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Pierre R. TheodoreAssociate Professor of Cardiothoracic Surgery

UCSF Medical CenterVan Auken Endowed Chair in Thoracic Surgery

Director of Thoracic Surgery Saint Mary’s Medical Center

TUMORS OF THE NECK WITH EXTENSION INTO THE SUPERIOR MEDIASTINUM: APPROACHES

AND PITFALLS

ACCESS TO THE SUPERIOR MEDIASTINUM: INTRODUCTION• Cornerstone is Communication:

• Planned Approach• Extent of Exposure / Tailored Incision• Preoperative Imaging – Contrast Materials• Cell Type; Nodal Status; Calcification; Recurrent Laryngeal

Nerve Status • Airway Management• Understanding Limitations and Capacities

The Impact of Distant Metastases at Presentation on Prognosis in Patients with Differentiated Carcinoma of the Thyroid Gland Nixon et al Thyroid. September 2012, 22(9): 884-889.

Thyroid Cancer in Chest: Location, RAI Avidity and Age CASE DISCUSSION

• 44 year old Asian Male• Asthma Symptoms unresponsive to

bronchodilators• Biopsy proven Papillary Thyroid Cancer

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RELATIVELY LITTLE DISEASE BURDEN IN NECK CROWDED SUPERIOR MEDIASTINUM

AIRWAY MANAGEMENT DISCUSSION RECURRENT LARYNGEAL NERVE RISK

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TRACHEAL INVASION? RECONSTRUCTION OPTIONS Mass Delivery into Neck

Early Isolation of Innominate VeinIdentification of Recurrent Around Aortic ArchDelivery to position anterior of great vessels

Mass

Innominate Vein

Ascending AortaPericardium

AIRWAY STENOSIS RESOLUTION STERNOTOMY VERSIONSUpper Sternal Split favored

• Mabubrotomy• Manubrectomy (historical)• Median Sternotomy• Transverse Sternotomy• Camera Aided with Sternal Suspension Techniques

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STERNAL DIVISIONTRAPDOOR INCISION: BULKY OR SUPERMEDISTINAL DISEASE WITH PULMONARY METASTASES

Sternal PlatingFacilitates Closured with Limited SternotomySecureGood For Stellate Fractures of Sternum with Upper Sternal Split

Courtesy of Synthes

CLOSE EVALUATION FOR CHRONIC CALCIFICATION

Cancer Imaging 2007; 7 Issue A S56-S62

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ACCESS VIA THE STERNAL SPLIT CASE 2• 36 year old graduate student• Progressive Chest pain and swelling in base of neck• Biopsy suggestive of neurogenic tumor• Staged Procedure versus Resection in One Setting

EXTENSION INTO POSTEROLATERAL NECK SUPERIOR SULCUS OCCUPIED BY TUMOR

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EXTENSION THROUGH THORACIC INLET GANGLIONEUROMA THROUGH THORACIC INLET

THORACIC ECTOPIC THYROID

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CONCLUSIONS• Communication• Airway Management on Anesthesia Induction• Careful Sternotomy with reconstruction with Plating

• Calcification Recognition• Prognosis Based on RAI Avidity and Location of Thoracic Disease

-FDR

“BE SINCERE, BE BRIEF, BE SEATED”