Prezerakos Georgios K, Sayal Parag, Kourliouros Antonios, Pericleous Periclis, Ladas George, Casey Adrian
Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
Royal Brompton Hospital, Sydney Street, London, UK.
Eur Spine J. 2018 Apr;27(4):902-912. doi: 10.1007/s00586-018-5512-5. Epub 2018 Feb 14.
Cervicothoracic paravertebral neoplasms extending into the mediastinum pose a surgical challenge due the complex regional anatomy, their biological nature, rarity and surgeon's unfamiliarity with the region. We aim to define a surgical access framework addressing the aforementioned complexities whilst achieving oncological clearance.
We carried out a retrospective review of 28 consecutive patients operated in two tertiary referral centres between 1998 and 2015. Pathology was located paravertebrally from C6 to T4 with superior mediastinum invasion. Patients were operated jointly by a spinal and a thoracic surgeon.
Tumours were classified according to subclavian fossa involvement as anteromedial, anterolateral and posterior and according to histology in benign nerve sheath tumour group (n = 10) and malignant bone or soft tissue tumours (n = 18). Three surgical routes were utilised: (1) median sternotomy (n = 11), (2) anterior cervical transsternal approach (n = 7) and (3) high posterolateral thoracotomy (n = 10). Resection was en bloc with wide margins in 22 cases, marginally complete in 3 and incomplete in 3. Complications included Horner's syndrome (n = 3), infection (n = 2) and transient neurological deficit (n = 4). In the nerve sheath tumour group, no recurrence or reoperation took place with a median follow-up of 4.5 years. In the malignant bone and soft tissue group, 96% of the patients were alive at 1 year, 67% at 2 years and 33% at 5 years. No vascular injuries or operative related deaths were observed.
Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relationship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides minimal morbidity/maximum resection and satisfactory oncological outcomes. These slides can be retrieved under Electronic Supplementary Material.
由于该区域解剖结构复杂、肿瘤生物学特性特殊、发病率低以及外科医生对该区域不熟悉，延伸至纵隔的颈胸段椎旁肿瘤的手术治疗颇具挑战。我们旨在定义一种手术入路框架，以应对上述复杂性，同时实现肿瘤学上的根治。
我们对1998年至2015年间在两家三级转诊中心连续接受手术的28例患者进行了回顾性研究。病理检查发现肿瘤位于C6至T4椎旁并侵犯上纵隔。患者由脊柱外科医生和胸外科医生联合手术。
根据锁骨下窝受累情况，肿瘤分为前内侧、前外侧和后部，并根据组织学分为良性神经鞘瘤组（n = 10）和恶性骨或软组织肿瘤组（n = 18）。采用了三种手术路径：（1）正中胸骨切开术（n = 11），（2）颈前经胸骨入路（n = 7）和（3）高位后外侧开胸术（n = 10）。22例患者实现了广泛切缘的整块切除，3例为边缘完整切除，3例为不完全切除。并发症包括霍纳综合征（n = 3）、感染（n = 2）和短暂性神经功能缺损（n = 4）。在神经鞘瘤组中，中位随访4.5年，无复发或再次手术情况。在恶性骨和软组织组中，1年生存率为96%，2年生存率为67%，5年生存率为33%。未观察到血管损伤或手术相关死亡。
根据与锁骨下窝的关系以及多学科参与对伴有纵隔延伸的颈胸段椎旁肿瘤进行分类，可以采用结构化的手术方法，实现最小的发病率/最大程度的切除，并获得满意的肿瘤学结局。这些幻灯片可在电子补充材料中获取。
