Editorial comment: En bloc vertebrectomy for lung cancer invading the spine: surgical serenity and optimism warrant innovation

Innovation in medicine increasingly becomes challenging. Ethical considerations and regulations discourage progressively skilled surgeons to develop new techniques, particularly as it pertains to extended aggressive resections. The case of en bloc vertebrectomy for lung cancer attached to the spine is a pure demonstration of surgical developments that were possible in a recent past but that would probably not be allowed today.

In the current issue of this journal, Dr Schirren and his colleagues emphasize the benefits of such surgical aggressiveness, as they report a 5-year survival rate of 47% in patients, who underwent radical en bloc surgery including spinal resection [1]. Nearly one out of two patients can thus hope to survive 5 years following surgical resection of a lung cancer invading the vertebral column! These fascinating results confirm previously published data [2,3]. Such survival rates, associated with a very low postoperative mortality, support the suggestion by the Association for the Study of Lung Cancer (IASLC) Staging Committee to downstage these T4 tumors from stage IIIB to stage IIIA, provided the nodal status be limited to N0 or N1 [4]. Accordingly, in centers of excellence, a surgical resection can be offered to selected patients with such disease. Appropriately, in the study by Dr Schirren and colleagues, patients with N2 disease were precluded from resection [1].

From a technical point of view, the authors’ choice is a two-stage procedure: a primary posterior midline incision, followed by a posterolateral thoracotomy. It differs from the technique we initially described, where an anterior cervicothoracic approach was followed by a posterolateral thoracotomy, and then a posterior incision [5]. We preferred the posterior stage to be last to allow spinal stabilization, followed by both vertebral resection and reconstruction at the same time. Subsequently, our approach was simplified into a two-incision procedure [6]. Currently, the first stage includes an initial transmanubrial approach, allowing both the specific anatomical cervical dissection needed by these apex invading tumors, and the hilar time of the upper lobectomy, as well as the mediastinal lymph node dissection and the thoracic wall division [7]. The second stage takes the patient in the prone position where, through a posterior approach we extract the en bloc surgical specimen, after spinal stabilization, and finally perform the vertebral reconstruction. The advantages of the transmanubrial approach, which gives an outstanding access to the supra-clavicular area, but also to the upper mediastinum, preserving the scapular girdle function, have rendered this approach very popular [8]. Through this approach, combined use of the conventional and thoracoscopic instruments generally allows to perform the upper lobectomy, without needing an additional thoracotomy. This front then back sequence also allows a very safe anterior control of the vertebral column, before performing the spinal division.

Though using a different sequence to the approach we have popularized, Dr Schirren and colleagues’ technique is an en bloc resection, and they are reporting better local control than previously described by others, who have embraced the intra-lesional philosophy to treat such tumors [9]. Traditionally, the anterior approach was proposed solely to tackle anteriorly located lesions. Our experience, however, now supports using the anterior incision in all cases, including posteriorly located superior sulcus tumors. Indeed, we now find that the direct view obtained from the front greatly facilitates the access to the anterior spinal plane. As a result, we now favor the transmanubrial approach upfront in all cases for apical tumors, without any other thoracotomy than that given by the opening of the first intercostal space.

In the current series, a few patients were found, on final pathological examination, to have had T3 tumors only [1]. The authors found no outcome differences when comparing these T3 patients to those who actually had true pathological T4 tumors, an observation we also noted out of our own experience [10]. These results could be related to the optimal local control afforded by this extended no-touch resection, including the cases where the tumor is simply adjacent to the spine, without direct invasion of the bone. Obviously, in these cases, an extravertebral resection could potentially expose the patient to an early local recurrence and failure. As a matter of fact, in our series, the 5-year survival for patients with pathological T4 invasion of the vertebral body, who could benefit from a complete R0 resection, was 40%.

We strongly agree with Dr Schirren and colleagues as they emphasize the role of a multimodal therapeutic approach in these T4 tumors. Among 32 patients in our series, only 21 were treated preoperatively by induction: either chemotherapy alone (n = 16), chemoradiation (n = 4), or radiation alone (n = 1) [10]. Our retrospective analyses demonstrated better outcomes in patients, who received induction chemotherapy before surgery. As well, recent series have shown far better results in patients treated with preoperative chemoradiotherapy followed by surgery [2,3].

The authors have to be congratulated for such achievements in the treatment of these difficult cases. Including their series, nearly 130 cases of vertebrectomy for lung cancer attached to the spine have been published to date [1–3,9,10]. In trained hands, this technically demanding surgical challenge can be achieved with tolerable postoperative turbulence. To duplicate such excellent results, one needs: (1) an excellent multidisciplinary team, including spinal surgeons; (2) surgical serenity; and (3) surgeon’s and patient’s strong optimism.

In conclusion, these data support that patients, who suffer from vertebral invasion by a lung carcinoma, in particular with Pancoast tumors, should be offered to be assessed at the nearest specialized referral center, where an interdisciplinary thoracic–spinal surgical program is established.

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