A 62-year-old man was found to have squamous cell carcinoma of the antero-posterior apex of the left lung with invasion to the body of the second thoracic vertebra (Th2), adjacent rib (ribs 1-3) and subclavian artery, as shown by computed tomography (Fig. 1). We performed TBLB and made the diagnosis of squamous cell carcinoma of the lung. Pretreatment TNM staging was stage-IIIA(c-T4N0M0). Induction chemotherapy with cisplatin (CDDP) and TS-1 and radiotherapy (total 50 Gy) obtained a slight decrease in the tumor size and incomplete pain relief. After restaging confirmed a persistent yc-T4N0M0 tumor, complete resection was planned.
The surgical procedure included four steps. The diagram of the surgery is shown in Fig. 2.
First, the transmanubrial approach allowed us to obtain tumor-free margins of the anterior cervical structures. The tumor surrounded the left subclavian artery. Therefore, we dissected the subclavian artery, which was reconstructed with an artificial artery (Gore-Tex  expanded polytetrafluoroethylene graft, 8 mm in diameter), together with wedge resection in the left upper lobe. The left vertebral artery and left transverse cervical artery was also dissected. The anterior wound was temporary closed.
In the second step, classic posterolateral thoracotomy allowed us to obtain tumor-free margins in the section of the chest wall (ribs 1-3). The tumor was adherent to the esophagus. Thus, we dissected the adventitia of the esophagus and performed left upper lobectomy. We were unable to perform en bloc resection, therefore, intralesional resections were performed. Thoracotomy was temporary closed.
In the third step, a posterior midline incision was made with the patient in the prone position by a spine surgeon. Th2 total vertebrectomy (ediculotomy and en block laminectomy) was then performed. The intervertebral disks of superior and inferior to the involved vertebral body were resected. A titanium mesh case in conjunction with bone grafting and ventral osteosynthesis was subsequently performed after total vertebrectomy.
All vertebrectomies were perforemed by one orthopedic surgeon. A pathological examination confirmed complete margin-free resection of the lung cancer invading the chest wall and vertebral body.
Finally, we performed omentum resection to cover the thoracic cavity resected area and reconstructed the chest wall. The chest wall was reconstructed using a double layer of polypropylene mesh (Bard Mesh, C.R. Bard Inc., Karlsruhe, Germany) with the patient in the neutral lateral position after placement of a chest tube. The mesh was sutured to the ribs and thoracotomy was closed. The operative time was 33.3 h and intraoperative bleeding was 6640 ml.
Pathologically, complete resection was achieved. The pathological diagnosis was yp-T4N0M0 squamous cell carcinoma, and the histologic response for evaluating the tumor response to induction therapy was two (Ef2).
The patient was discharged from our hospital 87 days after surgery. The major postoperative complication was laryngeal recurrent nerve paralysis.
Unfortunately, the patient developed local recurrence 10 months after surgery. He underwent chemoradiation and has had no distant metastasis 12 months after surgery.