Surgical resection for advanced lung cancer using the hemi-clamshell approach

The hemi-clamshell (HCS) approach consists of partial sternotomy with antero-lateral thoracotomy. This study evaluated the utilities and outcomes of the HCS approach in advanced lung cancer patients.

We retrospectively investigated 45 patients who underwent surgery for advanced lung cancer via the HCS procedure between 2000 and 2014, the indications for surgery being tumour invasion extending to the aorta arch in 5, descending aorta in 9, main pulmonary artery in 5, superior vena cava in 6, right or left atrium in 4, apical thoracic dome in 7 patients and mediastinal lymphadenopathy for left-sided lung cancer in 12. Preoperative chemo-radiation induction therapy was given to 33 of these patients.

We performed 34 lobectomies, including 8 sleeve lobectomies, 10 pneumonectomies and 1 wedge resection of the lung. Cardiovascular reconstruction of the aortic arch was performed in 3, descending aorta in 4, subclavian arteries in 4, superior vena cava in 5, atrial wall in 4 and pulmonary artery in 12 patients with some overlap. En bloc chest wall resection was performed in 7 patients. Lymphadenectomy in the pre-tracheal and subcarinal areas was routinely performed. Forty-two operations (93%) were complete resections. No postoperative mortalities occurred and the 5-year survival rate for all patients was 53%.

The HCS approach is suitable for advanced lung cancer, including invasion of mediastinal structures, the apical dome and mediastinal lymph nodes. It provides a wide view of the mediastinum and apex of the chest, and safe access to the thoracic great vessels, resulting in better long-term survival rates.