Asia expert consensus on segmentectomy in non-small cell lung cancer: A modified Delphi study

Left S3 + S8 Segmentectomy with Rare Interlobar A3 Vascular Anomaly: A Case Report

INTRODUCTION

Segmentectomy is being accepted as a valid operative procedure for small peripheral non-small cell lung cancer. Understanding pulmonary artery (PA) variations is essential to ensure safe and reliable surgeries. Herein, we report a case of left S3 and S8 segmentectomy involving a complete interlobar branch of the left A3, a relatively rare anomaly reported in less than 0.56% of cases in previous studies.

CASE PRESENTATION

A woman in her sixties was referred to our hospital with two nodules in the left upper lobe anterior segment (S3, 1.1 × 0.8 cm) and the lower lobe anterior basal segment (S8, 1.8 × 1.7 cm), suggestive of double primary lung cancer. Preoperative thin-slice computed tomography (CT) and three-dimensional CT revealed a vascular anomaly in which the entire left A3 branched from the interlobar PA. Left S3 and S8 segmentectomies were performed via thoracotomy. The interlobar A3 branched at nearly the same level as the A6. After cutting the V3b and V3c veins, the intersegmental plane and the interlobar A3 were sequentially divided using staplers. To prevent torsion of the remaining lung, the edges of the apico-posterior segment (S1+2) and the lingular segment were loosely secured with silk sutures. The operative times were 4 h and 8 min with minimal blood loss. Pathological examination revealed that both nodules were squamous cell carcinomas of the lungs (pT1bN0M0, pStage IA2). The patient remained recurrence-free for over 1 year.

CONCLUSIONS

Complete interlobar branching of the left A3 is uncommon. During left S3 segmentectomy in cases involving an interlobar A3, the S1+2 and lingular segments may become solitary blocks, necessitating measures to prevent torsion.

Analysis of lymph node metastasis based on consolidation tumor ratio and maximum standardized uptake value in clinical stage IA non-small cell lung cancer

Background

Sublobar resection has been established as an acceptable treatment for early-stage non-small cell lung cancer (NSCLC). As a result, preoperative prediction of lymph node (LN) metastasis is becoming an important factor in determining surgical strategy. This study aimed to investigate the predictive accuracy of the consolidation tumor ratio (CTR) and the maximum standardized uptake value (maxSUV) of the primary tumor for LN metastasis in patients with clinical stage IA NSCLC.

Methods

We performed a retrospective analysis using data from 1,338 patients with clinical stage IA NSCLC who underwent surgery between 2011 and 2019. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to identify the optimal maxSUV and CTR for predicting LN metastasis. Multivariate logistic regression analysis was performed to identify independent predictors of LN metastasis. Survival analyses were performed using Cox proportional hazards models to identify prognostic factors for death and recurrence.

Results

Among the 896 patients who underwent lobectomy with systematic LN dissection, 9.8% (88 patients) were found to have LN metastasis. The ROC curve for CTR revealed an AUC of 0.689 [95% confidence interval (CI): 0.646-0.732, P<0.001], while the ROC curve for maxSUV yielded an AUC of 0.748 (95% CI: 0.705-0.791, P<0.001) for predicting LN metastasis. In pure solid mass (CTR =1) with maxSUV exceeding 5.0, LN metastasis was observed in 13.8% of tumor 0-2 cm and 25.7% of tumor 2.1-3 cm. Multivariate analysis identified CTR >0.5 (HR =1.741, 95% CI: 1.122-2.701, P=0.01) and maxSUV >5.0 (HR =2.004, 95% CI: 1.421-2.825, P<0.001) as independent prognostic factors for disease-free survival.

Conclusions

In clinical stage IA NSCLC, LN metastasis can be predicted using CTR and maxSUV of the primary mass. It is crucial not to underestimate the rate of LN metastasis when determining the surgical extent.

Segmentectomy for non-peripheral and peripheral small-sized non-small-cell lung cancer

OBJECTIVES

To compare the oncological outcomes of segmentectomy for non-peripheral versus peripheral small-sized non-small-cell lung cancer (NSCLC).

METHODS

This retrospective observational study included patients with clinical stage IA1-A2 NSCLC who underwent segmentectomy. Patients were separated based on tumour distance index (DI, which was calculated as the ratio of the distance from the entrance of the segmental bronchus to the proximal tumour margin to the distance to the lobar pleura along the same line): non-peripheral group (DI ≤ 2/3) and peripheral group (DI > 2/3). Disease-free survival (DFS) and overall survival were compared with log-rank tests.

RESULTS

850 patients were included, comprising 274 in the non-peripheral group and 576 in the peripheral group. Recurrence occurred in 68 patients (24 in the peripheral group and 44 in the non-peripheral group), and 56 patients died (22 in the peripheral group and 34 in the non-peripheral group). Log-rank tests showed no statistical differences in 5-year DFS (92.2% vs 91.2%) and 5-year overall survival (96.3% vs 93.6%) between the two groups, but higher margin recurrence occurred in the non-peripheral group. Multivariable analysis revealed that age, tumour diameter, consolidation-to-tumour ratios, pathological subtype and pathologic stage were independent risk factors for DFS. Subgroup analysis indicated that patients with a non-peripheral solid NSCLC had a worse 5-year DFS (62.1% vs 76.3%) and a higher margin recurrence rate (13.2% vs 2.0%).

CONCLUSIONS

Segmentectomy for small-sized non-peripheral NSCLC could gain a comparable outcome to the peripheral, but worse DFS and higher margin recurrence occurred in the non-peripheral solid NSCLC.

Safety and efficacy of anatomical tunneling technique for precise lung segment resection in complex anatomical settings

BACKGROUND

Thoracoscopic segmentectomy is the main surgical method for the treatment of earlylung cancer. With the promotion of technology and increasingly accurate criteria for lung subsegments, lung nodules with complex positions involving intersegmental and multisegments have become technical bottlenecks. This study aimed to verify whether seeking anatomical conditions for creating a fissure by tunneling techniques with precise resection of lung segments could solve this bottleneck problem.

METHODS

The clinical data of patients with lung nodules ≤ 2 cm located in the complex position in the Department of Thoracic Surgery of Jiangsu Provincial People's Hospital from January 2019 to August 2023 were collected. Date analyzed the characteristics of patients who underwent seeking anatomical conditions for creating a fissure by tunneling techniques with precise resection of lung segments (segment group) at complex setting and compared the surgical outcomes and complications between these lobectomy patients (lobectomy group) at similar locations.

RESULTS

A total of 22 patients were included segment group and 47 patients were included lobectomy group. Except for the depth ratio or tumor size or consolidation tumor ratio (CTR), there were no significant differences in the other baseline data between the two groups. All patients in segment group received a satisfactory surgical margin. Compared to the lobectomy group, surgical outcomes were better in segment group (p < 0.05 for postoperative hospital stay and the counts of resected subsegments).

CONCLUSION

Seeking anatomical conditions for creating a fissure by tunneling techniques is a promising technique for performing precise resection of lung segments with a safe resection margin for patients with lung nodules at complex positions involving multiple segments. It can be used as a precise resection of lung segments technique.

Contribution of fluorescence imaging to thoracoscopic anatomical segmentectomy: a multicenter propensity matching analysis

BACKGROUND

Thoracoscopic anatomical segmentectomy is increasingly recognized for managing early-stage lung cancer. However accurately identifying intersegmental planes (ISPs), especially in complex lung segments, remains challenging. In comparison to conventional methods, fluorescence imaging represents a novel solution. This study aimed to examine the potential benefits of fluorescence imaging in single-port thoracoscopic anatomical segmentectomy.

METHODS

A multicenter (three regional hospitals), retrospective, comparative analysis was conducted using data from 402 consecutive patients who underwent single-port thoracoscopic anatomical segmentectomy from June 2020 to December 2022. The cohort included 191 patients treated with the fluorescence method and 211 patients treated with the modified inflation-deflation method. Among the cohort, 130 patients were placed in the simple segmentectomy group and 272 in the complex segmentectomy group. Propensity score matching (PSM) was used to adjust for baseline differences between the fluorescence and modified inflation-deflation subgroups in the complex segmentectomy group. Perioperative outcomes were compared between the groups.

RESULTS

In the simple segmentectomy group, no significant differences were observed between the fluorescence and modified inflation-deflation methods regarding segmental resection time, intraoperative blood loss, postoperative chest tube drainage and duration, postoperative pain, length of hospital stay, complication rate, or hospital costs. In the complex segmentectomy group, however, fluorescence imaging significantly shortened segmental resection time (69.37±28.22 vs. 78.80±34.66 min; P=0.03), while reducing intraoperative blood loss (P=0.046); and improving visual analogue scale (VAS) pain scores on the first postoperative day (P=0.006). Both methods demonstrated comparable safety and oncologic effectiveness.

CONCLUSIONS

Fluorescence-guided single-port thoracoscopic anatomical segmentectomy demonstrated comparable perioperative safety and effectiveness to the modified inflation-deflation technique while offering advantages, such as shorter segmental resection time, for complex segmentectomies.

Unveiling the synergetic benefits of the tunneling technique using stapler tractor in precise resection of lung segments: a retrospective cohort study

Background

Tunneling technique has shown preliminary promise in lung segmentectomy which requires the use of staplers in specific procedures. However, the obstacle when staples pass is the most obvious factor hindering the implementation and development of this technique. This study investigated whether the obstacle of the technology could be addressed by using an innovative self-designed stapler tractor and analyzed the combined and respective advantages of them.

Methods

The clinical data of patients with lung nodules located near anatomical sites with potential tunnel creation treated by segmentectomy were analyzed in this retrospective case-control study. The data were divided into four groups according to four distinct surgical strategies: In Group A, the tunneling technique was performed with a stapler tractor; in Group B, the tunneling technique was performed without a stapler tractor; in Group C, didn't perform the tunneling technique but using stapler tractor in a normal approach; and in Group D, neither performed the technique nor used the stapler tractor. The general linear data, operation times, intraoperative adverse events, postoperative recovery and complications were compared.

Results

Compared with other groups, Group A exhibited the best surgical outcomes in comprehensive aspects. Separately, the tunnel groups (Group A&B) had better outcomes in the macro implementation of operation, including resection margin, the number of sampled intrapulmonary lymph nodes and resected subsegments, while the staple tractor groups (Group A&C) performed better on details of the procedure, including operation time, conversion to thoracotomy, and intraoperative bleeding (p < 0.05). Both of them were beneficial for shorter hospital stay, and the tunnel group was more advantageous.

Conclusion

The tunneling technique is an advanced and beneficial surgical strategy for performing precise resection of lung segments while a stapler tractor can promote and facilitate it as a supplementary instrument. They show more combined benefits in effectively minimizing the occurrence of erroneous injuries and enhancing the operational efficacy.

Empowering lung cancer treatment: Harnessing the potential of natural phytoconstituent-loaded nanoparticles

Lung cancer, the second leading cause of cancer-related deaths, accounts for a substantial portion, representing 18.4% of all cancer fatalities. Despite advances in treatment modalities such as chemotherapy, surgery, and immunotherapy, significant challenges persist, including chemoresistance, non-specific targeting, and adverse effects. Consequently, there is an urgent need for innovative therapeutic approaches to overcome these limitations. Natural compounds, particularly phytoconstituents, have emerged as promising candidates due to their potent anticancer properties and relatively low incidence of adverse effects compared to conventional treatments. However, inherent challenges such as poor solubility, rapid metabolism, and enzymatic degradation hinder their clinical utility. To address these obstacles, researchers have increasingly turned to nanotechnology-based drug delivery systems (DDS). Nanocarriers offer several advantages, including enhanced drug stability, prolonged circulation time, and targeted delivery to tumor sites, thereby minimizing off-target effects. By encapsulating phytoconstituents within nanocarriers, researchers aim to optimize their bioavailability and therapeutic efficacy while reducing systemic toxicity. Moreover, the integration of nanotechnology with phytoconstituents allows for a nuanced understanding of the intricate molecular pathways involved in lung cancer pathogenesis. This integrated approach holds promise for modulating key cellular processes implicated in tumor growth and progression. Additionally, by leveraging the synergistic effects of phytoconstituents and nanocarriers, researchers seek to develop tailored therapeutic strategies that maximize efficacy while minimizing adverse effects. In conclusion, the integration of phytoconstituents with nanocarriers represents a promising avenue for advancing lung cancer treatment. This synergistic approach has the potential to revolutionize current therapeutic paradigms by offering targeted, efficient, and minimally toxic interventions. Continued research in this field holds the promise of improving patient outcomes and addressing unmet clinical needs in lung cancer management.

Oncological feasibility of segmentectomy for inner-located lung cancer

Objective

Oncological feasibility of segmentectomy for internal non-small cell lung cancer (NSCLC) has not been assessed adequately. We assessed the oncological feasibility of segmentectomy for inner-located NSCLC by investigating surgical margins and patient prognosis after undergoing the procedure.

Methods

Of the 3555 patients who underwent resection for lung cancer between 2013 and 2019 at our institution, 659 patients who underwent segmentectomy for clinical stage 0 to stage1A NSCLC were included in this study. Patients were separated into 2 groups according to whether the tumor was in the inner or outer third of the lung area. Clinical characteristics and prognoses were retrospectively compared between the groups.

Results

Of the included 659 cases, 183 (27.8%) were inner-located, and 476 (72.2%) had outer-located NSCLC. The surgical margin was significantly shorter in the inner-located group than in the outer group (median, 16 vs 25 mm; P < .001). The 5-year recurrence-free survival and overall survival probabilities were 91.1%/91.8% (P = .530) and 94.1%/95.6% (P = .345) for inner/outer-located groups, respectively. Multivariate analysis showed that clinical stage IA2 or 3 (P = .043), lymphovascular invasion (P < .001), and surgical margins <20 mm (P = .017) were independent prognostic factors for recurrence-free survival. The location of the inner or outer tumors was not related to the prognosis.

Conclusions

For clinical stage 0 to stage1A NSCLC, tumor location in the inner two-thirds of the lung was not associated with prognosis after segmentectomy. Because one of the independent prognostic factors is margin distance, segmentectomy for inner-located NSCLC would be oncologically acceptable when an adequate surgical margin is secured.

[Indocyanine green fluorescence in thoracoscopic segmentectomy: indications and benefits]

OBJECTIVE

To determine the role of ICG fluorescence in segmentectomies.

MATERIAL AND METHODS

One surgical team performed 178 thoracoscopic anatomical segmentectomies in two hospitals between 2017 and 2023. Of these, 93 (52.2%) patients underwent ICG fluorescence perfusion tests. This study was retrospective and consecutive. Intraoperative and early postoperative results were analyzed. Patients were divided into 3 equal periods. Ventilation and perfusion methods were used to navigate the intersegmental planes in the first period. In the second one, only ventilation methods were used due to the absence of ICG. In the third period, the choice of navigation method was determined by «surgical complexity of segment».

RESULTS

In 74% of patients, surgeries were performed for primary or metastatic lung tumors. The scheduled procedure was performed in all patients. However, 2 ones required lobectomy for total resection. Uneventful postoperative period was observed in 69.7% of patients. Other ones had complications grade I-IIIA. No reoperations or mortality were recorded.

CONCLUSION

ICG perfusion is not inferior to ventilation methods in identification of intersegmental planes. This method is also more convenient for thoracoscopy. ICG fluorescence thoracoscopy is the only method in patients with COPD scheduled for thoracoscopic segmentectomy with two or more intersegmental planes.