Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man's land.

Abstract

Cervicothoracic paravertebral neoplasms extending into the mediastinum pose a surgical challenge due the complex regional anatomy, their biological nature, rarity and surgeon's unfamiliarity with the region. We aim to define a surgical access framework addressing the aforementioned complexities whilst achieving oncological clearance. We carried out a retrospective review of 28 consecutive patients operated in two tertiary referral centres between 1998 and 2015. Pathology was located paravertebrally from C6 to T4 with superior mediastinum invasion. Patients were operated jointly by a spinal and a thoracic surgeon. Tumours were classified according to subclavian fossa involvement as anteromedial, anterolateral and posterior and according to histology in benign nerve sheath tumour group (n=10) and malignant bone or soft tissue tumours (n=18). Three surgical routes were utilised: (1) median sternotomy (n=11), (2) anterior cervical transsternal approach (n=7) and (3) high posterolateral thoracotomy (n=10). Resection was en bloc with wide margins in 22 cases, marginally complete in 3 and incomplete in 3. Complications included Horner's syndrome (n=3), infection (n=2) and transient neurological deficit (n=4). In the nerve sheath tumour group, no recurrence or reoperation took place with a median follow-up of 4.5years. In the malignant bone and soft tissue group, 96% of the patients were alive at 1year, 67% at 2years and 33% at 5years. No vascular injuries or operative related deaths were observed. Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relationship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides minimal morbidity/maximum resection and satisfactory oncological outcomes. These slides can be retrieved under Electronic Supplementary Material.