CR1. Resection of Metastatic Neuroendocrine Cervicothoracic Tumor and Arterial Reconstruction of the Innominate, Right Common Carotid, Right Subclavian Artery, and Recurrent Laryngeal Nerve Neurorrhaphy

49-year-old female presented with history of metastatic neuroendocrine tumor of the terminal ileum and symptomatic oligoprogression in the right cervicothoracic region. Diagnosis was made 12 months prior, when she presented with new onset syncopal episodes. During initial workup, findings were notable for PET-avid lesions in the terminal ileum, small bowel mesentery, liver, interventricular cardiac septum, and right paratracheal region. A biopsy of the paratracheal lesion revealed a Grade 2 well-differentiated neuroendocrine tumor with Ki-67: 3-5%. She was started on long-acting octreotide. At 12 month follow up, the patient experienced progressive dysphagia, dysphonia, and neuropathic symptoms in her right upper extremity including weakness.
Her performance status was excellent. Physical exam notable for a palpable right supraclavicular mass and normal neurovascular exam of the right upper extremity. Recent imaging showed 6.4 cm right paratracheal mass with focal involvement of the proximal right common carotid, distal innominate, and encasement of the proximal right subclavian artery. The tumor extended along the vertebral artery and involved the neural foramina at C6/C7. The case was presented at our neuroendocrine multidisciplinary tumor board meeting with recommendation for surgical resection of the right cervicothoracic mass followed by staged small bowel resection. Preoperative assessment was satisfactory. The patient was informed of the risks, benefits, and alternatives to surgery. She wanted to proceed with surgical resection.

In the operating room, the patient was placed supine with a shoulder roll and arms tucked. General anesthesia was induced, and monitoring lines including an endotracheal tube with recurrent laryngeal nerve monitoring were placed. Standard antibiotic and deep vein thrombosis prophylaxis were given. A low-neck thyroidectomy incision was made and extended lateral to the right and down to the upper chest at the midline in case a sternal split was required. During lateral and central neck dissection, the right recurrent laryngeal nerve was noted to be encased by the tumor distally and will need to be sacrificed. It was also determined that the distal innominate, proximal subclavian, and common carotid artery needed to be resected en-block with the tumor. To limit ischemia, arterial reconstruction was performed prior to tumor resection. An 8mm graft was sutured as end-to-side to another 8mm graft. Next, we sutured end-to-end beveled the 8mm graft to a 12mm graft. This created a 12mm to 8mm tapered graft with an additional 8 mm side branch to recreate the innominate artery bifurcation. Weight based heparin given. Arterial clamping and resection were performed. The anastomosis was constructed first in the innominate artery, followed by common carotid which established cerebral blood flow. Clamp time was 15 minutes. Finally, the right subclavian artery anastomosis was performed. We finalized the en-bloc resection of the tumor by dividing deep neck muscular adherences and pleura. The Ansa hypoglossi was dissected off sternothyroid muscle and sutured to the right recurrent laryngeal nerve. Direct layngoscoscopy was performed and carboxymethylcellulose gel was injected into the right paraglottic space. The patient tolerated the procedure well. Discharged on day 4 on regular diet without complications. At 1-, 6-, and 10-month follow up the patient is asymptomatic and without evidence of disease progression.

Authors
Jarot Guerra (1), Anastasios Maniakas (2), Sophia Khan (3), Anthony Estrera (4), Ravi Rajaram (1)
Institutions
(1) University of Texas MD Anderson Cancer Center, Houston, TX, (2) UT MD Anderson Cancer Center, Houston , TX, (3) UT MD Anderson Cancer Center, Houston, TX, (4) University of Texas - Houston, Houston, TX

Thoracic