gms | German Medical Science

Introduction: Pancoast tumors invading the spine at the cervicothoracic junction still represent a clinical challenge because of the close anatomical relationship between the tumor and the vital structures in the thoracic outlet. Tumor recurrence following an initial high-dose chemoradiation therapy carries a high risk of tetraplegia due to the direct invasion of the spine and the risk of instability as a result of pathological vertebral fracture. The available treatment modalities are limited. Survival time for most patients after second-line chemotherapy remains poor. Delivery of re-irradiation is mainly limited by the tolerance dose of the spinal cord. Salvage surgery is a special issue for which the clinical experience is to date very limited.

Material and methods: We performed salvage surgery “as an ultima ratio” approach in three patients with local recurrence of pancoast tumors and vertebral invasion at the cervicothoracic junction. All patients initially underwent posterior spinal fixation in prone position, followed by a complete tumor resection in lateral decubitus position All patient had double lumen intubation. Pulmonary resections were always combined with thoracic wall resection. The stabilization of the anterior column of the spine was achieved with a titanium expandable cage after complete vertebrectomy in accordance of the tumor extent.

Results: Salvage surgery including pulmonary and vertebral resection was combined with a 360° degree spinal fixation was performed in two women and one man with a median age of 45 years. Histopathological analysis revealed in one case a metastases of the cervical carcinoma and two recurrences of non-small cell lung carcinoma. The median radiation dose applied to tumor site was 59.4 Gy [45-66 Gy].The median operation time was 6h36min.The extent of thoracic wall resection included in two patients resection of the first to third ribs and in one resection of the first to fifth ribs. Pulmonary resections consisted of a bilobectomy, a lobectomy and a wedge resection combined with radical lymph node dissection. The spine resections included vertebrectomy of T1-T3 in two and T1-T2 in one patient. All patients are still alive and remain at the end of the analysis without evidence of local recurrence.The median follow up interval was 29 months [range 10.3- 68.3 month]. The postoperative survival-time was 69.1, 29.5 and 10.8 month respectively.

Conclusion: The wide tumor invasion into the bony structures of the spine at the cervicothoracic junction represents an extraordinary clinical situation with a high risk of tetraplegia. The available experience with salvage surgery following high-dose chemoradiation in this specific entities is very limited today. As our results suggest vertebral involvement is not an absolute contraindication for radical resection of pancoast tumors. Salvage surgery might offer a treatment option for patient despite extended malignant disease. However, the careful patient selection is mandatory, since a prolonged operation time can be expected.