The Incidence of Winged Scapula after Thoracic Cancer Surgery: A Prospective Cohort Study

Abstract

Background Lung cancer is the leading cause of cancer-related deaths, and surgery is still the first treatment of choice in early and locally advanced cases. One of the iatrogenic complications is the serratus anterior palsy, which could lead to a winged scapula (WS). Unfortunately, the incidence of this deficit in thoracic surgery is unclear. Our primary aim was to determine the incidence of WS in lung cancer patients in a single-center experience.

Methods We conducted a retrospective analysis of prospectively collected data with patients eligible for oncological thoracic surgery from March 2013 until January 2014. A physical evaluation of the WS was performed pre- and postoperatively, at the discharge and after 1 year of follow-up.

Results A total of 485 patients were evaluated; 135 (27.8%) showed WS. Longer operative time (p < 0.0001), type of surgery (p < 0.0001), lymphadenectomy (p < 0.0001), and neoadjuvant treatment prior surgery (p = 0.0005) were significantly related to the WS injury. Multivariable analysis showed that type of surgery was significantly associated with WS (p < 0.0001). After 1 year, 41.6% still had WS.

Conclusion The incidence of WS was similar to the literature. As WS incidence is underdiagnosed, assessment and correct education about possible deficits or impairments should be improved. Moreover, when a minimally invasive approach is not planned, it is a good clinical practice to discuss surgical strategies with surgeons to reduce this deficit.

Keywords

lung neoplasms - lung cancer - thoracic surgery - nervous system trauma - rehabilitation - physical therapy specialty

Ethical Approval Statement

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the European Institute of Oncology Ethics Committee approved this study (R321/15-IEO 345).

Data Availability Statement

The data supporting this study's findings are available from the corresponding author, LFNT, upon reasonable request.

Authors' Contribution

L.F.N.T., F.S., R.F.K.C.S., F.P., L.B. and L.P. contributed to the study conception and design. Data collection was performed by L.F.N.T., F.S., R.F.K.C.S. All the authors made the critical revision of the article and gave the final approval of the version to be published.

Publikationsverlauf

Eingereicht: 13. Februar 2024

Angenommen: 28. März 2024

Artikel online veröffentlicht:
02. Mai 2024

• References

• 1 American Cancer Society. Key Statistics for Lung Cancer. Accessed August 15, 2023 at: https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html
• 2 Bertolaccini L, Casiraghi M, Spaggiari L. Immunotherapy in the neoadjuvant settings: a new challenge for the thoracic surgeon?. Interact Cardiovasc Thorac Surg 2020; 30 (01) 1-3
• 3 Conforti F, Pala L, Pagan E. et al. Effectiveness of intensive clinical and radiological follow-up in patients with surgically resected NSCLC. Analysis of 2661 patients from the prospective MAGRIT trial. Eur J Cancer 2020; 125: 94-103
• 4 Hazell SZ, Mai N, Fu W. et al. Hospitalization and definitive radiotherapy in lung cancer: incidence, risk factors and survival impact. BMC Cancer 2020; 20 (01) 334
• 5 Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol 2009; 27 (15) 2553-2562
• 6 Nagasaka M, Gadgeel SM. Role of chemotherapy and targeted therapy in early-stage non-small cell lung cancer. Expert Rev Anticancer Ther 2018; 18 (01) 63-70
• 7 Soria J-C, Tan DSW, Chiari R. et al. First-line ceritinib versus platinum-based chemotherapy in advanced ALK-rearranged non-small-cell lung cancer (ASCEND-4): a randomised, open-label, phase 3 study. Lancet 2017; 389 (10072): 917-929
• 8 Detterbeck F, Molins L. Video-assisted thoracic surgery and open chest surgery in lung cancer treatment: present and future. J Vis Surg 2016; 2: 173
• 9 Casiraghi M, Galetta D, Borri A. et al. Ten years' experience in robotic-assisted thoracic surgery for early stage lung cancer. Thorac Cardiovasc Surg 2019; 67 (07) 564-572
• 10 Belmonte R, Monleon S, Bofill N, Alvarado ML, Espadaler J, Royo I. Long thoracic nerve injury in breast cancer patients treated with axillary lymph node dissection. Support Care Cancer 2015; 23 (01) 169-175
• 11 Nevola Teixeira LF, Lohsiriwat V, Schorr MC. et al. Incidence, predictive factors, and prognosis for winged scapula in breast cancer patients after axillary dissection. Support Care Cancer 2014; 22 (06) 1611-1617
• 12 Rizzi Sde A, Haddad CA, Giron PS, Pinheiro TL, Nazário AC, Facina G. Winged scapula incidence and upper limb morbidity after surgery for breast cancer with axillary dissection. Support Care Cancer 2016; 24 (06) 2707-2715
• 13 Bizzarri F, Davoli G, Bouklas D, Oncchio L, Frati G, Neri E. Latrogenic injury to the longthoracic nerve: an underestimated cause of morbidity after cardiac surgery. Tex Heart Inst J 2001; 28 (04) 315-317
• 14 Duncan MA, Lotze MT, Gerber LH, Rosenberg SA. Incidence, recovery, and management of serratus anterior muscle palsy after axillary node dissection. Phys Ther 1983; 63 (08) 1243-1247
• 15 Alloubi I, Jougon J, Delcambre F, Baste JM, Velly JF. Early complications after pneumonectomy: retrospective study of 168 patients. Interact Cardiovasc Thorac Surg 2010; 11 (02) 162-165
• 16 Isono T, Mori S, Kusumoto H, Shiono H. Winged scapula following axillary thoracotomy with long thoracic nerve preservation. BMJ Case Rep 2020; 13 (02) e232970
• 17 Carbognani P, Spaggiari L, Rusca M. et al. Electromyographic evaluation of the spared serratus anterior after postero-lateral thoracotomy. J Cardiovasc Surg (Torino) 1996; 37 (05) 529-530
• 18 Akçali Y, Demir H, Tezcan B. The effect of standard posterolateral versus muscle-sparing thoracotomy on multiple parameters. Ann Thorac Surg 2003; 76 (04) 1050-1054
• 19 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61 (04) 344-349
• 20 Hoppenfeld S, Hutton R. Physical Examination of the Spine and Extremities. Stanley Hoppenfeld. New York: Appleton Century Crofts; 2005
• 21 Alcelik I, Marsh DJ, Savvidis P, Stewart MP. Bilateral traumatic long thoracic nerve palsies. J Trauma 2008; 65 (03) 712-714
• 22 Bal S, Elshershari H, Celiker R, Celiker A. Thoracic sequels after thoracotomies in children with congenital cardiac disease. Cardiol Young 2003; 13 (03) 264-267
• 23 Kauppila LI, Vastamäki M. Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients. Chest 1996; 109 (01) 31-34
• 24 Chappuis F, Justafré J-C, Duchunstang L, Loutan L, Taylor WR. Dengue fever and long thoracic nerve palsy in a traveler returning from Thailand. J Travel Med 2004; 11 (02) 112-114
• 25 Delmonte S, Massone C, Parodi A, Rebora A. Acquired winged scapula in a patient with systemic lupus erythematosus. Clin Exp Rheumatol 1998; 16 (01) 82-83
• 26 Toshkezi G, Dejesus J, Jabre JF, Hohler A, Davies K. Long thoracic neuropathy caused by an apical pulmonary tumor. J Neurosurg 2009; 110 (04) 754-757
• 27 Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest 2004; 126 (03) 915-925
• 28 Overpeck DO, Ghormley RK. Paralysis of the serratus magnus muscle. J Am Med Assoc 1940; 114 (20) 1994-1996
• 29 Salazar JD, Doty JR, Tseng EE. et al. Relationship of the long thoracic nerve to the scapular tip: an aid to prevention of proximal nerve injury. J Thorac Cardiovasc Surg 1998; 116 (06) 960-964
• 30 Vastamäki M, Kauppila LI. Etiologic factors in isolated paralysis of the serratus anterior muscle: a report of 197 cases. J Shoulder Elbow Surg 1993; 2 (05) 240-243
• 31 Nath RK, Lyons AB, Bietz G. Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: long-term results in 50 cases. BMC Musculoskelet Disord 2007; 8: 25
• 32 Rodríguez-Torres J, Lucena-Aguilera MDM, Cabrera-Martos I, López-López L, Torres-Sánchez I, Valenza MC. Musculoskeletal signs associated with shoulder pain in patients undergoing video-assisted thoracoscopic surgery. Pain Med 2019; 20 (10) 1997-2003
• 33 Miranda APB, de Souza HCD, Santos BFA. et al. Bilateral shoulder dysfunction related to the lung resection area after thoracotomy. Medicine (Baltimore) 2015; 94 (44) e1927
• 34 Li WWL, Lee TW, Yim APC. Shoulder function after thoracic surgery. Thorac Surg Clin 2004; 14 (03) 331-343
• 35 Landreneau RJ, Hazelrigg SR, Mack MJ. et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993; 56 (06) 1285-1289
• 36 Li WWL, Lee RLM, Lee TW. et al. The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy. Eur J Cardiothorac Surg 2003; 23 (03) 390-396
• 37 Applewhite MK, White MG, James BC. et al. Ultrasonic, bipolar, and integrated energy devices: comparing heat spread in collateral tissues. J Surg Res 2017; 207: 249-254
• 38 Bandi G, Wen CC, Wilkinson EA, Hedican SP, Moon TD, Nakada SY. Comparison of blade temperature dynamics after activation of Harmonic Ace scalpel and the Ultracision Harmonic Scalpel LCS-K5. J Endourol 2008; 22 (02) 333-336
• 39 Kim J-S, Kim M-H, Ahn D-H, Oh JS. Comparison of shoulder protraction strength and electromyography activity of serratus anterior and pectoralis major in subjects with or without a winged scapula. J Sport Rehabil 2019; 28 (03) 272-277
• 40 Vastamäki M, Vastamäki H, Pikkarainen V, Ristolainen L. Initial electromyography fails to predict long-term outcome of isolated serratus palsy. Scand J Surg 2018; 107 (04) 356-359
• 41 Ormel HL, van der Schoot GGF, Sluiter WJ, Jalving M, Gietema JA, Walenkamp AME. Predictors of adherence to exercise interventions during and after cancer treatment: a systematic review. Psychooncology 2018; 27 (03) 713-724