Left Subclavian Artery and Jugular Vein Replacement With Chest Wall Resection and Reconstruction for Pre-Treated Ewing Sarcoma
This is the case of a 53 year old woman, non smoker,
diagnosed with Ewing sarcoma of the left thoracic outlet. The lesion involved
the subclavian vessels, first left 2 ribs, and brachial plexus, possible
involvement of the apex of the left lung. No distant metastasis were evident on
the scans.
The patient underwent induction chemotherapy (5 cycles of VAC regimen)
according to the multidisciplinary evaluation. The lesion was reduced from
66x80x65 mm to 39x18mm.
Of note, before the surgery, the patient presented with a hyposphygmic left
upper limb, with significant neurological impairment and hypotrophy of the
musculature of left arm, forearm and hand.
She underwent left manubriotomy, first and second left ribs resection en bloc
with phrenic nerve, brachial plexus, left jugular vein and subclavian artery.
A left jugular-innominate vein by-pass was performed with reinforced PTFE 8.0mm
prosthesis, and the subclavian artery by-pass with Goretex 8.0mm prosthesis.
The chest wall defect was repaired with a 15x15cm Vycril prosthesis.
The pathologist reported an R0 resection of the Ewing sarcoma. The patient
developed a left chylothorax requiring a surgical second look which was insufficient
and the patient underwent to pleuro-peritoneal Denver shunt implant.
At the end of the video a picture of the vascular interposition grafts and a
picture of the specimen are showed.
References
Spaggiari L, Pastorino U. Anterior approach to the superior
sulcus tumors: the transmanubrial osteomuscular sparing approach. J Thorac
Cardiovasc Surg. 1999;117(5):1042-4. doi: 10.1016/S0022-5223(99)70403-4.
Spaggiari L, Pastorino U. Subclavian artery involvement by apical chest tumors:
a specific indication for the transmanubrial approach. J Thorac Cardiovasc
Surg. 1999;117(3):627-628. doi:10.1016/s0022-5223(99)70351-x
Lahon B, Mercier O, Fadel E, et al. Subclavian artery resection and
reconstruction for thoracic inlet cancer: 25 years of experience. Ann Thorac
Surg. 2013;96(3):983-989. doi:10.1016/j.athoracsur.2013.04.032
Matsuguma H, Nakahara R, Ishikawa Y, Suzuki H, Ui A, Yokoi K. Transmanubrial
osteomuscular sparing approach for lung cancer invading the anterior part of
the thoracic inlet. Gen Thorac Cardiovasc Surg. 2010;58(3):149-54. doi:
10.1007/s11748-009-0484-3. Epub 2010 Mar 28
Wright CD, Mathisen DJ. Superior sulcus tumors. Curr Treat Options Oncol. 2001
Feb;2(1):43-9. doi: 10.1007/s11864-001-0015-7.
