case_images: PMC11766227_01
case_images: CT scan transverse image crossing T9 shows a lytic, moth-eaten change involving the anterior part of the T9 vertebral body with huge anterior mediastinal soft tissue partially surrounding and displacing the aorta. The transpedicular trocar track for biopsy is visible.
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case_images: T9 vertebral body (Figure 1), with huge soft tissue mass better described by MRI as invading the mediastinum and contouring the aorta.
case_images: (a) MR (T1_mDIXON_TSE) sagittal image shows the longitudinal tumor extension in the mediastinum originating from the vertebral body of T9 and invading the anterior part of T8 and T10 vertebral bodies without involvement of the disks. The disks T7-T8 and T10-T11 seem the best levels for cranial and caudal resection levels. (b) MR (T2W_mDixon_TSE FS) transverse image at T9 level clarifies that the aorta wall is not infiltrated and that there is a tumor-free zone from the posterior tumor margin and the posterior vertebral wall (according to the WBB staging system: layer A, only part of layer B, no layer C involvement). At this level (the largest tumor extension), the AP diameter of the T9 vertebral body is 28 mm, and the distance between the tumor and the posterior wall is 13 mm. The tumoral soft tissue expands on left side in the retro-pleural space to the level of the cost-transverse joint in T9 (sectors 8 to 4 according to the WBB staging system). (c) MR (T2W_mDixon_TSE FS) transverse image at T8: the tumors is much smaller in the mediastinum end and it is invading only the peripheral vertebral body cortex. The retro-pleural invasion on the left arrives at the level of the posterior longitudinal ligament (sectors 7 to 5 according to the WBB staging system). (d) MR (T2W_mDixon_TSE FS) transverse image at T10: the tumor invades the anterior part of the vertebral body; sectors 4 and 5 are not involved in the tumor.
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case_images: The tumor tissue invades the anterior part of the T8 and T10 vertebral bodies without involvement of the disks (Figure 2a). The tumoral soft tissue expands on left side in the retro-pleural space up to the level of the cost-transverse joint in T9 (sector 8 to 4 according to the WBB staging system) (Figure 2b), while in T8 (Figure 2c) and T10 (Figure 2d) sectors 4 and 5 are not involved in the tumor. A, only part of layer B, no layer C involvement). At the level of the largest tumor extension, the AP diameter of the T9 vertebral body was 28 mm, and the distance between the tumor and the posterior wall was 13 mm (Figure 2b).
case_images: WBB planning of enbloc resection of the reported case. The tumor-free area between the posterior tumor margin and the posterior vertebral wall allows us to consider the possibility of saving the continuity of the spinal canal. Targeting the tumor-free margin and the integrity of the canal surgery should also be performed.
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case_images: A second posterior approach with the original "L" osteotomy can be staged as a further sub-type of type 3 (Figure 3).
case_images: Intraoperative image at the end of the left antero-lateral trans-pleural approach (at the seventh rib). The tumor mass can be seen covered by the parietal pleura as an effective margin. The descending aorta has been isolated and fully released without violations of the tumor mass. The segmental vessels are ligated at the origin. The anterior part of disks T7-T8 and T10-T11 has been excised. The left T7 segmental artery is prepared for planned anastomosis with the fibula feeding artery. Before the closure, a Gore-Tex mesh is positioned over the tumor mass for protection and to easily find the safely released peritumoral area during the posterior approach.
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: Second stage. Patient in prone position. Posterior midline approach, and positioning of Carbon Fiber-Reinforced PEEK (CFRP) (Carboclear by Carbofix), screws in the pedicles of T5, T6, T7, T11, and T12. Excision of rib segments proximal to the spine at T8, T9, and T10; lateral release of the vertebral bodies reaching Gore-Tex mesh left over the released area during the anterior approach.
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: (a) The Tomita saw is inserted left to right in the interspace T7-T8 inside the excised disk, leaving the posterior part of the disk intact. Its extremity is shifted along the right side of the spine up to disk T10-T11 (whose posterior half is similarly spared), where it is retrieved to the left side. (b) The anesthesiologist is asked to collapse the left lung in order to gain access to the lateral aspect of the vertebral bodies without injuring the parenchyma. By surgical robot (Excelsius by Globus) guidance, two percutaneous K wires are introduced on the coronal plane left to right, just below the superior endplate of T8 and just above the inferior endplate of T10, at a safe distance from the tumor and the vertebral posterior wall. Navigation is necessary in this phase because it is not possible to visualize the tumor inside of the vertebral body, and navigation is only able to guide the insertion, avoiding tumor violation. (c) The K-wires are introduced slightly dorsal to the plane of the Tomita saw to guide the osteotomy on the correct coronal plane to save the posterior part of the vertebral bodies without violating the tumor mass (arrows suggest the direction left-to-right).
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: A screw is positioned in the left pedicle of T9 (uninvolved by the tumor) to stop the coronal osteotomy and to act as a pivot to start a sagittal osteotomy ending in "L-shaped" osteotomy. Again, screw insertion is guided by surgical navigation in order to avoid the end of the screw reaching the margin of the tumor.
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: (a) The extremities of the Tomita saw are exteriorized by short incisions in order to cut on the desired coronal plan, running on the guide of the couple of K-wires. (b) Intraoperative picture of the Tsaw osteotomy on the coronal plane, always under navigation system control. To avoid damage to the soft tissues during the resection on the coronal plane, two plastic cannulas are used, which are positioned through the chest wall and inside which the saw is slid. In the image, while the first operator keeps the saw wire tensioned, the second operator positions the proximal cannula with Kocher pliers.
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: (a) As soon as the saw comes into contact with the screw positioned in the left pedicle of T9, the handles of the saw are removed and the two extremities of the wire are slid back through the percutaneous paths. (b) The two extremities of the wire are then brought out vertically through the surgical wound. The handles are assembled on the wire again and repositioned along a sagittal direction. (c) Pulling up the handles, with the wire oriented in a vertical direction along the sagittal plane, the "L" osteotomy is completed at the T9 level, where the tumor grows laterally to sector 4. The T9 screw is therefore used first as a constraint to stop the saw along the resection in the coronal plane, and then as a guide for the osteotomy on the sagittal plane, providing the correct direction and avoiding a deviation of the saw.
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: (a) By careful manual manipulations, the specimen was removed. (b) The tumor, covered by a thick margin of healthy tissue and still protected by the Gore-Tex mesh, was removed from the left side. The coronal resection of the vertebral bodies of T8 and T10 and the effect of the sagittal leg of the "L-shaped" osteotomy can be seen, allowing the inclusion of sectors 4 and 5 of T9 in the enbloc resection, corresponding to the lateral retropleural tumor extension (panel A) and to other angles of the excised specimen in panels (B,C).
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case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: Post-operative CT scan image at the lower T9 level, distal to the sagittal leg of the osteotomy. As planned, the coronal osteotomy spared the circumference of the spinal canal and runs some millimeters from the tumor posterior margin. A Gore-Tex sheet is left, creating a new compartment from the mediastinum. Panel (A), axial section. Panels (B,C), coronal and sagittal sections showing the grafted fibula.
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case_images: PMC11766227_01_jcm-14-00349-g011.jpg
case_images: jcm-14-00349-f011
case_images: The surgical procedure is illustrated in Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10 and Figure 11 and described in the corresponding legends.
case_images: Pathologist's specimen of the resected vertebrae.
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case_images: This was also defined as "marginal" (Figure 12).
case_images: PMC11766227_02