoperative radiotherapy (median , 56 Gy) was given to 25 (86%) patients, either alone (n = 14) or in c ombination 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 inv olving the thoracic inlet and results in encouraging long-term surviva l.