Minimally Invasive Surgery to Superior Sulcus Tumor after Induction Chemoradiotherapy: The Combination of Transmanubrial Approach and Uniportal Video-Assisted Thoracic Surgery

Background: Superior sulcus tumor (SST) is a locally advanced lung cancer requiring challenging surgery.Extensive thoracotomy is typically needed but is highly invasive.We present a case where minimally invasive surgery for SST was achieved by combining transmanubrial approach (TMA) and uniportal video-assisted thoracic surgery (VATS) following induction chemoradiotherapy (ICRT).Methods: Case presentation: A 61-year-old woman with right SST (suspected subclavian artery invasion, cT4N1M0 stage IIIA) underwent ICRT after ineffective immune checkpoint inhibitor therapy.Two cycles of cisplatin/vinorelbine with concurrent radiotherapy (40 Gy) resulted in 19% tumor shrinkage.Results: TMA: TMA involved an inverted L-shape incision, sternum, and first rib transection to access the tumor.While significant fibrosis was observed around the subclavian vessels due to radiotherapy, vascular reconstruction was unnecessary, and the tumor could be dissected.Uniportal VATS: The patient was repositioned in the lateral position, and a 4 cm uniport was set in the sixth intercostal space.After lower mediastinal lymph node dissection (LND), pulmonary vein, pulmonary arteries, and the upper-bronchus were dissected sequentially.Then, the interlobar fissure between the upper and middle/lower lobes was divided, completing the right upper lobectomy.Finally, upper mediastinal LND was performed, the surgery was achieved (operation time: 378 minutes).Postoperative course: Pain was mild, with no analgesics needed after postoperative day (POD) 7. The patient was discharged without complications on POD 15.Pathology: ypT-1aN0 with 1% viable tumor cells (almost complete response).Conclusion: In the era of minimally invasive lung cancer surgery, surgeons must master diverse approaches and select the most appropriate one tailored to individual cases.A surgical video is presented.