Mazel Ch, Grunenwald D, Laudrin P, Marmorat J L
Orthopaedic Department, Institut Mutualiste Montsouris, Paris, France.
Spine (Phila Pa 1976). 2003 Apr 15;28(8):782-92; discussion 792. doi: 10.1097/01.BRS.0000058932.73728.A8.
A new surgical technique for en bloc resection of posterior mediastinum tumors invading the spine is described.
To demonstrate that major soft tissue tumors of the thoracic apex (Pancoast Tobias syndrome) or posterior mediastinum tumors can be removed en bloc even though the vertebral body or the foramina are invaded.
En bloc surgery of tumor is accepted today as being the goal of carcinologic surgery with the best results for survival. Until now, no surgical technique has been described for radical excision of soft tissue tumors invading the thoracic spine adjacent to the ribs and lung. We reviewed our 8 years' experience of 36 such cases and report outcome and survival rates.
The authors have joined their abilities and technique to enable complete en bloc extratumoral resections of lung tumors or posterior mediastinum tumors invading the adjacent soft tissue and spine. The surgical technique recommended by the authors is different at the cervicothoracic and medium thoracic level. At the cervicothoracic level, the authors first perform an anterior approach with dislocation of the sternoclavicular joint and dissection of the subclavian vessels with exposure of the brachial plexus. Dissection of the tumor from the anterior soft tissues is then performed but is kept attached to the adjacent spine. Dissection of lung hilum and its division are done through the same approach. At the thoracic level, the authors perform a posterior lateral thoracotomy for dissection of lung hilum and division of its elements. The lung and the adjacent tumoral ribs are not removed but are carefully kept undissected against the spine. Thoracoscopy can replace the open thoracotomy in small and medium-sized tumors. En bloc extratumoral resection is the second step performed through a median posterior cervicothoracic or thoracic approach. Vertebrectomy is complete or partial depending on the type of extension against or inside the vertebrae.
Thirty-six cases have been operated on with this technique. Vertebrectomy was complete in seven cases and partial in 29. Follow-up ranges from 6 days to 7.2 years (average, 23.3 months). One patient died 1 year postoperatively from an unrelated cause. Only 35 patients are available for follow-up analysis. Twenty-one patients (60%) are dead, with an average survival of 16.7 months 8 days to 44 months. The 14 others (40%) are alive (average, 38.26 months; range, 8-87 months).
Even though a learning curve is necessary to achieve this extreme type of surgery, selective preoperative screening of patients is mandatory. Interesting results today confirm the feasibility of possible treatment of tumors still considered unresectable.
描述了一种整块切除侵犯脊柱的后纵隔肿瘤的新手术技术。
证明即使椎体或椎间孔受到侵犯，胸尖部的主要软组织肿瘤（潘科斯特·托拜厄斯综合征）或后纵隔肿瘤也可整块切除。
肿瘤整块切除术如今被认为是肿瘤外科手术的目标，对生存效果最佳。到目前为止，尚未有针对侵犯肋骨和肺附近胸椎的软组织肿瘤进行根治性切除的手术技术描述。我们回顾了8年中36例此类病例的经验，并报告了结果和生存率。
作者联合各自的能力和技术，以实现对侵犯相邻软组织和脊柱的肺肿瘤或后纵隔肿瘤进行完整的肿瘤外整块切除。作者推荐的手术技术在颈胸段和胸中段有所不同。在颈胸段，作者首先采用前路手术，脱位胸锁关节，解剖锁骨下血管并暴露臂丛神经。然后从前方软组织中分离肿瘤，但使其与相邻脊柱相连。通过相同的入路进行肺门解剖及其分离。在胸段，作者进行后外侧开胸术以解剖肺门并分离其结构。肺和相邻的肿瘤肋骨不切除，而是小心地保持与脊柱相连而不进行分离。对于中小型肿瘤，胸腔镜可替代开胸手术。肿瘤外整块切除是通过颈胸段或胸段后正中入路进行的第二步。根据椎体侵犯或内部侵犯的类型，椎体切除术可为全椎体切除或部分椎体切除。
采用该技术进行了36例手术。7例全椎体切除，29例部分椎体切除。随访时间为6天至7.2年（平均23.3个月）。1例患者术后1年因无关原因死亡。仅35例患者可供随访分析。21例患者（60%）死亡，平均生存时间为16.7个月（8天至44个月）。其余14例（40%）存活（平均38.26个月；范围8 - 87个月）。
尽管要完成这种极端类型的手术需要学习曲线，但对患者进行选择性术前筛查是必要的。如今有趣的结果证实了对仍被认为无法切除的肿瘤进行可能治疗的可行性。
