A minimally invasive and safe surgical approach to resect anterior superior sulcus tumors

Highlights • A surgical approach for SST to treating these tumors is technically demanding, and complete resection may be difficult to accomplish.• We experienced a case of locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection.• This surgical approach (VATS observation and transmanubrial approach) was effective and safe.• VATS lobectomy is minimally invasive and safe after the transmanubrial approach.


Introduction
Superior sulcus tumors are a wide range of tumors invading an area of the apical chest wall called the thoracic inlet. The unique characteristics of superior sulcus tumors lie in the anatomy of region where these tumors occur. For this reason, a surgical approach to treating these tumors is technically demanding, and complete resection may be difficult to accomplish [1]. The treatment of superior sulcus tumor has evolved greatly over the years; initially thought to be inoperable, the first case of surgical removal was reported in 1956 by Chardack and MacCallum [2]. In the 1990s, induction chemoradiotherapy followed by radical surgical resection was introduced as a new standard treatment for superior sulcus tumors. This treatment brought in improved outcomes and remains the gold standard today [1]. We experienced a case of a locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection. This work has been reported in line with the SCARE criteria [3].

Case presentation
A 71-year-old Japanese man presented at our hospital due to left anterior chest pain and an abnormal chest computed tomography (CT) scan showing a 40 × 33 × 30-mm tumor located at the left anterior apex of the thoracic inlet. This tumor had invaded the first and second rib and was located near the subclavian vein (Fig. 1). This patient has chronic renal failure and is undergoing peritoneal dialysis.
We performed bronchoscopy to make a definitive diagnosis but were unable to obtain a diagnosis. 18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography showed an increase standard uptake value in the tumor (Fig. 2). There was no significant distant metastasis. We did not performe neoadjuvant therapy because we determined that this tumor was resectable. Therefore, we performed surgical resection for this superior sulcus tumor located at the anterior apex of the thoracic inlet because the tumor was suspected to be local invasive lung cancer.    The surgical procedure included three steps. The diagram of the surgery and surgical view are shown in Fig. 3. First, we performed VATS (Video-assisted thoracic surgery) exploration via the left thoracic cavity. We then confirmed the resectability and lack of dissemination. Second, via the transmanubrial approach, we obtained tumor-free margins of the anterior cervical structures. The tumor was located near the subclavian vessels, and we were able to remove the tumor from these major vessels safely. We then disconnected the anterior first and second ribs using a wire saw. We were able to cut off the tumor invading anterior chest wall before closing the anterior wound. After that, we reconstructed the anterior chest wall using Gore-Tex Dual Mesh (Japan Gore-tex Inc., Tokyo, Japan) and closed the anterior wound. Third, through VATS in the left lateral decubitus position, we performed left upper lobectomy and mediastinal lymph node dissection. The operative time was 8 h 7 min, and the amount of intraoperative bleeding was 580 ml.
Pathologically, complete resection was achieved. The pathological diagnosis was stage IIB squamous cell carcinoma (p-T3N0M0). The patient was discharged from our hospital 13 days after surgery. This surgery was successful, with no postoperative complications.

Discussion
Two points should be noted in association with this case. First, this surgical approach (VATS exploration and transmanubrial approach) was effective and safe for treating a superior sulcus tumor located at the anterior apex of the thoracic inlet. We first performed VATS via the left thoracic cavity. Rosso et al. reported that "VATS observation first" is useful for excluding previously undetected pleural dissemination and for precisely defining the tumor location [7]. We therefore agree with Rosso's "VATS observation first" approach. The lesion in this patient was suspected of invasion the subclavian vessels. Therefore, the transmanubrial approach was useful for removing the tumor from major vessels. We were fortunately able to remove the tumor from the subclavian vessels without issue; however, if we had not been able to remove it, we could alternatively have resected and reconstructed the subclavian artery via the transmanubrial approach. Indeed, we previously reported several aggressive surgeries in which we used the transmanubrial approach and resected/reconstructed major vessels [4][5][6].
Second, VATS lobectomy is minimally invasive and safe after the transmanubrial approach for managing anterior superior sulcus tumor. We performed left upper lobectomy and mediastinal lymph node dissection through VATS in the left lateral decubitus position after adopting the transmanubrial approach. Given the visual difficulty of performing lobectomy via the transmanubrial approach, it is necessary to change the position to the lateral decubitus position. However, thoracotomy is highly invasive. Therefore, VATS lobectomy is a good approach. As in the present case, VATS lobectomy can be performed if the tumor-invaded area of the anterior chest wall can be cut off via the transmanubrial approach. The present patient experienced little pain, and the postoperative course was good.

Conclusion
We experienced a case of locally advanced superior sulcus tumor located at the anterior apex of the thoracic inlet and performed complete resection.

Funding
We have no sources of funding for our research.

Ethical approval
We got ethical approval from ethical committee of Kokura memorial hospital, Japan.

Consent
We had informed consent from this patient for writing this paper.

Registration of research studies
My research registry number is 1565.

Provenance and peer review
Not commissioned, externally peer-reviewed.

Declaration of Competing Interest
We have no conflicts of interest.