| [Backgrounds]Tumors of the cervicothoracic junction(TCTJ)refer to the tumor which is extension from the thoracic entrance to the mediastinum,derived from the neck tumor expansion to the thoracic cavity,or the origin of the thoracic tumor over the thoracic entrance to the neck.The histologic origin of TCTJ is complex and the incidence is relatively low,in which is more common in the upper lung tumors,neurogenic tumors and thyroid tumors and so on.Because of the complex anatomy of the neck and chest junction,tumors often have close proximity to important structures,such as nerves and vessels,and often involve various clinical manifestation,such as pain,breath,Horner 's syndrome,etc.In addition,the operation space of tumor occupying space is narrow.Surgery is easy to damage some important structures,leading to serious complications and adverse consequences.Therefore,the traditional thoracic surgical incision has a poor therapeutic effect and the risk of surgical injury is high.TCTJ is considered to be a restricted area for thoracic surgery and the difficult challenges to some extent.A comprehensive preoperative evaluation and reasonable choice of surgical incision and path are the key factors for resection of the tumor and reduce complications.At present,this kind of operation has been more developed than before,and some surgical cases that were previously inoperable have been subjected to rigorous assessments to obtain surgical opportunities,thereby prolonging the survivalof patients and improving the quality of life of patients.Therefore,it is an important way to improve the diagnosis and treatment rate of cervical cancer at border junctions in order to strengthen the recognition of cervical and thoracic junction tumor surgical incisions at all levels of hospitals.[Objectives]This article reviews the related cases of thoracic surgery in our hospitaland analyzed the surgical approaches and the operative results of the surgical procedures and incisions of the cervicothoracic junction.The purpose of this study is to improve the understanding of the complicated surgical path and incision of the primary cervical thoracic junction,and provide reference for the choice of the incision selection for the surgical operation of the neck and chest junction.[Methods]We collected total of 16 patients with TCTJ who underwent complex incisions at the cervical and thoracic junctions from September 2010 to February 2018.Obtain clinical data of patients,including clinical manifestations,preoperative examination,the selection of the surgical incision,pathological types of tumors,removal of clavicle and ribs,complete resection,intraoperative blood loss,operation time,postoperative drainage volume,complications,Life time and other information.The operation methods and points of each incision were reviewed,and the advantages and disadvantages of each incision and the effect of treatment were analyzed.[Results]1.We collected 16 cases of primary TCTJ with complex surgical incisions,with an average age of 47.7(25-65)years.In this group,6 cases were found by physical examination,5 complained of chest and back pain,3 had chest tightness and shortness of breath,and 4 had cough and expectoration.2.Pathological types include neurogenic tumors(10 cases),non small cell lung cancer(3 cases),fibromatosis local sarcoma(1 cases),solitary fibroma(1 cases),and hard fibroma(1 cases),of which 12 cases of benign tumors,3 cases of malignant,1patients with fibromatosis and local fibrosarcoma.Except for 3 cases of upper lung sulcus tumor,the size of other tumors ranged from 5x2.7x2.4cm3~13x9x8cm3.In this group of patients,6 cases had longer tumor diameters exceeding 8cm.3.In addition to routine CT examination,4 patients underwent neck and / or chest MRI examination.4 patients underwent thoracic revascularization and 8underwent fibrobronchoscopy.CT-guided biopsy was performed in 7 patients before surgery but one of the puncture cases was inconsistent with postoperative pathological results.4.Of the 16 cases,5 cases were combined with assisted thoracoscopy,3 with neck incision or supraclavicular incision combined with thoracic incision,2 with Paulson incision,2 with "L" incision and 4 with hemi-clamshell incision.Complete resection of the tumor was achieved in 14 cases and the complete resection rate was87.5%.Only 2 palliative resections were performed in the thoracoscopic assisted incision group and the "L" incision group.In 16 cases,there were 7 cases of rib resection,2 cases of clavicular excision,2 cases of chest wall,upper lobectomy and mediastinal lymph node dissection,1 cases of cuneate excision neck and mediastinal lymph node biopsy.5.The overall average time of operation was 3.87 hours in 16 patients,and the average total blood loss was 490.63 ml.The average drainage volume was 913.81 ml in3 days postoperative.The average time for removal of the drainage tube was 7.25 days.The average length of hospital stay was 23.94 days.The average discharge time was 10.75 days.The average operative time of thoracoscopic combined open incision group,neck or supraclavicular incision combined with thoracic incision group,Paulson incision group,"L" incision group and hemi-clamshell incision group was2.68,4.33,4.54,4.22,4.56 hours,respectively.The average intraoperative blood loss was 300,700,475,325 and 662.5ml;the average postoperative drainage volume was532,705.3,1030,1450 and 1221.2mlin 3 days postoperative.It was 5.2,7.3,8.5,10,and 7.75 days.The average length of stay was 18.6,25.7,40.5,21.5,and 22.5 days.The average discharge time after surgery was 9.2,9,10.5,13,and 13 days,respectively.6.All patients did not die during perioperative period.There were especial cases of postoperative complications of shoulder numbness,severe pain,encapsulated pleural effusion,and pulmonary bullae rupture.Only 1 case had long term complications of slight numbness in the shoulder and upper arm.7.The average follow-up time of the whole group was 25.3(1.5-91)months.No recurrence or death was found in 12 cases of benign tumors completely followed up.Among the 4 malignant tumors,2 cases underwent complete tumor resection and 2cases underwent palliativeresection.At present,except 1 case of malignant tumor patients lost to follow-up after 20 months,the remaining 3 cases have all died and the survival time was 10.5,1.5,21 months.There was a statistically significant differencein overall survival(OS)between patients with benign tumors and those with malignant tumors(P = 0.0017)and there was a statistically significant difference in overall survival between group of palliative and group of complete resection(P =0.0059).?Conclusions?1.Reasonable choice of incision are key factors for complete resection ofthe tumors of the cervicothoracic junction,which can reduce unnecessary exploratory surgery.2.The degree of trauma of the Paulson incision and the hemi-clamshell incisionis similar,and the trauma of this two is larger than the thoracoscopic combined open incision.3.The pathological nature and complete resection are closely related to the prognosis of patients undergoing surgery for cervicothoracic junction tumor.Careful choice must be taken. |
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