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Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man’s land

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PurposeCervicothoracic 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. Methods 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. ResultsTumours 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. Conclusions 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. Graphical abstractThese slides can be retrieved under Electronic Supplementary Material. Open image in new window
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Vol:.(1234567890)
European Spine Journal (2018) 27:902–912
https://doi.org/10.1007/s00586-018-5512-5
1 3
ORIGINAL ARTICLE
Paravertebral tumours ofthecervicothoracic junction extending
intothemediastinum: surgical strategies inanomans land
GeorgiosK.Prezerakos1· ParagSayal1· AntoniosKourliouros2· PericlisPericleous2· GeorgeLadas2· AdrianCasey1
Received: 13 August 2017 / Revised: 9 January 2018 / Accepted: 4 February 2018 / Published online: 14 February 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Abstract
Purpose 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.
Methods 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.
Results 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.
Conclusions Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relation-
ship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides
minimal morbidity/maximum resection and satisfactory oncological outcomes.
Graphical abstract These slides can be retrieved under Electronic Supplementary Material.
Key points
[cervicothoracicneoplasms; paravertebral tumours; thoracic outlet;
sympathetic chain schwannoma; primary bone tumours ]
1. Paravertebral tumours of the cervicothoracic junctionare rare and
anatomically challengingto excise lesions, comprisingnerve sheath
and primary bone tumours
2. We studied the outcomes of 28 consecutive patients employing
threedifferent surgicalapproaches
3. En bloc resection was achieved in 23 cases; 0% recurrence in
benign pathologies at 5 years ; 96% survival at 1 year, 67% at 2 years
and 33% at 5 years in malignant pathologies
Mazel C, Grunenwald D, Laudrin P, Marmorat JL (2003) Radical excision in
the management of thoracic and cervicothoracictumors involving the
spine: results in a series of 36 cases. Spine 28:782-792
CLASSIFICATION SYSTEM & APPROACH ALGORITHM
[Citation]
Approach
SubclavicularFossa
Involvement
Vertebral Column
Involvement
Tumour Location Cervicothoracic
Junction
C6-T4
Paravertebral
Partial vertebral
body
Costotransverse
joint
Anteromedial
Limited median
sternotomy
Anterolateral
Anterior cervical
trans-sternal
Posterior
High posterolateral
thoracotomy
Vertebral Body
Posterior elements
Intracanalicular
Posterolateral
Combined (anterior
release + posterior
vertebrectomy)
Take Home Messages
1.Anterior medial neoplasmscan be approached viaanteriorcervical
approach combined with limitedmedian sternotomyalone ;Distal
subclavian involvementmandatesananteriortrans-sternaltechnique
2. Classification of cervicothoracicparavertebral neoplasms with mediastinal
extension according to the their relationship with the subclavicularfossa
allows for a structured surgical approach.
3. Dual specialty involvement and provides minimal morbidity/maximum
resection and satisfactory oncological outcomes
[Citation]
Keywords Cervicothoracic neoplasms· Paravertebral tumours· Thoracic outlet· Sympathetic chain schwannoma· Primary
bone tumours
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s0058 6-018-5512-5) contains
supplementary material, which is available to authorized users.
Extended author information available on the last page of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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