Video-Assisted Thoracoscopic or Open Lobectomy in Early-Stage Lung Cancer

Initial outcomes with uniportal video-assisted lung resection

OBJECTIVES

Uniportal video-assisted lung resection is increasingly reported, but adoption in North America has been low. This study examines the early experience with the uniportal technique by a surgeon experienced in multiportal thoracoscopic surgery.

METHODS

Operation was performed using a 4-cm incision crossing the anterior axillary line. Primary objectives were to evaluate short-term outcomes, and secondary objectives included evaluation for learning curve and oncological outcomes for patients with non-small cell lung cancer.

RESULTS

Over a 45-month period, 212 patients underwent uniportal lung resection. Procedures included 128 lobectomies (60.4%), 41 segmentectomies (19.3%), 40 wedge resections (18.9%) and 3 extended resections (1.4%). Conversion was required in 24 patients (12.8%); 17 to multiportal surgery and 7 to thoracotomy. Major adverse events occurred in 13 patients (6.1%) and included 3 deaths (1.4%). Median hospital stay was 3 days, and median chest tube duration was 2 days. When comparing the early and late experience, there was no difference in hospital stay, adverse events, conversion and readmissions. The mean number of lymph nodes and nodal stations dissected were 10.08 and 4.79, respectively. The number of nodal stations dissected improved with experience (P < 0.001).

CONCLUSIONS

Uniportal video-assisted lung resection is safe with good perioperative outcomes. Lymph node dissection improved with experience; otherwise, no significant learning curve was demonstrated when transitioning from a multiport approach.

Immunotherapy for Early-Stage Non-Small Cell Lung Cancer: A Practical Guide of Current Controversies

The role of immunotherapy as systemic therapy for nonmetastatic non-small cell lung cancer (NSCLC) has evolved rapidly over the last decade. There are several well-conducted phase 3 clinical trials evaluating immunotherapy in the neoadjuvant, perioperative, adjuvant and nonoperative setting. In this narrative review, we summarize the data from these studies and discuss ongoing controversies in applying these data to clinical practice. These controversies relate to the value of the adjuvant component of perioperative immunotherapy, treatment of patients with PDL1 negative tumors, defining resectability, optimal use of operative versus nonoperative management, the role of stereotactic radiation therapy for very early lung cancers, and management of tumors with an oncogenic driver.

A randomized study of cryoablation of intercostal nerves in patients undergoing minimally invasive thoracic surgery

OBJECTIVES

Minimally invasive thoracic surgery can cause significant pain, and optimizing pain control after surgery is highly desirable. We examined pain control after intercostal nerve block with or without cryoablation of the intercostal nerves.

METHODS

This was a randomized study (NCT05348447) of adults scheduled for a minimally invasive thoracic procedure. Each intercostal space near the incision site was injected with lidocaine and bupivacaine with epinephrine (standard of care). The cryoanalgesia group also had 5 to 6 intercostal nerves ablated. The primary outcome was the amount of narcotics (in morphine milligram equivalents taken during the postoperative hospital stay and the first 2 weeks postdischarge. Secondary outcomes were incentive spirometry volume and pain scores in the hospital and pain and neuropathy scores at 2 weeks.

RESULTS

Our final cohort contained 103 patients (52 standard of care and 51 cryoanalgesia). There were no differences between the treatment groups in morphine milligram equivalents administered during the hospital stay (44.9 vs 38.4 mg), total morphine milligram equivalents at 2 weeks (108.8 vs 95.2 mg), or pain assessed by visual analog scale on postoperative day 1 (3.8 and 3.3), postoperative day 2 (2 and 3.5), or 2 weeks (2 and 3.5) for standard of care and cryoanalgesia group patients, respectively. The decrease in incentive spirometry during the postoperative period was not significantly different between the 2 groups. Patients in the cryoanalgesia group had higher neuropathy scores (8 vs 13; P = .019) 2 weeks after surgery.

CONCLUSIONS

In this randomized study, cryoanalgesia did not decrease postoperative pain or narcotic requirements. Cryoanalgesia increased neuropathic pain 2 weeks after surgery.

Diagnostic Dilemma of Rounded Atelectasis in the Left Lower Lobe Showing High Uptake of 18F-Fluorodeoxyglucose: A Surgical Conundrum

Differentiating rounded atelectasis from lung cancer can be challenging. Rounded atelectasis has a low-to-moderate maximum standardized uptake value of 18F-fluorodeoxyglucose (18F-FDG); however, some cases show high uptake, meaning that radiology-based diagnoses may not always be accurate. Herein, we report a rare surgical case of a patient with rounded atelectasis exhibiting considerable 18F-FDG uptake. A 55-year-old man with a 37-pack-year smoking history was referred to our hospital for further investigation of an abnormal shadow in the left lower lung field. Chest computed tomography (CT) revealed a 45-mm solid tumor with bronchovascular convergence forming a "comet tail" sign in the left lower lung lobe. Positron emission tomography/CT with 18F-FDG showed increased uptake within a 30-mm region of the subpleural mass (SUVmax: 6.5). These findings necessitated a differential diagnosis to distinguish rounded atelectasis from lung cancer. The patient underwent video-assisted thoracoscopic left lower lung lobectomy with hilar lymph node dissection. Pathological investigation revealed granulomatous pleuritis and pneumonitis with no evidence of malignancy, consistent with rounded atelectasis. The patient had an uneventful postoperative course and was discharged six days after surgery. During a two-year follow-up period, no health-related issues, including lung cancer development, have been observed. This rare case highlights the importance of a thorough investigation to exclude the possibility of lung cancer before confirming a diagnosis of rounded atelectasis in patients with pulmonary lesions exhibiting high 18F-FDG accumulation.

Data-driven prediction of prolonged air leak after video-assisted thoracoscopic surgery for lung cancer: Development and validation of machine-learning-based models using real-world data through the ePath system

Introduction

The reliability of data-driven predictions in real-world scenarios remains uncertain. This study aimed to develop and validate a machine-learning-based model for predicting clinical outcomes using real-world data from an electronic clinical pathway (ePath) system.

Methods

All available data were collected from patients with lung cancer who underwent video-assisted thoracoscopic surgery at two independent hospitals utilizing the ePath system. The primary clinical outcome of interest was prolonged air leak (PAL), defined as drainage removal more than 2 days post-surgery. Data-driven prediction models were developed in a cohort of 314 patients from a university hospital applying sparse linear regression models (least absolute shrinkage and selection operator, ridge, and elastic net) and decision tree ensemble models (random forest and extreme gradient boosting). Model performance was then validated in a cohort of 154 patients from a tertiary hospital using the area under the receiver operating characteristic curve (AUROC) and calibration plots.

Results

To mitigate bias, variables with missing data related to PAL or those with high rates of missing data were excluded from the dataset. Fivefold cross-validation indicated improved AUROCs when utilizing key variables, even post-imputation of missing data. Dichotomizing continuous variables enhanced performance, particularly when fewer variables were employed in the decision tree ensemble models. Consequently, regression models incorporating seven key variables in complete case analysis demonstrated superior discriminatory ability for both internal (AUROCs: 0.77-0.84) and external cohorts (AUROCs: 0.75-0.84). These models exhibited satisfactory calibration in both cohorts.

Conclusions

The data-driven prediction model implementing the ePath system exhibited adequate performance in predicting PAL post-video-assisted thoracoscopic surgery, optimizing variables and considering population characteristics in a real-world setting.

Analgesic Efficacy of Thoracoscopic Direct-View Versus Ultrasound-Guided Thoracic Paravertebral Block in Multi-Port Video-Assisted Thoracoscopic Lung Surgery: A Randomized Controlled Non-Inferiority Study

Purpose

This study compares the analgesic effects of the Thoracoscopic Direct-view Thoracic Paravertebral Nerve Block (DTPVB) with those of the Ultrasound-guided Thoracic Paravertebral Nerve Block (UTPVB), providing a clinical reference.

Patients and Methods

Sixty-eight patients undergoing three-port video-assisted thoracic surgery (VATS) with general anesthesia were randomly assigned to either the DTPVB group (Group D, n = 34) or the UTPVB group (Group U, n = 34). Both groups received a 10 mL injection of 0.75% ropivacaine at the T4 and T7 interspaces. Primary outcomes were cumulative sufentanil equivalents from the start of lung manipulation to 24 hours postoperatively, with group differences assessed against a non-inferiority margin of 5 μg (Δ). Secondary outcomes include postoperative pain scores, analgesic consumption, patient satisfaction, adverse effects, and other related indicators.

Results

The cumulative use of sufentanil equivalents from the start of lung manipulation to 24 hours postoperatively was 35.0 ± 6.1 μg in Group D and 33.2 ± 5.6 μg in Group U, with no significant difference (P = 0.217). The difference in cumulative sufentanil equivalents (Group D minus Group U) was 1.8 (95% CI -1.07, 4.65), within the non-inferiority margin of 5 (Δ). Postoperative pain scores, analgesic consumption, adverse effects, and complications were similar were similar between groups. However, DTPVB was associated with lower anxiety and higher satisfaction (P<0.001). At 15 minutes post-block, ropivacaine plasma concentrations were higher in Group D (P=0.024).

Conclusion

DTPVB, via transmural pleural puncture, was non-inferior to UTPVB in analgesic efficacy from the beginning of the manipulation of the lungs in operation to 24h postoperatively. DTPVB provides a good alternative, especially for patients who are anxious before surgery, have difficulty cooperating with UTPVB, or in cases where UTPVB puncture fails. However, when using high concentrations of ropivacaine, greater vigilance for toxicity is required.

[Sublobar resection in early-stage NSCLC: towards a new therapeutic standard?]

Until now, the gold standard surgical treatment for early-stage non-small-cell lung cancer (NSCLC) has been pulmonary lobectomy with lymph node dissection. However, several cohort studies have suggested that infra-lobar resection may provide equivalent survival while better preserving quality of life and lung function. The results of two prospective randomized phase III studies comparing sublobar resection (segmentectomy or wedge resection) have recently been published. The JCOG 0802 trial focused on cT1a-b NSCLC and showed significantly better survival in the segmentectomy group, but a higher rate of local recurrence. The CALGB 140503 trial involving stage Ia NSCLC showed no difference in survival and recurrence rate between the two groups. Some questions remain unanswered in these studies, particularly in the CALGB 140503 trial where a majority of patients had an atypical resection. Pending clarification, the complexity of this new surgery calls for oncological rigor in terms of indications and technique, as well as compliance with quality criteria.

Tumour spread through air spaces is a determiner for treatment of clinical stage I non-small cell lung Cancer: Thoracoscopic segmentectomy vs lobectomy

BACKGROUND

The choice of surgical procedure for early-stage non-small cell lung cancer (NSCLC) with tumour spread through air spaces (STAS) remain debated. This study aimed to analyse the prognostic influence of STAS on thoracoscopic segmentectomy compared to lobectomy for clinical stage I NSCLC.

METHODS

This retrospective study included prospectively collected data of consecutive patients who underwent thoracoscopic segmentectomy or lobectomy for clinical stage I NSCLC from September 2020 to September 2023 at a high-volume hospital. We assessed overall survival (OS) and recurrence-free survival (RFS) using Kaplan-Meier estimator with log-rank test. LASSO-Cox and Cox regression analyses identified independent factors for survivals of STAS presence.

RESULTS

Among the 785 patients in the study, 151 (19.2 %) had STAS-positive NSCLC. No significant difference was observed in OS and RFS between patients with the presence and absence of STAS, nor between those undergoing thoracoscopic segmentectomy and lobectomy for NSCLC in the absence of STAS. Whereas worse survivals were found in segmentectomy for patients with STAS when compared to lobectomy (3-year OS: 58.4 % vs 89.0 %, P < 0.001; 3-year RFS: 69.8 % vs 82.7 %, P < 0.001). On multivariable analysis, segmentectomy (vs. lobectomy) and increased maximum standardized uptake value in positron emission tomography were independent prognostic factors of OS (hazard ratio [HR] 5.81, P = 0.010; HR 1.12, P = 0.022) and RFS (HR 5.78, P = 0.004; HR 1.10, P = 0.025) among patients with STAS.

CONCLUSIONS

In this study, segmentectomy for clinical stage I NSCLC with STAS had inferior RFS and OS when compared to lobectomy.

Determinants of successful minimally invasive surgery for resectable non-small cell lung cancer after neoadjuvant therapy

OBJECTIVE

Minimally invasive surgery (MIS) (video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery) for pulmonary resection is standard in early-stage non-small cell lung cancer because it is associated with better perioperative outcomes than thoracotomy. MIS for resection of more advanced non-small cell lung cancer (Stages IB-IIIB) treated with neoadjuvant therapy has been utilized. However, the determinants of success are not well defined.

METHODS

A single institution retrospective review of a prospectively maintained database was conducted, querying for patients with clinical Stage IB through IIIB non-small cell lung cancer who had resection after neoadjuvant systemic therapy without radiation from 2013 to 2022. Patients were grouped by surgical approach; that is, open versus MIS. Successful MIS was defined by no conversion, R0 resection, and no major (grade 3 or greater) morbidity. Analyses by intent-to-treat assessed outcomes by Wilcoxon rank-sum test and Fisher exact test. (Multivariable regression analysis identified variables that contributed to successful MIS resection.) RESULTS: Of 627 eligible patients, 360 (57%) had open and 267 (43%) had MIS procedures. Most patients (79.1%) received neoadjuvant platinum-based chemotherapy, and 21.9% were treated with immunotherapy or targeted therapy alone or combined with chemotherapy. Among MIS resections, 179 (67%) were performed by video-assisted thoracoscopic surgery and 88 (33%) by robot-assisted thoracoscopic surgery. The conversion rate was 16% (n = 43). Successful MIS resection was achieved in 77% of patients. Multivariable regression analysis showed that pretreatment clinical N stage was a significant determinant of success, but not pretreatment clinical T stage or type of neoadjuvant therapy.

CONCLUSIONS

Following neoadjuvant systemic therapy for clinical stage IB or IIIB non-small cell lung cancer, MIS resection can be successfully accomplished and should be considered in appropriate patients. Presence of pretreatment nodal disease is associated with higher odds of conversion, major morbidity, and incomplete resection.

Safety and efficacy of neoadjuvant cisplatin + S-1 combined with radiation therapy for locally advanced non-small cell lung cancer

PURPOSE

To assess the safety and efficacy of neoadjuvant chemoradiotherapy with cisplatin plus S-1 for advanced non-small cell lung cancer (NSCLC), with a focus on real-world outcomes.

METHODS

This retrospective study analyzed 32 patients with stage II-III NSCLC eligible for resection, who received preoperative induction therapy between January 2012 and December 2022. Specifically, 20 patients received cisplatin, S-1, and radiation therapy.

RESULTS

Among the 32 patients who received induction therapy, the objective response rate (ORR) was 56.2%, and surgical resection was feasible in 29 patients (90.6%). The 5 year recurrence-free survival (RFS) rate was 76.4%, and the 3- and 5 year overall survival (OS) rates were 86.2% and 82.3%, respectively. In the cisplatin + S-1 + radiation therapy group (n = 20), the ORR was 65.0%, and surgical resection was feasible in 17 patients (85.0%). The 3-year RFS and OS rates were 78.3% and 83.8%, respectively. Ef. 3 (complete pathological response) was observed in 3 patients (10.3%). No recurrences occurred in the non-adenocarcinoma subgroup (n = 6), indicating better outcomes relative to the adenocarcinoma group (5-year RFS, 100% vs. 61.4%; p = 0.07).

CONCLUSIONS

Induction therapy, particularly with cisplatin + S-1 + radiation was associated with promising RFS and OS in locally advanced NSCLC, with favorable tolerability and effectiveness.

Video-Assisted vs. Robotic-Assisted Thoracoscopic Surgery in Lung Cancer: A Comprehensive Review of Techniques and Outcomes

Lung cancer is the primary cause of cancer-related mortality globally; hence, several medical and surgical approaches have been developed for its management. This can be easily recognized with the evolution from the traditional open thoracotomy toward minimally invasive procedures-in particular, video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS)-in treating lung cancer. There has been a lot of controversy around the advantages and limitations of these procedures. VATS has been proven to be beneficial in treating early-stage lung cancer. Yet, the restricted mobility of its instruments, as well as the lack of a three-dimensional visualization of anatomical components, make the new RATS desired. RATS uses advanced technology, which has resulted in an exceptional high-definition, three-dimensional image of the working field. This has also led to fine dissection with great precision and accuracy, better lymph node removal, reduced postoperative recovery time, and better outcomes. Compared to VATS, there is less blood loss, shorter hospital stays, and less pleural effusion drainage. Despite its higher cost due to the expensive surgical systems, training and maintenance fees, and longer operative time, RATS has started to gain more use, potentially enhancing patient outcomes as experience and technological improvements progress.

[Video-assisted thoracic surgery-Indications, importance and technique]

Video-assisted thoracic surgery (VATS) is a safe and effective surgical procedure. Completely minimally invasive operations must be distinguished from hybrid procedures. The VATS can be used for diagnostic and treatment purposes for all oncological and non-oncological diseases of the thoracic organs. The VATS is the preferred surgical procedure for a large number of diseases. Nevertheless, the procedure-specific limitations of VATS must be taken into account in individual cases. In the hands of experienced surgeons complex thoracic surgical procedures can be safely performed. In order to benefit from the advantages of this minimally invasive surgical procedure, integration into a fast-track concept is mandatory.

Outcomes After Surgical Management of Early-Stage Lung Cancer in Octogenarians: An In-Depth Analysis of a Nationally Representative Cohort

INTRODUCTION

As the United States population ages more octogenarians are undergoing surgical resection for lung cancer. We aimed to provide an updated and expanded assessment of age-related risks associated with surgical resections for early-stage NSCLC.

METHODS

The Surveillance, Epidemiology, and End Results and Medicare databases were queried for stage IA NSCLC cases treated by surgery between 2006 and 2018. Analyses included generalized linear models for one-year mortality and Cox proportional hazards models for five-year survival.

RESULTS

One-year all-cause mortality among 4061 octogenarians was more than double that of the youngest group (age: 65-69 y): 15.2% versus 7.3%, p value less than 0.001. Octogenarians were discharged to extended skilled nursing facility stays more than three times as often as the youngest group (19.9% versus 6.3%, p < 0.001). For those with skilled nursing facility duration greater than 30 days, there was a 36% greater one-year mortality risk compared with those discharged to home or home-health. In adjusted analyses, octogenarians had 62% greater one-year mortality risk compared with those aged below 80 years (risk ratio = 1.62, 95% confidence interval: 1.48-1.78). The risk of death within five years was 52% higher (hazard ratio = 1.52, 95% confidence interval: 1.42-1.62). Additional factors associated with one-year mortality included male sex, higher comorbidity burden, lower county median income, open approach, and sub-lobar resection.

CONCLUSIONS

This analysis provides an updated and expanded characterization of age-related outcomes on the basis of a large national cohort representative of elderly patients treated outside of clinical trials. Substantial gaps in survival and discharge disposition motivate further research and the development of interventions to help improve outcomes in older patients.

One-stage versus two-stage thoracoscopic surgery for synchronous bilateral pulmonary nodules: a propensity score-matched analysis

BACKGROUND

The aim of this study was to compare the surgical efficacy of one-stage and two-stage video-assisted thoracoscopic surgery (VATS) for bilateral multiple pulmonary nodules (BMPNs).

METHODS

A retrospective analysis was made of 156 patients, 84 who underwent one-stage and 72 who underwent two-stage VATS for BMPNs at our department between January 2019 and December 2022. Perioperative and long-term outcomes were compared between the two groups using propensity score-matched (PSM) analysis.

RESULTS

There were 48 patients in each group after PSM. No significant difference was observed in operation time, blood loss, rates of overall complications, and 3-year overall survival (p>0.05) between one-stage and two-stage groups. The one-stage procedure was associated with shorter length of stay (5 days [IQR 4-5.75 days] vs. 9 days [IQR 7-10 days]; p<0.001), as well as lower total cost (14626.3 ± 4149.4 vs. 18975.9 ± 3720.8 USD, p<0.001) compared to the two-stage procedure. The one-stage group was associated with better 3-year RFS compared with the two-stage group (90.7% vs. 75.3%, p = 0.039).

CONCLUSION

One-stage and two-stage VATS for BMPNs are both safe and feasible in selected patients. One-stage procedure possess potential advantages in reducing hospital stay and cost, as well as preventing tumor progression.

Awake thoracic surgery for lung cancer treatment: where we are and future perspectives-our experience and review of literature

BACKGROUND

Lung cancer is the first cause of cancer-related death. Awake lung resection is a new frontier of the concept of minimally invasive surgery. Our purpose is to demonstrate the feasibility of this technique for lobar and sublobar lung resection in NSCLC patients.

METHODS

We retrospective reviewed all the medical charts of patients who underwent awake lung resection in our center between March 2018 and March 2024, focusing on patients with NSCLC, and we compared our results with the ones found in literature.

RESULTS

Among 45 patients treated with awake lung resections, we selected 15 patients with NSCLC and finally analyzed the results of 12 patients who underwent VATS awake lung resection, 3 lobectomies and 9 wedge resections. The median Charlson comorbidity index (CCI) was 3 and we had 5 patients (41.67%) with a CCI ≥ 4 and a median FEV1 of 56%. We report only 2 conversions to general anesthesia (16.67%) and no conversion to open thoracotomy. We used a nebulizator for the atomization of lidocaine on the lung surface to reduce the cough reflex. Our post-operative results are in line with literature, with a low complication rate (2 patients, 16.67%) and a median length of stay of 5 days. We safely performed a proper lymph node dissection in all 3 lobectomies. Median Overall Survival and Disease-Free Survival were 11 months.

CONCLUSIONS

Awake lung resections are a feasible way to perform a minimally invasive surgical procedure in NSCLC patients, with low risk of conversion to open surgery.

Optimum diagnostic pathway and pathologic confirmation rate of early stage lung cancer: Results from the VIOLET randomised controlled trial

BACKGROUND

Pathologic confirmation of lung cancer influences treatment selection for suspected early-stage lung cancer. High pre-treatment tissue confirmation rates are recommended. We sought to define management and outcomes of patients undergoing surgery for primary lung cancer in a UK multi-centre clinical trial.

METHODS

VIOLET compared minimally invasive video-assisted thoracic surgery versus open surgery for known or suspected lung cancer. Diagnostic patient pathways were identified and methods of tissue confirmation were documented. The outcome of inappropriate lobectomy for benign disease or inappropriate wedge resection for primary lung cancer was compared with respect to the pathologic diagnosis.

FINDINGS

From July 2015 to February 2019, 502 patients were randomised and underwent surgery; 262 (52%) had a pre-operative pathologic confirmed diagnosis of primary lung cancer, 205 did not have a pre-operative biopsy and 35 had a non-diagnostic pre-operative biopsy. Of the 240 participants without pre-operative pathologic confirmation of primary lung cancer, intraoperative biopsy and frozen section analysis was undertaken in 144 (60%). The remaining 96 underwent direct surgical resection without tissue confirmation (19% of the entire cohort). Confirmation of histologic diagnosis before surgery was less costly than diagnosis in the operating theatre. The inappropriate surgery rate was 3.6% (18/502 participants, 7 lobectomy for benign disease, 11 wedge resection for lung cancer).

INTERPRETATION

Low levels of inappropriate resection can be achieved at pre-operative tissue confirmation rates of 50% through a combination of intra-operative confirmatory biopsy and correct risk estimation of lung cancer. Practice needs to be monitored to ensure acceptable levels are consistently achieved.

Preoperative planning programme in minimally invasive lung surgery reduces intraoperative adverse events

OBJECTIVES

While minimally invasive surgery (MIS) is the preferred approach in patients with early-stage lung cancer, intraoperative adverse events (IOAE) may still occur. The objective of this study was to assess the impact of a dedicated preoperative planning program on adverse event occurrence.

METHODS

A single-centre cross-sectional comparative study was conducted, including all patients with proven/suspected lung cancer undergoing curative MIS, prior (September 2021-October 2022) and after (November 2022-January 2024) the implementation of a preoperative planning program. The preoperative planning program consisted of a weekly assessment of upcoming surgical cases, evaluating surgical strategy, anatomical variations and anticipating surgical difficulties. Data were prospectively collected. The primary outcome was the rate of IOAE. Secondary outcomes were conversion rate, healthcare-associated adverse events and postoperative morbi-mortality.

RESULTS

We included 553 patients, 290 without preoperative planning and 263 undergoing a preoperative planning program. The overall IOAE rate was 11.4%, significantly lower after preoperative planning (7.6% vs 14.8%, P = 0.008). The overall healthcare-associated adverse events rate was 23.2%, significantly lower after preoperative planning (17.1% vs 28.6%, P = 0.0014). There were no statistical differences before and after preoperative planning for conversion rate (8.37% vs 10.7%, P = 0.354), complication rate (33.1% vs 34.5%, P = 0.73) and 90-day mortality (0.38% vs 2.07%, P = 0.126). Preoperative planning program impacted surgical strategy in 61/263 patients (23.2%) including a change in the extent of resection in 25/263 patients (9.5%).

CONCLUSIONS

Implementation of a systematic preoperative planning program in MIS for lung cancer decreases IOAE enabling an improvement in surgical safety.

Financial burden of complications following lung resection: a scoping review protocol

INTRODUCTION

Global healthcare expenditures are rising, driven largely by increased spending in both high- and low-income countries with hospitalisation as a primary contributor. Respiratory diseases, particularly lung cancer, pose significant public health and economic challenges with thoracic surgery as the standard curative treatment. Complications post resection, such as arrhythmias, infections and respiratory failure, result in substantial healthcare costs and resource demands. Although studies have explored the economic impact of surgeries, there is a limited comprehensive analysis of the financial burden of postoperative complications after lung resection surgery. To address this gap, this scoping review aims to map existing literature on lung resection complications and associated costs, providing insights for future research and healthcare policy.

METHODS AND ANALYSIS

This scoping review will be conducting according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews standards. Eligible peer-reviewed articles and grey literature will be identified across Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database and Cochrane Central Register of Controlled Trials. Cost data will be converted into US dollars as per the Federal Reserve Bank of St Louis and adjusted for inflation as per the US Bureau of Labor Statistics Consumer Price Index inflation calculator.

ETHICS AND DISSEMINATION

Ethics approval was not required. The results will be communicated through established professional networks, conference presentations and publication in peer-reviewed journals.

Systematic Review of Sublobar Resection for Treatment of High-Risk Patients with Stage I Non-Small Cell Lung Cancer

Sublobar resection offers a parenchymal-sparing surgical alternative to lobectomy and includes wedge resection and segmentectomy. Sublobar resection has been historically utilized in high-risk patients with compromised lung function; however, the technique is becoming more prevalent for normal-risk patients with peripheral stage IA non-small cell lung cancer (NSCLC) <2 cm. In this article, we summarize the technique of sublobar resection, the importance of surgical margins and lymph node sampling, patient selection, perioperative complications, outcomes, and the impact of sublobar resection on the quality of life. There is limited data on short-term and long-term outcomes after sublobar resection for stage I NSCLC in high-risk patients. Results from randomized clinical trials (RCTs) of sublobar resection have been variable. We have summarized the results of the ACOSOG Z4032 RCT, which compared outcomes in high-risk patients who underwent sublobar resection alone versus sublobar resection with brachytherapy for stage I NSCLC. In addition, we have summarized recent findings of the CALGB/Alliance 140503 RCT comparing sublobar resection and lobectomy, which suggested that disease-free survival after sublobar resection in patients with small (<2 cm) peripheral stage IA NSCLC was non-inferior to lobectomy, and another RCT (JCOG 0802) of segmentectomy vs. lobectomy for small peripheral clinical stage IA NSCLC, where segmentectomy was associated with better overall survival despite a higher local recurrence rate. Sublobar resection is primarily performed with minimally invasive approaches, including robotic-assisted and video-assisted thoracoscopic techniques. From an oncologic perspective, obtaining adequate surgical margins and performing an adequate lymph node evaluation are critical for good outcomes after sublobar resection.

Perioperative Immunotherapy for Node-Negative Non-Small Cell Lung Cancer-Current Evidence and Future Directions

Neoadjuvant immunotherapy has gone from an idea to an indication in locally advanced lung cancer. Several phase III trials have demonstrated the superiority of neoadjuvant chemoimmunotherapy compared with chemotherapy in this setting. Although such progress has revolutionized the treatment of locally advanced disease, the unmet needs of stage I and stage II patients without lymph node disease have largely been underrepresented in existing trials. Up-front resection with few patients going on to complete adjuvant therapy remains the norm for most stage I and II patients. Emerging evidence now supports the exploration of supplemental checkpoint blockade in well-selected early-stage, node-negative patients with large tumors and no actionable driver mutations. Although concerns surrounding safety and risk exist, patient selection could be substantially improved using novel biomarker approaches that leverage our understanding of the tumor immune microenvironment of lung cancer. This review provides a comprehensive overview of the opportunities and controversies of perioperative immunotherapy in node-negative lung cancer.

Intensive care unit admissions following enhanced recovery video-assisted thoracoscopic surgery lobectomy

OBJECTIVES

Video-assisted thoracoscopic surgery (VATS) lobectomy combined with enhanced recovery after surgery (ERAS) protocols has improved postoperative outcomes, yet concerns persist regarding complications and readmissions. Limited research has explored intensive care unit (ICU) admissions and outcomes within this context. The goal of this study was to analyse ICU admissions following VATS lobectomy within an established ERAS protocol.

METHODS

Consecutive patients who underwent VATS lobectomy between 2018 and 2023 were included. Patient data were obtained from our prospective institutional database, while ICU data were extracted from electronic patient records.

RESULTS

Of 2099 patients included, 48 (2.3%) required ICU admission. The median age was 70 (interquartile range: 64-76) years, with ICU patients being older and predominantly male (73%). Overall 30-day mortality was 1.0% with an ICU mortality of 31%. Multiple logistic regression revealed significant associations between ICU admission and male gender (P ≤ 0.001), diabetes mellitus (P = 0.026), heart failure (P = 0.040) and diffusing capacity for carbon monoxide (0.013). Median time to ICU admission was 4 days (interquartile range: 2-10). Respiratory failure was the primary reason for ICU admission (60%). Severe surgical complications accounted for 8.3% of all ICU admissions.

CONCLUSIONS

In an ERAS setting, the incidence of ICU admissions following VATS lobectomy was 2.3%, with a mortality rate of 31%. Respiratory failure was the leading cause of ICU admission.

Neoadjuvant and Adjuvant Treatments for Early Stage Resectable NSCLC: Consensus Recommendations From the International Association for the Study of Lung Cancer

Advances in the multidisciplinary care of early stage resectable NSCLC (rNSCLC) are emerging at an unprecedented pace. Numerous phase 3 trials produced results that have transformed patient outcomes for the better, yet these findings also require important modifications to the patient treatment journey trajectory and reorganization of care pathways. Perhaps, most notably, the need for multispecialty collaboration for this patient population has never been greater. These rapid advances have inevitably left us with important gaps in knowledge for which definitive answers will only become available in several years. To this end, the International Association for the Study of Lung Cancer commissioned a diverse multidisciplinary international expert panel to evaluate the current landscape and provide diagnostic, staging, and therapeutic recommendations for patients with rNSCLC, with particular emphasis on patients with American Joint Committee on Cancer-Union for International Cancer Control TNM eighth edition stages II and III disease. Using a team-based approach, we generated 19 recommendations, of which all but one achieved greater than 85% consensus among panel members. A public voting process was initiated, which successfully validated and provided qualitative nuance to our recommendations. Highlights include the following: (1) the critical importance of a multidisciplinary approach to the evaluation of patients with rNSCLC driven by shared clinical decision-making of a multispecialty team of expert providers; (2) biomarker testing for rNSCLC; (3) a preference for neoadjuvant chemoimmunotherapy for stage III rNSCLC; (4) equipoise regarding the optimal management of patients with stage II between upfront surgery followed by adjuvant therapy and neoadjuvant or perioperative strategies; and (5) the robust preference for adjuvant targeted therapy for patients with rNSCLC and sensitizing EGFR and ALK tumor alterations. Our primary goals were to provide practical recommendations sensitive to the global differences in biology and resources for patients with rNSCLC and to provide expert consensus guidance tailored to the individualized patient needs, goals, and preferences in their cancer care journey as these are areas where physicians must make daily clinical decisions in the absence of definitive data. These recommendations will continue to evolve as the treatment landscape for rNSCLC expands and more knowledge is acquired on the best therapeutic approach in specific patient and disease subgroups.

Open thoracotomy versus VATS versus RATS for segmentectomy: a systematic review & Bayesian network meta-analysis

BACKGROUND

Recent trials suggest that more conservative resections such as segmentectomy are non-inferior to more radical approaches. Most segmentectomy can be safely performed using video-assisted thoracoscopic surgery (VATS). The clinical benefits of robotic-assisted thoracoscopic surgery (RATS) remain unclear. We aimed to perform a systematic review evaluating the outcome of open thoracotomy, VATS, and RATS for segmentectomy.

METHODS

A systematic database search was conducted of original articles exploring the outcome of open versus VATS versus RATS segmentectomy in PubMed, EMBASE and SCOPUS. The primary outcome was 30-day mortality. Secondary outcomes were hospital readmission, air leak, and post-operative pneumonia respectively.

RESULTS

11 studies were included with a total patient sample size of 7280. There were no differences between the three approaches in terms of 30-day mortality, hospital readmission, air leak, and post-operative pneumonia.

CONCLUSION

There are no significant differences between the three approaches in the clinical outcomes measured. While our analysis demonstrates the potential benefits of RATS, it is important to note that the steep learning curve associated with this technique may impact its wider adoption and efficacy in the community. Further randomised control studies are required to compare the short and long terms results of VATS and RATS approaches.

Neoadjuvant pembrolizumab plus chemotherapy followed by adjuvant pembrolizumab compared with neoadjuvant chemotherapy alone in patients with early-stage non-small-cell lung cancer (KEYNOTE-671): a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

At the first interim analysis of the KEYNOTE-671 trial, adding perioperative pembrolizumab to neoadjuvant chemotherapy significantly improved event-free survival in participants with early-stage non-small-cell lung cancer (NSCLC). We report overall survival and health-related quality of life outcomes from the second interim analysis.

METHODS

KEYNOTE-671 was a global phase 3 trial done at 189 medical centres. Eligible participants (aged ≥18 years) with resectable stage II, IIIA, or IIIB (N2) NSCLC were randomly assigned (1:1) to four cycles of neoadjuvant pembrolizumab (200 mg administered intravenously every 3 weeks) plus cisplatin-based chemotherapy followed by surgery and 13 cycles of adjuvant pembrolizumab (200 mg administered intravenously every 3 weeks) or to four cycles of neoadjuvant placebo (administered intravenously every 3 weeks) plus cisplatin-based chemotherapy followed by surgery and 13 cycles of adjuvant placebo (administered intravenously every 3 weeks). Randomisation was done centrally using an interactive response technology system and was stratified by disease stage, PD-L1 expression, histology, and geographical region in blocks of four. Participants, investigators, and sponsor personnel were masked to treatment assignments; local pharmacists were unmasked to support treatment preparation. The dual primary endpoints were overall survival and event-free survival evaluated in the intention-to-treat population. This study is registered at ClinicalTrials.gov, NCT03425643, and is ongoing but closed to enrolment.

FINDINGS

Between May 11, 2018, and Dec 15, 2021, 797 participants were randomly assigned to the pembrolizumab group (n=397) or the placebo group (n=400). Median study follow-up at the second interim analysis was 36·6 months (IQR 27·6-47·8). 36-month overall survival estimates were 71% (95% CI 66-76) in the pembrolizumab group and 64% (58-69) in the placebo group (hazard ratio 0·72 [95% CI 0·56-0·93]; one-sided p=0·0052; threshold, one-sided p=0·0054). Median event-free survival was 47·2 months (95% CI 32·9 to not reached) in the pembrolizumab group and 18·3 months (14·8-22·1) in the placebo group (hazard ratio 0·59 [95% CI 0·48-0·72]). In the as-treated population, grade 3-5 treatment-related adverse events occurred in 179 (45%) of 396 participants in the pembrolizumab group and in 151 (38%) of 399 participants in the placebo group. Treatment-related adverse events led to death in four (1%) participants in the pembrolizumab group and three (1%) participants in the placebo group.

INTERPRETATION

The significant overall survival benefit of neoadjuvant pembrolizumab plus chemotherapy followed by adjuvant pembrolizumab compared with neoadjuvant chemotherapy alone coupled with a manageable safety profile support the use of perioperative pembrolizumab in patients with resectable, early-stage NSCLC.

FUNDING

Merck Sharp & Dohme, a subsidiary of Merck & Co, Rahway, NJ, USA.

The Surgical Renaissance: Advancements in Video-Assisted Thoracoscopic Surgery and Robotic-Assisted Thoracic Surgery and Their Impact on Patient Outcomes

Minimally invasive thoracic surgery has advanced the treatment of lung cancer since its introduction in the 1990s. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) offer the advantage of smaller incisions without compromising patient outcomes. These techniques have been shown to be safe and effective in standard pulmonary resections (lobectomy and sub-lobar resection) and in complex pulmonary resections (sleeve resection and pneumonectomy). Furthermore, several studies show these techniques enhance patient outcomes from early recovery to improved quality of life (QoL) and excellent oncologic results. The rise of RATS has yielded further operative benefits compared to thoracoscopic surgery. The wristed instruments, neutralization of tremor, dexterity, and magnification allow for more precise and delicate dissection of tissues and vessels. This review summarizes of the advancements in minimally invasive thoracic surgery and the positive impact on patient outcomes.

Contemporary Video-Assisted Thoracoscopic Lobectomy for Early-Stage Lung Cancer

The treatment of non-small cell lung cancer (NSCLC) has evolved tremendously in recent decades as innovations in medical therapies advanced concomitantly with minimally invasive surgical techniques. Despite early skepticism regarding its benefits, video-assisted thoracoscopic surgery (VATS) techniques for the surgical resection of early-stage NSCLC have now become the standard of care. After being the subject of many studies since its inception, VATS has been shown to cause less postoperative pain, have shorter recovery time, and have fewer overall complications when compared to conventional open approaches. Furthermore, some studies have shown it to have comparable oncological outcomes, though more higher evidence studies are needed. Newer technologies and improved surgical instruments, advancements in nodule localization techniques, and improved preoperative staging procedures have allowed for the development of newer, less invasive techniques such as uniportal VATS and parenchymal-sparing sublobar resections, which might further improve postoperative rates of complications in specific cases. These minimally invasive approaches have allowed surgeons to offer surgery to high-risk patients and those who would otherwise not tolerate conventional thoracotomy, though some relative contraindications still exist. This review aims to describe the evolution of VATS lobectomy, current techniques, its indications, contraindications, preoperative testing, benefits, and outcomes in patients with stage I and II NSCLC.

CT-guided percutaneous marking of small pulmonary nodules with [99mTc]Tc-Macrosalb is very accurate and allows minimally invasive lung-sparing resection: a single-centre quality control

PURPOSE

The detection of small lung nodules in thoracoscopic procedure is difficult when the lesions are not located within the outer border of the lung. In the case of ground-glass opacities, it is often impossible to palpate the lesion. Marking lung nodules using a radiotracer is a known technique. We analysed the accuracy and safety of the technique and the potential benefits of operating in a hybrid operating room.

METHODS

57 patients, including 33 (58%) females with a median age of 67 years (range 21-82) were included. In 27 patients, we marked and resected the lesion in a hybrid room. In 30 patients, the lesion was marked at the department of radiology the day before resection. [99mTc]Tc-Macrosalb (Pulmocis®) was used at an activity of 1 MBq in the hybrid room and at an activity of 3 MBq the day before to get technical feasible results. Radioactivity was detected using the Neoprobe® detection system.

RESULTS

Precise detection and resection of the nodules was possible in 95% of the lesions and in 93% of the patients. Complete thoracoscopic resection was possible in 90% of the patients. Total conversion rate was 10%, but conversion due to failure of the marking of the nodule was observed in only 5% of the patients. Histology revealed 28 (37%) primary lung cancers, 24 (32%) metastases and 21 (28%) benign lesions. In 13 (23%) patients, minor complications were observed. None of them required additional interventions.

CONCLUSION

The radio-guided detection of small pulmonary nodules is very accurate and safe after CT-guided injection of [99mTc]Tc-Macrosalb. Performing the operation in a hybrid room has several logistic advantages and allows using lower technetium-99m activities. The technique allows minimally invasive lung sparing resection and prevents overtreatment of benign and metastatic lesions.

Postoperative outcomes in patients with diabetes after enhanced recovery thoracoscopic lobectomy

BACKGROUND

Diabetes is considered a general surgical risk factor, but with few data from enhanced recovery (ERAS) otherwise known to improve outcome. Therefore, this study aimed to investigate postoperative outcomes of patients with diabetes who underwent video-assisted thoracoscopic surgery (VATS) lobectomy in an established ERAS setting.

METHODS

We retrospectively analysed outcome data (hospital stay (LOS), readmissions, and mortality) from a prospective database with consecutive unselected ERAS VATS lobectomies from 2012 to 2022. Complete follow-up was secured by the registration system in East Denmark.

RESULTS

We included 3164 patients of which 323 had diabetes, including 186 treated with insulin and antidiabetic medicine, 35 with insulin only and 102 with antidiabetic medicine only. The median LOS was 3 days, stable over the study period. There were no differences in terms of LOS, postoperative complications, readmissions or 30 days alive and out of hospital. Patients with diabetes had significantly higher 30- and 90-day mortality rates compared to those without diabetes (p < .001), but also had higher preoperative comorbidity. Preoperative HbA1c levels did not correlate with postoperative outcomes.

CONCLUSION

In an ERAS setting, diabetes may not increase the risk for prolonged LOS, complications, and readmissions after VATS lobectomy, however with higher 30- and 90-day mortality probably related to more preoperative comorbidities.

Outcomes of single- versus multi-port video-assisted thoracoscopic surgery: Data from a multicenter randomized controlled trial of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer

Objectives

Surgery through a single port may be less painful because access is supplied by 1 intercostal nerve or more painful because multiple instruments are used in 1 port. We analyzed data collected from the video-assisted thoracoscopic surgery group of a randomized controlled trial to compare differences in pain up to 1 year.

Methods

Groups were compared in a prespecified exploratory analysis using direct (regression) and indirect comparison (difference with respect to thoracotomy). In-hospital visual analogue scale pain scores were used, and analgesic ratios were calculated. After discharge, pain was evaluated using European Organization for Research and Treatment of Cancer Quality of Life Questionnaires-Core 30 scores up to 1 year.

Results

From July 2015 to February 2019, we randomized 503 participants. After excluding 50 participants who did not receive lobectomy, surgery was performed using a single port in 42 participants (predominately by a single surgeon), multiple ports in 166 participants, and thoracotomy in 245 participants. No differences were observed in-hospital between single- and multiple-port video-assisted thoracoscopic surgery when modeled using a direct comparison, mean difference of -0.24 (95% CI, -1.06 to 0.58) or indirect comparison, mean difference of -0.33 (-1.16 to 0.51). Mean analgesic ratio (single/multiple port) was 0.75 (0.64 to 0.87) for direct comparison and 0.90 (0.64 to 1.25) for indirect comparison. After discharge, pain for single-port video-assisted thoracoscopic surgery was lower than for multiple-port video-assisted thoracoscopic surgery (first 3 months), and corresponding physical function was higher up to 12 months.

Conclusions

There were no consistent differences for in-hospital pain when lobectomy was undertaken using 1 or multiple ports. However, better pain scores and physical function were observed for single-port surgery after discharge.

A scoping review of lung cancer surgery with curative intent: workup, fitness assessment, clinical outcomes

Lung cancer surgery with curative intent has significantly developed over recent years, mainly focusing on minimally invasive approaches that do not compromise medical efficiency and ensure a decreased burden on the patient. It is directly linked with an efficient multidisciplinary team that will perform appropriate pre-operative assessment. Caution is required in complex patients with several comorbidities to ensure a meaningful and informed thoracic surgery referral leading to optimal patient outcomes.

Lymph node dissection in lung cancer surgery

Lung cancer, a leading cause of cancer-related death, often requires surgical resection for early-stage cases, with recent data supporting less invasive resections for tumors smaller than 2 cm. Central to resection is lymph node assessment, an area of controversy worldwide, compounded by advances in minimally invasive techniques. The review aims to assess current standards for lymph node assessment, recent data from the surgical era, and the immunobiological basis of how lymph node metastases impact patient outcomes. The British Thoracic Society guidelines recommend systematic nodal dissection during lung cancer resection, without specifying node removal or sampling. Historical data on mediastinal lymph node dissection (MLND) survival benefits are inconclusive, although proponents argue for lower recurrence rates. Recent trials such as ACOSOG Z0030 found no survival difference between MLND and nodal sampling, reinforcing the need for robust staging. While lobe-specific dissection strategies have been proposed, they currently lack consensus. JCOG1413 aims to compare the clinical benefits of lobe-specific and systematic dissection. TNM-9 staging revisions emphasize the prognostic significance of single-station N2 involvement. Robotic surgery shows promise, with trials such as RAVAL, which reported comparable outcomes to video-assisted thoracic surgery (VATS) and improved lymph node sampling. Immunobiological insights suggest preserving key immunological sites during lymphadenectomy, especially for patients receiving adjuvant immunotherapy. In conclusion, the standard lymph node resection strategy remains unsettled. The debate between systematic and selective dissection continues, with implications for staging accuracy and patient outcomes. As minimally invasive techniques evolve, robotic surgery emerges as an effective and low-risk approach to delivering optimal lymph node assessment.

Readmission after enhanced recovery video-assisted thoracoscopic surgery wedge resection

BACKGROUND

Despite the implementation of Enhanced Recovery After Surgery (ERAS) programs, surgical stress continues to influence postoperative rehabilitation, including the period after discharge. However, there is a lack of data available beyond the point of discharge following video-assisted thoracoscopic surgery (VATS) wedge resection. Therefore, the objective of this study is to investigate incidence and risk factors for readmissions after ERAS VATS wedge resection.

METHODS

A retrospective analysis was performed on data from prospectively collected consecutive VATS wedge resections from June 2019 to June 2022. We evaluated main reasons related to wedge resection leading to 90-day readmission, early (occurring within 0-30 days postoperatively) and late readmission (occurring within 31-90 days postoperatively). To identify predictors for these readmissions, we utilized a logistic regression model for both univariable and multivariable analyses.

RESULTS

A total of 850 patients (non-small cell lung cancer 21.5%, metastasis 44.7%, benign 31.9%, and other lung cancers 1.9%) were included for the final analysis. Median length of stay was 1 day (IQR 1-2). During the postoperative 90 days, 86 patients (10.1%) were readmitted mostly due to pneumonia and pneumothorax. Among the cohort, 66 patients (7.8%) had early readmissions primarily due to pneumothorax and pneumonia, while 27 patients (3.2%) experienced late readmissions mainly due to pneumonia, with 7 (0.8%) patients experiencing both early and late readmissions. Multivariable analysis demonstrated that male gender, pulmonary complications, and neurological complications were associated with readmission.

CONCLUSIONS

Readmission after VATS wedge resection remains significant despite an optimal ERAS program, with pneumonia and pneumothorax as the dominant reasons. Early readmission was primarily associated with pneumothorax and pneumonia, while late readmission correlated mainly with pneumonia.

Intersurgeon variations in postoperative length of stay after video-assisted thoracoscopic surgery lobectomy

Objectives

To identify factors associated with prolonged postoperative length of stay (LOS) after VATS lobectomy (VATS-L), explore potential intersurgeon variation in LOS and ascertain whether or not early discharge influences hospital readmission rates.

Methods

We conducted a retrospective analysis of patients who underwent VATS-L at a single academic center between 2018 and 2021. Each VATS lobectomy procedure was performed by 1 of 7 experienced thoracic surgeons. The primary end point of interest was prolonged LOS, defined as an index LOS >3 days.

Results

Among 1006 patients who underwent VATS lobectomy, 632 (63%) had a prolonged LOS. On multivariate analysis, the factors independently associated with prolonged LOS were: surgeon (P < .001), patient age (odds ratio [OR], 1.03; 95% CI, 1.02-1.06), operation time (OR, 1.01; 95% CI, 1.01-1.01), postoperative complication (OR, 3.60; 95% CI, 2.45-5.29), and prolonged air leak (OR, 8.95; 95% CI, 4.17-19.23). There was no significant association between LOS and gender, body mass index, coronary artery disease, prior atrial fibrillation, American Society of Anesthesiologists score >3, and prior ipsilateral thoracic surgery or sternotomy. There was no association between LOS ≤3 days and hospital readmission (20 [5.3%] vs 39 [5.9%]; OR, 0.88; 95% CI, 0.50-1.53).

Conclusions

An intersurgeon variation in postoperative LOS after VATS-L exists and is independent of patient baseline characteristics or perioperative complications. This variation seems to be more closely related to differences in postoperative management and discharge practices rather than to surgical quality. Postoperative discharge within 3 days is safe and does not increase hospital readmissions.

Neoadjuvant nivolumab plus chemotherapy in resectable non-small-cell lung cancer in Japanese patients from CheckMate 816

In the open-label, phase III CheckMate 816 study (NCT02998528), neoadjuvant nivolumab plus chemotherapy demonstrated statistically significant improvements in event-free survival (EFS) and pathological complete response (pCR) versus chemotherapy alone in patients with resectable non-small-cell lung cancer (NSCLC). Here we report efficacy and safety outcomes in the Japanese subpopulation. Patients with stage IB-IIIA, resectable NSCLC were randomized 1:1 to nivolumab plus chemotherapy or chemotherapy alone for three cycles before undergoing definitive surgery within 6 weeks of completing neoadjuvant treatment. The primary end-points (EFS and pCR) and safety were assessed in patients enrolled at 16 centers in Japan. Of the Japanese patients randomized, 93.9% (31/33) in the nivolumab plus chemotherapy arm and 82.9% (29/35) in the chemotherapy arm underwent surgery. At 21.5 months' minimum follow-up, median EFS was 30.6 months (95% confidence interval [CI], 16.8-not reached [NR]) with nivolumab plus chemotherapy versus 19.6 months (95% CI, 8.5-NR) with chemotherapy; hazard ratio, 0.60 (95% CI, 0.30-1.24). The pCR rate was 30.3% (95% CI, 15.6-48.7) versus 5.7% (95% CI, 0.7-19.2), respectively; odds ratio, 7.17 (95% CI, 1.44-35.85). Grade 3/4 treatment-related adverse events were reported in 59.4% versus 42.9% of patients, respectively, with no new safety signals identified. Neoadjuvant nivolumab plus chemotherapy resulted in longer EFS and a higher pCR rate versus chemotherapy alone in Japanese patients, consistent with findings in the global population. These data support nivolumab plus chemotherapy as a neoadjuvant treatment option in Japanese patients with resectable NSCLC.

Energy devices versus electrocoagulation in video-assisted thoracoscopic lobectomy: a propensity-match cohort study

BACKGROUND

The aim of the study was to compare the effect on perioperative outcome of intraoperative use of different devices for tissue dissection (electrocoagulation [EC] or energy devices [ED]) in patients who underwent video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

METHODS

We retrospectively reviewed 191 consecutive patients who underwent VATS lobectomy, divided into two cohorts: ED (117 patients), and EC (74 patients); after propensity score matching, 148 patients were extracted, 74 for each cohort. The primary endpoints considered were complication rate and 30-day mortality rate. The secondary endpoints considered were length of stay (LOS) and the number of lymph nodes harvested.

RESULTS

The complication rate did not differ between the two cohorts (16.22% EC group, 19.66% ED group, P=0.549), before and after propensity matching (16.22% for both EC and ED group, P=1.000). The 30-day mortality rate was 1 in the overall population. Median LOS was 5 days for both groups, before and after propensity match, with the same interquartile range, (IQR: 4-8). ED group had a significantly higher median number of lymph nodes harvested (ED median: 18, IQR: 12-24; EC median: 10, IQR: 5-19; P=0.0002). The difference was confirmed after the propensity score matching (ED median: 17, IQR: 13-23; EC median: 10, IQR: 5-19; P=0.0008).

CONCLUSIONS

ED dissection during VATS lobectomy did not lead to different complication rates, mortality rates, and LOS compared to EC tissue dissection. ED use led to a significantly higher number of intraoperative lymph nodes harvested compared to EC use.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Impact of surgical approach on 90-day mortality after lung resection for nonsmall cell lung cancer in high-risk operable patients

Introduction

Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients.

Methods

We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients.

Results

Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02-0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30-0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively).

Conclusion

By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.

Modifications to the video-assisted thoracoscopic surgery technique reduce 1-year mortality and postoperative complications in intrathoracic tumors

OBJECTIVE

The purpose of the study is to analyze the immediate outcomes and results of video-assisted thoracoscopic lobectomy and lung resection performed in the surgical department of the AOC between 2014 and 2018.

METHODS

For the period from 2014 to 2018, 118 patients with peripheral lung cancer were operated on in the surgical department of the AOC. The following operations were performed: lobectomy in 92 cases (78%), of which: upper lobectomy, 44 (47.8%); average lobectomy, 13 (14.1%); lower lobectomy, 32 (35%); bilobectomy, 3 (3.3%). All patients underwent extensive lymphadenectomy on the side of the operation. In 22 patients, for various reasons, preservation of thoracotomy was performed.

RESULTS

The absence of N0 lymph node damage was observed in 82 patients (70%), the first-order lymph node damage N1 in 13 (11%), N2 in 13 (11%), N3 in 5 (4%), and NX in 5 (4%). Histological examination revealed: squamous cell carcinoma - 35.1%, adenocarcinoma - 28.5%, undifferentiated carcinoma - 8.3%, NSCLC - 5.6%, NEO - 4.6%, sarcoma - 1.8%. At the same time, in 12.7% of patients, mts was detected - lung damage, and in 3.4%, malignant cells were not detected. Most patients were activated on the first day after surgery.

CONCLUSION

An analysis of the direct results of the study allows us to conclude that video-assisted thoracoscopic surgery is a highly effective, minimally invasive, safe method for treating peripheral lung cancer, which allows us to recommend it for wider use in oncological practice.

Is underutilization of adjuvant therapy in resected non-small-cell lung cancer associated with socioeconomic disparities?

OBJECTIVES

Although adjuvant systemic therapy (AT) has demonstrated improved survival in patients with resected non-small-cell lung cancer (NSCLC), it remains underutilized. Recent trials demonstrating improved outcomes with adjuvant immunotherapy and targeted treatment imply that low uptake of systemic therapy in at-risk populations may widen existing outcome gaps. We, therefore, sought to determine factors associated with the underutilization of AT.

METHODS

The National Cancer Database (2010-2018) was queried for patients with completely resected stage II-IIIA NSCLC and stratified based on the receipt of AT. Logistic regression was used to identify factors associated with AT delivery. The Kaplan-Meier method was applied to estimate survival after propensity-matching to adjust for confounders.

RESULTS

Of 37 571 eligible patients, only 20 616 (54.9%) received AT. While AT rates increased over time, multivariable analysis showed that older age [adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.43-0.47], male sex (aOR 0.88, 95% CI 0.85-0.93) and multiple comorbidities (aOR 0.86, 95% CI: 0.81-0.91) were associated with decreased AT. Socioeconomic factors were additionally associated with underutilization, including public insurance (aOR 0.70, 95% CI: 0.66-0.74), lower education indicators (aOR 0.93, 95% CI: 0.88-0.97) and living more than 10 miles from a treatment facility (aOR 0.89, 95% CI: 0.85-0.93). After propensity matching, receipt of adjuvant therapy was associated with improved overall survival (median 76.35 vs 47.57 months, P ≤ 0.001).

CONCLUSIONS

AT underutilization in patients with resected stage II-III NSCLC is associated with patient, institutional and socioeconomic factors. It is critical to implement measures to address these inequities, especially in light of newer adjuvant immunotherapy and targeted therapy treatment options which are expected to improve survival.

Radicality and safety of mediastinal lymphadenectomy in lung resection: a comparative analysis of uniportal thoracoscopic, multiportal thoracoscopic, and thoracotomy approaches

BACKGROUND

Lung cancer poses a significant challenge with high mortality rates. Minimally invasive surgical approaches, including the uniportal thoracoscopic technique, offer potential benefits in terms of recovery and patient compliance. This study focuses on evaluating the radicality of mediastinal lymphadenectomy during uniportal thoracoscopic lung resection, specifically assessing the reachability of established lymphatic stations.

METHODS

A comparative study was conducted at the University Hospital Ostrava from January 2015 to July 2022, focusing on the evaluation of radicality in mediastinal lymphadenectomy across three patient subgroups: uniportal thoracoscopic approach, multiportal thoracoscopic approach, and thoracotomy approach. The study implemented the routine identification and excision of 8 lymph node stations from the respective hemithorax to assess the radicality of lymph node harvesting.

RESULTS

A total of 428 patients were enrolled and evaluated. No significant differences were observed in the number of lymph nodes removed between the subgroups. The mean number of lymph nodes removed was 6.50 in the left hemithorax and 6.49 in the right hemithorax. The 30-day postoperative morbidity rate for the entire patient population was 27.3%, with 17.5% experiencing minor complications and 6.5% experiencing major complications. Statistically significant differences were observed in major complications between the uniportal approach and the thoracotomy approach (3.5% vs 12.0%, p = 0.002). The overall mortality rate in the study population was 3%, with a statistically significant difference in mortality between the uniportal and multiportal approaches (1.0% vs 6.4%, p = 0.020).

CONCLUSIONS

The uniportal approach demonstrated comparable accessibility and lymph node yield to multiportal and thoracotomy techniques. It is equivalent to established methods in terms of postoperative complications, with fewer major complications compared to thoracotomy. While our study indicates a potential for lower mortality following uniportal lung resection in comparison to multiportal lung resection, and demonstrates comparable outcomes to thoracotomy, it is important to approach these findings cautiously and refrain from drawing definitive conclusions.

Determining the optimal time to report mortality after lobectomy for lung cancer: An analysis of the time-varying risk of death

Objective

Surgical mortality has traditionally been assessed at arbitrary intervals out to 1 year, without an agreed optimum time point. The aim of our study was to investigate the time-varying risk of death after lobectomy to determine the optimum period to evaluate surgical mortality rate after lobectomy for lung cancer.

Methods

We performed a retrospective study of patients undergoing lobectomy for lung cancer at our institution from 2015 to 2022. Parametric survival models were assessed and compared with a nonparametric kernel estimate. The hazard function was plotted over time according to the best-fit statistical distribution. The time points at which instantaneous hazard rate peaked and stabilized in the 1-year period after surgery were then determined.

Results

During the study period, 2284 patients underwent lobectomy for lung cancer. Cumulative mortality at 30, 90, and 180 days was 1.3%, 2.9%, and 4.9%, respectively. Log-logistic distribution showed the best fit compared with other statistical distribution, indicated by the lowest Akaike information criteria value. The instantaneous hazard rate was greatest during the immediate postoperative period (0.129; 95% confidence interval, 0.087-0.183) and diminishes rapidly within the first 30 days after surgery. Instantaneous hazard rate continued to decrease past 90 days and stabilized only at approximately 180 days.

Conclusions

In-hospital mortality is the optimal follow-up period that captures the early-phase hazard during the immediate postoperative period after lobectomy. Thirty-day mortality is not synonymous to "early mortality," as instantaneous hazard rate remains elevated well past the 90-day time point and only stabilizes at approximately 180 days after lobectomy.

Risk factors for loss of pulmonary function after wedge resection for peripheral ground-glass opacity dominant lung cancer

OBJECTIVES

This study aimed to identify the risk factors for pulmonary functional deterioration after wedge resection for early-stage lung cancer with ground-glass opacity, which remain unclear, particularly in low-risk patients.

METHODS

We analysed 237 patients who underwent wedge resection for peripheral early-stage lung cancer in JCOG0804/WJOG4507L, a phase III, single-arm confirmatory trial. The changes in forced expiratory volume in 1 s were calculated pre- and postoperatively, and a cutoff value of -10%, the previously reported reduction rate after lobectomy, was used to divide the patients into 2 groups: the severely reduced group (≤-10%) and normal group (>-10%). These groups were compared to identify predictors for severe reduction.

RESULTS

Thirty-seven (16%) patients experienced severe reduction. Lesions with a total tumour size ≥1 cm were significantly more frequent in the severely reduced group than in the normal group (89.2% vs 71.5%; P = 0.024). A total tumour size of ≥1 cm [odds ratio (OR), 3.287; 95% confidence interval (CI), 1.114-9.699: P = 0.031] and pleural indentation (OR, 2.474; 95% CI, 1.039-5.890: P = 0.041) were significant predictive factors in the univariable analysis. In the multivariable analysis, pleural indentation (OR, 2.667; 95% CI, 1.082-6.574; P = 0.033) was an independent predictive factor, whereas smoking status and total tumour size were marginally significant.

CONCLUSIONS

Of the low-risk patients who underwent pulmonary wedge resection for early-stage lung cancer, 16% experienced severe reduction in pulmonary function. Pleural indentation may be a risk factor for severely reduced pulmonary function in pulmonary wedge resection.

Are chest drains routinely required after thoracic surgery? A drainology study of on-table chest-drain removals

Objectives

Advances in perioperative management for thoracic surgery have accelerated the postoperative recovery of patients by decreasing postoperative pain and the incidence of complications. We aimed to study whether it's safe to remove chest drains on table in selected cases.

Methods

This was a 5-year retrospective analysis of protocolized chest-drain removal on the operating table. The chest drain was removed in patients undergoing sublobar/wedge lung resection and other minor thoracic procedure (pleural biopsy, mediastinal mass biopsy/resection) via a thoracoscopic approach (video-assisted thoracoscopic surgery). Chest drains were removed at the end of the operation if air leak as documented by the digital drain was less than 20 mL/min. Outcome data on postdrain removal pneumothorax, effusion, and need for further intervention were obtained by reviewing the postoperative chest films, all reported by a radiologist.

Results

Between 2016 and 2021, 107 patients underwent drain removal in theater. Mean age (standard deviation) was 58 (17) years and 54 (50.5%) were male. Postdrain removal pneumothorax occurred in 22 patients (21%), pleural effusion in 6 (5.6%), and 21 of 22 postoperative pneumothoraces were managed conservatively without reinsertion of chest drain. As it is our standard policy to leave no pneumothorax in patients undergoing surgical management of primary spontaneous pneumothorax, only 1 such patient (0.9%) had a drain reinserted as a result. The median (interquartile) length of hospital stay was 1 day (1-2), and 14 patients (13%) were discharged on surgery day.

Conclusions

Our results demonstrate that on table chest-drain removal in selected cases is safe and repeatable using a digital drain, challenging the practice of routine drain insertion after thoracic surgery.

Pulmonary Lobectomy for Early-Stage Lung Cancer with Uniportal versus Three-Portal Video-Assisted Thoracic Surgery: Results from a Single-Centre Randomized Clinical Trial

Video-assisted thoracic surgery (VATS) is a consolidated approach; however, there is no consensus on the number of ports leading to less postoperative pain. We compared early postoperative pain after uniportal and three-portal VATS lobectomy for early-stage NSCLC. In this randomized clinical trial, patients undergoing VATS lobectomy were randomly assigned to receive uniportal (U-VATS Group) or three-portal (T-VATS Group) VATS. The inclusion criteria were age ≤ 80 years and ASA < 4. The exclusion criteria were clinical T3, previous thoracic surgery, induction therapy, chest radiotherapy, connective tissue or vascular diseases, major organ failure, and analgesics or corticosteroids use. The postoperative analgesia protocol was based on NRS. Pain was measured as analgesic consumption; the secondary endpoints were intra- and postoperative complications, conversion rate, surgical time, dissected lymph nodes, hospital stay, and respiratory function. Out of 302 eligible patients, 120 were included; demographics were distributed homogeneously. The mean cumulative morphine consumption (CMC) in the U-VATS Group after 7 days was lower than in the T-VATS Group (77.4 mg vs. 90.1 mg, p = 0.003). Intraoperative variables and postoperative complications were comparable. The 30-day intercostal neuralgia rate was lower in the U-VATS Group, without reaching statistical significance. Patients undergoing U-VATS showed a lower analgesic consumption compared with the T-VATS Group; analgesic consumption was moderate in both groups.

Days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in the era of enhanced recovery

BACKGROUND

Days alive and out of hospital is proposed as a valid and patient-centred quality measure for perioperative care. However, no procedure-specific data exist after pulmonary wedge resection. The aim of this study was to assess the first 90 days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in an optimized enhanced recovery programme.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients undergoing enhanced recovery thoracoscopic wedge resections from January 2021 to June 2022 in a high-volume centre was carried out. All factors leading to hospitalization, readmission, and death were evaluated individually. A logistic regression model was used to evaluate predictors. Additionally, a sensitivity analysis was performed.

RESULTS

A total of 433 patients were included (21.7% (n = 94) with non-small cell lung cancer, 47.6% (n = 206) with metastasis, 26.8% (n = 116) with benign nodules, and 3.9% (n = 17) with other lung cancers). The median duration of hospital stay was 1 day. The median of postoperative 30 and 90 days alive and out of hospital was 28 and 88 days respectively. Air leak (112 patients) and pain (96 patients) were the most frequent reasons for reduced days alive and out of hospital from postoperative day 1 to 30, whereas treatment of the original cancer or metastasis (36 patients) was the most frequent reason for reduced days alive and out of hospital from postoperative day 31 to 90. Male sex, reduced lung function, longer dimension of resection margin, pleural adhesions, and non-small cell lung cancer were independent risks, confirmed by a sensitivity analysis.

CONCLUSION

Days alive and out of hospital within 90 days after enhanced recovery thoracoscopic wedge resection was only reduced by a median of 2 days, mainly due to air leak and pain.

Surgical site wound infection and wound pain after video-assisted thoracoscopy in patients with lung cancer: A meta-analysis

A meta-analysis was performed to comprehensively assess the effects of video-assisted thoracoscopy on surgical site wound infection and wound pain in patients with lung cancer. Studies on video-assisted thoracoscopy for lung cancer were collected from PubMed, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and Wanfang database, from inception to January 2023. Two researchers independently screened the literature, extracted the data, and evaluated the quality of the included studies according to the inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.4 software. Thirty-one articles with a total of 3608 patients were included, with 1809 in the video-assisted thoracoscopy group and 1799 in the control group. Compared with the control group, video-assisted thoracoscopy significantly reduced surgical site wound infection (odds ratio: 0.22, 95% confidence interval [CI]: 0.14-0.33, P < .001) and surgical site wound pain at postoperative day 1 (standardised mean difference [SMD]: -0.90, 95% CI: -1.17 to -0.64, P < .001) and postoperative day 3 (SMD: -1.59, 95% CI: -2.25 to -0.92, P < .001). Thus, these results showed that video-assisted thoracoscopy may have beneficial outcomes by reducing surgical site wound infection and pain. However, owing to the large variation in sample sizes and some methodological shortcomings, further validation is needed in future studies with higher quality and larger sample sizes.

Long-Term Oncologic Outcomes in Robot-Assisted and Video-Assisted Lobectomies for Non-Small Cell Lung Cancer

This study compares long-term outcomes in patients undergoing video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) lobectomy for non-small cell lung cancer (NSCLC); all consecutive patients who underwent RATS or VATS lobectomy for NSCLC between July 2015 and December 2021 in our center were enrolled in a single-center prospective study. The primary outcomes were overall survival (OS), disease-free survival (DFS), and recurrence rate. The secondary outcomes were complication rate, length of hospitalization (LOS), duration of chest tubes (LOD), and number of lymph node stations harvested. A total of 619 patients treated with RATS (n = 403) or VATS (n = 216) were included in the study. There was no significant difference in OS between the RATS and VATS groups (3-year OS: 75.9% vs. 82.3%; 5-year OS: 70.5% vs. 68.5%; p = 0.637). There was a statistically significant difference in DFS between the RATS and VATS groups (3-year DFS: 92.4% vs. 81.2%; 5-year DFS: 90.3% vs. 77.6%; p < 0.001). Subgroup analysis according to the pathological stage also demonstrated a significant difference between RATS and VATS groups in DFS in stage I (3-year DFS: 94.4% vs. 88.9%; 5-year DFS: 91.8% vs. 85.2%; p = 0.037) and stage III disease (3-year DFS: 82.4% vs. 51.1%; 5-year DFS: 82.4% vs. 37.7%; p = 0.024). Moreover, in multivariable Cox regression analysis, the surgical approach was significantly associated with DFS, with an HR of 0.46 (95% CI 0.27-0.78, p = 0.004) for RATS compared to VATS. VATS lobectomy was associated with a significantly higher recurrence rate compared to RATS (21.8% vs. 6.2%; p < 0.001). LOS and LOD, as well as complication rate and in-hospital and 30-day mortality, were similar among the groups. RATS lobectomy was associated with a higher number of lymph node stations harvested compared to VATS (7 [IQR:2] vs. 5 [IQR:2]; p < 0.001). In conclusion, in our series, RATS lobectomy for lung cancer led to a significantly higher DFS and significantly lower recurrence rate compared to the VATS approach. RATS may allow more extensive nodal dissection, and this could translate into reduced recurrence.