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Combined Video Assisted Lobectomy and En Bloc Vertebral Resection for a T4 Non-Small Cell Lung Cancer

Monday, May 10, 2010

STSA Surgical Motion Picture 2009 Annual Meeting

This case illustrates a combined video assisted right upper lobectomy followed by en bloc resection of involved chest wall and vertebral body through a posterior approach. It demonstrates that minimally invasive techniques may be applied to patients with advanced lung cancers to reduce patient morbidity.

A 56 year old male smoker developed a left piriform sinus squamous cell cancer. This was treated with a total laryngectomy, total pharyngectomy, bilateral neck dissections and left radial forearm fasciocutaneous free tissue transfer for pharyngoesophageal reconstruction. Tumor stage was T2N2. He received adjuvant cisplatin chemotherapy and ajuvant radiation with a high neck IMRT field to 66 Gy and a low neck field to 50 Gy with a 16 Gy boost. Surveillance CT scans demonstrated the development of a right upper lobe lung mass with limited involvement of the third thoracic vertebrae. Needle biopsy was of the mass was positive for squamous cell carcinoma. FDG-PET scan demonstrated no evidence of regional or distant metastatic disease. After review of his previous radiation fields, further radiation therapy was withheld. He was treated with three cycles of neoadjuvant cisplatin and docetaxel chemotherapy. Re-staging demonstrated no progression of disease.

The patient was taken to the operating room for a video assisted right upper lobectomy and followed by an en block resection of the lung and the involved vertebral body through a posterior approach. After entering the right pleural space the tumor was indentified invading the chest wall and third vertebral body. Using cautery, a trench with a 1 to 2 cm margin was created surrounding the area of invasion by the lung tumor. This trench extended through the endothoracic fascia. Next an anatomic right upper lobectomy was performed. First the superior pulmonary vein was divided. Next the truncus anterior branch of the pulmonary artery was encircled and divided. Lastly, the bronchus was divided with a heavy wire endoscopic stapler. The minor fissure and posterior portion of the major fissure were then divided with and endoscopic stapler. This left the right upper lobe attached only at the area of tumor adherence to the vertebral body. A supreme intercostals vein was seen to be running behind the tumor and was ligated. The chest incisions were then closed.

The patient was subsequently placed in a prone position in an open Jackson frame. A posterior midline incision was made and the vertebral column was exposed. Posterior spinal instrumentation with bilateral pedicle screws was performed next to provide stability. Screws were placed through the pedicles of the first through sixth thoracic vertebral bodies on the left and the first, second, fifth and sixth on the right. A rod was placed through the pedicle screws on the left prior to resection. Subsequently, a subtotal corpectomy of the third thoracic vertebral body was performed en bloc with the lung mass, the right upper lobe of the right lung and the involved portions of the second through fourth ribs on the right. An anterior spinal fusion of the second through fourth thoracic vertebral bodies was then performed using allograft. This was followed by placement of a rod through the right sided pedicle screws to complete stabilization.

The pathologic specimen included the right upper lobe of the lung, the third thoracic vertebral body and adjoining chest wall. Final pathology demonstrated a T3N0 squamous cell lung cancer. This case demonstrates that a combined video assisted pulmonary resection with a posterior en bloc vertebral resection is feasible for select stage T4 lung cancers.

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