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A multidisciplinary surgical approach to superior sulcus tumors with vertebral invasion

A multidisciplinary surgical approach to superior sulcus tumors with vertebral invasion
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   1999;68:1778-1784  Ann Thorac Surg Reginald F. Munden and Stephen G. Swisher Nesbitt, Joe B. Putnam, Jr, Jack A. Roth, Kelly W. Merriman, Ian E. McCutcheon, Sunil Gandhi, Garrett L. Walsh, Ritsuko Komaki, Ziya L. Gokaslan, Jonathan C.  invasionA multidisciplinary surgical approach to superior sulcus tumors with vertebral the World Wide Web at: The online version of this article, along with updated information and services, is located Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 1999 by The Society of Thoracic Surgeons. is the official journal of The Society of Thoracic Surgeons and the The Annals of Thoracic Surgery  by on May 31, 2013 ats.ctsnetjournals.orgDownloaded from   A Multidisciplinary Surgical Approach to SuperiorSulcus Tumors With Vertebral Invasion Sunil Gandhi,  MD  , Garrett L. Walsh,  MD  , Ritsuko Komaki,  MD  , Ziya L. Gokaslan,  MD  , Jonathan C. Nesbitt,  MD  , Joe B. Putnam, Jr,  MD  , Jack A. Roth,  MD  ,Kelly W. Merriman,  MPH  , Ian E. McCutcheon,  MD  , Reginald F. Munden,  MD  , andStephen G. Swisher,  MD Departments of Thoracic and Cardiovascular Surgery, Radiation Oncology, Neurosurgery, and Radiology, The University of TexasM.D. Anderson Cancer Center, Houston, Texas Background . Vertebral body invasion by superior sul-cus tumor has traditionally been considered a contrain-dication to surgical resection. Attempts at definitive ra-diation or chemoradiation have not been successful.Recent advances in spinal instrumentation have allowedmore complete resection of vertebral body tumors. We,therefore, reviewed our recent experience with vertebralresection of superior sulcus tumors.  Methods . All patients (n  17) undergoing resection ofsuperior sulcus tumors with T4 involvement of the ver-tebrae from October 18, 1990 to September 21, 1998 at theUniversity of Texas M.D. Anderson Cancer Center(MDACC) were evaluated. Their clinical and pathologicdata were reviewed and analyzed for short- and long-term outcomes. Results . Total vertebrectomy was performed in 7 pa-tients (42%), partial vertebrectomy in 7 (42%), and 3 (18%)underwent neural foramina or transverse process resec-tion. The median hospital stay was 11 days. Postoperativecomplications occurred in 7 patients (42%) and includedpneumonia (6, 36%), arrhythmia (2, 12%), cerebrospinalfluid leak (2, 12%), wound breakdown (1, 6%), andreoperation for bleeding (1, 6%). Sixteen out of 17 pa-tients received preoperative or postoperative radiationtherapy. No perioperative mortality occurred. All pa-tients remained ambulatory after spinal reconstruction.Overall actuarial survival at 2 years was 54%, with 11patients still alive 2 to 50 months after resection. Locore-gional tumor recurrence was noted in all 6 patients whohad positive surgical margins, as opposed to 1 out of 11patients (9%) with negative margins (  p  <  0.006). Addi-tionally, the 2-year actuarial survival of patients withnegative microscopic margins was 80% versus 0% forpositive margins (  p < 0.0006). Conclusions . An aggressive multidisciplinary approachto superior sulcus tumors with vertebral invasion canlead to long-term survival with acceptable morbidity ifnegative margins can be obtained. Vertebral body inva-sion should no longer be considered a contraindicationfor resection of superior sulcus tumors.(Ann Thorac Surg 1999;68:1778–85)© 1999 by The Society of Thoracic Surgeons D efining the optimal management of superior sulcustumors continues to remain a challenge. Despitethe low incidence of metastases, the difficult location of the tumor and the propensity to invade surroundingthoracic inlet structures has made surgical resectiondifficult in many cases. Vertebral column invasion bythese tumors have traditionally been a contraindicationto surgery due to poor long-term survival [1–4]. Assuggested by Ginsberg and associates [1], failure toachieve a complete resection by traditional surgical tech-niques may be the reason for the poor long-term survivalin this group. We have recently described an aggressivemultidisciplinary approach to metastatic spinal tumors inwhich complete surgical resections can be achieved by acombination of transthoracic vertebrectomy, reconstruc-tion with methylmethacrylate, and spinal fixation withlocking plate and screw constructs [5]. This paper reportsour preliminary results with this aggressive surgicalapproach in patients with superior sulcus tumors invad-ing the vertebral body. Material and Methods We reviewed all patients (n  17) undergoing resection of superior sulcus tumors with T4 involvement of the ver-tebrae from October 18, 1990 to September 21, 1998 at theUniversity of Texas M.D. Anderson Cancer Center(MDACC). Factors evaluated included race, gender, pre-senting symptoms, preoperative medical history, tumorlocation, size, histology, and preoperative laboratory andradiographic studies. Intraoperative factors included op-erative time, estimated blood loss, transfusion require-ments, and technical details of surgery as described inResults. Preoperative radiation therapy was given by 6-or 18-MV liner accelerators to a dose of 30 Gy for 2 to 3weeks followed by surgery in 3 to 4 weeks after comple- Presented at the Thirty-fifth Annual Meeting of The Society of ThoracicSurgeons, San Antonio, TX, Jan 25–27, 1999.Address reprint requests to Dr Swisher, Department of Thoracic andCardiovascular Surgery, University of Texas M.D. Anderson CancerCenter, 1515 Holcombe Blvd, Box 109, Houston, TX 77030; © 1999 by The Society of Thoracic Surgeons 0003-4975/99/$20.00Published by Elsevier Science Inc PII S0003-4975(99)01068-1  by on May 31, 2013 ats.ctsnetjournals.orgDownloaded from   tion of radiation therapy. Postoperative radiation therapywas initiated usually 4 to 6 weeks after surgery with a totaldose of 54 Gy/27 fractions (60 Gy/30 fractions [2 Gy/fraction] or 60 Gy/50 fractions [1.2 Gy/fraction, Bid] withconcurrentcisplatinandoraletoposideasaradiosensitizer).The short- and long-term outcomes were obtained fromhospital records and the MDACC tumor registry. Recur-rences (both local and distant), perioperative adjuvanttreatments, and status at last follow-up were obtained.Statistical analysis was performed in conjunction withour departmental statistician (K.W.M). Student’s  t   test,   2  , and Fisher’s exact test were used as appropriate.Survival curves were calculated using the Kaplan-Meiermethod with log-rank     2 analysis for survival compari-sons. Statistical significance was assumed at  p    0.05. Results Characteristics of Superior Sulcus Tumors Seventeen patients underwent surgical resection of su-perior sulcus tumors meeting T4 criteria of vertebralinvasion (Table 1). All patients were male with a medianage of 56 years (range 36 to 80 years). The majority of tumors that were resected were adenocarcinoma (n  11,65%), followed by squamous cell carcinoma (n  5, 29%),and large cell carcinoma (n  1, 6%). The median size was6.3 cm (range 2 to 9 cm). The diagnosis of superior sulcustumor was made on the basis of an apical mass with ahistologic diagnosis of non-small cell lung cancer andgreater than 50% of the tumor above the first rib. Beforesurgery, the radiographic clinical stage was T3 in 4patients (nos. 1, 9, 12, and 13) and T4 in 13 patients. Aftersurgery, T4 criteria of vertebral invasion was docu-mented by surgery or pathology in all patients. Vertebralbody involvement was documented in 14 patients (82%)ranging from 10% to 50% of the vertebral body. Periostealor neural foramina involvement was noted in the otherpatients (n    3, 18%). Involvement of the subclavianartery was noted in 2 patients (12%). The majority of patients were node negative (N0, n  12, 71%), although3 patients had involved hilar nodes (N1, 18%) and 2patients had isolated ipsilateral supraclavicular nodes(N3 positive, N2 and N1 negative, 12%). Treatment of Superior Sulcus Tumors Of the 17 patients undergoing surgical resection, 7 (42%)underwent total vertebrectomy, 7 (42%) underwent par-tial vertebrectomy, and 3 (18%) underwent neural foram-ina or transverse process resection (Table 1). Three pa-tients (18%) had one vertebral body resected while 11(65%) had multiple vertebral bodies resected (2 bodies, 9patients [54%]; 3 bodies, 2 patients [18%]). Methyl-methacrylate with anterior and posterior fixation wasrequired in 7 patients because of the multiple levelsinvolved. Pulmonary resection included lobectomy in 10patients (60%) and wedge resection in 7 (40%). All pa-tients underwent mediastinal lymphadenectomy. In 2patients (12%), subclavian artery resection was per-formed with placement of a Gore-Tex interposition graft.The majority of patients were treated with radiationtherapy (n  16, 94%) either postoperatively (n  12, 72%)or preoperatively (n  4, 24%). Chemotherapy was givento an additional 7 patients (42%) either preoperatively (3,18%) or postoperatively (4, 24%). Surgical Technique Surgical technique emphasized an attempt to achieve anegative surgical margin of all areas including the in-volved vertebrae. The resections were performed via aposterolateral thoracotomy incision in the majority of cases (n    15) with an extension over the vertebrae if posterior fixation was required. Three patients with ex-tensive involvement of the thoracic inlet required ananterior cervical approach either solely (2 patients), asdescribed by Darteville and associates [6], or in additionto the posterior approach (1 patient), as described byGrunenwald [7], to dissect the tumor free of the cervicalstructures, perform vascular reconstruction if needed,and divide the anterior portion of the chest wall. Aposterolateral incision was then performed in most pa-tients (n    15) through the fifth intercostal space. Theinvolved ribs were disarticulated and resected en blocwith the involved chest wall and lung parenchyma.Formal lobectomy was performed in 10 patients (60%)and a segmental or wedge resection was performed in 7(43%). Mediastinal lymph node dissection was performedof the hilar, carinal, paratracheal, esophageal, and infe-rior pulmonary ligament lymph nodes.The involved vertebrae were then resected separatelyby neurosurgery according to the amount of vertebralinvolvement. In patients with only neural foramina ortransverse process involvement (n    3), the transverseprocess was drilled out with a high-speed diamond burrpower drill. The nerve root sleeve was then visualizedand ligated at the nerve root proximal to the dorsal rootganglion. Involvement of the surrounding osseous ele-ments was ablated with additional high-speed diamondburr resection (n  14). If there was significant extensionof the tumor into the spinal canal or gross invasion of theproximal transverse process, facet joints, or lamina, amultilevel laminectomy was performed with a posteriormidline extension of the thoracotomy incision (Figs 1, 2).This allowed visualization of the thecal sac as well as theipsilateral nerve roots involved with tumor. After nerveroot transection and removal of the main specimen, theremainder of involved vertebral body was removed witha combination of high-speed diamond burr, various sizedcurettes, and cavitron ultrasonic aspirator (CUSA). Thevertebrectomy defect was reconstructed with methyl-methacrylate using the chest tube technique as describedby Cooper and Errico and their colleagues [8, 9]. Meth-ylmethacrylate was injected into and around a chest tube,which was fixed between vertebrae and acted as frame-work for the reconstructed vertebrae. The spinal cordwas protected from the exothermic reaction of the meth-ylmethacrylate by wooden tongue blades and cold salineirrigation. Anterior fixation was obtained with an anteriorcervical locking plate and screw construct. Additionalposterior segmental fixation was done in extensive resec-1779 Ann Thorac Surg GANDHI ET AL1999;68:1778–85 VERTEBRAL INVASION OF SUPERIOR SULCUS TUMORS  by on May 31, 2013 ats.ctsnetjournals.orgDownloaded from       T   a    b    l   e    1 .    C    h   a   r   a   c    t   e   r    i   s    t    i   c   s   o    f    P   a    t    i   e   n    t   s    U   n    d   e   r   g   o    i   n   g    R   e   s   e   c    t    i   o   n    f   o   r    S   u   p   e   r    i   o   r    S   u    l   c   u   s    T   u   m   o   r   s    I   n   v   o    l   v    i   n   g    V   e   r    t   e    b   r   a 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    B   r   a   c    h    i   a    l   p    l   e   x   u   s    6    N    0    N   o   n   e    P   o   s    t   o   p    R    U    L    l   o    b   e   c    t   o   m   y    P   e   r    i   o   s    t   e   u   m    T    1 ,    T    2    S   u    b   c    l   a   v    i   a   n   a   r    t   e   r   y    N   e   u   r   a    l    f   o   r   a   m    i   n   a    S   e   c    t    i   o   n    i   n   g    N   e   g   a    t    i   v   e    3    4    N   o    N   o    A    l    i   v   e    8    8    0    S   q   u   a   m   o   u   s    5    0    %    T    2 ,    T    3    V   e   r    t   e    b   r   a    l    b   o    d   y    E   p    i    d   u   r   a    l    6 .    5    N    0    P   r   e   o   p    P   r   e   o   p    R    U    L   w   e    d   g   e   r   e   s   e   c    t    i   o   n    R    i    b   s    1  –    4    T   o    t   a    l    T    2 ,    T    3    V   e   r    t   e    b   r   e   c    t   o   m   y    P   o   s    i    t    i   v   e    1    3    Y   e   s    N   o    D   e   c   e   a   s   e    d    9    6    1    A    d   e   n   o   c   a   r   c    i   n   o   m   a    T    1 ,    T    2    T   r   a   n   s   v   e   r   s   e   p   r   o   c   e   s   s    P   o   s    t   e   r    i   o   r   e    l   e   m   e   n    t   s    7    N    0    P   r   e   o   p    P   r   e   o   p    R    U    L   w   e    d   g   e   r   e   s   e   c    t    i   o   n    T   o    t   a    l    T    1 ,    T    2    V   e   r    t   e    b   r   e   c    t   o   m   y    R    i    b   s    1  –    2    N   e   g   a    t    i   v   e    2    5    N   o    N   o    A    l    i   v   e    1    0    5    4    A    d   e   n   o   c   a   r   c    i   n   o   m   a    2    5    %    T    2    V   e   r    t   e    b   r   a    l    b   o    d   y    C   o   r    t   e   x    T    1    V   e   r    t   e    b   r   a    l    b   o    d   y    T    1 ,    T    2    T   r   a   n   s   v   e   r   s   e   p   r   o   c   e   s   s    N   e   u   r   a    l    f   o   r   a   m    i   n   a    6 .    5    N    0    P   o   s    t   o   p    P   o   s    t   o   p    R    U    L   w   e    d   g   e   r   e   s   e   c    t    i   o   n    R    i    b   s    1  –    3    T   o    t   a    l    T    2    V   e   r    t   e    b   r   e   c    t   o   m   y    P   a   r    t    i   a    l    T    1 ,    T    3    V   e   r    t   e    b   r   e   c    t   o   m   y    N   e   g   a    t    i   v   e    2    4    N   o    Y   e   s    A    l    i   v   e 1780  GANDHI ET AL Ann Thorac Surg VERTEBRAL INVASION OF SUPERIOR SULCUS TUMORS 1999;68:1778–85  by on May 31, 2013 ats.ctsnetjournals.orgDownloaded from       1    1    5    6    A    d   e   n   o   c   a   r   c    i   n   o   m   a    1    0    %    T    2 ,    T    3    V   e   r    t   e    b   r   a    l    b   o    d   y    T   r   a   n   s   v   e   r   s   e   p   r   o   c   e   s   s    E   p    i    d   u   r   a    l    6    N    1    P   o   s    t   o   p    P   o   s    t   o   p    L    U    L    l   o    b   e   c    t   o   m   y    P   a   r    t    i   a    l    T    2    V   e   r    t   e    b   r   e   c    t   o   m   y    T   o    t   a    l    T    3    V   e   r    t   e    b   r   e   c    t   o   m   y    P   o   s    i    t    i   v   e    1    2    Y   e   s    N   o    D   e   a    d    1    2    6    3    S   q   u   a   m   o   u   s    T    1    T   r   a   n   s   v   e   r   s   e   p   r   o   c   e   s   s    N   e   u   r   a    l    f   o   r   a   m    i   n   a    2    N    0    N   o   n   e    P   o   s    t   o   p    R    U    L   w   e    d   g   e   r   e   s   e   c    t    i   o   n    R    i    b   s    1  –    3    P   a   r    t    i   a    l    T    1    V   e   r    t   e    b   r   e   c    t   o   m   y    N   e   g   a    t    i   v   e    1    2    N   o    N   o    A    l    i   v   e    1    3    5    6    S   q   u   a   m   o   u   s    C    7 ,    T    1   v   e   r    t   e    b   r   a    l   c   o   r    t   e   x    B   r   a   c    h    i   a    l   p    l   e   x   u   s    9    N    0    N   o   n   e    P   o   s    t   o   p    R    U    L    l   o    b   e   c    t   o   m   y    R    i    b   s    1  –    5    N   e   u   r   a    l    f   o   r   a   m    i   n   a   s   e   c    t    i   o   n    i   n   g    N   e   g   a    t    i   v   e    1    1    N   o    N   o    A    l    i   v   e    1    4    4    8    A    d   e   n   o   c   a   r   c    i   n   o   m   a    1    0    %    T    1 ,    T    2    V   e   r    t   e    b   r   a    l    b   o    d   y    N   e   u   r   a    l    f   o   r   a   m    i   n   a    T   r   a   n   s   v   e   r   s   e   p   r   o   c   e   s   s    7 .    5    N    0    N   o   n   e    P   o   s    t   o   p    R    U    L    l   o    b   e   c    t   o   m   y    R    i    b   s    1  –    3    P   a   r    t    i   a    l    T    1 ,    T    2    V   e   r    t   e    b   r   e   c    t   o   m   y    N   e   g   a    t    i   v   e    1    1    N   o    N   o    A    l    i   v   e    1    5    3    8    A    d   e   n   o   c   a   r   c    i   n   o   m   a    1    5    %    T    2 ,    T    3    V   e   r    t   e    b   r   a    l    b   o    d   y    E   p    i    d   u   r   a    l    P   o   s    t   e   r    i   o   r   e    l   e   m   e   n    t    3    N    0    N   o   n   e    P   o   s    t   o   p    L    U    L    l   o    b   e   c    t   o   m   y    R    i    b   s    1  –    4    T   o    t   a    l    T    2 ,    T    3    V   e   r    t   e    b   r   e   c    t   o   m   y    P   a   r    t    i   a    l    T    1    V   e   r    t   e    b   r   e   c    t   o   m   y    N   e   g   a    t    i   v   e    9    N   o    N   o    A    l    i   v   e    1    6    5    7    L   a   r   g   e   c   e    l    l    5    0    %    T    1    V   e   r    t   e    b   r   a    l    b   o    d   y    T    1  -    T    2    T  -   p   r   o   c   e   s   s   ;    P   o   s    t   e    l   e   m   e   n    t ,    B   r   a   c    h    i   a    l   p    l   e   x   u   s ,    S   u    b   c    l   a   v    i   a   n   a   r    t   e   r   y    8    N    3    P   o   s    t   o   p    P   o   s    t   o   p    R    U    L   w   e    d   g   e   r   e   s   e   c    t    i   o   n    T   o    t   a    l    T    1    V   e   r    t   e    b   r   e   c    t   o   m   y    P   a   r    t    i   a    l    T    2    V   e   r    t   e    b   r   e   c    t   o   m   y    R    i    b   s    1  –    3    P   o   s    i    t    i   v   e    6    Y   e   s    N   o    A    l    i   v   e    1    7    6    5    S   q   u   a   m   o   u   s    2    5    %    T    1 ,    T    2    V   e   r    t   e    b   r   a    l    b   o    d   y    E   p    i    d   u   r   a    l    P   o   s    t   e   r    i   o   r   e    l   e   m   e   n    t   s    7    N    0    P   o   s    t   o   p    P   o   s    t   o   p    R    U    L    /    R    M    L    l   o    b   e   c    t   o   m   y    R    i    b   s    1  –    4    P   a   r    t    i   a    l    T    1 ,    T    2    V   e   r    t   e    b   r   e   c    t   o   m   y    N   e   g   a    t    i   v   e    2    N   o    N   o    A    l    i   v   e 1781 Ann Thorac Surg GANDHI ET AL1999;68:1778–85 VERTEBRAL INVASION OF SUPERIOR SULCUS TUMORS  by on May 31, 2013 ats.ctsnetjournals.orgDownloaded from 
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