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Transcervical approach (Dartevelle technique) for resection of lung tumors invading the thoracic inlet, sparing the clavicle
To the Editor:
After the report of Dartevelle and associates1 in the Journal, my colleagues and I changed our surgical technique for resection of lung tumors invading the thoracic inlet. Now we use the anterior cervical approach whenever possible. We completely agree with the authors that this approach allows good exposure of the cervical expansions of the neoplasm, mainly in the posterior planes. The exposure is much better than that obtained with the traditional posterolateral-paravertebral thoracotomy described by Shaw, Paulson, and Kee.2 Moreover, toilette of the supraclavicular lymph nodes, which in these cases may be the first lymphatic stations to be involved, is much easier and more complete with this approach. The anterior cervical approach also offers good exposure of the subclavian vessels, even though these vessels are also well exposed with the posterior approach after the first rib is removed.
The technique, as described, includes the resection of the medial half of the clavicle to allow free access to the thoracic inlet. However, the clavicle usually is not infiltrated by the tumor. Moreover, because of its role in the stability and function of the shoulder girdle, sparing the clavicle may be advisable.
We recently treated two patients with cancer of the upper lobe of the lung invading the thoracic inlet, which was entirely resected through the Dartevelle cervical approach, sparing the clavicle.
A 57-year-old man had adenocarcinoma of the apex of the right lung deeply invading the thoracic inlet, particularly in its medial part, and infiltrating the anterior portion of the first ribs and both subclavian vessels. The tumor extended posteriorly to the ligament layer of the anterolateral portion of the first two thoracic vertebral bodies. The anteriop portions of the second and third roots of the brachial plexus were marginally infiltrated by the tumor. Computed tomographic scan failed to show enlarged mediastinal nodes. The tumor was removed entirely through this anterior approach, with an en bloc resection of the subclavian vessels. The lung apex was stapled. Polytetrafluoroethylene prostheses were used to reconstruct the subclavian vessels. Recovery was uneventful, and the patient underwent postoperative radiotherapy.
A 54-year-old man had adenocarcinoma of the apex of the left lung extending deeply into the posterior part of the thoracic inlet. The tumor entirely filled the space between the vertebral bodies and the brachial plexus, reaching the level of the cervical emergence of the first brachial plexus root. The neoplasm infiltrated the entire first rib and the posterior arch of the second rib. It spared the other cervical structures with the exception of the few afferent nerves to the inferior brachial plexus root coming from the first thoracic branch. The apex of the left lung was stapled and the neoplasm was radically removed en bloc with the ribs involved. Recovery was uneventful, and the patient underwent postoperative radiotherapy. A small local recurrence at the upper cervical limits of the tumor has recently been detected by computed tomographic scan (sixth postoperative month) and is scheduled to be removed.
In these cases the medial end of the clavicle was simply disarticulated from the sternum and pulled downward. This is a simple maneuver that provides an equally wide surgical field. After the clavicular insertions of the sternocleidomastoid and pectoralis major muscles have been divided, the medial part of the clavicle is completely free. After sternal disarticulation, the medial part of the clavicle can be pulled downward without effort, rotating at the external end articulation with the scapula. The conic shape of the upper thoracic cage allows the clavicle to be completely out of the operative field when rotated downward as much as 30 to 40 degrees ( Fig. 1 ).
Fig. 1. The thoracic inlet is fully exposed simply by disarticulating the clavicle from the sternum and pulling it downward (inset). In this case a large tumor is invading the thoracic inlet posterior to the brachial plexus (left; white arrows). The tumor was removed en bloc with the ribs (right). p, Brachial plexus; a, subclavian artery; v, subclavian vein; cl, clavicle.
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At the end of the resection, the clavicle is brought back to its physiologic position and fixed to the sternum with two metallic stitches ( Fig. 2 ).
Fig. 2. After the resection is completed, the clavicle is approximated to the sternum and fixed with two metallic stitches. In this case the clavicle was fixed a bit lower than its physiologic position to better compensate for the thoracic cage defect resulting from removal of the first and second ribs.
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Pectoralis major and sternocleidomastoid muscle insertions are then reconstructed, so that a substantially normal appearance of the upper thorax and full stability and function of the shoulder girdle can be restored. The presence of the clavicle moreover allows better repair of the anterior defect of the thoracic cage when the second and possibly the third ribs (anterior arc) are also removed.
Stefano Nazari, MD
Department of Surgery
IRCCS San Matteo
University of Pavia
27100 Pavia, Italy
1. Dartevelle PG, Chapelier AR, Macchiarini P, Lenot B, Cerrina J, Ladurie FLR, et al. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J THORAC CARDIOVASC SURG1993;105:1025-34.
2. Shaw RR, Paulson DL, Kee JL. Treatment of the superior sulcus tumor by irradiation followed by resection. Ann Surg 1961;154:29-40.