A 71-year-old Japanese male presented at our hospital due to left back pain and an abnormal chest computed tomography (CT) scan showing a 80 x 70 x 60-mm tumor located in the left middle apex of the thoracic inlet. This tumor was located near the subclavian artery, and the subclavian lymph nodes were swollen (Fig. 1).
We performed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The tumor was found to be an adenocarcinoma (clinical-T3N3M0 stage IIIB), so we performed definitive chemoradiation therapy (radiation total: 61.4 Gy, weekly CBDCA and paclitaxel, 6 courses). After this treatment, slight reduction in the tumor size was noted, and the subclavian lymph nodes were no longer swollen. At this point, we diagnosed the tumor as cy-T3M0M0 stage IIB adenocarcinoma. We then performed surgical resection for this superior sulcus tumor located from the anterior to posterior apex of the thoracic inlet.
The surgical procedure included four steps. The diagram of the surgery and surgical view are shown in Fig. 2. First, we performed VATS 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 artery, 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 and performed subclavian aria lymph node dissection before closing the anterior wound. Third, through classic posterolateral thoracotomy (Paulson's thoracotomy), we obtained tumor-free margins in a section of the chest wall (ribs 1, 2, and 3). We then performed left upper lobectomy and mediastinal lymph node dissection. Finally, we reconstructed the chest wall using a double layer of polypropylene mesh (Bard Mesh, C.R. Bard Inc., Karlsruhe, Germany) with the patient in the neutral lateral position after the placement of a chest tube. The mesh was sutured to the ribs, and the thoracotomy was closed. The operative time was 10 h, and the intraoperative bleeding was 1200 ml.
Pathologically, complete resection was achieved. The pathological diagnosis was yp-T3N0M0 adenocarcinoma, and the histologic response for evaluating the tumor response to induction therapy was two (Ef2). The patient was discharged from our hospital 18 days after surgery. This surgery was successful, with no major postoperative complications. The patient remains healthy and recurrence-free at 2.5 years after the operation.