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J Thorac Cardiovasc Surg 1994;108:389-390
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Different approaches for management of apical invasive lung cancers

Second Department of Surgery
Nagoya City University, Medical School
Mizuho-cho, Mizuho-ku
Nagoya, 467 Japan

To the Editor:

In the June 1993 issue of the JOURNAL, Dartevelle and coworkers ¹ reported that the anterior transcervical-thoracic approach afforded safe exposure for radical resection of non-small-cell lung cancer involving the thoracic inlet. Although surgical therapy for apical invasive lung cancer remains a difficult problem, their anterior transcervical-thoracic approach is excellent.

We classify apical invasive lung cancers into anterior apical and superior sulcus tumors according to their location. The involved structures in the thoracic inlet are different between those tumors, with resultant different subjects for resection. ²Dartevelle and colleagues ¹ added a complementary posterolateral thoracotomy if further chest wall or major pulmonary resections were necessary, and 20 of their 29 patients required this further treatment. This high ratio suggests that when major pulmonary resection is required according to computed tomographic and magnetic resonance imaging scans, thoracotomy should be performed at the site from which lung tissue was resected. Sixteen of 21 tumors situated posteriorly necessitated complementary thoracotomy; therefore, Dartevelle's group does not recommend this operation for superior sulcus tumors.

We select different approaches for apical invasive lung cancers according to the tumor location. ³ The anterior approach,which was reported by Masaoka, Ito, and Yasumitsu ⁴ in 1979, is used for anterior apical tumors. This approach consists of a median sternotomy, anterior intercostal thoracotomy, and hemi-cervical collar incision. The anterior approach affords resection of subclavian vessels followed by reconstruction with a graft and major pulmonary resection without posterolateral thoracotomy. However, superior sulcus tumors cannot be easily removed by this approach because resection of involved transverse processes and the head of the ribs is particularly difficult. The hook approach ³ is selected for superior sulcus tumors and anterior apical tumors without involvement of the sternum. A long curved periscapular skin incision around the axilla from the level of the seventh cervical vertebra to the midclavicular line above the nipple is performed. Changing the position of the patient by tilting the operating table and moving the arm affords safe and complete exposure of the entire thoracic inlet. Resection of subclavian vessels followed by reconstruction with a graft and dissection of the brachial plexus are easily performed. Furthermore, the ipsilateral supraclavicular lymph nodes can be resected through the same incision. The 5-year survival of 26.8% in 31 patients who underwent resection by various approaches ³ is encouraging.

References

1. Dartevelle PG, Chapelier AR, Macchiarini P, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J THORAC CARDIOVASC SURG 1993;105:1025-34.[Abstract]
   
2. Masaoka A, Mizuno T, Shibata K, Yamakawa Y, Niwa H. Characterization of the apical invading lung cancers at different localization: emphasis of anterior apical tumor. Nagoya Med J 1987;32:137-46.
   
3. Niwa H, Masaoka A, Yamakawa Y, Fukai I, Kiriyama M. Surgical therapy for apical invasive lung cancer: different approaches according to tumor location. Lung Cancer 1993;10:63-71.[Medline]
   
4. Masaoka A, Ito Y, Yasumitsu T. Anterior approach for tumor of the superior sulcus. J THORAC CARDIOVASC SURG 1979;78:413-5.[Abstract]
   

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