CPT® Code 32504

1. Indications

The procedure is indicated for patients presenting with apical lung tumors, specifically Pancoast tumors, which may exhibit the following characteristics:

• Invasion of Chest Wall Structures The tumor has invaded the chest wall, necessitating surgical intervention to remove the affected tissue.
• Neurological Involvement The tumor may infiltrate nearby neurovascular structures, including the lower roots of the brachial plexus and intercostal nerves, which can lead to significant neurological symptoms.
• Presence of Lymphatic Involvement The tumor may also involve lymph vessels, indicating a more advanced stage of disease that requires surgical resection.

2. Procedure

The surgical procedure for CPT® Code 32504 involves several critical steps, which are detailed as follows:

• Step 1: Incision The surgeon typically begins by making a posterolateral thoracotomy incision. This incision is strategically placed in the back, below the shoulder blade, and extends around the side of the chest, following the curvature of the ribs to the front. In cases where there is significant vertebral involvement, the incision may be extended to include the neck for better access.
• Step 2: Exposure of the Lung Apex Once the incision is made, the surgeon carefully exposes the apex of the lung. This step is crucial for visualizing the tumor and surrounding structures that may be affected.
• Step 3: Resection of Ribs The posterior aspects of the first, second, and sometimes the third ribs are resected to facilitate access to the tumor. This step is essential when the tumor has invaded the chest wall.
• Step 4: Neurovascular Dissection If the tumor has infiltrated neurological structures, the surgeon will dissect and sever the nerve roots, typically at the T1 and C8 levels, and occasionally at the C7 level. This dissection is critical to ensure complete tumor removal and to address any neurological complications.
• Step 5: Tumor Mobilization and Resection The apical lung mass is then mobilized and resected. Depending on the extent of the tumor's invasion, the surgeon may remove the apical lung segment, the upper lobe, or, in rare cases, the entire lung along with the affected chest wall.
• Step 6: Chest Tube Placement After the tumor has been resected, chest tubes are placed to facilitate drainage of any fluid or air that may accumulate in the pleural space postoperatively.
• Step 7: Closure of Incision Finally, the incision is closed using sutures, ensuring that the surgical site is properly secured for healing.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any complications related to the surgery, such as infection or respiratory issues. The placement of chest tubes will require careful management to ensure proper drainage and to prevent pneumothorax. Patients may experience pain at the surgical site, which will need to be managed appropriately. Follow-up imaging may be necessary to assess for any residual tumor or complications. If chest wall reconstruction was performed, additional considerations for recovery and rehabilitation may be required to support the healing process and restore function.