En bloc vertebra resections and lung cancer
Non-small cell lung cancer (NSCLC) invading the chest wall and vertebral bodies account for less than 5% of newly diagnosed patients, and their surgical management still represents, despite recent advances in material research, multimodality therapy and surgical techniques, a clinical unmet issue. They usually occur as direct unilateral invasion involving mostly the antero-lateral paths of the vertebral bodies, and costovertebral groove. Computed tomography and magnetic resonance imaging studies are pivotal to assess operability and guide the type of surgical management which must always aim the en bloc resection of the tumor with clean surgical margins and spine reconstruction. While there is no need of vertebral body resection for NSCLC invading the ipsilateral ribs and vertebral transverse processes, hemi-vertebrectomy or total vertebrectomy is required when tumors invade the ipsilateral side or more than 50 percent of the vertebral body, respectively. Different approaches (anterior, posterior or their combination, etc.) and different types of vertebral resection and stabilization have been described. Preoperatively, one may consider embolization of the endovascular intercostal-somatic arteries feeding the tumor one day before the operation to mitigate intraoperative blood losses. Despite high morbidity and tumor recurrence rates, 5-year survival rates of 60% have been recently reported for NSCLC invading the vertebral body. As a consequence, surgery shall be considered in well-selected NSCLC patients and in large-volume thoracic and spine surgical.