RESUMO
The operative management of pathological fractures at the cervicothoracic junction is a surgical challenge. Here, we present the case of a 48-year-old male patient presenting with 2 months of progressive left upper extremity weakness as well as back and bilateral arm pain (Karnofsky Performance Status 60%) who was found to have pathological fractures from C7, T1, and T2 due to metastatic renal cell carcinoma. Renal cell carcinoma is known to metastasize to bone and cause cord compression.1 Given the extensive metastasis with this highly vascular tumor, endovascular embolization was performed preoperatively to minimize intraoperative blood loss.2 Surgical management consisted of a two-stage procedure. Posterior spinal fusion from C2-T7 with C7-T2 decompression was performed during stage 1. Stage 2 consisted of a trans-sternal approach for C7, T1, and T2 corpectomy for cord decompression and placement of a cage and plate for anterior column support.3 Although prior surgeons have suggested to access upper thoracic pathology through an interaortocaval window, in this case we demonstrate a trans-sternal approach to C6-T3 that starts superior to the innominate vein and aortic arch and angles inferiorly dorsal to these vascular structures.4 When planning for a manubriotomy/trans-sternal approach, access to T1/T2 remains the most decisive factor and is most successful with a sternotomy.5 At 12-month follow-up, the patient demonstrated improvement in his left upper extremity strength and overall functional status (3/5 strength in hand grip and interossei with 5/5 in all remaining motor groups; Karnofsky Performance Status 80%). The patient consented to participate in the surgery and surgical video.
RESUMO
PURPOSE: To assess the safety and efficacy of the third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor osimertinib as neoadjuvant therapy in patients with surgically resectable stage I-IIIA EGFR-mutated non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: This was a multi-institutional phase II trial of neoadjuvant osimertinib for patients with surgically resectable stage I-IIIA (American Joint Committee on Cancer [AJCC] V7) EGFR-mutated (L858R or exon 19 deletion) NSCLC (ClinicalTrials.gov identifier: NCT03433469). Patients received osimertinib 80 mg orally once daily for up to two 28-day cycles before surgical resection. The primary end point was major pathological response (MPR) rate. Secondary safety and efficacy end points were also assessed. Exploratory end points included pretreatment and post-treatment tumor mutation profiling. RESULTS: A total of 27 patients were enrolled and treated with neoadjuvant osimertinib for a median 56 days before surgical resection. Twenty-four (89%) patients underwent subsequent surgery; three (11%) patients were converted to definitive chemoradiotherapy. The MPR rate was 14.8% (95% CI, 4.2 to 33.7). No pathological complete responses were observed. The ORR was 52%, and the median DFS was 40.9 months. One treatment-related serious adverse event (AE) occurred (3.7%). No patients were unable to undergo surgical resection or had surgery delayed because of an AE. The most common co-occurring tumor genomic alterations were in TP53 (42%) and RBM10 (21%). CONCLUSION: Treatment with neoadjuvant osimertinib in surgically resectable (stage IA-IIIA, AJCC V7) EGFR-mutated NSCLC did not meet its primary end point for MPR rate. However, neoadjuvant osimertinib did not lead to unanticipated AEs, surgical delays, nor result in a significant unresectability rate.