'Trap-door' and 'clamshell' surgical approaches for the management of pediatric tumors of the cervicothoracic junction and mediastinum

Background/Purpose For pediatric tumors of the cervicothoracic junction, an isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection. We retrospectively examined “trap-door” and “clamshell” pediatric thoracotomies as a surgical approach to these tumors. Methods We searched our database for pediatric patients with cervicothoracic tumors who underwent clamshell or trap-door thoracotomy between 1991 and 2013, reviewing tumor characteristics, surgical technique, completeness of resection, morbidity, and outcome. Results Trap-door (n = 13) and clamshell (n = 4) thoracotomies were performed for neuroblastoma (n = 9), non-rhabdomyosarcoma soft tissue sarcoma (n = 4), germ cell tumor (n = 2), rhabdomyosarcoma (n = 1), and neuroendocrine small cell carcinoma (n = 1). Fourteen of these cervicothoracic tumors were primary, and three were metastatic. Gross total resection was achieved in 15 patients (94%). Operative complications included vocal cord paralysis (n = 2), mild upper-extremity neuropraxia (n = 2), and hemidiaphragm paralysis (n = 1), All but one involved encased nerves. Overall survival was 61% for the series and 80% for patients with primary tumors. Eleven (73%) of 15 patients who underwent gross total resection had no evidence of recurrence. Three patients with metastatic disease died of distant progression within 1.3 years. Conclusions Gross total resection of primary cervicothoracic tumors can be accomplished with specialized exposure in pediatric patients with minimal morbidity.