Our technique of combined full thoracoscopic (no access incision) and posterior midline approach for en bloc resection of non-small cell lung cancer invading the spine: tips and tricks

Introduction

Due to its several advantages (1), the development and adoption of minimally invasive surgery for major lung resections has accelerated in recent years and has become the first choice for performing lobectomies and anatomical segmentectomies. With the advancement in surgical instruments and technology, increasingly complex procedures are now being performed by minimally invasive approaches.

En bloc resection of lung cancers invading the vertebral column remains a major challenge for both surgeons and patients. This operation is one of the most aggressive treatments for lung cancer patients, and has historically been associated with high morbidity including prolonged mechanical ventilation, lung infections, and cerebrospinal fluid leakage (2). High-volume centers have evaluated and validated the effectiveness of video-assisted thoracoscopic surgery (VATS) lobectomy with concurrent spine resection (3-6).

At our institution, Grunenwald et al. first describe a total vertebrectomy for en-bloc resection of lung cancer invading the spine in 1996 (7). With ongoing technological advancements and building upon our initial experience, this study aims to describe our current technique of full thoracoscopic (no access incision) lobectomy with spinal resection, highlighting our tips and tricks that facilitate the “close chest” en-bloc resection of non-small cell lung cancer (NSCLC) with vertebral invasion. The small sample size precludes us from drawing any statistical conclusions. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-144/rc).

Preoperative preparations and requirements

We retrospectively analyzed patients who underwent surgery between Nov 29, 2018 and Nov 24, 2021 at the Montsouris Mutualist Institute for NSCLC invading the spine. Patients were treated with a full thoracoscopic lobectomy and mediastinal lymphadenectomy, performed en-bloc with posterior vertebral resection under a single-stage anesthesia. By “full thoracoscopy” we refer to a procedure utilizing 100% video display without any access incision and performed only by trocars and dedicated endoscopic instruments.

This study conducted a retrospective analysis of prospectively collected data.

Preoperative investigations included contrast-enhanced computer tomography (CT)-scan, vertebral magnetic resonance image (MRI), 18F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET)-scan, cerebral MRI, bronchofibroscopy, pulmonary and cardiac function tests. All patients had a preoperative CT-guided biopsy to confirm the histological diagnosis. Patients with suspected mediastinal lymph node invasion (smaller dimeter ≥10 mm and/or positive at PET-scan), underwent endobronchial ultrasound (EBUS)-guided staging. Patients with positive mediastinal lymph nodes were precluded for surgery. All patients eligible for surgery, received neoadjuvant chemo-radiotherapy treatment and were finally considered for surgery only if they demonstrated a response to induction treatment or at least no progression. The response to neoadjuvant treatment and the absence on progression were evaluated by a CT scan, vertebral MRI and cerebral MRI, after 2 cycles of chemotherapy and 40 Gy at radiotherapy. Surgery was performed between 3 and 6 weeks after the completion of the induction treatment.

The criteria for resection were: (I) a confirmed histologic diagnosis of NSCLC; (II) absence of mediastinal nodal involvement; (III) no distant metastasis; and (IV) lack of progression following the neoadjuvant chemo-radiotherapy.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

The patients were all operated by a senior thoracic surgeon and a senior orthopedic surgeon.

Thoracic procedure

For the thoracic procedure, we use a full thoracoscopic approach with CO₂ insufflation (closed chest). All thoracic procedures were conducted under general anesthesia, using single-lung ventilation through a double lumen endotracheal tube. The patients were placed in a classical posterolateral decubitus position. Four video access ports were established: a 12 mm camera port, 2–3 cm below the tip of the scapula, one anterior 12 mm port at the 6th or 7th intercostal space and two 5 mm ports in the 5th and 7th intercostal respectively. The 5 mm ports were placed posteriorly, in the interscapulo-vertebral space for the right approach and anteriorly, along the anterior axillary line for the left approach (Figure 1A,1B). Only airtight trocars were used. The surgeon was positioned behind the patient for the right lung resections and in front of the patient for the left lung resections. After entry in the pleural space, a medium flow CO₂ insufflation was started with Airseal System (AirSeal^® CONMED, New York, USA), achieving a final intrathoracic pressure of 8 mmHg. A deflectable thoracoscope (LTF, Olympus, Tokyo, Japan) provided with a distal charge coupled device (CCD) was used connected to a high-definition camera system (HDTV) (Exera II, Olympus, Tokyo, Japan).

Figure 1 Patients were placed in a classical posterolateral decubitus position; the yellow star indicates the back of the patient. (A) Right side approach. The surgeon is placed at the back of the patient. The scapula is outlined in black. Trocars placement for the right side approach. (B) Left side approach. The surgeon is placed on the front of the patient. For female patients, the breast contour is drawn to avoid placing trocars in the breast. The scapula is outlined in black. Trocars placement for a left side approach.

The operating steps for the thoracic phase are as follows:

• Chest cavity inspection;
• Chest wall preparation around tumoral vertebral invasion;
• Stappler division of the lung parenchyma surrounding the tumor;
• Rib section;
• Vertebral bodies dissection and esophageal protection with a 2 mm Gore-Tex mesh;
• Lung lobectomy and mediastinal lymph node radical dissection;
• Chest extraction of the surgical specimen, chest drainage and closure of the trocar ports.

Surgical procedure description

After inspection, the operation began with the opening of the parietal pleura and preparation of the chest wall around the tumor invasion area. On the rib side, a minimal safety margin of about 2 cm from the tumor invasion was maintained. Following the dissection of the costal and vertebral bodies all around the parietal invasion as completely as possible using the energetic sealer forceps by Enseal System (ENSEAL X1 Curved Jaw Tissue Sealer and the Generator G11, Ethicon Inc., Cincinnati, OH, USA), the lung parenchyma was transected at a safe distance from the tumor using a stapler device thus separating it from the affected area (Video 1). After the deep resection of the intercostal spaces and the trunk muscles down to the subcutaneous tissue with the Enseal System, the ribs were cut using an endoscopic rib cutter (SCANLAN^® Dennis Rib Cutter, Saint Paul, Minnesota, USA; 10 mm) inserted through the 12 mm trocar (Figure 2A-2C) (Video 2). The preparation of the vertebral bodies was then started. The vertebral bodies adjacent to the tumor invasion were dissected and exposed their entire lateral part, opposite to the tumor invasion and the mediastinum was opened along its length. The space between the vertebral bodies and the esophagus was carefully dissected and widely opened in both cranial and caudal directions, as extensively as possible. A 2 mm Gore-Tex mesh is then placed between the vertebral bodies and esophagus, in order to protect the latter from the orthopedic scissors during vertebral bodies sectioning maneuvers (Figure 2A, Video 3). This Goretex mesh was subsequently removed by the orthopedist at the time of vertebral resection via the posterior approach.

Figure 2 Intrathoracic chest wall preparation. (A) Dissection around the tumour. (B) Lateral arch rib dissection. (C) Lateral rib section with the endoscopic rib cutter (SCANLAN^® Dennis Rib Cutter, 10 mm); the instrument is visible at upper pole of the picture.

A standard upper lobectomy was then performed using a fissure-based approach. The fissure was opened to permit the resection between clips or staplers of the segmental arteries. On the right side, after division of the A2 artery, we usually dissect and divide the central vein, followed by the dissection and division of the bronchus using a stapler. Finally, the mediastinal artery is stapled, followed by the minor fissure, usually including the V1 vein. When a central vein doesn’t exist, the upper lobe vein is dissected after the mediastinal artery division, and stapled separately.

On the left side, after opening the fissure and dividing the segmental arteries, usually we open the hilum to facilitate the division of the upper lobe pulmonary vein, the mediastinal artery, and the left upper lobe bronchus.

On both sides, a standard radical mediastinal lymph node dissection was performed, including at least lymph node stations 2, 4 and 7 on the right side and 5, 6 and 7 on the left side.

The specimen is then placed in an Endobag (Endo Catch™ Gold, Covidien, Dublin, Ireland) and extracted through the 12 mm trocar which is slightly enlarged.

A chest tube was inserted through the camera port, and the remaining wounds were closed using the standard techniques.

The surgical technique of the thoracic phase of en-bloc VATS left upper lobectomy and spinal resection is summarized in Video 1.

Spinal procedure

With VATS procedure completed, the patient was first turned to the dorsal position and the double lumen endotracheal tube was replaced with a single lumen endotracheal tube. Then the patient was placed in the prone position using a head holder. In this series, only partial resection of the vertebral bodies was performed.

Exposure of cervicothoracic or thoracic spine was achieved via a single midline approach.

Dissections were extended unilaterally up to 7–8 cm along the ribs adjacent to the affected vertebra. Then, spinal fixation was realized using arthrodesis with transpedicular screws and roods on the contralateral side, before partial spondylectomy.

After cutting a bony furrow from the facet joints on the tumor-affected side, the corresponding nerve roots were identified and divided after proximal ligation adjacent to the spinal cord within the canal.

An oblique osteotomy was completed on the vertebral body and performed in posterior-to-anterior direction.

The resection is completed to on the upper and the lower parts of the spine by transection of the vertebral isthmus. By this means, a variable portion of the vertebral body can be resected according to the obliquity of the vertebral osteotomy.

As described earlier, the esophagus was protected during the thoracoscopic step, by using a 2 mm Goretex mesh.

The surgical specimen—including chest wall, pulmonary parenchyma with the tumor and the lateral part of the vertebral body—was translated forward, rotated around the cord and extracted laterally in en-bloc fashion.

Contralateral fixation with transpedicular screws and rods was then performed to complete the stabilization of the spine (Figure 3).

Figure 3 Posterior approach for spinal resection. (A) Final aspect after partial T2 and T3 vertebral body resection and extraction of the surgical specimen. (B) Postoperative day 1 chest X-ray.

In some cases, fibular strut grafts were used when more than one-third of the vertebral body was resected.

Particular attention was given to protecting the distal roots of the brachial plexus on the side of the bone resection.

For example, in the case of T2 bone resection, the T1 root in the foramen above must be neurolysed in its intracanal, foraminal and extraforaminal portions, so as not to be torn or damaged by the exit of the K2 rib during the extraction of the surgical specimen.

Similarly, in cases involving T1 vertebral resection, the C8 root was protected to avoid potential damage from the K1 rib during en-bloc extraction.

All patients were extubated immediately postoperatively in the recovery room.

They were allowed unrestricted movements immediately after surgery. No plastic jacket was prescribed because of the strength of the spine fixation. However, a cervical Minerva orthosis was used to prevent head drop resulting from cervicothoracic muscle injuries.

Postoperative considerations and tasks

Between Nov 29, 2018 and Nov 24, 2021 at the Montsouris Mutualist Institute (Paris, France) five patients were successively operated for NSCLC invading the spine by a full thoracoscopic lobectomy and mediastinal lymphadenectomy, en-bloc with posterior vertebral resection in a single stage anesthesia. There were 4 men and 1 woman, mean age 56 years (range, 45–71 years). All patients presented with thoracic pain and were either active or former smokers. Only two patients had comorbidities, including one with a history of a cT3N0M0 gastric adenocarcinoma treated by surgery and radio-chemotherapy 10 years before. The tumor was located in the right upper lobe in 4 patients and in the left upper lobe in one patient. None of the cases involved subclavian vessel invasion or invasion of the spinal canal. In 2 patients the tumor was only in contact with the lateral aspects of the spine (foramina, transverse processes, costovertebral joint and the lateral side of the body, pedicle remaining free). Three patients had minimal invasion of the vertebral body at the MRI examination. Therefore, none of the patients required complete vertebral body resection and no patient underwent hemivertebrectomy involving more than 3 levels. The mean tumor size was 37 mm (range, 23–68 mm). The details of the vertebral tumoral invasion at MRI are shown in Table 1. All patients presented mediastinal lymph nodes smaller than 10 mm in the short diameter. Only one patient presented a positive lymph node at PET-scan [maximum standardized uptake value (SUVmax) 2.5] in the right latero-tracheal station associated with a right upper lobe tumor but preoperative EBUS evaluation was negative. Histological examination confirmed 4 adenocarcinomas and 1 adeno-squamous carcinoma with and all tumors staged cT4N0M0.

All patients received a neoadjuvant treatment consisting of platinum-based chemotherapy and concomitant radiotherapy, leading to a partial radiological response in all cases. Surgery included 4 upper lobectomies and 1 upper left lobectomy, all combined with lateral vertebrectomy for at least two vertebral bodies. No patient required conversion to thoracotomy. The mean total operative time (thoracic and spinal) was 562 minutes (range, 495–660 minutes), with a mean thoracic operative time of 293 minutes (range, 238–350 minutes) and a mean vertebral operative time of 270 minutes (range, 195–310 minutes). The mean operative blood loss was 704 mL (range, 370–1,300 mL), with a mean thoracic operative blood loss of 140 mL (range, 50–400 mL) and a mean vertebral operative blood loss of 564 mL (range, 320–1,200 mL). One patient had significant intraoperative bleeding of 1,200 mL during the spinal time, secondary to a vertebral artery injury. The chest drain was removed on the second postoperative day in all cases except for one patient who developed a postoperative empyema requiring pleural drainage for 21 days. Only one patient (20%) developed a major postoperative complication (Table 1). All patients experienced neuropathic pain and needed intense postoperative pain management. There was no in-hospital mortality. The mean postoperative length of stay was 10,4 days (range, 5–23 days), with a median of 9 days. Complete resection (R0) was achieved in all cases. Pathological examination revealed a complete pathological response (ypT0N0) in 3 patients, residual vertebral body tumor invasion (ypT4N0) in one patient and residual parietal pleural invasion (ypT3N0) in one patient. Only the patient with postoperative vertebral body residual invasion received adjuvant chemotherapy. During follow-up no loco-regional recurrences were recorded. However, one patient developed multiple brain metastasis 4 month after the surgery followed by an adrenal gland metastasis 8 months later. This patient underwent a multimodal treatment including whole brain irradiation, neurosurgical resection, multiple stereotaxic brain irradiation sessions and finally chemotherapy for the brain metastasis and immunotherapy followed by surgical resection of the adrenal gland metastasis. The patient is still alive and in follow-up for 3 stable brain lesions, without any treatment for over a year.

The mean global follow-up was 50 months (range, 38–63 months). All patients are currently alive, but affected by residual neuropathic pain requiring ongoing analgesic management.

Tips and pearls

Stappler division of the lung parenchyma around the tumor

One of the main challenges of lobectomy in the case of peripheral tumor invasion of the chest wall is the lack of lung parenchyma mobility. This makes it difficult to control the pulmonary hilar vessels. The conventional solution is to start the procedure with the chest wall resection. In cases of vertebral body invasion, very few surgical teams opt to start with vertebral body resection via a posterior approach, followed by en-bloc lobectomy through an open thoracotomy (OT) (8). Historically, after performing a standard lobectomy with mediastinal lymphadenectomy, the lobe is left in the thoracic cavity, attached to the vertebral bodies waiting for vertebral resection. In that case, as soon as the lobar vein is divided, arterial blood from the chest wall and spinal tumor neovascularization starts filling the lobe, causing a dramatic increase in its volume (Figure 4A). When using a full thoracoscopy procedure, this has a greater negative impact on the visibility. The surgical field is restricted and the image becomes very dark. In addition, the parenchyma loses its flexibility, become fragile and prone to tearing under manipulation, resulting in an uncontrollable continuous bleeding (Video 4). Moreover, due to the increased volume and rigidity of the lobe at the end of the procedure, extraction en-bloc with the resected vertebral body via the posterior approach can be extremely challenging, increasing the risk of the tumor rupture (Figure 4B). In our historical series, Grunenwald et al. needed to reopen the anterior incision in four cases, in order to remove large specimens safely (7).

Figure 4 Surgical specimens in situ (A,C) and after en bloc vertebral resection (B,D,E). (A) Right upper lobe aspect appended to the vertebral tumour invasion, after sectioning its venous drainage. (B) Upper lobe en bloc with vertebral resection specimen. (C) Vertebro-tumoral lung tumor block after the stapled transection of the normal parenchyma. (D,E) Posterior and anterior aspect of the resected vertebro-tumoral lung tumor block, after the stapled transection of the normal parenchyma.

With increasing experience, we decided to start the thoracic procedure with the chest wall preparation around the involved vertebral bodies, including lateral costal sectioning, without any traction on the tumoral chest invasion. Once the chest wall preparation is completed, we perform a stapled transection of the normal lung parenchyma, at a safe macroscopic distance from the tumor, in order to reduce the volume of the specimen (Figure 4C-4E) and ensuring its safe extraction through the posterior approach following the vertebral resection. The main purpose of our technique is to maintain oncological principles by preventing any violation of the tumor block (9,10).

Additionally, this approach facilitates the release of the anterior vertebral body from the posterior mediastinal structures, further optimizing the surgical workflow.

Esophageal protection

In our very first published series, one patient developed an esophageal fistula related to a transpedicular screw and died (2). To prevent this complication, we decided to systematically open the mediastinal space between the vertebral bodies and the esophagus and to place a 2 mm Goretex sheet under thoracoscopic guidance, in order to protect the esophagus from the blind posterior spinal instrumentation. In open surgery, this dissection is facilitated by the transmanubrial approach, but it can be challenging in thoracoscopic approach. To avoid esophageal injury during the dissection, it is crucial to maintain contact with the vertebral body.

CO2 insufflation

One of the advantages of the full thoracoscopic approach (closed chest surgery), is the possibility to use CO₂ insufflation which largely facilitates the dissection particularly for the posterior mediastinum preparation. Intrathoracic positive pressure using CO₂ aids complete lung collapse and provides a better surgical field, especially for esophageal dissection (11). In our opinion, positive intrathoracic pressure opens surgical planes and widens narrow spaces like the posterior mediastinum.

Chest wall preparation and costal incision

Another crucial aspect of the vertebral resection is the lateral extent of the costal resection. The posterior approach is performed through a midline vertical incision at the level of affected vertebral bodies. Since the orthopedic surgeon cannot directly visualize the lateral extension of the tumor invasion, there is a risk of inadequate lateral resection margins. For this reason, we recommend performing the lateral costal incision under thoracoscopic control. Moreover, it is also very important to deeply dissect the intercostal spaces, really down to the skin. The posterior thoracic wall is very thick in this region due to the overlying muscle and fat pad, which can prevent the orthopedist from visualizing the lateral limits of the resection. This precaution is even more important if an endoscopic rib cutter is unavailable as the orthopedist will then perform the rib resection via the posterior approach and in this case the muscle section of the posterior thoracic wall will serve as a reference for the lateral margin making this otherwise blind step of the posterior approach safer. Other authors performed the costovertebral body cut and instrumentation under thoracoscopic control (4,5). An alternative technique involves inserting two peridural needles into the chest wall from the outside under VATS guidance at the upper and lower pole of the tumour: the needles serve as markers to guide the extent of the spinal resection and the posterior midline incision (4). In these cases, the patient is either in prone position or in lateral decubitus respectively, all along the procedure.

Time management

This surgery consists of two distinct steps: the lung resection and the vertebral resection. The total operative time for both procedures is particularly long. In our series the mean operative time was 562 minutes (range, 495–660 minutes), with mean thoracic operative time of 293 minutes (range, 238–350 minutes) and mean orthopedics operative time of 270 minutes (range, 195–310 minutes). Introducing the thoracoscopy approach did not significantly change the operative duration compared to our OT historical series (2) in which the mean duration of surgery was 9.5 hours (range, 6.5–15 hours). Because of the length of the procedure, as others (12), in our historical series we opted for a staged approach over two consecutive days. In the afternoon of the first day, a posterolateral thoracotomy for pulmonary resection associated with the intrathoracic chest wall preparation was performed followed, in the morning of the second day, by a dorsal approach for vertebral resection and specimen extraction en-bloc with the resected lobe. Other authors preferred a staged approach with a longer interval, performing the vertebral resection first, followed by a posterolateral thoracotomy for lung and chest wall resection one or even two weeks later (13). In our current full thoracoscopic series, all patients underwent a 1-day procedure without complications related to the length of the operation. All patients were extubated in at the end of surgery and were allowed to move freely immediately after the operation demonstrating the feasibility and safety of a single-stage, minimally invasive approach.

Discussion

In 1996, Grunenwald et al. first published a series of 7 cases of patients who underwent total vertebrectomy for en-bloc resection of lung cancer invading the spine at the Thoracic Department of Montsouris Mutualiste Institut (7). In this case-series, an anterior cervical approach which allowed the dissection of cervical structures with tumor-free margins was combined with a classic posterolateral thoracotomy allowed the section of the chest wall and vertebrectomy through an enlarged posterior approach. The surgical technique evolved throughout the published series. The 3-incision approach evolved to a 2-incision approach with the development of the transmanubrial cervicothoracic anterior approach, which allowed execution of the thoracic steps of the resection without a conventional thoracotomy. A total of 32 patients underwent partial or total vertebrectomy for non-small cell lung cancer with spinal extension, between 1993 and 2004 in Department of Thoracic Surgery, Montsouris Mutualiste Institut (14).

Thoracoscpic approach

With the development of the thoracoscopic procedures, surgeons began using them in order to monitor sub-pleural dissection and vertebral resection (4,15), or to perform hybrid video-assisted procedures: video-assisted pulmonary lobectomy combined with the transmanubrial approach, for anterior Pancoast tumor resection (16), or video-assisted pulmonary lobectomy combined with limited posterolateral Shaw-Paulson thoracotomy, for Pancoast tumor (17). The benefits of the thoracoscopic lobectomy are now well established. In 2013, Stoker et al. (3) compared 4 patients who underwent anatomical lobectomy by VATS to 4 patients who underwent traditional OT, both with simultaneous instrumented posterior spinal reconstructions with corpectomy, for 8 consecutive patients with an upper lobe NSCLC invading the spine, at a single institution. In the VATS group only one patient required conversion to OT due to dense intrathoracic scar tissue. In the postoperative period, all patients in the OT group experienced an acute respiratory distress syndrome and/or respiratory failure whereas no such complications were registered in the VATS group. The mean hospital stay was 24±31 and 5.8±1.0 days for the VATS group. The authors concluded that VATS with posterior spinal reconstruction represented a novel and viable approach for the complete resection of T4 NSCLC.

In Department of Thoracic Surgery, Montsouris Mutualiste Institut, the thoracoscopic program for the major lung resection started in the early 2000’s and the first results of a series of 56 patients with a full thoracoscopic (closed chest) lobectomy and segmentectomy were published in 2008 (18).

With increasing experience, we have progressively performed more complex procedures and in 2018 we introduced a combined full thoracoscopic and posterior midline approach for en-bloc resection of NSCLC invading the spine. When comparing our historical series of OT lobectomies with posterior approach series (10) to our current series of full thoracoscopic lobectomies with posterior approach series for primary lung cancer invading the vertebral bodies, we observed several improvements. The median hospital stay, the mean operative blood loss and the postoperative major morbidity were 30 vs. 9 days, 2,600 mL (range, 800–6,200 mL) vs. 704 mL (range, 370–1,300 mL) and 52.6% vs. 20%, respectively. Because these are historical series, the differences are obviously not exclusively related to the minimally invasive approach, but thoracoscopy is part of them.

While these differences are not exclusively attributable to the minimally invasive approach due to the historical nature of the comparisons, the use of thoracoscopy has undoubtedly played an important role.

In this series, we did not encounter any particular difficulties related to the induction treatment. Indeed, it is known that surgical dissection of vessels after induction chemotherapy is more challenging, particularly due to more extensive oozing and sometimes a certain degree of fibrosis. This is even more difficult if induction treatment is indicated due to the involvement of the hilar lymph node. However, in our series, none of the patients had positive lymph nodes.

Regarding preoperative radiotherapy, all patients received stereotactic radiotherapy focused on the tumor. Due to the peripheral location of these tumors, we believe that radiotherapy has little impact on pulmonary hilar dissection in these types of tumors.

Nowadays, the classic thoracoscopic procedure can be successfully replaced by the robotic thoracoscopy, which is known to facilitate the surgeon’s task thanks to better vision and articulated instruments, especially for complex procedures (10).

The small sample size in this series, precludes us from drawing any conclusions concerning long term survival. Nevertheless, we cannot fail to emphasize that all the patients are alive with at least 3 years of survival. These favorable oncological outcomes are certainly multifactorial. Improved patient referral pathways, the widespread adoption and ease of access of computed tomography, may explain earlier stages at diagnosis. The introduction of PET scanning and EBUS evaluation enhanced staging accuracy allowing a better patient selection and the exclusion of patients with mediastinal lymph node invasion, who should not be considered for this kind of extended surgery.

More recently, the association of immunotherapy with chemotherapy protocols during neoadjuvant treatment for stage IB–IIIA patients (19,20), demonstrates a significant improvement in survival, but also a significant increase in complete pathological response on surgically resected specimens. More specific studies will be necessary to assess whether the addition of immunotherapy to radio-chemotherapy for induction treatment for patients with vertebral invasion, could allow the surgical indication to be extended in case of lymph node involvement.

Limitations

Despite our positive findings, we acknowledge several limitations of this study. The patient population was highly selected and underwent surgery at an experienced high-volume thoracoscopic center. This study is also limited by the modest number of patients enrolled and by its single-centre retrospective nonrandomized nature. The lack of case-matched comparison of the peri-operative events, limit our ability to draw solid conclusions about the potential advantages of full thoracoscopy (close chest) over other thoracoscopic approaches. Thus, our results should be interpreted with caution because they may not reflect the general outcomes following spine resection for pulmonary sulcus lung cancer.

Conclusions

In conclusion, our study shows that full thoracoscopy combined with a posterior approach is a safe and effective technique for en-bloc resection of NSCLC invading the spine. CO₂ insufflation, esophageal protection and stappler division of the lung parenchyma around the tumor, facilitate the dissection and reduce the perioperative complications.

Nevertheless, this surgical technique is reserved for selected patients (limited vertebrae invasion, small lesion in the lung) and performed by VATS expert surgeons. Consequently, no recommendations can be made.

Future studies should focus on long-term oncologic outcomes of introducing minimal invasive techniques in complex procedures, especially robotic surgery to further optimize patient care.

Acknowledgments

The authors would like to acknowledge the role of Professor Dominique Grunenwald for having described and implemented the fundamentals of this technique. We thank Gabriela Marinescu, Ana Bolintineanu and Calin Bolintineanu, for kindly reviewing our manuscript for English grammar and language.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-144/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-144/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-144/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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