P3.01-72 Pulmonary Resection in a Prone Position for Lung Cancer Invading the Spine: Two Cases Report

Abstract

The prone position is usually not selected for pulmonary resection. The intraoperative body position is an important issue in surgery for non-small cell lung cancer (NSCLC) invading the spine because the standard intraoperative body position for vertebrectomy is a prone position, while that for pulmonary resection is a lateral decubitus position. Intraoperative changes in body position are correlated with disadvantages such as the risks of infection and nerve injury. We have previously reported significantly favorable clinical outcome of induction chemoradiotherapy (iCRT) followed by surgery among patients with clinical T3 or T4 locally advanced NSCLC, compared with initial surgery. iCRT can prevent cancer cell microresidues at local sites and to eradicate micrometastatic disease at distant sites. Case 1: A 60-year-old man was found to have squamous cell carcinoma of the left lung with invasion of the adjacent chest wall and vertebral bodies from Th3 to Th5 and his clinical stage (UICC 7th edition) was diagnosed as c-stage IIIA (cT4N0M0). Case 2: A 63-year-old man was found to have adenocarcinoma of the right lung with invasion of the adjacent chest wall and Th3 and Th4 vertebral bodies and was diagnosed as c-stage IIIA (cT4N1M0). They were treated with iCRT consisting of two cycles of cisplatin plus docetaxel with concurrent radiotherapy of total 46 Gy. They obtained a moderate decrease in tumor size after iCRT (restaging ycT4N0M0: Case 1, ycT4N0M0: Case 2). The surgery was started in the prone position. After partial vertebrectomy and chest wall resection were performed using an O-arm with a navigation system, upper lobectomy with systemic lymph node dissection (sLND) was performed through the chest wall defect via the posterior approach. Firstly, all pulmonary arterial branches to upper lobe were divided. Next, after division of the posterior and anterior interlobar fissure, the upper lobe bronchus was transected. Finally, the upper pulmonary vein was divided, and sLND was performed under an excellent view. Pathologic examination confirmed complete resection of squamous cell carcinoma invading the vertebral bodies and a diagnosis of Ef3 and ypN0 in Case 1, and complete resection of adenocarcinoma adjacent to the vertebral bodies, which had not been infiltrated, and a diagnosis of Ef2 and ypN0 in Case 2. Lobectomy with systemic LND in the prone position, especially after wide resection of the bony thorax, can be performed via the posterior approach without any significant difficulties in the patients with NSCLC invading the spine.