Lung Cancer with Direct Extension to T2 and T3
The patient is a 44-year-old female who presented with right-sided chest pain in October 2009, which precipitated a CT scan and an MRI. The imaging tests demonstrated a mass in her right upper lobe adjacent to T2. She had a biopsy performed that same month demonstrating non-small cell lung cancer. A mediastinoscopy revealed no evidence of malignancy.
The patient has no pain radiation into her upper or lower extremities and no numbness or weakness in the upper or lower extremities. She has not experienced loss of bowel or bladder control, and she has no problems with balance or tripping.
She is married with 3 children, and she works at a bank. She smoked 1 pack of cigarettes a day until her lung cancer diagnosis. She had a hysterectomy and has a history of colon polyps, but she is otherwise healthy.
On examination, the patient is 5'6" and 165 pounds. She ambulates with a normal gait and is able to stand on her toes and heels. She is also able to stand on each leg independently.
Motor strength examination demonstrates normal motor strength throughout her upper and lower extremities, and her sensation to light touch is intact.
The patient's reflexes are 2+ at the biceps, triceps, brachioradialis, patella, and Achilles. Inverted radial reflex, Babinski sign, Hoffmann sign, and Romberg sign are all negative.
Her cervical and lumbar spine range of motion is normal, and her breathing is non-labored. Peripheral pulses are palpable, and there is no evidence of peripheral edema.
The patient underwent induction chemotherapy and radiation therapy prior to surgery. A PET scan prior to surgery demonstrated no evidence of metastatic disease.
Figure 1: Pre-op coronal (left) and sagittal (right) x-rays
Figure 2: Pre-op axial CT scans
Figure 3: Pre-op axial MRIs showing location of the tumor
Figure 4: Pre-op axial MRI-a closer look at the tumor
Figure 5: Pre-op sagittal MRIs
The patient was diagnosed with right upper lobe superior sulcus non-small cell lung cancer with direct extension to T2 and T3.
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After undergoing induction chemotherapy and radiation therapy, the patient was treated with en-bloc tumor resection, including removal of the tumor in her right upper lobe (via video-assisted thoracoscopy), the right-sided portion of the T2 and T3 vertebral bodies, and T1-T2, T2-T3, and T3-T4 discs, as well as the proximal portion of the right T2 and T3 ribs and rib heads, were also removed (via a posterior approach).
Figure 6: Intra-operative photo of tumor removal
Figure 7: Post-op surgical photo of the tumor
Figure 8: Post-op coronal (left) x-ray and sagittal (right) x-ray
The patient has done extremely well. She is essentially asymptomatic aside from occasional back ache. Most importantly, she is now 1 ½ years postop and has no evidence of cancer (either recurrence or metastatic).
I think Dr. Buchowski did a good job with this case. It is difficult to achieve a curative resection of the tumor in this particular location, and it appears that this was an attempt at a curative resection.
I do have several questions about the case, though:
- What was the extent of the work-up to ensure that there was no other tumor present?
- This approach appears to be an attempt to do a curative procedure. How would you ensure that you got the entire tumor out, assuming that this is a curative procedure?
- If this was an attempt to do a curative procedure, why weren't the entire vertebral bodies removed at T2 and T3?
- Was there grafting or a fusion procedure done? With the excision of that much bone and other important structures that ensure spinal stability, what was done to ensure spinal stability?
- Was there post-op CT and MRI to assess the adequacy of the tumor removal?
- What did Dr. Buchowski do with the neural elements on the side of the tumor incision? Were the nerve roots removed?
In approaching a case like this, I would've done as Dr. Buchowski didutilizing pre-operative chemotherapy and radiation.
I would have not, however, used video-assisted thoracoscopy. I would have attempted to approach in a lateral position and expose the spine from inside the chest and posteriorly. An open exposure would be used to see the tumor from the front and the back.
I think it all goes back to adequate decompression. With anterior/posterior exposure of the tumor, you can safely remove the tumor with en-bloc resection, if you're going for a curative procedure.
In response to Dr. Cohen's questions:
What was the extent of the work-up to ensure that there was no other tumor present? A PET scan was performed prior to the operation to rule out metastatic disease. In addition, during the operation, prior to removal of the tumor, mediastinoscopy was performed and lymph nodes were sent to pathology to make sure that there was no evidence of lymph node involvement. This portion of the operation was performed by the thoracic surgeons.
This approach appears to be an attempt to do a curative procedure. How would you ensure that you got the entire tumor out, assuming that this is a curative procedure? This was an en bloc resection with the aim being a curative procedure. The advantage of performing a resection of a superior sulcus tumor with direct extension to the spine in this manner (VATS anteriorly followed by posterior resection and reconstruction) is that it obviates the need for a formal thoracotomy.
We have found that the majority of patients who require a formal thoracotomy (followed by a posterior resection and reconstruction) to resect their tumor develop respiratory failure and/or ARDS post-operatively; in contrast, those who undergo the procedure reported here usually do not. Pre-operative imaging and planning was used to make sure that the tumor in its entirety with negative margins was excised during the operation.
If this was an attempt to do a curative procedure, why weren’t the entire vertebral bodies removed at T2 and T3? T2 and T3 were not removed in their entirety as only the very lateral portion of the vertebral bodies was involved on the imaging studies. We typically find during these procedures that the most involved portion includes the rib, the rib head, the costovertebral joint, and the lateral cortex of the vertebral body.
Was there grafting or a fusion procedure done? With the excision of that much bone and other important structures that ensure spinal stability, what was done to ensure spinal stability? Posterior iliac crest bone grafting was utilized to increase the likelihood of achieving a solid fusion. When performing the operation, a hemilaminectomy is performed to preserve posterior bony surface area to help achieve a fusion. As less than 1/3 of the vertebral body is excised, I do not feel that a formal anterior reconstruction and fusion is necessary. In cases where a larger amount of vertebral body/bodies has to be removed, an anterior reconstruction and fusion is performed.
Was there post-op CT and MRI to assess the adequacy of the tumor removal? Post-operative PET scans have been performed and these have demonstrated no evidence of tumor recurrence at the surgical site or development of metastatic disease.
What did Dr. Buchowski do with the neural elements on the side of the tumor incision? Were the nerve roots removed? The T1 nerve root was preserved, but the T2 and T3 nerve roots were sacrificed to allow an en bloc resection.
Was this a posterolateral approach to the spine? Was it a costotransversectomy? Yes, this was a posterolateral approach, but not a costotransversectomy in that the ribs, the rib heads, and the costovertebral joints (as well as the pleura and left upper lobe) had to remain attached to the lateral aspect of the T2 and T3 vertebral bodies to guarantee negative margins and allow resection of the tumor en bloc.