among stage iiia non - small cell lung cancer patients , t4n0 - 1 cases can be good candidates for surgery and have a relatively favorable postoperative prognosis [ 1 , 2 ] .
however , most t4 cases with thoracic vertebral invasion may not be operated as complete resection with vertebrectomy is challenging .
we report the case of a male patient with primary lung pleomorphic carcinoma invading the thoracic vertebra who underwent complete resection with en bloc total vertebrectomy after embolization of the tumor - feeding vessels .
a 35-year - old japanese man presented with a 6-month history of left back pain .
chest x - ray and ct revealed that a tumor ( 43  34 mm ) in s1 + 2 of the left lung had invaded the third thoracic vertebra ( fig .
an mri revealed that the tumor had invaded the third thoracic vertebra and the third rib ( fig .
1c ) . as no nodal or distant metastasis was identified by whole - body ct and bone scintigram , we planned a primary surgery with a clinical diagnosis of lung cancer invading thoracic vertebrae ( ct4n0m0 , stage iiia ) . to prevent massive bleeding during resection of the tumor with vertebral invasion , arterial embolization was performed prior to surgery , and the first , second , and third intercostal arteries feeding the tumor ( fig .
we performed a complete resection consisting of left upper lobe lobectomy and lymph node resection ( nd2a-2 ) , partial resection of the second and third ribs , and total en bloc spondylectomy of the third thoracic vertebra .
pathological examination showed that all resection margins were free from malignant cells , and the final pathological diagnosis was pleomorphic carcinoma of the lung ( pt4n0m0 , stage iiia ) .
we conducted 3 cycles of adjuvant chemotherapy ( cisplatin , 80 mg / m ; docetaxel , 60 mg / m )   followed by oral administration of s-1 [ 4 , 5 ] and radiation to the primary tumor field .
the patient is alive at 14 months after surgery and without any evidence of tumor recurrence .
patients with primary lung cancer invading the vertebral column are rarely operated [ 6 , 7 ] as the postoperative survival is poor ( 5-year survival rates , 1620% ) [ 6 , 8 ] . however ,
when complete resection is achieved , favorable prognosis might be expected for such patients [ 6 , 7 ] .
thus , complete resection with vertebrectomy , especially total vertebrectomy , is challenging in the field of lung cancer surgery . in the present case , we adopted surgical treatment for the following reasons : ( 1 ) no nodal or distant metastasis was identified by whole - body ct and bone scintigram , and ( 2 ) complete en bloc tumor resection can be expected by total vertebrectomy of the third thoracic vertebra . prior to surgery , we performed embolization of the tumor - feeding arteries to prevent possible uncontrollable bleeding during vertebretcomy .
we performed surgery first because complete resection is expected by this technique without preoperative induction therapy .
in addition , life - threatening or extremely unpleasant spinal cord invasion and/or meningitis may occur when chemoradiation therapy does not result in tumor shrinkage .
accordingly , we conducted adjuvant chemotherapy and radiation after surgery . as summarized , a careful preoperative evaluation is essential to determine surgical indication , surgical approach , and sequence of multimodality therapy for t4 tumor with vertebral invasion .
 we present a case who had left upper lobectomy with total vertebrectomy after arterial embolization in preparation for intraoperative bleeding . a 35-year - old man complained of left back pain . 
 chest ct revealed a tumor in s1 + 2 of the left lung , invading the third thoracic vertebra . 
 as no nodal or distant metastasis was detected , we performed left upper lobectomy and lymph node dissection ( nd2a-2 ) after embolization of the vessels feeding the tumor in order to reduce intraoperative bleeding . 
 in addition , the team of orthopedics performed en bloc resection of the third thoracic vertebra and parts of the left third and fourth ribs 
 . histological examination of the tumor revealed pleomorphic carcinoma ( pt4n0m0 , stage iiia ) . 
Introduction
Case Presentation
Discussion