Large chest tumors have always been challenging in thoracic surgery, especially when the tumors invade the thoracic outlet. Due to the small operation space and anatomic complexity of the thoracic outlet, complete resection of large chest tumors invading the thoracic outlet is difficult.
Several surgical approaches have been designed for chest tumors invading the thoracic outlet, such as the anterior transcervical-thoracic approach and its corresponding modification proposed by Dartevelle [1, 2], the transmanubrial osteomuscular sparing approach proposed by Grunenwald [3], and the supraclavicular approach or an approach combined with video-assisted thoracoscopic surgery (VATS) proposed by Bandiera and Sakuraba, et al. [4,5,6,7]. Each of these approaches has its advantages and disadvantages. However, in some specific cases with large tumors, these surgical approaches may not meet the requirements of the task.
Here, we present a case of a large neurilemmoma invading the thoracic outlet that was resected through a modified approach based on sternotomy combined with a supraclavicular approach.
Case presentations
The case was a 56-year-old woman admitted to a local hospital due to sudden syncope. A routine blood test showed a low Hb of 58 g/L and normal blood glucose, and a subsequent CT scan showed a large mass in the right chest cavity with atelectasis and pleural effusion. The patient was given anti-shock treatment and had a good recovery. After being discharged from the local hospital, she had occasional chest discomfort and did not receive any further treatment over the next 4 years.
After admission to our hospital, Horner’s syndrome on the right was detected by physical examination. Then, the patient accepted a needle biopsy, blood tests including AFP and β-HCG, and an enhanced CT scan. The biopsy pathology result did not support a tumor diagnosis because the sample mainly consisted of blood clots and a few fibrous connective tissues covered with a single layer of flat epithelium, and the blood AFP and β-HCG tests were also negative.
Enhanced CT showed a 15.2 × 12.0 cm round mass (soft tissue density with a large area of low density and calcification) in the right chest cavity with invasion into the thoracic outlet with atelectasis of the upper lobe, and the enhanced scan showed gradual delayed and nonhomogeneous enhancement, with a thick blood vessel-like area in the mass, indicating a diagnosis of solitary pleural fibroma.
Surgical technique
After excluding any contraindications, the patient accepted surgical treatment. For good exposure of the cranial side of the tumor invading the thoracic outlet and the caudal side of the tumor to the level of the inferior pulmonary vein (Fig. 1a), we designed a sternotomy combined with a supraclavicular approach. The patient was placed in the supine position with the neck hyperextended and the head turned away from the involved side. After endotracheal intubation, a median sternal splitting was performed. Subsequently, a transverse incision was made from the upper edge of the right midpoint of the clavicle to the upper edge of the sternum, intersecting with the median sternotomy incision. After separating the subcutaneous tissue, the sternocleidomastoid muscle was transected above the clavicular tendon, exposing the scalenus anterior muscle, scalenus medius muscle, and subclavian arteries and veins. The sternum was then opened, and the incision near the sternoclavicular joint (forming an “inverted L” angle, Fig. 1b) was retracted outward and upward to further expose the thoracic outlet. First, the tumor was dissected from the mediastinal structures, such as the hilum, superior vena cava, right innominate vein, and aortic arch. Next, the cranial side of the tumor adjacent to the subclavian vessels was carefully separated. The caudal side and lateral part of the tumor were then bluntly dissected from the upper lobe and chest wall. Finally, the tumor and the paraspinal portion were separated using blunt dissection and energy instruments.
a. CT manifestation of the patient; b. the “inverted L” incision (median sternotomy combined with a supraclavicular incision); c. exposure of important structures of the thoracic outlet after tumor removal; d. Pathological specimen
The postoperative pathology diagnosis was neurilemmoma of 15 × 10 × 9 cm, with extensive haemorrhage, degeneration, necrosis, and reactive hyperplastic vessels. (Superior Mediastinal Lymph Node): No tumor identified in the lymph node. Immunohistochemistry: SMA (negative), Desmin (negative), S-100 (positive), SOX10 (positive), Vimentin (positive), CD34 (negative), CK (AE1/AE3) (negative), WT-1 (negative), MC (negative), Ki-67 (+, 3%), STAT6 (negative), ALK (negative), PGP9.5 (positive), GFAP (negative), D2-40 (positive), CK5/6 (negative), Synaptophysin (negative). The patient was discharged 9 days after surgery with good recovery. Three months later, the patient was in good condition, and the preoperative Horner’s syndrome was relieved.
During this surgery, a thorough intraoperative evaluation confirmed complete separation of the tumor from the surrounding tissues, allowing for its thorough excision. The postoperative pathology report indicated that all margins were free of tumor cells, and no metastasis was found in the resected lymph nodes. Postoperative imaging showed no signs of residual tumor or recurrence. Regular follow-up monitoring, including imaging examinations, has shown no signs of recurrence to date, confirming that an R0 resection was achieved.
We conducted regular telephone follow-ups with the patient to monitor postoperative recovery and assess for any signs of tumor recurrence. During these follow-ups, the patient consistently reported no symptoms indicative of recurrence. The patient underwent routine postoperative imaging and clinical examinations at a local medical facility, which, according to the patient’s verbal report, indicated no evidence of tumor recurrence. Unfortunately, despite our requests, the patient has been unable to provide us with the official examination reports. Efforts are ongoing to assist the patient in obtaining and submitting these reports. We will continue to monitor the patient closely and aim to include more comprehensive data from future follow-ups in subsequent updates.
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