Dartevelle P G, Chapelier A R, Macchiarini P, Lenot B, Cerrina J, Ladurie F L, Parquin F J, Lafont D
Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, Le Plessis Robinson, France.
J Thorac Cardiovasc Surg. 1993 Jun;105(6):1025-34.
We describe an original anterior transcervical-thoracic approach required for a safe exposure and radical resection of non-small-cell lung cancer 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 performed: (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 spinal 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 posterior thoracotomy may be required for resection of the chest wall below the second rib. Between 1980 and 1991, 29 patients underwent radical en bloc resection of the inlet tumor, chest wall (ribs 1 and 2), and underlying lung, either through the anterior transcervical approach alone (n = 9) or with an additional posterior thoracotomy (n = 20). The inferior root of the brachial plexus, either alone (n = 11) or with the phrenic nerve (n = 4), was involved and resected in 15 patients (52%). Twelve patients (41%) had a vascular involvement that included the subclavian artery alone (n = 3); subclavian artery and subclavian vein (n = 3); subclavian artery, subclavian vein, and vertebral artery (n = 2); subclavian artery and vertebral artery (n = 1); subclavian vein 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 anastomosis (n = 2), and the median graft patency was 18.5 months (range, 6 to more than 73 months); only 1 patient had postradiotherapy graft occlusion in the revascularized artery 6 months after operation. We performed 14 wedge resections, 14 lobectomies, and 1 pneumonectomy. There were no operative or hospital deaths. Postoperative radiotherapy (median, 56 Gy) was given to 25 (86%) patients, either alone (n = 14) or in combination 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 involving the thoracic inlet and results in encouraging long-term survival.
我们描述了一种原始的经颈胸前路手术方法，该方法对于安全暴露和根治性切除侵犯胸廓入口颈部结构的非小细胞肺癌是必需的。通过一个大的L形颈前切口，在切除锁骨内侧半后，可进行以下步骤：（1）解剖或切除锁骨下静脉；（2）切断前斜角肌并切除受侵犯的膈神经颈段；（3）暴露锁骨下动脉和椎动脉；（4）将臂丛神经解剖至椎间孔；（5）切断受侵犯的肋骨；（6）直接或通过将颈切口延伸至三角胸肌沟整块切除胸壁和肺肿瘤。对于切除第二肋以下的胸壁，可能需要额外进行后外侧开胸手术。1980年至1991年间，29例患者接受了整块根治性切除胸廓入口肿瘤、胸壁（第1和第2肋）及下方肺组织，其中单独通过经颈前路手术（n = 9）或联合额外后外侧开胸手术（n = 20）。15例患者（52%）的臂丛神经下干单独（n = 11）或与膈神经一起（n = 4）受侵犯并被切除。12例患者（41%）有血管受侵犯，包括单独侵犯锁骨下动脉（n = 3）；锁骨下动脉和锁骨下静脉（n = 3）；锁骨下动脉、锁骨下静脉和椎动脉（n = 2）；锁骨下动脉和椎动脉（n = 1）；单独侵犯锁骨下静脉（n = 1）；单独侵犯椎动脉（n = 1），或锁骨下动脉和椎动脉（n = 1）。锁骨下动脉通过人工血管置换（n = 7）或端端吻合（n = 2）进行血管重建，人工血管通畅时间中位数为18.5个月（范围为6至超过73个月）；仅1例患者在术后6个月出现放疗后血管重建动脉人工血管闭塞。我们进行了14例楔形切除术、14例肺叶切除术和1例全肺切除术。无手术或医院死亡病例。25例（86%）患者接受了术后放疗（中位数为56 Gy），单独放疗（n = 14）或联合辅助全身化疗（n = 11）。中位随访时间为2.5年，总体2年和5年生存率分别为50%和31%。这种经颈胸入路为涉及胸廓入口的非小细胞肺癌提供了安全的暴露和根治性切除，并带来了令人鼓舞的长期生存结果。
