A single-arm study of sublobar resection for ground-glass opacity dominant peripheral lung cancer

VATS right apical segmentectomy for lung cancer in a patient with tracheal bronchus

INTRODUCTION

A tracheal bronchus is rarely observed, occurring in only 1% of all patients who undergo thoracic surgeries. We rarely encounter lung cancer in a patient with a tracheal bronchus; however, it is essential to know the distinctive perioperative management strategy for patients with a tracheal bronchus.

CASE PRESENTATION

We report a 72-year-old man with lung cancer located in the right apical segment supplied by a tracheal bronchus. Annual chest computed tomography performed as follow-up after colon cancer resection showed an enlarging pulmonary nodule with pure ground-glass opacity, which was suspected to be lung adenocarcinoma. The nodule was located in the right apical segment. The apical segment was independently supplied by a single pulmonary artery superior trunk and a tracheal bronchus that branched directly from the trachea at 1.2 cm above the carina. The pulmonary vein branching pattern was uncommon in that the central vein that usually runs through B2 (posterior bronchus) and B3 (anterior bronchus) was missing. The patient underwent video-assisted thoracoscopic apical segmentectomy under one-lung ventilation using a left-sided double-lumen tube.

DISCUSSION

Anomalous venous return accompanied with tracheal bronchus has been described in some reports. Since pulmonary vein is important during segmentectomy, the surgeon should pay particular attention to the venous return.

CONCLUSION

Preoperative three-dimensional graphic imagery helped us accurately identify the anatomical anomaly to enable the successful segmentectomy in a patient with a tracheal bronchus. We review the relevant literature regarding the perioperative management of patients with a tracheal bronchus.

Comparison of Perioperative Outcomes Between Precise and Routine Segmentectomy for Patients With Early-Stage Lung Cancer Presenting as Ground-Glass Opacities: A Propensity Score-Matched Study

Introduction

Segmentectomy is widely used for early-stage lung cancer presenting as single or multiple ground-glass opacities (GGOs). Precise segmentectomy is the recommended procedure in China. However, clinically, most routine segmentectomies are performed using only high-resolution computed tomography (CT). The aim of this study was to evaluate the effect of two segmentectomy approaches for GGOs in the lung.

Methods

From January 2020 to September 2020, 55 precise segmentectomies performed with real-time guidance using 3D reconstruction and 343 routine segmentectomies for patients with single or multiple GGOs were performed as uniportal procedures. To reduce bias related to outcomes, preoperative clinical factors were used for propensity score matching (1:1); 55 precision and 55 routine segmentectomies were selected and further analyzed. Perioperative outcomes, namely operation time, blood loss, resection margins, number of removed lymph nodes, postoperative pulmonary function (1 month after surgery), length of postoperative stay, and postoperative complications were compared between the two groups.

Results

Patients constituted 43 men and 67 women, with an age range of 25–68 years (median: 53 years). No significant differences were seen between the groups regarding blood loss, complications, histological type, and postoperative pulmonary function, and there were no 30-day postoperative deaths in either group. The median operation time for the Precision group (74 min) was longer than in the Routine group (55 min) (p <0.01), and the number of removed lymph nodes in the Precision group (5 ± 1.1) was higher than in the Routine group (3 ± 0.8) (p <0.01). Chest tube duration days and postoperative stay days were similar in both groups; however, the rate of air leakage on postoperative day 1 was higher in the Precision group (p = 0.020). All patients in the Precision group had adequate resection margins. Four patients (7.3%) undergoing complex segmentectomy in the Routine group had inadequate resection margins and required resection of additional lung tissue.

Conclusion

Routine segmentectomy can significantly shorten the operation time and might prevent postoperative air leakage in uniportal segmentectomy for lung GGOs. However, precision segmentectomy may be more precise for complex cases, ensuring adequate resection margins and lymph node dissection.

Transition of Treatment for Ground Glass Opacity-Dominant Non-Small Cell Lung Cancer

Lobectomy has been the standard surgical treatment for non-small cell lung cancer (NSCLC). Over the decades, with the dramatic development of radiographic tools, such as high-resolution computed tomography (HRCT), and the widespread practice of low-dose helical CT for screening, the number of cases diagnosed with small-cell lung cancers with ground glass opacity (GGO) at early stages has been increasing. Accordingly, mainly after 2000, many retrospective studies and prospective trials have shown that patients with lung adenocarcinoma with GGO have a good prognosis and may be candidates for sublobar resection. Previous studies indicated that HRCT findings including the maximum diameter of the tumor, GGO ratio, and a consolidation/tumor ratio (CTR) are simple and useful tools to predict tumor invasiveness and prognosis in patients with NSCLC with GGO. Thus, sublobar resection may be considered a “standard therapy” for peripheral GGO-dominant small-cell lung adenocarcinomas. Ultimately, some of such tumors might not require surgical resection. A multicenter, prospective study has just begun in Japan to evaluate the validity of follow-up for small-sized GGO-dominant small-cell lung cancer. Lung cancers that do not require surgery should be identified. This study reviewed retrospective and prospective studies on GGO tumors and discussed the treatment strategies for such tumors.

Watershed analysis of the target pulmonary artery for real-time localization of non-palpable pulmonary nodules

Background

Some pulmonary nodules are not suitable for computed tomography-guided percutaneous localization. This study aimed to investigate the feasibility and safety of real-time localization for these non-palpable pulmonary nodules using watershed analysis of the target pulmonary artery during thoracoscopic wedge resection.

Methods

Watershed analysis is a novel technique that can be used to create a specific area on the lung surface for nodule localization. This analysis is performed by temporarily blocking the target pulmonary artery and using indocyanine green fluorescence during surgery. In our study, the surgery was simulated and evaluated preoperatively using a high-precision three-dimensional reconstruction model obtained by multidetector spiral computed tomography. The lung was observed using an infrared thoracoscopy system after an intravenous injection of indocyanine green (2.5 mg/mL), and the white-to-blue transitional zone was marked using electrocautery, after which a wedge resection was performed.

Results

A total of 25 out of 26 patients underwent successful wedge resection. The mean tumor size and depth based on computed tomography scans were 13.2±6.4 and 12.2±7.8 mm, respectively. The mean operation duration was 142.6±52.8 min. The mean bleeding volume during surgery was 12.9±9.7 mL. The mean drainage tube indwelling time was 35.6±20.0 h, and the median length of postoperative stay was 3 days (range, 2-6 days).

Conclusions

Our experience showed that the watershed analysis of the target pulmonary artery for nodule localization was safe and feasible. It may become an effective and attractive alternative method for localizing non-palpable pulmonary nodules in selected patients undergoing thoracoscopic wedge resection.

Association between number of dissected lymph nodes and survival in stage IA non-small cell lung cancer: a propensity score matching analysis

BACKGROUND

For patients with stage IA non-small cell lung cancer (NSCLC) with tumor size ≤ 2 cm, the prognostic significance of the number of removed lymph nodes (NLNs) through different surgical methods remains unclear. To determine the association of NLNs with cancer-specific survival (CSS) and overall survival (OS) in patients with stage IA NSCLC with tumor size ≤ 2 cm who underwent different lung surgeries.

METHODS

We retrospectively enrolled 7293 patients from the Surveillance, Epidemiology and End Results database. Median NLNs was used to classify the patients into two groups: group A with NLNs ≤ 5 and group B with NLNs > 5. Propensity score matching (PSM) was performed to decrease selection bias. Kaplan-Meier analysis and Cox regression analysis were performed to identify the association between NLNs and survival outcomes.

RESULTS

Group B had better survival than group A in the unmatched cohort and matched cohort (all P < 0.05). Multivariable analyses revealed that the NLNs significantly affected CSS and OS of eligible cases in the unmatched cohort and matched cohort. Additionally, we found that the NLNs was a protective prognostic predictor of OS for patients who underwent wedge resection, segmental resection, or lobectomy.

CONCLUSION

The NLNs was a protective prognostic factor in NSCLC patients with tumor size ≤ 2 cm. We demonstrated that patients with > 5 NLNs in the cohort of wedge resection, segmental resection, or lobectomy exhibited a significantly better OS.