TECHNIQUE FOR RESECTING PRIMARY AND METASTATIC NONBRONCHOGENIC TUMORS OF THE THORACIC OUTLET

Although primary or metastatic nonbronchogenic tumors infrequently arise in or involve the thoracic outlet, they represent a major surgical challenge because of their tendency to encapsulate outlet structures. Fourteen patients with a histologically proven primary (n = 8) or metastatic (n = 6) nonbronchogenic outlet tumor were treated by an anterior transcervical approach, including an L-shaped cervicotomy extended into the deltopectoral groove, resection of the internal half of the clavicle, and, in the case of tumor involvement, resection of the jugular and subclavian veins, phrenic nerve, subclavian artery, brachial plexus, and ribs. All patients underwent a radical resection. Tumors extended to bony (usually the first rib), muscular (usually the anterior scalenus muscle), and nerve (usually the phrenic nerve) outlet structures in 8, 10, and 7 patients, respectively. Ten patients had involvement of outlet vessels: 6 had simple ligature (n = 5) or wedge resection (n = 1) of the subclavian vein and related branches, 1 had revascularization of both the subclavian vein by an end-to-end anastomosis and the subclavian artery by a ringed polytetrafluoroethylene graft, 1 had revascularization of the subclavian artery alone, and 2 had revascularization between the left brachiocephalic vein and superior vena cava (ringed polytetrafluoroethylene graft). Follow-up venograms showed complete patency of the anastomoses. There was one postoperative death (7%) due to multiorgan system failure. Other complications were mild and short-lasting. With a median follow-up of 3.4 years, all patients but 1 (who had systemic progression) are alive and disease free 3 to 127 months postoperatively. Radical resection of primary or metastatic nonbronchogenic outlet tumors and encouraging long-term survival can be achieved using the technique presented.