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Video-assisted pulmonary lobectomy combined with transmanubrial approach for anterior Pancoast tumor resection: case report
© Rosso et al. 2016
Received: 5 October 2015
Accepted: 4 April 2016
Published: 14 April 2016
The mini-ivasive approach to superior sulcus tumors is an uncommon procedure that is still far from standardization. We describe a hybrid surgical technique to approach “en block” chest resection and pulmonary lobectomy for anterior superior sulcus tumors.
A patient affected by right anterior Pancoast tumor surgically staged as cT4N0M0 (suspected anonymous vein invasion) underwent chemo-radiation induction therapy with satisfactory tumor reduction. The surgical operation comprised an initial VATS approach to the hilar structures followed by a limited C-shaped anterior contra-incision; finally, the right upper lobe “en block” with the anterior part of the first and second rib was removed. The whole procedure was conducted with the patient in the supine position; no rib retractors were used. The definitive stage was ypT0N0M0. The patient had an uneventful hospital stay and at the 9 months follow-up she was free from disease and post-thoracotomy syndrome.
In our opinion such hybrid VATS procedure has several advantages: starting with thoracoscopy it is possibleto exclude previously undetected pleural dissemination and to precisely define the tumor location as well as limits of the thoracic wall resection; time could be spared maintaining the patients in the supine position for both surgical times; postoperative pain and post-thoracotomy syndrome could be minimized avoiding the use of any rib retractor.
Thoracoscopic “en bloc” chest wall resection is a procedure not fairly usual for Video-assisted thoracoscopic surgery (VATS) lobectomy; this report describes technical details of an emerging new surgical procedure consisting in a hybrid technique for treatment of anterior Pancoast tumor.
Reported clinical experiences
Free Interval (weeks)
Cisplatin + etoposide
Supine + Lateral
1st rib + T1 root + Subcl. vein
Right arm mild edema
Cisplatin + Mitomycin C + Vindesine +45 Gy
1st rib + T1 root + Scalene m.
Left lung atelectasis
Phrenic nerve paralysis
Cisplatin + docetaxel + 60 Gy
Supine + Lateral
Lateral + Supine
1st + 2nd ribs
Carboplatin + Paclitaxel + 50 Gy
Lateral + Supine
1st rib + Subcl. vein
Carboplatin + Paclitaxel + 40 Gy
Lateral + Supine
Clavicle + 1st + 2nd ribs
Cisplatin + Pemetrexed + 60 Gy
1st + 2nd ribs
Postoperative pain never excided 4 on the visual analog scale; neither intraoperative nor postoperative complications were observed and the patient was discharged 9 days after surgery (pathological result: ypT0N0M0). At the twelve-month follow-up the patient was free from disease and post-thoracotomy syndrome.
Discussion and conclusions
In our opinion, the VATS procedure had several theoretical advantages. Rib retractors, known source of pain, were not used in any of the incisions; lobectomy was conducted through well-known accesses avoiding the uncommon transmanubrial adit for lobar dissection; Grunenwald contra-incision was shortened; unnecessary resection of thoracic wall was avoided. The “VATS observation first” has the advantage to exclude previously undetected pleural dissemination and to precisely define the tumor location; for instance, a needle inserted through the chest wall under endoscopic vision can help in focusing and minimizing the resection of rib segments. The majority of Authors change the patients’ position during the operation; on the contrary, we experienced a simple lobar dissection with the patient in the supine position: adopting the anterior approach to the hilar structures (Copenhagen approach), there is no reason to move the parenchyma from the position that it takes naturally after exclusion from the ventilation. In addition, we avoided the time-consuming maneuvers for patient repositioning (not less than 30 min in our theater) and the risk of endotracheal tube displacement.
We modified the Grunenwald incision extending the sternal section to the second intercostal space and reducing the lateral extension on the caudal edge; such variation was created in order to guarantee an easy access to great venous vessels.
Despite the experiences in hybrid approach to anterior Pancoast tumors are limited and technical details are inhomogeneous, it is possible to argue that the mini-invasive surgery could be effective on these patients. We strongly support the “VATS observation first” philosophy and patient supine position to face anterior Pancoast tumor with hybrid techniques. Further studies are advisable in order to define the real advantage of hybrid approaches on open surgery.
A written consent for publication was obtained from the patient.
A special thanks to Professor H. Date for data update.
No funding was provided.
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