Anatomic segmentectomy for the solitary pulmonary nodule and early-stage lung cancer

Impacts of Positive Margins and Surgical Extent on Outcomes After Early-Stage Lung Cancer Resection

BACKGROUND

Sublobar resection of early-stage non-small cell lung cancer (NSCLC) is increasingly considered appropriate but may compromise margins compared with lobectomy. This study evaluated resection extent, margin status, and survival in patients with clinical stage I NSCLC.

METHODS

Patients with clinical T1-2 N0 M0 NSCLC in the National Cancer Database (2006-2020) who were treated with primary surgery were compared stratified by margin status. The potential benefit of radiation was explored in subgroup analysis of patients who underwent sublobar resection with positive margins.

RESULTS

Positive margins occurred in 5089 (2.8%) of 181,824 patients and were more common in sublobar resections compared with lobectomy (4.3% vs 2.4%; P < .001). Sublobar resection had the strongest association with positive margins in multivariable analysis (odds ratio, 2.06; 95% CI, 1.91-2.23; P < .001). Patients with positive margins were more likely to undergo both adjuvant chemotherapy (16% vs 13%; P < .001) and radiation (17% vs 1%; P < .001) but had worse survival in univariate analysis (44.0% 5-year overall survival vs 69.2%; P < .001) and multivariable Cox analysis (hazard ratio, 1.71; 95% CI, 1.63-1.78; P < .001) in the entire cohort, as well as in a univariate subset analysis of lobectomy (46.9% vs 70.4%; P < .001) and sublobar resection (37.5% vs 64.1%; P < .001). Postoperative radiation for patients who underwent sublobar resection with positive margins did not improve 5-year overall survival (36.3% for irradiated patients vs 38.3% for nonirradiated patients; P = .57), and patients who underwent sublobar resection with positive margins who were treated with radiation had survival inferior to that of patients who underwent lobectomy with negative margins.

CONCLUSIONS

Positive margins occur more frequently after sublobar resection of clinical stage I NSCLC compared with lobectomy. Patients with positive margins have worse survival than patients who undergo complete resection and are not rescued by postoperative radiation.

Comparison of lobectomy and sublobar resection for stage I non-small cell lung cancer: a meta-analysis based on randomized controlled trials

Background

This meta-analysis aimed to compare the prognostic between lobectomy and sublobar resection in patients with stage I non-small cell lung cancer (NSCLC).

Methods

We conducted a detailed search in PubMed, Embase, Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) comparing the prognosis of lobectomy and sublobar resection for stage I NSCLC, with the primary outcomes being overall survival (OS) and disease-free survival (DFS).

Results

A total of 2222 patients were included in the 5 RCTs. The results showed no statistical difference in OS (HR=0.87, p=0.445) and DFS (HR=0.99, p=0.918) between patients who underwent lobectomy and sublobar resection during the total follow-up period. In terms of dichotomous variables, there were no statistical differences in OS (relative ratio [RR]=1.05, p=0.848) and DFS (RR=1.21, p=0.075) between the two groups during the total follow-up period, as well as 5-year OS (RR=0.96, p=0.409) and 5-year DFS (RR=0.95, p=0.270). In addition, subgroup analysis showed a better prognosis for non-adenocarcinoma patients with sublobar resection than lobectomy (HR=0.53, p=0.037), but also an increased cause of cancer death (not limited to lung cancer) (RR=1.56, p=0.004).

Conclusion

Our results showed that for stage I NSCLC, lobectomy is usually not a justified operation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023407301, identifier CRD42023407301.

Buccal mucosal application of dissolvable microneedle patch containing photosensitizer provides effective localized delivery and phototherapy against oral carcinoma

The effectiveness of phototherapy using photosensitizers is limited by the challenges in their delivery at the site of irradiation. Here, we demonstrate the localized application of a photosensitizer-loaded microneedle patch for effective photodynamic and photothermal therapy in oral carcinoma. Indocyanine green (ICG) was studied as a photosensitizer for its effect on oral carcinoma, FaDu cells. Different parameters including concentration, near-infrared (NIR) laser irradiation intensity and irradiation time were optimized while measuring temperature increase and reactive oxygen species (ROS) generation in FaDu cells. A dissolvable microneedle (DMN) patch made of sodium carboxymethyl cellulose and sodium alginate was fabricated by the micromolding technique. DMN showed sufficient mechanical strength for insertion in the excised porcine buccal mucosa. DMN dissolved within 30 s in phosphate buffer and 30 min in the excised buccal mucosa. Confocal microscopy studies revealed DMN penetration up to a depth of 300 µm within the buccal mucosa. ICG-DMN applied on the back of the rat was found to be localized at the application site before and after irradiation using an 808 nm NIR laser. ICG-DMN was applied on the FaDu xenografted tumor model in athymic nude mice. The localized temperature increase and ROS generation significantly (P<0.05) decreased the tumor volume after ICG-DMN application compared with the control group. In conclusion, DMN can be developed for the localized administration of photosensitizers for phototherapy in oral carcinoma.

Sublobar Resection for Early-Stage Lung Cancer: An Oncologically Valid Procedure?

In the era of minimally invasive surgery, the role of sublobar resection comprising anatomical segmentectomy and wide wedge excision remains controversial [...]

Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review

Background

Pulmonary surgery is an innovative discipline with increasing demands for minimally invasive techniques in complicated anatomical resections, warranting adequate preoperative imaging of relevant surgical anatomy to ensure safe and radical resection of target lesions. Over the recent years, the emergence of imaging techniques enabling three-dimensional reconstruction has exerted promising influence on pulmonary surgery, facilitating optimal surgical planning and easier identification of the spatial relationship between bronchovascular structures in the individual patient and aiding the safe resection of target pulmonary lesions. The goal of this mini-review is to provide an overview of three-dimensional computed tomography imaging within pulmonary surgery.

Methods

The authors performed a targeted qualitative review of the literature to identify current trends and to provide better understanding of three-dimensional reconstruction within the boundaries of pulmonary surgery.

Results

Three-dimensional reconstructive techniques can be used for resectability assessment, identification of surgically relevant interindividual anatomic variance and may improve perioperative outcomes.

Discussion

Three-dimensional reconstruction using computed tomography imaging improves surgical planning and there is evidence that it results in shorter operative times, less intraoperative blood loss and lower rates of surgical conversion, as it can be applied both pre- and intraoperatively.

Division of the intersegmental demarcation using the "modified hand-tearing method" is safe and feasible in thoracoscopic anatomical segmentectomy

BACKGROUND

The accurate and safe division of the intersegmental demarcation (ISD) is critical and challenging during thoracoscopic anatomical segmentectomy. Here, we provide an improved technique which emphasizes the application of an electric hook and blunt division of ISD. The technique is termed as the "modified hand-tearing method" (MHT method) with combined application of an electric hook and staplers. The study aimed to review the outcomes of patients who underwent thoracoscopic anatomical segmentectomy, with or without the MHT method in our institute and assess its feasibility and safety. In addition, we compared the feasibility between video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) using the MHT method.

METHODS

From 2018 July to 2021 June, we retrospectively analyzed 701 patients who underwent segmentectomy. Using propensity score matching, data of two well-matched pairs of 276 cases in the MHT method and non-MHT method groups, and two well-matched pairs of 40 cases in the VATS and RATS subgroups were obtained. The clinical and perioperative characteristics of patients were compared between groups.

RESULTS

Compared with the non-MHT method group, the MHT method group had shorter operation time and shorter postoperative hospital stay. Period of chest tube drainage and postoperative total drainage and postoperative complications had no between-group difference. Compared with VATS, the RATS subgroup had less intraoperative bleeding and shorter postoperative hospital stay.

CONCLUSION

Division of ISD using the MHT method has advantages in precision and ease of operation, so it has the potential to become a feasible and effective method for thoracoscopic anatomical segmentectomy.

Near-infrared fluorescence guided surgery: State of the evidence from a health technology assessment perspective

Different applications of near-infrared fluorescence-guided surgery are very promising, and techniques that help surgeons in intraoperative guidance have been developed, thereby bridging the gap between preoperative imaging and intraoperative visualization and palpation. Thus, these techniques are advantageous in terms of being faster, safer, less invasive, and cheaper. There are a few fluorescent dyes available, but the most commonly used dye is indocyanine green. It can be used in its natural form, but different nanocapsulated and targeted modifications are possible, making this dye more stable and specific. A new active tumor-targeting strategy is the conjugation of indocyanine green nanoparticles with antibodies, making this dye targeted and highly selective to various tumor proteins. In this mini-review, we discuss the application of near-infrared fluorescence-guided techniques in thoracic surgery. During lung surgery, it can help find small, non-palpable, or additional tumor nodules, it is also useful for finding the sentinel lymph node and identifying the proper intersegmental plane for segmentectomies. Furthermore, it can help visualize the thoracic duct, smaller bullae of the lung, phrenic nerve, or pleural nodules. We summarize current applications and provide a framework for future applications and development.

Bibliometric Analysis of 50 Most Cited Articles Comparing Lobectomy with Sublobar Resection

BACKGROUND

 Recent years have seen an increase in the number of studies of the sublobar resection approach in non-small cell lung cancer (NSCLC) surgery. The purpose of this bibliometric analysis is to assess the significance and impact of articles comparing sublobar resection and lobectomy in NSCLC surgery.

MATERIAL AND METHODS

 The Web of Science database was searched to identify studies comparing sublobar resection and lobectomy in NSCLC surgery published between 2005 and 2020 (accessed: September 11, 2020). The 50 most cited articles were analyzed by years, countries, authors, authors' affiliations, journals, journals' addresses, and impact factors.

RESULTS

 The bibliometric analysis revealed that the most cited article had 443 citations, while the total number of citations of all articles was 2,820. The mean number of citations, in turn, was 56.4 ± 75.62 (1-443) times. The highest number of publications over the past 15 years was in 2016, with eight articles. The Annals of Thoracic Surgery (n = 10; 20%) had the highest number of publications on the list. The articles included in the present study were mostly (n = 35, 70%) published in U.S. journals. While multiple subject matters and analyses were presented by many studies, survival was the topic of greatest interest, with 37 (74%) studies.

CONCLUSION

 This study revealed that interest in studies comparing sublobar resection with lobectomy has increased in recent years. It also presents both quantitative and qualitative analyses of the most cited articles in the literature on this topic. Therefore, it can serve as a guide for researchers.

Long-Term Outcomes in Stage I Lung Cancer After Segmentectomy with a Close Resection Margin

Background

In general, a 2-cm surgical margin is recommended for limited resection to obtain equivalent oncologic outcomes to lobectomy for lung cancer. This study aimed to examine the patterns of recurrence and prognostic factors for recurrence in patients with a close parenchymal resection margin.

Methods

From January 2009 to April 2017, 156 patients with stage I lung cancer who underwent segmentectomy with a close resection margin (<2 cm) were enrolled. Recurrence-free survival and overall survival were assessed. In addition, predisposing factors for recurrence were evaluated.

Results

The mean tumor size was 1.7±0.8 cm and the parenchymal resection margin was 1.1±0.6 cm. Recurrence developed in 17 (10.7%) of the 156 patients, and the 5-year recurrence-free survival rate was 88.9%. Distant metastasis (7.7%) was the predominant recurrence pattern. The isolated local recurrence rate was 1.9%. Multivariate Cox regression analysis revealed that age, tumor size, mediastinal lymph node dissection, postoperative complications, and histologic type were significant predisposing factors for recurrence. However, parenchymal margin distance did not significantly affect the long-term prognosis.

Conclusion

Segmentectomy with a close resection margin for early-stage lung cancer in selected patients resulted in acceptable recurrence and survival. However, patients with tumors larger than 2 cm, squamous cell carcinoma histology, and insufficient mediastinal evaluation should be carefully followed up for recurrence.

Three-Dimensional Computed Tomography Bronchography and Angiography-Guided Thoracoscopic Segmentectomy for Pulmonary Nodules

BACKGROUND

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) provides detailed imaging information for pulmonary segmentectomy. This study was performed to verify the feasibility of 3D-CTBA-guided thoracoscopic segmentectomy for the treatment of pulmonary nodules.

METHODS

A retrospective analysis was performed on all patients who underwent 3D-CTBA-guided uniport thoracoscopic segmentectomies or subsegmentectomies for pulmonary nodules in the period from May 2019 to May 2020. All of the information related to perioperative management and surgical operations was retrieved from the medical records and operating notes for detailed analysis.

RESULTS

A total of 104 eligible operations involving the resection of 110 nodules with diameters in the range of 5-20 mm were included. Under 3D-CTBA guidance, the pulmonary nodules were located with an accuracy of 100% (110/110) and the median resection margin was 24.3 mm (17-33 mm). Additionally, the segmental (subsegmental) bronchi, arteries, and veins were identified with accuracy rates of 100% (104/104), 96.2% (100/104), and 94.2% (98/104), respectively. The postoperative complications consisted of 3 cases of pulmonary infection (2.9%), 6 cases of arrhythmia (5.8%), 2 cases of hemoptysis (1.9%), 4 cases of air leak (3.8%), and 2 cases of subcutaneous emphysema (1.9%). No perioperative death occurred.

CONCLUSION

3D-CTBA-guided thoracoscopic segmentectomy is an effective surgical approach for the management of pulmonary nodules.

Virtual randomized study comparing lobectomy and particle beam therapy for clinical stage IA non-small cell lung cancer in operable patients

To the best of our knowledge there have been no randomized controlled trials comparing lobectomy-a standard treatment for patients with early-stage non-small cell lung cancer (NSCLC)-and particle beam therapy (PBT), the best performing existing radiotherapy. We conducted a virtual randomized trial in medically operable patients with stage IA NSCLC to compare lobectomy and PBT effectiveness. A Markov model was developed to predict life expectancy after lobectomy and PBT in a cohort of patients with stage IA NSCLC. Ten thousand virtual patients were randomly assigned to each group. Sensitivity analyses were performed as model variables and scenarios changed to determine which treatment strategy was best for improving life expectancy. All estimated model parameters were determined using variables extracted from a systematic literature review of previously published articles. The preferred strategy differed depending on patient age. In young patients, lobectomy showed better life expectancy than that of PBT. The difference in life expectancy between lobectomy and PBT was statistically insignificant in older patients. Our model predicted lobectomy as the preferred strategy when operative mortality was under 5%. However, the preferred strategy changed to PBT if operative mortality post lobectomy was over 5%. For medically operable patients with stage IA NSCLC, our Markov model revealed the preferred strategy of lobectomy or PBT regarding operative mortality changed with varying age and comorbidity. Until randomized controlled trial results become available, we hope the current results will provide a rationale background for clinicians to decide treatment modalities for patients with stage IA NSCLC.

The postoperative chest in lung cancer

Most of the complications following lung cancer surgery occur in the early postoperative period and can result in significant morbidity and mortality. Delayed complications can also occur. Diagnosing these complications can be challenging because clinical manifestations are non-specific. Imaging plays an important role in detecting these complications in a timely manner and facilitates prompt interventions. Hence, it is important to have knowledge of the expected anatomical alterations following lung cancer surgeries, and the spectrum of post-surgical complications and their respective imaging findings to avoid misinterpretations or delay in diagnosis.

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.

Optimal Surgery Type and Adjuvant Therapy for T1N0M0 Lung Large Cell Neuroendocrine Carcinoma

Background

The appropriate treatment strategy for T1N0M0 lung large cell neuroendocrine carcinoma (LCNEC) was not well illustrated. We evaluated the efficacy of different surgery types and adjuvant therapy on patients with T1N0M0 LCNEC.

Methods

Patients diagnosed T1N0M0 LCNEC from 2004 to 2016 were identified in the surveillance, epidemiology, and end results (SEER) database. Clinical characteristics, treatment and survival data were collected. The efficacy of surgery type and adjuvant therapy stratified by tumor size was assessed. Overall survival(OS) was evaluated by the Kaplan-Meier method, and relevant survival variables were identified by the Cox proportional hazard model.

Results

From 2004 to 2016, 425 patients were included in this study, 253 (59.5%) patients received lobectomy, and 236 (55.5%) patients had 4 or more lymph nodes removed. Patients received lobectomy had better survival than those received sublobar resection(P=0.000). No matter tumor size less than 2 cm or 2 to 3 cm, lobectomy was significantly prolonged survival. Compared with no lymph nodes removed, lymph nodes dissection was associated with more remarkable OS(P<0.000). 4 or more regional lymph nodes dissection predicted better OS compared with 1 to 3 regional lymph nodes dissection(P=0.014). After surgery, adjuvant chemotherapy did not contribute to extended survival in patients with tumor less than 2 cm(P=0.658), and possibly for tumor 2 to 3 cm(P=0.082). Multivariate analysis showed that age and lobectomy were independent prognostic factors(P=0.000).

Conclusion

Our results suggest that lobectomy and lymph nodes dissection were associated with significantly better survival. Extensive regional lymph node dissection(4 or more) was more effective in prolonging survival than 1 to 3 lymph nodes dissection. Adjuvant chemotherapy was not associated with extended survival for tumor less than 2 cm, and possibly for tumor 2 to 3 cm.

Video-Assisted Thoracoscopic Segmentectomy for Deep and Peripheral Small Lung Cancer

Background  We aimed to retrospectively compare the long-term prognosis and recurrence after segmentectomy between nonsmall cell lung cancer (NSCLC) patients with deep and peripheral lesions.

Methods  Data were extracted for 85 lobectomy-tolerable NSCLC patients with tumors measuring ≤2 cm, who underwent video-assisted thoracoscopic segmentectomy with curative intent during January 2006 to December 2014. Tumor location was determined by the surgeon using thin-slice (1 mm) and three-dimensional computed tomography. Overall and recurrence-free survival was compared between patients with peripheral and deep lesions using univariate and multivariate Cox proportional hazard models. The indications for segmentectomy included NSCLC measuring ≤2 cm and consolidation/tumor ratio ≤20%, solid NSCLC ≤1 cm, and indeterminate nodule ≤1.5 cm.

Results  No recurrence of peripheral and deep lesions was noted. The 5-year overall survival was 96.4% for all patients, and 100 and 95.3% for patients with deep and peripheral lesions, respectively. There was no significant difference between the overall survival rates associated with the deep and peripheral lesions (95% confidence interval [CI], 89.5–98.8, nonsignificant, 86.4–98.4, respectively; p  = 0.189). In a multivariate analysis, the American Society of Anesthesiologists score (hazard ratio [HR], 13.30; 95% CI, 1.31–210.36; p  = 0.028) and histology (HR, 0.03; 95% CI, 0.00–0.32; p  = 0.037) were independent prognostic factors for overall survival; tumor location was not a prognostic factor.

Conclusions  When video-assisted thoracoscopic segmentectomy with curative intent was performed with sufficient surgical margins, the location of small NSCLC did not affect recurrence risk and prognosis. Video-assisted thoracoscopic segmentectomy for small NSCLC is acceptable, regardless of the tumor location.

Short-term local control after VATS segmentectomy and lobectomy for solid NSCLC of less than 2 cm

Introduction

VATS pulmonary segmentectomy is increasingly proposed as a parenchyma‐sparing resection for tumors smaller than 2 cm in diameter. The aim of this study was to compare short‐term oncological results and local control in solid non‐small cell lung cancers (NSCLCs) <2 cm surgically treated by intentional VATS segmentectomy or lobectomy.

Methods

This study was a single center retrospective study of consecutive patients undergoing VATS lobectomy (VL) or segmentectomy (VS) for solid <2 cm NSCLC from January 2014 to October 2019.

Results

In total, 188 patients with a median age of 65 years (male/female: 99/89) underwent VS (n = 96) or VL (n = 92). Segmentectomies in the upper lobes were performed in 57% and as a single segment in 55% of cases. There was no statistically significant difference between VS and VL in terms of demographics, comorbidities, postoperative outcomes, dissected lymph node stations (2.89 ± 0.95 vs. 2.93 ± 1, P = 0.58), rate of pN1 (2.2% vs. 2.1%, P = 0.96) or pN2 upstaging (1.09% vs. 1.06%, P = 0.98). Adjuvant chemotherapy was given in 15% of patients in the VL and 11% in the VS group. During follow‐up (median: 23 months), no patients presented with local nodal recurrence or on the stapler line (VS group). Three patients on VL and two in VS groups presented with recurrence on the remnant operated lung. New primary pulmonary tumors were diagnosed in 3.3% and 6.3% of patients in the VL and VS groups, respectively.

Conclusions

Despite the short follow‐up, our preliminary data shows that local control is comparable for VATS lobectomy and VATS segmentectomy for patients with NSCLC <2 cm.

A retrospective study of the relationship between the pathologic subtype and lymph node metastasis of lung adenocarcinomas of ≤3 cm diameter

To analyze the relationship between pathologic subtype and lymph node metastasis for lung adenocarcinomas of ≤3 cm diameter.We retrospectively studied 384 patients with operable lung adenocarcinomas of ≤3 cm diameter that had been radically resected by lobectomy or anatomic segmentectomy with systematic nodal dissection, at the Fujian Medical University Union Hospital between March 2014 and March 2016.Lymph node metastasis pN1 + pN2 (pN+) was found in 2 of 104 (1.9%) patients with tumor diameter ≤1.0 cm, 12 of 159 (7.5%) patients with tumor diameter >1.0 cm but ≤2.0 cm, and 35 of 121 (28.9%) patients with tumor size >2.0 cm but ≤3.0 cm (P < .01). Lymph node metastasis pN+ was found in 19 of 53 (35.8%) patients with visceral invasion pleural (VIP) and 30 of 331 (9.0%) patients without VIP (P < .05). It was also found in 16 of 51 (31.3%) patients with high serum CEA concentrations and 28 of 297 (9.4%) patients with normal concentrations (P < .05). In a multivariate analysis, tumor diameter, VIP, high serum CEA concentration, and pathologic subtype were significant risk factors. The prevalences of lymph node metastasis pN+ were: 0.0% (0/2), 0.0% (0/89), 3.2% (1/31), 16.2% (34/209), 7.7% (1/13), 46.7% (7/15), 100% (4/4), and 11.8% (2/17) for adenocarcinoma in situ (AIS); minimally invasive adenocarcinoma (MIA); predominantly lepidic (LEP), acinar (ACI), papillary, solid (SOL), and micropapillary (MIP) tumors; and variants of invasive adenocarcinoma, respectively (P < .05). For predominant SOL and MIP tumors, the prevalences of lymph node involvement were significantly higher than for the other subtypes.We have shown that lymph node metastasis in patients with tumor diameter ≤3 cm differs according to lung adenocarcinoma subtype. AIS and MIA were not associated with lymph node metastasis; therefore, systematic nodal dissection may be unnecessary. The prevalence of lymph node metastasis rate was low for LEP, suggesting that systemic lymph node sampling is sufficient. In contrast, for other pathologic subtypes, including SOL and MIP, systematic lymph node dissection should be performed.

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Equivalent Survival Between Lobectomy and Segmentectomy for Clinical Stage IA Lung Cancer

BACKGROUND

The oncologic efficacy of segmentectomy is controversial. We compared long-term survival in clinical stage IA (T1N0) Medicare patients undergoing lobectomy and segmentectomy in The Society of Thoracic Surgeons database.

METHODS

The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data in 14,286 lung cancer patients who underwent segmentectomy (n = 1654) or lobectomy (n = 12,632) for clinical stage IA disease from 2002 to 2015. Cox regression was used to create a long-term survival model. Patients were then propensity matched on demographic and clinical variables to derive matched pairs.

RESULTS

In Cox modeling segmentectomy was associated with survival similar to lobectomy in the entire cohort (hazard ratio, 1.04; 95% confidence interval, 0.89-1.20; P = .64) and in the matched subcohort. A subanalysis restricted to the 2009 to 2015 population (n = 11,811), when T1a tumors were specified and positron emission tomography results and mediastinal staging procedures were accurately recorded in the database, also showed that segmentectomy and lobectomy continue to have similar survival (hazard ratio, 1.00; 95% confidence interval, 0.87-1.16). Subanalysis of the pathologic N0 patients demonstrated the same results.

CONCLUSIONS

Lobectomy and segmentectomy for early-stage lung cancer are equally effective treatments with similar survival. Surgeons from The Society of Thoracic Surgeons database appear to be selecting patients appropriately for sublobar procedures.

Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer

OBJECTIVES

The full thoracoscopic approach to major pulmonary resections is considered challenging and controversial as it might compromise oncological outcomes. The aim of this work was to analyse the results of a full thoracoscopic technique in terms of nodal upstaging and survival in patients with non-small-cell lung carcinoma (NSCLC).

METHODS

All patients who underwent a full thoracoscopic major pulmonary resection for NSCLC between 2007 and August 2016 were analysed from an 'intent-to-treat' prospective database. Overall survival and disease-free survival were estimated using the Kaplan-Meier curves and comparisons in survival using the log-rank test.

RESULTS

A total of 648 patients met the inclusion criteria, of whom 621 patients had clinical Stage I and 27 had higher stages (16 oligometastatic patients were excluded from the analysis, 11 cT3 or cT4). The mean follow-up was 34.5 months. There were 40 conversions to thoracotomy (6.3%). Thirty-day or in-hospital mortality was 0.95%. Complications occurred in 29.3% of patients. On pathological examination, 22.5% of clinical Stage I patients were upstaged. Nodal upstaging to N1 or N2 was observed in 15.8% of clinical Stage I patients. Five-year overall survival of the whole cohort was 75% and was significantly different between clinical Stages IA (76%) and IB (70.9%). For tumours <2 cm, no significant difference in overall survival was found for the segmentectomy group compared to the lobectomy group: 74% versus 78.9% (P = 0.634).

CONCLUSIONS

Long-term survival is not compromised by a full thoracoscopic approach. Our results compared favourably with those of video-assisted techniques.

Development and External Validation of a Nomogram for Predicting Survival in Patients With Stage IA Non-small Cell Lung Cancer ≤2 cm Undergoing Sublobectomy

Background: Postoperative prognosis of early stage non-small cell lung cancer (NSCLC) undergoing sublobectomy is heterogeneous. Therefore, we sought to construct a novel survival prediction model for stage IA NSCLC ≤2 cm undergoing sublobectomy.

Methods: Based on the data from the Surveillance, Epidemiology, and End Results (SEER) program, we successfully determined and incorporated independent prognostic markers to construct the nomogram. Internal validation of the constructed nomogram was conducted through 1,000 bootstrap resamples. The constructed nomogram was further subjected to external validation with an independent cohort of patients from two Chinese institutions. The performance of the survival prediction model was assessed by concordance index, calibration plots, and risk subgroup classification.

Results: A total of 3,238 patients from SEER registries (development cohort), as well as 769 patients from two Chinese institutions (validation cohort) was included. Gender, age, size, histologic type, grade, and examined lymph nodes count were identified as significant prognostic parameters. A novel nomogram was developed and externally validated. Concordance index of constructed nomogram was significantly better than that of the current TNM staging system. Calibration plots demonstrated an optimal consistency between the nomogram predicted and actual observed probability of survival. Survival curves of different risk subgroups within respective TNM stage demonstrated significant distinctions.

Conclusion: We developed and externally validated a survival prediction model for patients with stage IA NSCLC ≤2 cm undergoing sublobectomy. This novel nomogram outperforms the conventional TNM staging system and could help clinicians in postoperative surveillance and future clinical trial design.

Three-dimensional printing in the preoperative planning of thoracoscopic pulmonary segmentectomy

Background

The purpose of this study is to explore whether 3D printing has a better clinical value for making a preoperative plan than three-dimensional computed tomography (3D-CT) in thoracoscopic pulmonary segmentectomy.

Methods

We collected a total of 124 patients' clinical data who underwent thoracoscopic pulmonary segmentectomy from October 2017 to August 2018. According to the preoperative examination, the patients were divided into three groups: general group, 3D-CT group, and 3D printing group. The clinical data of each group were analyzed and compared.

Results

Compared with the general group, intraoperative blood loss in 3D-CT group and 3D printing group decreased significantly (P<0.05). Operation time in 3D-CT group and 3D printing group was significantly shorter than in the general group (P<0.05). Between 3D-CT group and 3D printing group intraoperative blood loss and operation time had no significant differences (P>0.05). Postoperative chest tube duration and postoperative hospital stay had no significant differences between each group P>0.05). The incidence of postoperative hemoptysis in the general group occurred higher than in the 3D-CT group and 3D printing group, but the differences were not statistically significant (P>0.05). Postoperative complications of pneumonia, atelectasis, and pulmonary air leakage (>6 d) had no significant differences between each group (P>0.05).

Conclusions

3D printing and 3D-CT for making a preoperative plan have an equivalent effect in thoracoscopic pulmonary segmentectomy for experienced surgeons. Preoperative simulations using 3D printing for the assessment of pulmonary vessel and bronchi branching patterns is beneficial for the safe and efficient performance of thoracoscopic pulmonary segmentectomy.

Selective lymph node dissection for clinical T1 stage non-small cell lung cancer

Background

More and more pulmonary nodules are detected by CT scan, and postoperative pathology reveals many lymph nodes without metastasis. The purpose of this study was to investigate the characteristics of T1 stage lymph node metastasis in non-small cell lung cancer (NSCLC) and to explore the indications for selective lymph node dissection (SLND).

Methods

A total of 841 patients with stage T1 of NSCLC were performed lobectomy and systemic lymphadenectomy. We analyzed the types of lymph node metastases and the relationship between lymph node metastasis and pulmonary pleural invasion, thrombosis of vascular carcinoma and tumor size in all patients.

Results

Among them, 257 cases of tumor in the right upper lobe (RUL) and 186 cases in the left upper lobe (LUL), and no metastasis was found in the inferior mediastinal lymph nodes. Tumor metastases occurred in subcarinal lymph nodes, with hilar and/or mediastinal lymph node metastasis. Among the 171 cases with right lower lobe (RLL) tumors and the 151 cases with left lower lobe (LLL) tumors, patients with superior lymph node metastasis were all associated with hilar and/or subcarinal lymph node metastasis. Among the 76 cases with right middle lobe (RML) tumors, no metastasis with inferior mediastinal lymph node was observed. Lymph node metastasis is much easier in patients with pulmonary pleural invasion or thrombosis of vascular cancer. The larger the tumor diameter, the greater the possibility of lymph node metastasis.

Conclusions

SLND is a feasible treatment for clinical T1 stage NSCLC under the guidance of intraoperative frozen results of lobe-specific lymph nodes.

Management of the inter-segmental plane using the "Combined Dimensional Reduction Method" is safe and viable in uniport video-assisted thoracoscopic pulmonary segmentectomy

Background

The management of the intersegmental plane (ISP) is challenging during uniport video-assisted thoracoscopic (VATS) pulmonary segmentectomy. Staplers and electrocautery have been used extensively in ISP management. However, both of them have their respective drawbacks. Currently, we have provided a revised technique termed as "Combined Dimensional Reduction Method" (CDR method), for managing the ISP with combined application of ultrasonic scalpel and staplers. The study aimed to review the outcomes of patients who underwent uniport VATS segmentectomy with or without the CDR method in our institute and assess the feasibility and safety of the CDR method.

Methods

From March 2017 to February 2018, 220 patients who underwent uniport VATS segmentectomy were retrospectively reviewed. By using IQQA software, pulmonary structures were reconstructed as three-dimensional (3D) images, making the targeted structures could be identified preoperatively. For the management of the ISP, in the CDR group, we firstly used the ultrasonic scalpel to trim the 3D pulmonary structure along the intersegmental demarcation, making the remaining targeted parenchyma both sufficiently thin enough and located on a 2D plane; thus, enabling easy use of staplers in managing ISP. Whereas, in the non-CDR group, we only use the staplers to manage the ISPs. The clinical characteristics, complications, and postoperative pulmonary functions were compared between the two groups.

Results

Propensity score analysis generated 2 well-matched pairs of 71 patients in CDR and non-CDR groups. There was no 30-day postoperative death or readmission in either group. The CDR group was significantly associated with the shorter operative time (178.3±35.8 vs. 209.2±28.7 min) (P=0.031) and postoperative stay (4.5±2.3 vs. 5.7±4.2 days) (P=0.041), compared to the non-CDR group. Moreover, no significant difference was observed in blood loss, a period of chest tube drainage, a period of ultrafine tube drainage, and postoperative pulmonary complications between the two groups. Moreover, the recovery rate of postoperative forced expiratory volume in 1 second (FEV1) or vital capacity (VC) at 1 and 3 months after segmentectomy was comparable between them.

Conclusions

The CDR method could make segmentectomy easier and more accurate, and therefore has the potential to be a viable and effective technique for uniport VATS pulmonary segmentectomy.

A Meta-Analysis Comparing Lobectomy versus Segmentectomy in Stage I Non-Small Cell Lung Cancer

Lobectomy is considered the standard strategy for early-stage non-small cell lung cancer (NSCLC). However, sublobar resection for NSCLC has recently received increased attention. The objective of this study was to compare 5-year survival, recurrence-free survival, postoperative mortality, and postoperative morbidities in patients who received segmentectomy versus those who received lobectomy through a meta-analysis. Sixteen studies were included and the combined hazard ratios or odds ratios were calculated. The results revealed that the 5-year survival rate after segmentectomy was comparable to that of lobectomy for stage IA NSCLC. However, segmentectomy for stage I NSCLC had lower rates of postoperative mortality and morbidities than lobectomy.

Surgery or radiotherapy for stage I lung cancer? An intention-to-treat analysis

INTRODUCTION

Surgery is the standard of care for early-stage lung cancer, with stereotactic ablative body radiotherapy (SABR) a lower morbidity alternative for patients with limited physiological reserve. Comparisons of outcomes between these treatment options are limited by competing comorbidities and differences in pre-treatment pathological information. This study aims to address these issues by assessing both overall and cancer-specific survival for presumed stage I lung cancer on an intention-to-treat basis.

METHODS

This retrospective intention-to-treat analysis identified all patients treated for presumed stage I lung cancer within a single large UK centre. Overall survival, cancer-specific survival, and combined cancer and treatment-related survival were assessed with adjustment for confounding variables using Cox proportional hazards and Fine-Gray competing risks analyses.

RESULTS

468 patients (including 316 surgery and 99 SABR) were included in the study population. Compared with surgery, SABR was associated with inferior overall survival on multivariable Cox modelling (SABR HR 1.84 (95% CI 1.32-2.57)), but there was no difference in cancer-specific survival (SABR HR 1.47 (95% CI 0.80-2.69)) or combined cancer and treatment-related survival (SABR HR 1.27 (95% CI 0.74-2.17)). Combined cancer and treatment-related death was no different between SABR and surgery on Fine-Gray competing risks multivariable modelling (subdistribution hazard 1.03 (95% CI 0.59-1.81)). Non-cancer-related death was significantly higher in SABR than surgery (subdistribution hazard 2.16 (95% CI 1.41-3.32)).

CONCLUSION

In this analysis, no difference in cancer-specific survival was observed between SABR and surgery. Further work is needed to define predictors of outcome and help inform treatment decisions.

Node-Positive Segmentectomy for Non-Small-Cell Lung Cancer: Risk Factors and Outcomes

BACKGROUND

Segmentectomy for well-selected early stage non-small-cell lung carcinoma (NSCLC) has been shown to have similar oncologic outcomes and survival to lobectomy. However, these data are based on the presumption that the disease is node negative. Few data exist regarding the risk factors for and the outcomes of patients with disease treated with segmentectomy that is found to be node positive. We sought to determine the risk factors for and outcomes of clinical stage I NSCLC patients who are treated with segmentectomy but are determined to be node positive.

PATIENTS AND METHODS

We queried patients with clinical stage I NSCLC ≤ 3 cm within the National Cancer Data Base between 2004 and 2014 who were treated with segmentectomy or lobectomy and found to have positive nodes. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) between segmentectomy and lobectomy. For comparison only, segmentectomy patients with pathologically node-negative disease were identified to determine predictors of node positivity after segmentectomy via multivariable logistic regression.

RESULTS

A total of 4556 patients with node-positive disease were identified, comprising 115 segmentectomy patients and 4441 lobectomy patients. Multivariable analysis identified increasing tumor size, squamous-cell histology, and increasing number lymph nodes sampled as significant predictors of node positivity after segmentectomy. There was no difference in OS between segmentectomy and lobectomy, with 3-year OS rates of 66.3% and 68.1%, respectively (P = .723).

CONCLUSION

There are discrete risk factors for discovering positive nodes after segmentectomy. Segmentectomy is associated with similar OS compared to lobectomy for clinical stage I NSCLC found to be node positive.

Extent of lymphadenectomy is associated with oncological efficacy of sublobar resection for lung cancer ≤2 cm

BACKGROUND

Sublobar resection (SLR) is an alternative to lobectomy for early non-small cell lung cancer. Comparative effectiveness of these 2 approaches might be modified by the extent of lymph node dissection.

METHODS

We utilized the Surveillance, Epidemiology, and End Results Program-Medicare dataset to identify patients with stage I non-small cell lung cancer aged 66 years or older with tumor size ≤2 cm. We compared patient characteristics with t tests for continuous variables and χ² tests for categorical variables. Kaplan-Meier curves were constructed to determine overall survival (OS) and cancer-specific survival (CSS). We evaluated OS and CSS among propensity-matched cohorts undergoing lobectomy versus SLR, particularly as it related to extent of lymphadenectomy.

RESULTS

Among 2757 lobectomies and 1229 SLR procedures performed for stage I tumors ≤2 cm, we propensity-matched 1124 patients from each group. Patients undergoing SLR were more likely to have no lymph nodes sampled (46.9% vs 6.4%; P < .001). OS (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.29-1.69) and CSS (HR, 2.06; 95% CI, 1.41-3.02) were worse following SLR. When propensity-matched cohorts of patients with at least 1 lymph node removed (n = 567 each group) were examined, the HRs for survival for SLR decreased (OS HR, 1.38; 95% CI, 1.12-1.69; CSS HR, 1.58; 95% CI, 0.97-2.57). Finally, when cohorts were propensity matched for ≥9 lymph nodes examined (n = 103 each group), there was no difference in OS (HR, 0.84; 95% CI, 0.50-1.39) or CSS (HR, 1.10; 95% CI, 0.35-3.41).

CONCLUSIONS

SLR leads to fewer lymph node removed and is associated with inferior survival compared with lobectomy. A more extensive lymphadenectomy may be associated with equivalent survival between matched patients undergoing SLR and lobectomy.

Application of indocyanine green fluorescence for precision sublobar resection

BACKGROUND

Increasing identification of small pulmonary nodules promotes sublobar resection, but localization and surgical margins of non-palpable pulmonary nodules through sublobar resection are challenging. Our aim was explicate the feasibility of applying indocyanine green (ICG) fluorescence to localized nodules, and to carry out surgical resection.

METHODS

A total of 46 patients with subpleural pulmonary nodules <3 cm were enrolled, including 35 for wedge resection and 11 for segmentectomy. For wedge resection, patients underwent computed tomography-guided percutaneous injection of ICG preoperatively. Wedge resection was carried out after confirmation of the fluorescence using fluoroscopy. For segmentectomy, ICG was injected through the peripheral vein during surgery and resection of the segmental plain was carried out. Detailed measurements were taken and information was collected for the whole procedure.

RESULTS

A total of 33 out of 35 patients underwent successful wedge resection using ICG fluorescence. Segmentectomy was successfully carried out for all 11 patients who underwent the procedure. For two patiens, the nodules failed to be localized with unclear fluorescence, and one patient with an undetected nodule was altered to perform lobectomy. For wedge resection, the mean tumor size and depth from the pleural surface were 7.8 ± 0.5 mm and 10.5 ± 1.6 mm, respectively. The median time taken for preoperative computed tomography-guided percutaneous injection was 28 min (range 18-40 min), and 25 min (range 16-30 min) for wedge resection. For segmentectomy, the ICG fluorescence occurred 14 s after injecting ICG through the peripheral vein, and the median duration was 15 min. All surgical margins were negative based on pathological evaluation.

CONCLUSIONS

The implementation of ICG fluorescence could provide surgeons carrying out precision sublobar resection with a time-saving surgical technique with less unnecessary intraoperative damage.

Is segmentectomy the future?

The role of anatomic segmentectomy as an acceptable, lung parenchymal sparing alternative to pulmonary lobectomy for the small peripheral stage I lung cancer is under great scrutiny today. This is not a new consideration, particularly for the patient with impaired cardiopulmonary reserve where preservation of lung function may be a critical issue in deciding on surgical resection for local/regional control of their cancer. In this review, we discuss the oncologic issues along with past and present evidence supporting "anatomic" lung preservational surgery in the management of lung cancer.

Percutaneous computed tomography-guided biopsy performed by thoracic surgeons in 955 patients: A paradigm shift in image-guided thoracic procedures

OBJECTIVES

Computed tomography-guided fine needle aspiration (CT-FNA) biopsy is a well-established diagnostic technique in the evaluation of lung nodules that is performed by radiologists in most centers. In this series, we analyzed the diagnostic and perioperative outcomes following CT-FNA performed by a dedicated group of thoracic surgeons.

METHODS

We conducted a retrospective analysis of 955 patients undergoing CT-FNA by the thoracic surgery service. Primary outcome variables included diagnostic yield and accuracy, number of needle passes, complication rates, and adequacy of specimen for molecular testing.

RESULTS

A satisfactory diagnostic specimen was obtained in 94.1% of cases. The average number of needle passes was 3.2 ± 1.5 (range, 1-10 passes). Diagnostic yield was significantly improved by increasing the number of passes from 1 to 2 to 3 passes (P = .0003). CT-FNA diagnostic accuracy was 88.8%. Diagnostic accuracy did not significantly improve with ≥4 passes (P = .20). Molecular testing was successful in 43.1%, and did not improve with ≥4 passes (P = .5). Molecular testing success did improve with the addition of core needle biopsy (P = .005). The pneumothorax rate for CT-FNA alone was 26.4%, and increased with ≥4 passes (P = .009). The median length of stay for CT-FNA alone was 0 days (range, 0-74 days), with same-day discharge in 67.5% of patients.

CONCLUSIONS

Thoracic surgeons can perform CT-FNA with excellent diagnostic yield and accuracy. Diagnostic yield, accuracy, and success in molecular testing do not improve with ≥4 CT-FNA passes. Pneumothorax rates do increase with ≥4 passes. The addition of core needle biopsy enhances success with molecular testing.

[Progress of Lung Margin During Sublobar Resection for Early-staged Non-small Cell Lung Cancer]

近年来随着低剂量计算机断层扫描(low-dose computed tomography, LDCT)、高分辨率CT(high-resolution CT, HRCT)的普及, 早期非小细胞肺癌的发现比率不断上升, 越来越多的胸外科医生探索手术方式的改良, 推动手术切除范围向更加合理的方向进展。临床研究发现肺切缘阴性较阳性有更低的局部肿瘤复发率, 因此亚肺叶切除术治疗早期肺癌术中保证肺切缘阴性具有重要的临床意义, 本文将就这一领域研究现状和进展作一综述。

Novel techniques for video-assisted thoracoscopic surgery segmentectomy

Small lung cancers are being increasing diagnosed because of advances in computed tomography (CT) and low-dose CT screening. Sublobar resection of peripheral, small lung nodules, such as ground-glass nodules, is a useful therapeutic option that obtains both a pathological diagnosis and radical cure. Lung segmentectomy is a better option than wedge resection for securing a sufficient surgical margin and can also be used to assess hilar nodes. Anatomical segmentectomy, however, is a technically more complicated operative procedure than standard lobectomy. We describe the issues and novel techniques of video-assisted thoracoscopic segmentectomy.

Uniportal Video-Assisted Thoracoscopic Surgery Segmentectomy

This article addresses technical details of uniportal VATS segmentectomy by lung segments, suggesting available techniques for lesion localization and identification of the intersegmental plane. Long-term results and superiority have not yet been characterized in standard VATS for lung malignancy. Indications include almost all thoracic procedures currently performed by conventional multiport VATS. We review our experience and published literature on the feasibility of uniportal VATS segmentectomy.

Detection of oncogenic mutations in resected bronchial margins by next-generation sequencing indicates early relapse in stage IA lung adenocarcinoma patients

Stage I non-small cell lung cancer (NSCLC) patients experience a relatively high rate of recurrence, ranging from about 30-35%. We hypothesized that this elevated risk of recurrence is due to the presence of tumor cells at bronchial margins which was undetected by conventional light microscopy. Patients with clinical stage IA (T1N0M0) NSCLC were enrolled in this study, which included 8 early-relapse(ER) and 6 no-relapse(NR) patients. Primary tumor, bronchial margin, and normal lung tissues were collected and sent to a central site for targeted next-generation sequencing analysis. All of the patients were lung adenocarcinoma. Gene mutations were identified in all tumor tissue samples (100%). Oncogenic mutations were identified in 87.5%(7/8) bronchial margins of early relapse patients, whereas only 16.7%(1/6) no-relapse (NR) patient of marginal tissue had identified gene mutation. Additionally, concordance between primary tumor and bronchial margins was relatively high, with 4 of 8 (50%) ER patients having at least one identical mutation. Moreover, according to the gene mutation status in marginal tissue, 87.5% (7/8) of patients with at least one gene mutation in the bronchial margins had local recurrence or metastasis, whereas only 16.7% (1/6) of patients without any mutation detected had signs of relapse, the recurrence rate was significantly higher than that of the negative mutation margin group ((p (log-rank) = 0.023). The existence of oncogenic mutations in bronchial margins may represent occult residual tumor and elevated risk of recurrence in early stage NSCLC patients. Thus, assessing molecular status in bronchial margins may help identify patients who might benefit from extensive surgery or adjuvant treatment.

Effect of the number of lymph nodes examined on the survival of patients with stage I non-small cell lung cancer who undergo sublobar resection

OBJECTIVES

Early stage lung cancer is being detected at a higher frequency with the implementation of screening programs. At the same time, medically complex patients with multiple comorbidities are presenting for surgery, with a concomitant rise in rates of sublobar resection. We sought to examine the effect of sampling lymph nodes on the outcomes of patients who undergo sublobar resection for small (<2 cm) stage I non-small cell lung cancer (NSCLC).

METHODS

All patients in the Surveillance, Epidemiology, and End Results database from 2004 to 2013 with small (<2 cm) stage I NSCLC who underwent sublobar resection (wedge/segmentectomy) and no other cancer history were included. The association of the number of lymph nodes examined (LNE; categories none, 1-3, 4-6, 7-9, >9) with the overall survival as well as disease-specific survival were examined using univariate as well as multivariate analyses while controlling for covariates such as age, size (<1 cm, >1 cm), grade, histology (adenocarcinoma vs others), and extent of resection (wedge/segmentectomy).

RESULTS

Data from 3916 eligible patients were analyzed. Seven hundred fifteen patients (18.3%) had segmentectomy. No lymph nodes were examined in 49% and 23% of wedge resection and segmentectomy patients, respectively. Among all eligible patients, 1132 (29%), 474 (12%), 228 (6%), and 328 (8%) patients had 1 to 3, 4 to 6, 7 to 9 and >9 LNE, respectively. Univariate analyses showed significant associations between overall and disease-specific survivals with age, grade, histology, sex, extent of surgery, and LNE. The association between the number of LNE and survival remained significant even after adjusting for significant covariates including extent of sublobar resection (hazard ratio for groups with LNE 1-3, 4-6, 7-9, and >9 compared with 0 LNE were 0.79, 0.77, 0.68, and 0.45 for overall survival; P < .001) and 0.85, 0.77, 0.71, and 0.44 for disease-specific survival (P < .05), respectively. In multivariate modeling, LNE was retained as a significant variable and extent of resection was not. In patients in whom at least 1 lymph node was examined, extent of resection was not predictive of outcome.

CONCLUSIONS

Many patients having sublobar resection for early stage NSCLC in the United States do not have a single lymph node removed for pathologic examination. The number of LNE is associated with improved survival, presumably due to avoidance of mis-staging. This association seems greater than the association with extent of resection (segmentectomy vs wedge resection). Appropriate lymph node examination remains an important part of resection for lung cancer even if the resection is sublobar.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.

[Progress of Sublobectomy for the Treatment of Stage I Non-small Cell Lung Cancer in the Elderly]

肺癌是世界范围内发病率最高的恶性肿瘤，且有逐年增加的趋势，随着人口老龄化和薄层电子计算机断层扫描（computed tomography, CT）的应用，老年早期肺癌被越来越多的发现，手术仍然是这类人群的主要治疗方式，目前主要手术方式为肺叶切除和亚肺叶切除两种，由于老年群体的特殊性，对手术方式的选择也趋于“个性化”，本文对这两种手术方式的选择问题做一综述。

Three-dimensional (3D)- computed tomography bronchography and angiography combined with 3D-video-assisted thoracic surgery (VATS) versus conventional 2D-VATS anatomic pulmonary segmentectomy for the treatment of non-small cell lung cancer

Background

Compared to the pulmonary lobe, the anatomical structure of the pulmonary segment is relatively complex and prone to variation, thus the risk and difficulty of segmentectomy is increased. We compared three‐dimensional computed tomography bronchography and angiography (3D‐CTBA) combined with 3D video‐assisted thoracic surgery (3D‐VATS) to perform segmentectomy to conventional two‐dimensional (2D)‐VATS for the treatment of non‐small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed the data of randomly selected patients who underwent 3D‐CTBA combined with 3D‐VATS (3D‐CTBA‐VATS) or 2D‐VATS at the Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University Hospital, from January 2014 to May 2017.

Results

The operative duration of 3D group was significantly shorter than the 2D group (P < 0.05). There was no significant difference in the number of dissected lymph nodes between the two groups (P > 0.05). The extent of intraoperative bleeding and postoperative drainage in the 3D group was significantly lower than in the 2D group (P < 0.05). Chest tube duration in the 3D group was shorter than in the 2D group (P < 0.05). Incidences of pulmonary infection, atelectasis, and arrhythmia were not statistically different between the two groups (P > 0.05). However, hemoptysis and pulmonary air leakage (>3d) occurred significantly less frequently in the 3D than in the 2D group (P < 0.05).

Conclusion

3D‐CTBA‐VATS is a more accurate and smooth technique and leads to reduced intraoperative and postoperative complications.

Thoracoscopic anatomical lung segmentectomy using 3D computed tomography simulation without tumour markings for non-palpable and non-visualized small lung nodules

OBJECTIVES

Although wedge resection can be curative for small lung tumours, tumour marking is sometimes required for resection of non-palpable or visually undetectable lung nodules as a method for identification of tumours. Tumour marking sometimes fails and occasionally causes serious complications. We have performed many thoracoscopic segmentectomies using 3D computed tomography simulation for undetectable small lung tumours without any tumour markings. The aim of this study was to investigate whether thoracoscopic segmentectomy planned with 3D computed tomography simulation could precisely remove non-palpable and visually undetectable tumours.

METHODS

Between January 2012 and March 2016, 58 patients underwent thoracoscopic segmentectomy using 3D computed tomography simulation for non-palpable, visually undetectable tumours. Surgical outcomes were evaluated.

RESULTS

A total of 35, 14 and 9 patients underwent segmentectomy, subsegmentectomy and segmentectomy combined with adjacent subsegmentectomy, respectively. All tumours were correctly resected without tumour marking. The median tumour size and distance from the visceral pleura was 14 ± 5.2 mm (range 5-27 mm) and 11.6 mm (range 1-38.8 mm), respectively. Median values related to the procedures were operative time, 176 min (range 83-370 min); blood loss, 43 ml (range 0-419 ml); duration of chest tube placement, 1 day (range 1-8 days); and postoperative hospital stay, 5 days (range 3-12 days). Two cases were converted to open thoracotomy due to bleeding. Three cases required pleurodesis for pleural fistula. No recurrences occurred during the mean follow-up period of 44.4 months (range 5-53 months).

CONCLUSIONS

Thoracoscopic segmentectomy using 3D computed tomography simulation was feasible and could be performed to resect undetectable tumours with no tumour markings.

Postoperative atrial fibrillation is less frequent in pulmonary segmentectomy compared with lobectomy

OBJECTIVE

The aim of this study was to elucidate the characteristics and predictors of postoperative atrial fibrillation (POAF) from the standpoint of surgical mode.

METHODS

Retrospective analysis was carried out on 607 patients who underwent lobectomy or segmentectomy for clinical stage IA lung cancer. We investigated the clinical factors to determine the predictors of the development of POAF.

RESULTS

Of the 607 patients, 443 underwent lobectomy, and 164 underwent segmentectomy. POAF developed in 37 patients. Of these, 34 (7.7%) were in the lobectomy group, and 3 (1.8%) in the segmentectomy group. In the univariate analysis for predictors of POAF, age (p < 0.01), history of ischemic heart disease (p = 0.03), FEV1.0% (p < 0.01) and surgical mode (p = 0.01) showed significant differences between the groups. The multivariate analysis revealed that increasing age (p < 0.01, HR 1.059, CI 1.015-1.106), surgical mode (p = 0.02, HR 5.734, CI 1.350-24.361) and FEV1.0% < 70% (p = 0.03, HR 2.182, CI 1.067-4.461) were independent predictors of POAF.

CONCLUSION

POAF was significantly less following segmentectomy compared with lobectomy.

Is left upper lobectomy always worthwhile for early stage lung cancer? A comparison between left upper lobectomy, trisegmentectomy, and lingulectomy

BACKGROUND AND OBJECTIVES

Lobectomy is the gold standard treatment for resectable Non-Small Cell Lung Cancer (NSCLC). We compared oncological outcomes of patients undergoing a "multi-segmentectomy" (trisegmentectomy or lingulectomy) and left upper lobectomy for early stage (T1-2, N0) NSCLC of the left upper lobe.

METHODS

We retrospectively analyzed all patients with pathological early stage (T1-T2 N0) NSCLC located in left upper lobe who underwent a lobectomy, a trisegmentectomy, or a lingulectomy between 2006 and 2013, focusing on surgical and oncological outcomes.

RESULTS

Among 159 patients, 105 patients underwent a lobectomy and 54 patients a multi-segmentectomy (33 lingulectomy and 21 trisegmentectomy). Actuarial mean Overall Survival was 87 months (95%CI 79-95) and 89 months (95%CI 76-101) for lobectomies and multi-segmentectomies, respectively (P-value: 0.895), while actuarial mean Disease Free Interval was 91 months (95%CI 82-100) and 96 months (95%CI 84-108) respectively (P-value: 0.565). We did not observe any difference in terms of local recurrence rate between the two groups (P = 0.337).

CONCLUSIONS

Lingulectomy and trisegmentectomy lead to similar oncological outcomes compared to left upper lobectomy for T1 and T2 N0 NSCLC, and they could be used as an alternative to lobectomy even in patients with a good pulmonary function.

Unplanned Procedures During Thoracoscopic Segmentectomies

BACKGROUND

Thoracoscopic sublobar resections (TSLRs) are gaining popularity, but are challenging. However, despite technical difficulties, the reported rate of adverse events, complications, and unplanned procedures is low. To understand this paradox, we have studied our series of TSLRs.

METHODS

We reviewed our prospective and intention-to-treat database on videothoracoscopic anatomical resections and extracted all planned thoracoscopic segmentectomies from January 2007 to July 2016. Intraoperative and postoperative data were analyzed. Unplanned procedures were defined as a conversion into thoracotomy or an unplanned additional pulmonary resection.

RESULTS

During the study period 284 thoracoscopic anatomical segmentectomies were performed in 280 patients. There were 124 men and 156 women with a mean age of 64 years (range, 18 to 86 years). Indication for segmentectomy was a proven or suspected non-small cell lung carcinoma in 184 patients, suspected metastasis in 51 patients, and benign lesion in 49 patients. In total, 23 patients had an unplanned procedure (8%). There were 10 unplanned thoracotomies (9 conversions and 1 reoperation; 3.1%) mainly for vascular injuries, and 15 unplanned additional resections (5.1%) distributed among oncological reasons (n = 7), per operative technical issues (n = 6) and postoperative adverse events (lingular ischemia, n = 2). Considering only the 235 patients operated on for cancer, the unplanned additional pulmonary resection rate for an oncological reason was 3%.

CONCLUSIONS

Although lower than for thoracoscopic lobectomies, the rate of unplanned procedure during TSLRs is of concern. It could most likely be reduced by technical refinements, such as a better preoperative planning.