Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man’s land

Prezerakos, Georgios; Sayal, Parag; Kourliouros, Antonios; Pericleous, Periclis; Ladas, George; Casey, Adrian

doi:10.1007/s00586-018-5512-5

Cited by 10 publications

(6 citation statements)

References 10 publications

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“…HS concerns a dramatic number of medical and surgical practitioners with respect to various causes located at head, neck, and thorax that are presented from birth to elderly seniors; the level of statistical evidence depending on the underling disorder, but, numerous entities are limited to several case reports [ 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 ].…”

Section: Discussionmentioning

confidence: 99%

Horner’s Syndrome and Lymphocele Following Thyroid Surgery

Cârșote

Nistor

Popa

et al. 2023

JCM

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Horner’s syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid–related HS represents an unusual entity underling thyroid nodules/goiter/cancer–HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2–6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly <0.5%, except for a ratio of 8.3% in one study), correlates with extended surgery, especially lateral/central neck dissection, and the presence of congenitally—aberrant lymphatic duct; it is, also, described after endoscopic procedures and chest-breast approach; it starts within days after surgery. Typically low-fat diet (even fasting and parental nutrition) and tube drainage are useful (as part of conservative management); some used octreotide, local sealing solutions like hypertonic glucose, Viscum album extract, n-Butyl-2-cyanoacrylate. Re-intervention is required in severe cases due to the risk of lymphorrhoea and chylothorax. Early identification of Tx-HS and Tx-L improves the outcome. Some iatrogenic complications are inevitable and a multifactorial model of prediction is still required, also taking into consideration standardized operatory procedures, skillful intra-operatory manipulation, and close post-operatory follow-up of the patients, especially during modern era when thyroid surgery registered a massive progress allowing an early discharge of the patients.

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Section: Discussionmentioning

confidence: 99%

Horner’s Syndrome and Lymphocele Following Thyroid Surgery

Cârșote

Nistor

Popa

et al. 2023

JCM

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“…The anterior access to the cervicothoracic junction and upper thoracic spine via partial sternotomy or sole manubriotomy has been previously described in cadaveric studies and several clinical studies [ 21 , 22 , 23 , 24 ]. The regional anatomy of the CTJ (including the aortic arch caudally), the underlying pathologies requiring surgical treatment, and the location at the interface of different surgical disciplines are challenging aspects of this approach which bring a risk of intra- and post-operative morbidity [ 2 , 8 , 9 , 11 , 14 ]. In our series of eight consecutive cases, we could illustrate that this approach warrants safe and effective access to the CTJ in an interdisciplinary effort with the use of contemporary neuromonitoring techniques.…”

Section: Discussionmentioning

confidence: 99%

“…In such cases, surgical therapy is often required to restore stability of the CTJ and upper thoracic spine [ 3 ]. In the literature, there are controversial opinions as to whether an anterior or posterior approach is most favorable to access this area of the spine [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ]. The posterior or posterior-lateral approach to the upper thoracic spine and the CTJ involve manipulation of the spinal cord [ 13 , 14 ] to reach the vertebral bodies and carry a pronounced risk for postoperative morbidity associated with these extended approaches [ 3 , 14 ].…”

Section: Introductionmentioning

confidence: 99%

Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome

Issa

Neumann

Al-Maisary

et al. 2023

JCM

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Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22–74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9–16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6–20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1–45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures.

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“…If treated correctly, PC clusters in a risk group of cancers with long-term survival in whom secondary malignancies, cardiac and other events far outweigh the risk of dying from PC [ 89 ]. In light of the poor outcomes of patients with recurrence or persistence of disease [ 13 , 38 ], the significant link between surgical under-treatment and poor outcomes (see [ 21 ]), and the significant technical complexities of oncological surgery in the mediastinum [ 90 , 91 , 92 , 93 , 94 , 95 ], we propose the following approach: unless individual observations indicate otherwise, patients with small lesions (<3.0 cm) and only moderate hypercalcemia (<3.0 mM) can be approached as if presenting with benign mediastinal adenomas. Patients with large lesions (≥3.0 cm) and concomitant severe hypercalcemia (≥3.0 mM) should be referred to centers with particular expertise in this to undergo planned oncological surgery.…”

Section: Discussionmentioning

confidence: 99%

Mediastinal Parathyroid Cancer

Schulte

Galatà

Talat

2022

Cancers

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Parathyroid cancer (PC) is rare, but its pre-operative recognition is important to choose appropriate access strategies and achieve oncological clearance. This study characterizes features of mediastinal parathyroid cancer (MPC) and explores criteria aiding in the pre-operative recognition of malignancy. We assembled data from 502 patients with mediastinal parathyroid neoplasms (MPNs) from a systematic review of the literature 1968–2020 (n = 467) and our own patient cohort (n = 35). Thirty-two of the 502 MPNs (6.4%) exhibited malignancy. Only 23% of MPC patients underwent oncological surgery. Local persistence and early recurrence at a median delay of 24 months were frequent (45.8%), and associated with a 21.7-fold (95%CI 1.3–351.4; p = 0.03) higher risk of death due to disease. MPCs (n = 30) were significantly larger than cervical PC (n = 330), at 54 ± 36 mm vs. 35 ± 18 mm (χ2 = 20; p < 0.0001), and larger than mediastinal parathyroid adenomas (MPA; n = 226) at 22 ± 15 mm (χ2 = 33; p < 0.01). MPC occurred more commonly in males (60%; p < 0.01), with higher calcium (p < 0.01) and parathyroid hormone (PTH) levels (p < 0.01) than MPA. Mediastinal lesions larger than 3.0 cm and associated with a corrected calcium ≥ 3.0 mM are associated with a more than 100-fold higher odds ratio of being malignant (OR 109.2; 95%CI 1.1–346; p < 0.05). The composite 3 + 3 criterion recognized 74% of all MPC with an accuracy of 83%. Inversely, no MPN presenting with a calcium < 3.0 mM and size < 3.0 cm was malignant. When faced with pHPT in mediastinal location, consideration of the 3 + 3 rule may trigger an oncological team approach based on simple, available criteria.

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Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man’s land

Cited by 10 publications

References 10 publications

Horner’s Syndrome and Lymphocele Following Thyroid Surgery

Horner’s Syndrome and Lymphocele Following Thyroid Surgery

Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome

Mediastinal Parathyroid Cancer

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