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

Evaluating the necessity of lymph node sampling in lung adenocarcinoma with ground glass opacities

BACKGROUND

Ground glass opacity is observed frequently in the early stages of lung adenocarcinoma and is associated with a favorable prognosis and a low incidence of lymph node metastasis. However, the necessity of lymph node sampling in these patients is questionable, although current guidelines still recommend it.

METHODS

Radiologic and clinical data were retrospectively collected and analyzed for 2,298 patients with lung cancer who underwent surgical resection for lesions ≤15 mm during 2022. Based on the consolidation tumor ratios, patients were categorized into 4 groups (pure ground glass opacity, ground glass opacity-predominant, solid-predominant, and pure solid). The incidence of lymph node metastasis in each group was examined.

RESULTS

A total of 2,298 patients with a median age of 54.0 years were enrolled in this study. Tumors were categorized into 4 types: 1,427 (62.1%) were pure ground glass opacity, which constituted the majority, while 421 (18.3%) were ground glass opacity-predominant, 330 (14.4%) were solid-predominant, and the remaining 120 (5.2%) were pure solid. Significant positive correlations were revealed between the consolidation tumor ratio group and pathologic grade (P < .001, ρ = 0.307), T stage (P < .001, ρ = 0.270), and N stage (P < .001, ρ = 0.105). Among the included cases, only 7 cases with metastasis were in the pure solid group. Within this group, 113 cases (94.2%) were N0, 5 cases (4.2%) were N1, and 2 cases (1.7%) were N2.

CONCLUSION

Lymph node metastasis exclusively occurred in the pure solid group, suggesting that for nodules <15 mm, lymph node sampling may be crucial for pure solid nodules but less so for those containing ground glass opacities.

[18F]FDG PET/CT is useful in discriminating invasive adenocarcinomas among pure ground-glass nodules: comparison with CT findings-a bicenter retrospective study

PURPOSE

Predicting the malignancy of pure ground-glass nodules (GGNs) using CT is challenging. The optimal role of [18F]FDG PET/CT in this context has not been clarified. We compared the performance of [18F]FDG PET/CT in evaluating GGNs for predicting invasive adenocarcinomas (IACs) with CT.

METHODS

From June 2012 to December 2020, we retrospectively enrolled patients with pure GGNs on CT who underwent [18F]FDG PET/CT within 90 days. Overall, 38 patients with 40 ≥ 1-cm GGNs were pathologically confirmed. CT images were analyzed for size, attenuation, uniformity, shape, margin, tumor-lung interface, and internal/surrounding characteristics. Visual [18F]FDG positivity, maximum standardized uptake value (SUVmax), and tissue fraction-corrected SUVmax (SUVmaxTF) were evaluated on PET/CT.

RESULTS

The histopathology of the 40 GGNs were: 25 IACs (62.5%), 9 minimally invasive adenocarcinomas (MIA, 22.5%), and 6 adenocarcinomas in situ (AIS, 15.0%). No significant differences were found in CT findings according to histopathology, whereas visual [18F]FDG positivity, SUVmax, and SUVmaxTF were significantly different (P=0.001, 0.033, and 0.018, respectively). The size, visual [18F]FDG positivity, SUVmax, and SUVmaxTF showed significant diagnostic performance to predict IACs (area under the curve=0.693, 0.773, 0.717, and 0.723, respectively; P=0.029, 0.001, 0.018, and 0.013, respectively). In the multivariate logistic regression analysis, visual [18F]FDG positivity discriminated IACs among GGNs among various CT and PET findings (P=0.008).

CONCLUSIONS

[18F]FDG PET/CT demonstrated superior diagnostic performance compared to CT in differentiating IAC from AIS/MIA among pure GGNs, thus it has the potential to guide the proper management of patients with pure GGNs.

Early Postoperative Patient-Reported Outcomes of Sarcopenia Versus Nonsarcopenia in Patients Undergoing Video-Assisted Thoracoscopic Surgery for Lung Cancer

BACKGROUND

To compare early postoperative patient-reported outcomes between sarcopenic and nonsarcopenic patients undergoing video-assisted thoracoscopic surgery (VATS) for lung cancer.

METHODS

The data used in this study were acquired from a longitudinal prospective study (CN-PRO-Lung 1) between November 2017 and January 2020. Skeletal muscle index was measured at L3 vertebral level on preoperative computed tomography to identify sarcopenia based on an established threshold. Symptoms severity and status of functional impairments were reported as proportions of patients with clinically relevant moderate-to-severe scores on 0-10 scales, which were measured by using the MD Anderson Symptom Inventory-Lung Cancer at baseline, daily postoperative hospitalization, and weekly after discharge up to 4 weeks. Symptom severity, functional status, and postoperative clinical outcomes were compared between the sarcopenia and nonsarcopenia groups.

RESULTS

This study included 125 patients undergoing VATS for lung cancer. Sarcopenia was identified in 34 (27.2%) patients. Sarcopenic patients reported more moderate-to-severe pain (P = 0.002) at discharge and more moderate-to-severe fatigue (P = 0.027) during the 4 weeks after discharge. Besides, sarcopenic patients had a longer recovery time from both pain (P = 0.002) and fatigue (P = 0.007) than nonsarcopenic patients. Meanwhile, no significant between-group difference was found in the postoperative clinical outcomes (all P > 0.05).

CONCLUSIONS

Sarcopenic patients undergoing VATS for lung cancer may have more pain and fatigue, as well as longer symptoms recovery time than nonsarcopenic patients during the early postoperative period.

The Lung Cancer Surgical Study Group of the Japan Clinical Oncology Group: outstanding contribution and entering a new phase

The Lung Cancer Surgical Study Group (LCSSG) of the Japan Clinical Oncology Group (JCOG) was organized in 1986 and initially included 26 collaborative institutions, which has increased to 52 institutions currently. JCOG-LCSSG includes thoracic surgeons, medical oncologists, pathologists, and radiotherapists. In the early period, the JCOG-LCSSG mainly focused on combined modality therapies for lung cancer. Since the 2000s, the JCOG-LCSSG has investigated adequate modes of surgical resection for small-sized and peripheral non-small cell lung cancer and based on the radiological findings of whole tumor size and ground-glass opacity. Trials, such as JCOG0802, JCOG0804, and JCOG1211, have shown the appropriateness of sublobar resection, which has significantly influenced routine clinical practice. With the introduction of targeted therapy and immunotherapy, treatment strategies for lung cancer have changed significantly. Additionally, with the increasing aging population and medical costs, tailored medicine is strongly recommended to address medical issues. To ensure comprehensive treatment, strategies, including surgical and nonsurgical approaches, should be developed. Currently, the JCOG-LCSSG has conducted numerous clinical trials to adjust the diversity of lung cancer treatment strategies. This review highlights recent advancements in the surgical field, current status, and future direction of the JCOG-LCSSG.

Accurate Selection of Sublobar Resection for Small Non-small Cell Lung Cancer

BACKGROUND

Although sublobar resection (wedge resection [Wed] or segmentectomy [Seg]) has become a standard operative procedure for clinical stages IA1 and IA2 non-small cell lung cancer (NSCLC) in Japan, the impact of this procedure on the prognosis and postoperative complications in real-world clinical practice is unknown.

METHODS

This study retrospectively analyzed risk factors for a poor prognosis and postoperative complications of 470 patients with clinical stage ≤ IA2 NSCLC who underwent surgery from 2012 to 2021.

RESULTS

Among the patients with a consolidation-to-tumor ratio (CTR) higher than 0.5, the 5-year relapse-free survival (RFS) rate was significantly lower in the Wed group (72.1%) than in the Seg (85.8%) and Lob (86.8%) groups (p < 0.01), but the difference between the Seg and Lob groups was not significant. Among patients with a CTR of 0.5 or lower, the 5-year RFS rate did not differ significantly among the three groups. Multivariable analysis of RFS showed that the prognosis was significantly worse in the Wed group than in the Lob group (hazard ratio, 2.83; p < 0.01), but the difference between the Wed and Seg groups or the between Seg and Lob groups was not significant. Multivariable analysis of postoperative complications showed a significantly lower risk in the Wed group than in the Seg group (odds ratio, 0.31; p < 0.01).

CONCLUSIONS

Seg could become the standard operative procedure for clinical stages IA1 and IA2 NSCLC patients. Wed is suggested to be an option for patients with a CTR of 0.5 or lower and has the advantage of avoiding postoperative complications.

Simultaneous thoracoscopic surgery in patients with atrial fibrillation and early-stage lung cancer

OBJECTIVES

Atrial fibrillation (AF) and early-stage lung cancer can both be treated under thoracoscopy. This study aims to evaluate the feasibility and safety of simultaneous thoracoscopic surgery for atrial fibrillation and early-stage lung cancer.

METHODS

This was a single-center, retrospective study of 865 patients with paroxysmal or non-paroxysmal AF who underwent surgical ablation between October 2014 and December 2021. Patients were divided into two groups according to whether they have undergone simultaneous thoracoscopic early-stage lung cancer surgery and resulting in 24 pairs of patients.

RESULTS

In total, 48 patients (24 matched pairs) were analyzed. The age was 63.71 ± 8.43 years. Procedure time and postoperative mechanical ventilation time were significantly lower in the group AF than group AFLC (Atrial fibrillation and lung cancer) (140.38 ± 27.53 vs. 230.79 ± 59.06 min, P<0.001; 5 vs 6.5 h, P = 0.002). There was no significant difference between the groups in terms of operative bleeding volume (90.00 ± 29.78 vs 85.83 ± 53.56 ml, P = 0.741), total postoperative drainage volume (1020.83 ± 516.5 vs 1406.25 ± 840.33 ml, P = 0.067), ICU (intensive care unit) length of stay (LOS) (43.5 vs 44 h, P = 0.33), hospitalization LOS (9.29 ± 1.92 vs 8.58 ± 1.98 days, P = 0.214) and incidence of freedom from AF or complications.

CONCLUSIONS

Simultaneous thoracoscopic surgical AF ablation and early-stage lung cancer is safe and feasible. It can be used as an alternative method for coexisting atrial fibrillation and lung cancer with acceptable operative risks.

The Overlooked Cornerstone in Precise Medicine: Personalized Postoperative Surveillance Plan for NSCLC

Non-small cell lung cancer recurrence after curative-intent surgery remains a challenge despite advancements in treatment. We review postoperative surveillance strategies and their impact on overall survival, highlighting recommendations from clinical guidelines and controversies. Studies suggest no clear benefit from more intensive imaging, whereas computed tomography scans reveal promise in detecting recurrence. For early-stage disease, including ground-glass opacities and adenocarcinoma in situ or minimally invasive adenocarcinoma, less frequent surveillance may suffice owing to favorable prognosis. Liquid biopsy, especially circulating tumor deoxyribonucleic acid, holds potential for detecting minimal residual disease. Clinicopathologic factors and genomic profiles can also provide information about site-specific metastases. Machine learning may enable personalized surveillance plans on the basis of multi-omics data. Although precision medicine transforms non-small cell lung cancer treatment, optimizing surveillance strategies remains essential. Tailored surveillance strategies and emerging technologies may enhance early detection and improve patients' survival, necessitating further research for evidence-based protocols.

Development of a genome atlas for discriminating benign, preinvasive, and invasive lung nodules

To tackle misdiagnosis in lung cancer screening with low-dose computed tomography (LDCT), we aimed to compile a genome atlas for differentiating benign, preinvasive, and invasive lung nodules and characterize their molecular pathogenesis. We collected 432 lung nodule tissue samples from Chinese patients, spanning benign, atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and invasive adenocarcinoma (IA). We performed comprehensive sequencing, examining somatic variants, gene expressions, and methylation levels. Our findings uncovered EGFR and TP53 mutations as key drivers in - early lung cancer development, with EGFR mutation frequency increasing with disease progression. Both EGFR mutations and EGF/EGFR hypo-methylation activated the EGFR pathway, fueling cancer growth. Transcriptome analysis identified four lung nodule subtypes (G1-4) with distinct molecular features and immune cell infiltrations: EGFR-driven G1, EGFR/TP53 co-mutation G2, inflamed G3, stem-like G4. Estrogen/androgen response was associated with the EGFR pathway, proposing a new therapy combining tyrosine kinase inhibitors with antiestrogens. Preinvasive nodules exhibited stem cell pathway enrichment, potentially hindering invasion. Epigenetic regulation of various genes was essential for lung cancer initiation and development. This study provides insights into the molecular mechanism of neoplastic progression and identifies potential diagnostic biomarkers and therapeutic targets for lung cancer.

The evolution of the treatment of non-small cell lung cancer: A shift in surgical paradigm to a more individualized approach

Surgical treatment is an integral part of the comprehensive therapeutic methods for lung cancer, especially for early-stage non-small cell lung cancer (NSCLC). With a deeper understanding of the disease, we found that lung cancer is more commonly detected in young females. For regions of Asia, more lung cancer has been detected in early-stage GGO-dominant non-smokers. Therefore, surgical strategies have also been reformed commensurate with the shift of the disease spectrum. However, the pursuit of lung-sparing individualized approaches has raised worldwide attention. Suitable surgical treatment within the curative time window is recommended to maximize the long-term benefit. This article summarizes the shift in surgical treatment for small NSCLCs and hopes to enlighten further innovations to fill in the gaps between the unmet needs and a more individualized approach.

CT morphological features and histogram parameters to predict micropapillary or solid components in stage IA lung adenocarcinoma

Objectives

This study aimed to construct prediction models based on computerized tomography (CT) signs, histogram and morphology features for the diagnosis of micropapillary or solid (MIP/SOL) components of stage IA lung adenocarcinoma (LUAC) and to evaluate the models' performance.

Methods

This clinical retrospective study included image data of 376 patients with stage IA LUAC based on postoperative pathology, admitted to Putian First Hospital from January 2019 to June 2023. According to the presence of MIP/SOL components in postoperative pathology, patients were divided into MIP/SOL+ and MIP/SOL- groups. Cases with tumors ≤ 3 cm and ≤ 2 cm were separately analyzed. Each subgroup of patients was then randomly divided into a training set and a test set in a ratio of 7:3. The training set was used to build the prediction model, and the test set was used for internal validation.

Results

For tumors ≤ 3 cm, ground-glass opacity (GGO) [odds ratio (OR) = 0.244; 95% confidence interval (CI): 0.103-0.569; p = 0.001], entropy (OR = 1.748; 95% CI: 1.213-2.577; p = 0.004), average CT value (OR = 1.002; 95% CI: 1.000-1.004; p = 0.002), and kurtosis (OR = 1.240; 95% CI: 1.023-1.513; p = 0.030) were independent predictors of MIP/SOL components of stage IA LUAC. The area under the ROC curve (AUC) of the nomogram prediction model for predicting MIP/SOL components was 0.816 (95% CI: 0.756-0.877) in the training set and 0.789 (95% CI: 0.689-0.889) in the test set. In contrast, for tumors ≤ 2 cm, kurtosis was no longer an independent predictor. The nomogram prediction model had an AUC of 0.811 (95% CI: 0.731-0.891) in the training set and 0.833 (95% CI: 0.733-0.932) in the test set.

Conclusion

For tumors ≤ 3 cm and ≤ 2 cm, GGO, average CT value, and entropy were the same independent influencing factors in predicting MIP/SOL components of stage IA LUAC. The nomogram prediction models have potential diagnostic value for identifying MIP/SOL components of early-stage LUAC.

Sublobar resection for small-sized non-small cell lung cancer: A comprehensive comparison between subsegmentectomy, segmentectomy and wedge resection

OBJECTIVES

Subsegmentectomy has been adopted for non-small cell lung cancer (NSCLC) for decades. This study aimed to compare the features between subsegmentectomy, segmentectomy and wedge resection for NSCLC.

MATERIALS AND METHODS

NSCLC patients who underwent subsegmentectomy, segmentectomy, or wedge resection between 2014 and 2019 were retrospectively screened. Demographic, radiomic, and perioperative characteristics between patients were compared. Further, log-rank test, univariate and multivariate Cox regression were used for prognostic evaluation.

RESULTS

There were 276, 670, and 494 patients undergoing subsegmentectomy, segmentectomy, and wedge resection, respectively. Patients with segmentectomy and subsegmentectomy had larger tumor sizes and greater distances to the pleura than those with wedge resection. Subsegmentectomy and segmentectomy were more likely to achieve adequate surgical margins than wedge resection (82.0 % vs. 79.5 % vs. 64.7 %, P < 0.001), which was especially true for nodules away from the pleura (80.2 % vs. 81.4 % vs. 55.8 %, P < 0.001). In addition, anatomic resection allowed for more lymph node dissection and required less preoperative localization than wedge reception. Subsegmentectomy preserved about two subsegments than segmentectomy (P < 0.001). The incidence of prolonged air leakage after subsegmentectomy (3.3 %) and wedge (1.8 %) was similar (P = 0.308). Notably, 66.8 % of patients who underwent segmentectomy or subsegmentectomy were considered unsuitable for wedge. During the follow-up (55.1 months), no tumor recurrence or death occurred in patients undergoing subsegmentectomy. No significant recurrence-free survival (P = 0.140) or overall survival (P = 0.370) difference existed between these groups.

CONCLUSIONS

Subsegmentectomy could achieve more adequate surgical margins than wedge resection and showed superiority for deep nodules. Compared to segmentectomy, subsegmentectomy could preserve more lung parenchyma.

A clinical nomogram for predicting occult lymph node metastasis in patients with non-small-cell lung cancer ≤2 cm

OBJECTIVES

Sublobar resection has been shown to be feasible for non-small-cell lung cancers (NSCLC) <2 cm in size based on several prospective studies. However, the prognosis of clinical N0 patients who experience an N-stage upgrade after surgery [known as occult lymph node metastasis (OLM)] may be worse. The ability of predict OLM in patients eligible for sublobar resection remains a controversial issue.

METHODS

Patients with NSCLC ≤2 cm in diameter and containing a solid component who underwent surgical treatment at the Affiliated Hospital of Qingdao University were retrospectively enrolled, and 1:1 case matching was performed. The risk factors were identified through logistic regression analyses and theoretical criteria, followed by the development of a nomogram that was evaluated using 200 iterations of 10-fold cross-validation.

RESULTS

After case matching, 130 pairs of patients were selected for modelling. According to the multivariable logistic regression analysis, the carcinoembryonic antigen level, consolidation tumour ratio, mean computed tomography number and tumour margin were included in the nomogram. The cross-validated average area under the receiver operating characteristic curve was found to be 0.86. Furthermore, calibration curve and decision curve analyses demonstrated the excellent predictive accuracy and clinical utility of the nomogram respectively.

CONCLUSIONS

By utilizing accessible characteristics, we developed a nomogram that predicts the probability of OLM in patients with NSCLC ≤2 cm with a solid component. Risk stratification with this nomogram could aid in surgical method decision-making.

CLINICAL REGISTRATION NUMBER

Not applicable.

Lobar or sublobar resection of peripheral stage I non-small cell lung cancer

PURPOSE OF REVIEW

We aim to highlight two recent clinical trials that have altered the approach of the management of stage I nonsmall cell lung cancer.

RECENT FINDINGS

The JCOG 0802 and CALGB 140503 trials demonstrated that sublobar resection is noninferior to lobectomy for overall and disease-free survival in patients with stage I nonsmall cell lung cancer.

SUMMARY

Since 1962, lobectomy has been deemed the gold standard treatment for operable lung cancer. However, two recent clinical trials have demonstrated that, for select patients, sublobar resection is oncologically noninferior; results, which are leading us into a new era for the surgical management of lung cancer. Notwithstanding the progress made by these studies and the opportunities that have been put forth, questions remain. This review aims at reviewing the results of both trials and to discuss future perspectives for the surgical treatment of lung cancer.

Effectiveness and safety of segmentectomy vs. wedge resection for the treatment of patients with operable non‑small cell lung cancer: A meta‑analysis and systematic review

The present study compared the differences in effectiveness and safety between segmentectomy (ST) and wedge resection (WR) in patients with operable non-small cell lung cancer (NSCLC). The PubMed, EMBASE, Cochrane Library and Web of Science databases were searched for papers published from inception until July 2023. The inclusion criteria were based on the population, intervention, comparator, outcomes and study designs. ROBINS-I was selected to assess the risk of bias and quality of evidence in the included non-randomised studies. Appropriate effect sizes were selected, and subgroup analyses, heterogeneity tests, sensitivity analyses and publication bias were applied. A total of 18 retrospective studies were included, involving 19,381 patients with operable NSCLC. The 5-year overall survival rate [hazard ratio (HR), 0.19; 95% confidence interval (CI), 0.04, 0.34; P=0.014; I2=76.3%], lung cancer-specific survival rate (HR, 0.3; 95% CI, 0.21, 0.38; P<0.01; I2=13.8%) and metastasis rate [odds ratio (OR), 1.56; 95% CI, 1.03, 2.38; P=0.037] in patients with operable NSCLC treated with WR were worse than those in patients treated with ST. The incidence of postoperative complications (OR, 0.44; 95% CI, 0.23, 0.82) in the WR group was lower than in the ST treatment group. There was no difference in postoperative recurrence (OR, 2.15; 95% CI, 0.97, 4.74; P=0.058) and mortality (risk difference, 0.04; 95% CI, -0.03, 0.11; P=0.287) between groups. Based on current evidence, patients with NSCLC treated with ST surgery have better postoperative survival but more complications than those patients treated with WT, while the effect of WR and ST on the recurrence rate and distant metastasis rate remains controversial.

Intentional wedge resection versus segmentectomy for ≤2 cm ground-glass-opacity-dominant non-small cell lung cancer: a real-world study using inverse probability of treatment weighting

BACKGROUND

Whether wedge resection is oncological suitable for ground glass opacity (GGO)-dominant non-small cell lung cancer (NSCLC) ≤2 cm is still debatable. The aim of this study is to investigate the short-term and long-term outcomes of intentional wedge resection and segmentectomy for those patients.

MATERIALS AND METHODS

This was a real-world study from one of the largest thoracic surgery centers in West China. Patients who underwent intentional wedge resection or segmentectomy for ≤2 cm CTR (consolidation-to-tumor) ≤0.5 NSCLC were consecutively included between December 2009 and December 2018. Data were prospectively collected and retrospectively reviewed. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Long-term outcomes, including overall survival (OS), recurrence-free survival (RFS), and lung cancer-specific survival (LCSS), were analyzed using Cox proportional model.

RESULTS

A total of 1209 patients were included (497 in the wedge resection group, 712 in the segmentectomy group). Compared to segmentectomy, wedge resection had a significantly lower rate of complications (3.8 vs. 7.7%, P =0.008), a shorter operating time (65 min vs. 114 min, P <0.001), and a shorter postoperative stay (3 days vs. 4 days, P <0.001). The median follow-up was 70.1 months. The multivariate Cox model indicated that wedge resection had survival outcomes that were similar to segmentectomy in terms of 5-year OS (98.8 vs. 99.6%, HR=1.98, 95% CI: 0.59-6.68, P =0.270), 5-year RFS (98.8 vs. 99.5%, HR=1.88, 95% CI: 0.56-6.31, P =0.307) and 5-year LCSS (99.9 vs. 99.6%, HR=1.76, 95% CI: 0.24-13.15, P =0.581).

CONCLUSION

Intentional wedge resection is an appropriate choice for ≤2 cm GGO-dominant NSCLC.

Enhancing surgical precision in early-stage non-small cell lung cancer: A novel approach through temporary pulmonary vascular occlusion

BACKGROUND

To evaluate a novel intraoperative localization technique utilizing temporary pulmonary arteriovenous occlusion for enhancing the precision of sublobar resections in early-stage NSCLC.

METHODS

Conducted from January to November 2023, this study involved 140 patients. During the surgery, key pulmonary vessels were identified using preoperative three-dimensional (3D) imaging and temporarily occluded with noninvasive clamps to isolate the target lung segment. Following vascular occlusion, indocyanine green (ICG) was administered intravenously to precisely delineate the resection margins. After visually confirming the marked areas, the clamps were released, and a targeted partial resection was performed on the delineated segment. Surgical data, including operation times, surgical margins, and hospitalization costs, were collected and compared with those from a historical control group of 110 patients who underwent traditional pulmonary wedge resections.

RESULTS

In the study group, the median surgical margin achieved was 16 mm, which was statistically significant compared to 15 mm in the control group (p < 0.05). Operation times were reduced to an average of 58.43 ± 12.962 min, showing a decrease from the control group's average of 69.50 ± 17.544 min (p < 0.05). Hospitalization costs were also lower, averaging $4772.98 ± 624.339 for the study group versus $5161.34 ± 856.336 for the control group (p < 0.05). Patient safety was maintained with no increase in surgical complications.

CONCLUSION

The technique, leveraging temporary pulmonary arteriovenous occlusion, offered a significant advancement in the surgical treatment of peripheral early-stage NSCLC. It reduced operation time and lowered overall surgical costs. This method represented a promising alternative to traditional surgical approaches.

Uniportal Video-Assisted Thoracoscopic Segmentectomy for Early-Stage Non-Small Cell Lung Cancer: Overview, Indications, and Techniques

Twenty years have passed since uniportal video-assisted thoracoscopic surgery (VATS) was first reported. Several reports have already proven the minimal invasiveness of uniportal VATS. In addition, two large clinical trials recently demonstrated the benefits of segmentectomy for small peripheral early-stage non-small cell lung cancer. Uniportal VATS segmentectomy is considered the most beneficial minimally invasive surgery for patients with early-stage lung cancer. However, a high level of skill and experience are required to achieve this goal. Only a few reports have discussed specific techniques, particularly for complex segmentectomies. In this Special Issue, we reviewed previous reports on uniportal VATS segmentectomy regarding the indications, instrument selection, marking of the tumor location, methods of intersegmental plane identification, and lymph node dissection, including our own techniques with video content.

Construction of a predictive model of 2-3 cm ground-glass nodules developing into invasive lung adenocarcinoma using high-resolution CT

Background

The purpose of this study was to analyze the imaging risk factors for the development of 2-3 cm ground-glass nodules (GGN) for invasive lung adenocarcinoma and to establish a nomogram prediction model to provide a reference for the pathological prediction of 2-3 cm GGN and the selection of surgical procedures.

Methods

We reviewed the demographic, imaging, and pathological information of 596 adult patients who underwent 2-3 cm GGN resection, between 2018 and 2022, in the Department of Thoracic Surgery, Second Affiliated Hospital of the Air Force Medical University. Based on single factor analysis, the regression method was used to analyze multiple factors, and a nomogram prediction model for 2-3 cm GGN was established.

Results

(1) The risk factors for the development of 2-3 cm GGN during the invasion stage of the lung adenocarcinoma were pleural depression sign (OR = 1.687, 95%CI: 1.010-2.820), vacuole (OR = 2.334, 95%CI: 1.222-4.460), burr sign (OR = 2.617, 95%CI: 1.008-6.795), lobulated sign (OR = 3.006, 95%CI: 1.098-8.227), bronchial sign (OR = 3.134, 95%CI: 1.556-6.310), diameter of GGN (OR = 3.118, 95%CI: 1.151-8.445), and CTR (OR = 172.517, 95%CI: 48.023-619.745). (2) The 2-3 cm GGN risk prediction model was developed based on the risk factors with an AUC of 0.839; the calibration curve Y was close to the X-line, and the decision curve was drawn in the range of 0.0-1.0.

Conclusion

We analyzed the risk factors for the development of 2-3  cm GGN during the invasion stage of the lung adenocarcinoma. The predictive model developed based on the above factors had some clinical significance.

Prediction of visceral pleural invasion of clinical stage I lung adenocarcinoma using thoracoscopic images and deep learning

PURPOSE

To develop deep learning models using thoracoscopic images to identify visceral pleural invasion (VPI) in patients with clinical stage I lung adenocarcinoma, and to verify if these models can be applied clinically.

METHODS

Two deep learning models, one based on a convolutional neural network (CNN) and the other based on a vision transformer (ViT), were applied and trained via 463 images (VPI negative: 269 images, VPI positive: 194 images) captured from surgical videos of 81 patients. Model performances were validated via an independent test dataset containing 46 images (VPI negative: 28 images, VPI positive: 18 images) from 46 test patients.

RESULTS

The areas under the receiver operating characteristic curves of the CNN-based and ViT-based models were 0.77 and 0.84 (p = 0.304), respectively. The accuracy, sensitivity, specificity, and positive and negative predictive values were 73.91, 83.33, 67.86, 62.50, and 86.36% for the CNN-based model and 78.26, 77.78, 78.57, 70.00, and 84.62% for the ViT-based model, respectively. These models' diagnostic abilities were comparable to those of board-certified thoracic surgeons and tended to be superior to those of non-board-certified thoracic surgeons.

CONCLUSION

The deep learning model systems can be utilized in clinical applications via data expansion.

What Is an Adequate Margin During Sublobar Resection of ≤3 cm N0 Subsolid Lung Adenocarcinomas?

BACKGROUND

Sublobar resection offers noninferior survival vs lobectomy for ≤2 cm non-small cell lung cancer and is commonly used for subsolid tumors. Although data exist for solid tumors, the minimum adequate margin of resection for subsolid adenocarcinomas remains unclear.

METHODS

This was a retrospective review of 1101 adenocarcinoma resections at our institution from 2006 to 2022. Inclusion criteria were tumors ≤3 cm with ≥10% radiographic ground glass, excised by sublobar resection. Exclusions were positive nodes or positive or unreported margin. The primary outcome was the rate of local recurrence (LR) at multiple thresholds of margin distance. The relationship between margin distance and solid component size was also explored.

RESULTS

Inclusion criteria were met by 194 patients. Median (interquartile range) tumor diameter and margin distance were 12 mm (9-17 mm) and 10 mm (5-17 mm), respectively. Median follow-up was 42.5 months. There was a progressive increase in LR with diminishing margin (0.1-cm decrements) from 1.5 cm to 0.5 cm. The difference in the rate of LR between "over" (n = 143) and "under" (n = 51) was most significant at 0.5 cm (8 of 51 [15.7%] vs 6 of 143 [4.2%]; P = .01) but did not reach α adjusted for multiple comparisons. On Cox regression for LR-free survival, margin ≤0.5 cm (P = .19) and solid component percentage (P = .14) trended to significance. Combining these using a ratio of margin distance-to-solid component size, a ratio of ≤1 showed a significantly higher rate of LR (7 [14.3%] vs 2 [2.0%], P = .009). Treatment of LRs provided at least intermediate-term survival in 87% of recurrences (median postrecurrence follow-up was 44 months).

CONCLUSIONS

During sublobar resection of subsolid lung adenocarcinomas, a margin distance-to-solid component size ratio of >1.0 appears to be a more reliable factor than margin distance alone to minimize local recurrence. Local recurrence, however, may not impact survival in patients with subsolid adenocarcinomas if timely treatment is administered.

So Now We Know-Reflections on the Extent of Resection for Stage I Lung Cancer

Lobectomy has been the standard treatment for stage I lung cancer in healthy patients, largely based on a randomized trial published in 1995. Nevertheless, research has continued regarding the role of sublobar resection. Three additional randomized trials addressing resection extent in healthy patients have recently been published. These 4 trials involve differences in design, eligibility, interventions, and intraoperative processes. Patients were ineligible if intraoperative assessment demonstrated stage > IA or inadequate resection margins. All trials consistently show no differences in perioperative morbidity, mortality, and postoperative changes in lung function between sublobar resection and lobectomy-consistent with other nonrandomized evidence. Long-term outcomes are generally encouraging of lesser resection, but some inconsistencies are apparent. The 2 larger recent trials demonstrated no overall survival difference while the others suggested better survival after lobectomy versus sublobar resection. Recurrence-free survival was found to be the same after lobectomy versus sublobar resection in 3 trials, despite higher locoregional recurrences after sublobar resection. The low 5-year recurrence-free survival (64%, regardless of resection extent) in 1 recent trial highlights the need for further optimization. Thus, there is high-level evidence that sublobar resection is a reasonable alternative to lobectomy in healthy patients. However, variability in long-term results suggests that aspects of patients, tumors and interventions need to be better understood. Therefore, we propose to apply sublobar resection cautiously; especially because there are no short-term benefits. Sublobar resection requires careful attention to intraoperative details (nodes, margins), and may be best suited for less aggressive (eg, ground glass, slow growing) tumors.

Comparison of early patient-reported outcomes between uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small-cell lung cancer

BACKGROUND

Analysis of patient-reported outcomes (PROs) offers valuable insights into distinguishing the effects of closely related medical procedures from the patient's perspective. In this study we compared symptom burden in patients undergoing uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small cell lung cancer (NSCLC).

METHODS

This study included patients with peripheral NSCLC from an ongoing longitudinal prospective cohort study (CN-PRO-Lung 3) who underwent segmentectomy or wedge resection with tumor diameter ≤ 2 cm and consolidation tumor ratio (CTR) ≤ 0.5. PROs data were collected using the Perioperative Symptom Assessment for Lung Surgery questionnaire pre-operatively, daily post-surgery up to the fourth hospitalization day, and weekly post-discharge up to the fourth week. Propensity score matching and a generalized estimation equation model were employed to compare symptom severity. In addition, short-term clinical outcomes were compared.

RESULTS

In total, data of 286 patients (82.4%) undergoing segmentectomy and 61 patients (17.6%) undergoing wedge resection were extracted from the cohort. No statistically significant differences were found in the proportion of moderate-to-severe symptoms and mean scores for pain, cough, shortness of breath, disturbed sleep, fatigue, drowsiness, and distress during the 4-day postoperative hospitalization or the 4-week post-discharge period before or after matching (all p > 0.05). Compared with segmentectomy, wedge resection showed better short-term clinical outcomes, including shorter operative time (p = 0.001), less intraoperative bleeding (p = 0.046), and lower total hospital costs (p = 0.002).

CONCLUSIONS

The study findings indicate that uniportal thoracoscopic segmentectomy and wedge resection exert similar early postoperative symptom burden in patients with peripheral NSCLC (tumor diameter ≤ 2 cm and CTR ≤ 0.5).

CLINICAL TRIAL REGISTRATION

Not applicable.

A nomogram based on the quantitative and qualitative features of CT imaging for the prediction of the invasiveness of ground glass nodules in lung adenocarcinoma

PURPOSE

Based on the quantitative and qualitative features of CT imaging, a model for predicting the invasiveness of ground-glass nodules (GGNs) was constructed, which could provide a reference value for preoperative planning of GGN patients.

MATERIALS AND METHODS

Altogether, 702 patients with GGNs (including 748 GGNs) were included in this study. The GGNs operated between September 2020 and July 2022 were classified into the training group (n = 555), and those operated between August 2022 and November 2022 were classified into the validation group (n = 193). Clinical data and the quantitative and qualitative features of CT imaging were harvested from these patients. In the training group, the quantitative and qualitative characteristics in CT imaging of GGNs were analyzed by using performing univariate and multivariate logistic regression analyses, followed by constructing a nomogram prediction model. The differentiation, calibration, and clinical practicability in both the training and validation groups were assessed by the nomogram models.

RESULTS

In the training group, multivariate logistic regression analysis disclosed that the maximum diameter (OR = 4.707, 95%CI: 2.06-10.758), consolidation/tumor ratio (CTR) (OR = 1.027, 95%CI: 1.011-1.043), maximum CT value (OR = 1.025, 95%CI: 1.004-1.047), mean CT value (OR = 1.035, 95%CI: 1.008-1.063; P = 0.012), spiculation sign (OR = 2.055, 95%CI: 1.148-3.679), and vascular convergence sign (OR = 2.508, 95%CI: 1.345-4.676) were independent risk parameters for invasive adenocarcinoma. Based on these findings, we established a nomogram model for predicting the invasiveness of GGN, and the AUC was 0.910 (95%CI: 0.885-0.934) and 0.902 (95%CI: 0.859-0.944) in the training group and the validation group, respectively. The internal validation of the Bootstrap method showed an AUC value of 0.905, indicating a good differentiation of the model. Hosmer-Lemeshow goodness of fit test for the training and validation groups indicated that the model had a good fitting effect (P > 0.05). Furthermore, the calibration curve and decision analysis curve of the training and validation groups reflected that the model had a good calibration degree and clinical practicability.

CONCLUSION

Combined with the quantitative and qualitative features of CT imaging, a nomogram prediction model can be created to forecast the invasiveness of GGNs. This model has good prediction efficacy for the invasiveness of GGNs and can provide help for the clinical management and decision-making of GGNs.

Ten-year follow-up outcomes of limited resection trial for radiologically less-invasive lung cancer

BACKGROUND

The JCOG0804/WJOG4507L single-arm confirmatory trial indicated a satisfactory 10-year prognosis for patients who underwent limited resection for radiologically less-invasive lung cancer. However, only one prospective trial has reported a 10-year prognosis.

METHODS

We conducted a multicenter prospective study coordinated by the National Cancer Center Hospital East and Kanagawa Cancer Center. We analyzed the long-term prognosis of 100 patients who underwent limited resection of a radiologically less-invasive lung cancer in the peripheral lung field. We defined radiologically less-invasive lung cancer as lung adenocarcinoma with a maximum tumor diameter of ≤2 cm, tumor disappearance ratio of ≥0.5 and cN0. The primary endpoint was the 10-year local recurrence-free survival.

RESULTS

Our patients, with a median age of 62 years, included 39 males. A total of 58 patients were non-smokers; 87 had undergone wide wedge resection and 9 underwent segmentectomy. A total of four cases were converted to lobectomy because of the presence of poorly differentiated components in the frozen specimen or insufficient margin with segmentectomy. The median follow-up duration was 120.9 months. The 10-year recurrence-free survival and overall survival rates of patients with lung cancer were both 96.0%. Following the 10-year long-term follow-up, two patients experienced recurrences at resection ends after wedge resection.

CONCLUSIONS

Limited resection imparted a satisfactory prognosis for patients with radiologically less-invasive lung cancer, except two cases of local recurrence >5 years after surgery. These findings suggest that patients with this condition who underwent limited resection may require continued follow-up >5 years after surgery.

Advancements in the diagnosis and treatment of sub‑centimeter lung cancer in the era of precision medicine (Review)

Lung cancer is the malignancy with the highest global mortality rate and imposes a substantial burden on society. The increasing popularity of lung cancer screening has led to increasing number of patients being diagnosed with pulmonary nodules due to their potential for malignancy, causing considerable distress in the affected population. However, the diagnosis and treatment of sub-centimeter grade pulmonary nodules remain controversial. The evolution of genetic detection technology and the development of targeted drugs have positioned the diagnosis and treatment of lung cancer in the precision medicine era, leading to a marked improvement in the survival rate of patients with lung cancer. It has been established that lung cancer driver genes serve a key role in the development and progression of sub-centimeter lung cancer. The present review aimed to consolidate the findings on genes associated with sub-centimeter lung cancer, with the intent of serving as a reference for future studies and the personalized management of sub-centimeter lung cancer through genetic testing.

Feasibility of thoracoscopic monosubsegmentectomy for small ground-glass opacity dominant lung cancer

BACKGROUND

Monosubsegmentectomy (MSS) involves removal of less lung parenchyma than monosegmentectomy (MS) does. However, the clinical efficacy of MSS in lung cancer treatment remains unclear, with concerns regarding insufficient surgical margins and increased complications.

METHODS

Between February 2015 and December 2019, patients who underwent thoracoscopic MSS (n = 126) or MS (n = 678) for small ground-glass opacity (GGO) dominant lung cancer were examined. The primary endpoints were the procedure success rate (defined as resection with a surgical margin ≥2 cm or tumor size) and surgical margin.

RESULTS

There were no significant differences in age, sex, smoking history, or comorbidities between the groups. Both groups achieved a success rate of 100%. No significant group differences were observed in the number of lymph nodes removed (p = 0.060), overall complications (p = 0.147), or major complications (p = 0.450). The MSS group had a smaller surgical margin (median, 17 vs. 21mm, p < 0.001) and longer operative time (median, 138 vs. 130 min, p = 0.005) than the MS group did. Propensity score-matched analysis of 122 pairs of patients revealed consistent results. Surgical margins were further compared based on the number of resected subsegments. The 1 subsegment group had the smallest median surgical margin, followed by the 2 and 3 subsegments groups (17, 20, and 23 mm, p < 0.001).

CONCLUSIONS

Thoracoscopic MSS is an acceptable option for treating patients with small-sized GGO-dominant lung cancer. However, the close surgical margins and prolonged operative time should be considered.

Clinical Utility of a CT-based AI Prognostic Model for Segmentectomy in Non-Small Cell Lung Cancer

Background Currently, no tool exists for risk stratification in patients undergoing segmentectomy for non-small cell lung cancer (NSCLC). Purpose To develop and validate a deep learning (DL) prognostic model using preoperative CT scans and clinical and radiologic information for risk stratification in patients with clinical stage IA NSCLC undergoing segmentectomy. Materials and Methods In this single-center retrospective study, transfer learning of a pretrained model was performed for survival prediction in patients with clinical stage IA NSCLC who underwent lobectomy from January 2008 to March 2017. The internal set was divided into training, validation, and testing sets based on the assignments from the pretraining set. The model was tested on an independent test set of patients with clinical stage IA NSCLC who underwent segmentectomy from January 2010 to December 2017. Its prognostic performance was analyzed using the time-dependent area under the receiver operating characteristic curve (AUC), sensitivity, and specificity for freedom from recurrence (FFR) at 2 and 4 years and lung cancer-specific survival and overall survival at 4 and 6 years. The model sensitivity and specificity were compared with those of the Japan Clinical Oncology Group (JCOG) eligibility criteria for sublobar resection. Results The pretraining set included 1756 patients. Transfer learning was performed in an internal set of 730 patients (median age, 63 years [IQR, 56-70 years]; 366 male), and the segmentectomy test set included 222 patients (median age, 65 years [IQR, 58-71 years]; 114 male). The model performance for 2-year FFR was as follows: AUC, 0.86 (95% CI: 0.76, 0.96); sensitivity, 87.4% (7.17 of 8.21 patients; 95% CI: 59.4, 100); and specificity, 66.7% (136 of 204 patients; 95% CI: 60.2, 72.8). The model showed higher sensitivity for FFR than the JCOG criteria (87.4% vs 37.6% [3.08 of 8.21 patients], P = .02), with similar specificity. Conclusion The CT-based DL model identified patients at high risk among those with clinical stage IA NSCLC who underwent segmentectomy, outperforming the JCOG criteria. © RSNA, 2024 Supplemental material is available for this article.

Oncological feasibility of segmentectomy for inner-located lung cancer

Objective

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

Methods

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

Results

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

Conclusions

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

Omitting Lymph Node Dissection for Small Ground-Glass Opacity-Dominant Tumors

BACKGROUND

The purpose of this study was to determine the optimal extent of lymph node dissection required in patients with small (≤3 cm) radiologically ground-glass opacity-dominant, peripheral, non-small cell lung cancer tumors.

METHODS

The study analyzed the clinicopathologic findings and surgical outcomes of 988 patients with radiologic, ground-glass opacity-dominant non-small cell lung cancer without lymph node involvement who underwent complete resection of the primary tumor between 2010 and 2020. Patients were followed up for 54.5 months (median). Kaplan-Meier curves and the log-rank test were used in statistical analyses of the prognosis.

RESULTS

Median age, whole tumor size, solid tumor size, and maximum standardized uptake values were 68 years, 1.7 cm, 0.4 cm, and 0.9, respectively. Sixty percent of the cohort was female (n = 590). Wedge resection, segmentectomy, and lobectomy were performed in 206, 372, and 410 patients, respectively. A total of 982 of 988 (99%) tumors were adenocarcinomas. One patient had hilar lymph node involvement; however, no mediastinal lymph node metastasis or hilar or mediastinal lymph node recurrence was detected. The 5-year overall survival rate was 96.5% (95% CI, 94.8%-97.7%). Excellent survival outcomes were achieved regardless of procedure (wedge resection, 94.7% [95% CI, 89.1%-97.5%]; segmentectomy, 96.9% [95% CI, 93.7%-98.5%]; and lobectomy, 97.1% [95% CI, 94.4%-98.5%]).

CONCLUSIONS

Omitting lymph node dissection may be acceptable with curative intent for small tumors with radiologic ground-glass opacity dominance. Appropriate surgical procedures such as wedge resection, segmentectomy, or lobectomy can provide satisfactory outcomes in patients with indolent tumors if surgical margins are secured.

Application of three-dimensional technology in video-assisted thoracoscopic surgery sublobectomy

Background

Due to the widespread use of imaging techniques, the detection rate of early-stage lung cancer has increased. Video-assisted thoracoscopic surgery (VATS) sublobectomy has emerged as a prominent alternative to lobectomy, offering advantages like reduced resection range, better preservation of lung function, and enhanced postoperative quality of life. However, sublobectomy is more intricate than lobectomy, necessitating a higher level of surgical proficiency and anatomical understanding.

Methods

Three electronic databases were searched to capture relevant studies from January 2016 to March 2023, which related to the application of three-dimensional(3D) technology in VATS sublobectomy.

Results

Currently, clinical departments such as orthopedics, hepatobiliary surgery, and urology have started using 3D technology. This technology is expected to be widely used in thoracic surgery in future. Now 3D technology assists in preoperative planning, intraoperative navigation and doctor-patient communication.

Conclusion

3D technologies, instrumental in locating pulmonary nodules and identifying variations in target lung segmental vessels and bronchi, play pivotal roles in VATS sublobectomy, especially in preoperative planning, intraoperative navigation, and doctor-patient communication. The limitations of 3D technology in clinical application are analyzed, and the future direction of existing 3D technology development is prospected.

The effect of spread through air spaces on postoperative recurrence-free survival in patients with multiple primary lung cancers

PURPOSE

The purpose of the study was to investigate the effect of spread through air spaces (STAS) on the postoperative prognosis of patients with multiple primary lung cancers staged from IA to IB based on tumor size.

METHODS

Clinicopathological and follow-up data of 122 patients with multiple primary lung cancers diagnosed at stages IA-IB and surgically treated at the Department of Thoracic Surgery, Shenzhen people's Hospital from January 2019 to December 2021 were retrospectively analyzed. The study involved 42 males and 80 females. STAS status was used to divide them into two groups (87 cases in STAS (-) and 35 cases in STAS (+)). A logistic regression analysis, univariate and multivariate Cox regression analysis, and Kaplan-Meier curves (K-M) were used to determine how STAS affected recurrence-free survival (RFS) in patients.

RESULTS

STAS (+) had a significantly higher recurrence rate than STAS (-). STAS was predicted by smoking history (P = 0.044), main tumor diameter (P = 0.02), and solid nodules on chest CT (P = 0.02). STAS incidence was not significantly different between lobectomy and sublobar resection groups (P = 0.17). Solid nodules on CT, tumor diameter, vascular invasion, pleural invasion, and STAS were significant predictors of recurrence in the univariate Cox regression analysis. Tumor diameter, pleural invasion and STAS were significant prognostic factors for recurrence in the multivariate Cox regression analysis. Furthermore, STAS (+) group was at greater risk of recurrence than STAS (-) group (34% vs. 0%, P < 0.05)。.

CONCLUSION

Stage IA-IB multiple primary lung cancer patients with STAS (+) had a higher recurrence rate and a shorter overall survival rate.

Prognostic implications of CT-defined ground glass opacity in clinical stage I-IIA grade 3 invasive non-mucinous pulmonary adenocarcinoma

AIM

To investigate the prognostic impact of computed tomography (CT)-defined ground glass opacity (GGO) in patients with clinical stage I-IIA grade 3 invasive non-mucinous pulmonary adenocarcinoma (INPA).

MATERIALS AND METHODS

The present study retrospectively enrolled 187 patients diagnosed with stage I-IIA grade 3 INPA. Their clinicopathological, radiological, and genetic information was evaluated systematically, and a 5-year follow-up was conducted to monitor disease recurrence and mortality. Patients were stratified based on the presence of a GGO component, and the Cox proportional hazard model was employed to assess the influence of clinicopathological factors and genetic variables on tumour outcomes. Recurrence-free survival (RFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Significant differences were observed in both OS and RFS based on the presence of a GGO component. The group with GGO exhibited superior OS (p=0.002) and RFS (p=0.029). Multivariate analysis revealed that the presence of a GGO component (hazard ratio [HR] = 0.412, 95% confidence interval [CI]: 0.177-0.959, p=0.040), clinical T2 stage (HR=2.473, 95% CI: 1.498-4.083, p<0.001), pathological N2 stage (HR=3.049, 95% CI: 1.800-5.167, p<0.001), and mixed high-grade patterns (HR=2.392, 95% CI: 1.418-4.036, p=0.001) were predictors of RFS.

CONCLUSION

The presence of a GGO component is strongly associated with a favourable prognosis in grade 3 INPA.

Predictors of residual simultaneous multiple ground-glass nodule progression after dominant lesion resection

OBJECTIVE

This study aimed to identify the predictive factors for the progression of residual simultaneous multifocal ground-glass nodules (SMGGNs) after resection of the dominant lesion.

METHODS

Patients (n = 3420) with primary lung cancer who underwent lung resections at our hospital between 2006 and 2016 were screened, and the data from 82 patients who had residual SMGGNs after undergoing surgery for the dominant lesion (pathologically stage 0-IIA) were retrospectively analyzed. Clinicopathological factors that predicted the growth of residual second dominant GGNs were identified.

RESULTS

Median total tumor and solid component sizes of the residual second dominant GGNs were 1.3 cm (interquartile range [IQR]: 0.6-2.0) and 0 cm (IQR: 0-0.7), respectively. During a median follow-up period of 54 months (IQR: 37-78 months), 35 (43%) lesions progressed. Logistic regression analysis revealed that age younger than 70 (OR: 10.54, 95% CI: 1.71-65.11), a dominant lesion with pure solid appearance (reference: GGN, OR: 18.16, 95% CI: 1.66-198.60), a second dominant GGN total size larger than 1.0 cm (OR: 12.27, 95% CI: 1.85-81.17), and a second dominant GGN solid component size larger than 0.5 cm (OR: 17.59, 95% CI: 3.58-86.47) were significant predictive factors for the progression of residual GGNs (all p values < 0.03). Based on an analysis of growth patterns, rapid growth was higher in second dominant GGNs with a part-solid appearance.

CONCLUSIONS

If the resected dominant lesion or the residual second dominant GGN exhibits high-risk factors, the second dominant GGN should be meticulously observed.

Safety and feasibility comparison between three different CT-guided localization techniques under systemic approach algorithm

INTRODUCTION

In the era of lung cancer screening, more and more sub-centimeter indeterminate lung lesions are being identified. It is difficult to approach these lesions and obtain tissue to confirm diagnosis. CT-guided navigation followed by surgical resection is the best way to overcome this difficulty. The aim of this study is to compare the safety and feasibility of wire and dye-tattoo CT-guided localization techniques.

MATERIALS AND METHODS

From September 2019 to August 2021, 418 patients who presented with single lung lesion and received single CT-guided localization were included in this study. Procedure details, navigation results, and related complications were compared.

RESULTS

For patients who received wire localization, majority (98.3 %) had perihilar lesions. In addition, 68 (57.1 %) patients received tangential approach because of lesions were blocked by bony or vital structure, abutting major fissure, or previous approach failure. The characteristics of lesion location was quite different than dye-tattooing technique (p = 0.033). As regards persistence of the target lesion localization, the interval between localization and surgery using ICG tattooing was 829.0 ± 552.9 min; much longer than the other two navigation techniques (p < 0.0001). As regards safety, patients who received wire localization had a higher rate of pneumothorax (p = 0.042) and pulmonary hemorrhage (p < 0.001) than the dye-tattooing techniques.

DISCUSSION

CT-guided navigation techniques are safe and feasible. Wire localization is suitable for centrally located lesions but the wire needs to be fixed properly and symptomatic pneumothorax monitored for. Dye-tattooing is more suitable for peripheral lesions, while ICG localization persists longer than other techniques.

Extent of surgical resection for radiologically subsolid T1N0 invasive lung adenocarcinoma: When is a wedge resection acceptable?

OBJECTIVE

To evaluate whether wedge resection (WR) was appropriate for the patients with peripheral T1 N0 solitary subsolid invasive lung adenocarcinoma.

METHODS

Patients with peripheral T1N0 solitary subsolid invasive lung adenocarcinoma who received sublobar resection were retrospectively reviewed. Clinicopathologic characteristics, 5-year recurrence-free survival, and 5-year lung cancer-specific overall survival were analyzed. Cox regression model was used to elucidate risk factors for recurrence.

RESULTS

Two hundred fifty-eight patients receiving WR and 1245 patients receiving segmentectomy were included. The mean follow-up time was 36.87 ± 16.21 months. Five-year recurrence-free survival following WR was 96.89% for patients with ground-glass nodule (GGN) ≤2 cm and 0.25< consolidation-to-tumor ratio (CTR) ≤0.5, not statistically different from 100% for those with GGN≤2 cm and CTR ≤0.25 (P = .231). The 5-year recurrence-free survival was 90.12% for patients with GGN between 2 and 3 cm and CTR ≤0.5, significantly lower than that of patients with GGN ≤2 cm and CTR ≤0.25 (P = .046). For patients with GGN≤2 cm and 0.25

CONCLUSIONS

WR might be appropriate for patients with invasive lung adenocarcinoma appearing as peripheral GGN ≤2 cm and CTR ≤0.5, but inappropriate for those with invasive lung adenocarcinoma appearing as peripheral GGN between 2 and 3 cm and CTR ≤0.5.

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Key Words

• lung invasive adenocarcinoma
• segmentectomy
• sublobar resection
• subsolid nodule
• wedge resection

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MESH Headings

• Humans
• Retrospective Studies
• Neoplasm Staging
• Pneumonectomy/adverse effects
• Adenocarcinoma of Lung/diagnostic imaging
• Adenocarcinoma of Lung/surgery
• Lung Neoplasms/diagnostic imaging
• Lung Neoplasms/surgery

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Affiliation(s)

Chao Zhang Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Yunjian Pan Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Hang Li Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Yang Zhang Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Bin Li Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Yiliang Zhang Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Xiaoyang Luo Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Longsheng Miao Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Longfei Ma Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Sufeng Chen Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Hong Hu Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Yihua Sun Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Yawei Zhang Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Jiaqing Xiang Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China
Shengping Wang Department of Oncology, Fudan University, Shanghai, China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
Yajia Gu Department of Oncology, Fudan University, Shanghai, China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
Yuan Li Department of Oncology, Fudan University, Shanghai, China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
Xuxia Shen Department of Oncology, Fudan University, Shanghai, China; Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
Zezhou Wang Department of Oncology, Fudan University, Shanghai, China; Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai, China
Ting Ye Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China.
Haiquan Chen Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, China; Institute of Thoracic Oncology, Fudan University, Shanghai, China; Department of Oncology, Fudan University, Shanghai, China.

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Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BACKGROUND

Video-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.

METHODS

Retrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.

RESULTS

30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).

CONCLUSIONS

We demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

CT imaging features of lung ground-glass nodule patients with upgraded intraoperative frozen pathology

PURPOSE

Intraoperative frozen section pathology (FS) is widely used to guide surgical strategies while the accuracy is relatively low. Underestimating the pathological condition may result in inadequate surgical margins. This study aims to identify CT imaging features related to upgraded FS and develop a predictive model.

METHODS

Collected data from 860 patients who underwent lung surgery from January to December 2019. We analyzed the consistency rate of FS and categorized the patients into three groups: Group 1 (n = 360) had both FS and Formalin-fixed Paraffin-embedded section (FP) as non-invasive adenocarcinoma (IAC); Group 2 (n = 128) had FS as non-IAC but FP as IAC; Group 3 (n = 372) had both FS and FP as IAC. Clinical baseline characteristics were compared and propensity score adjustment was used to mitigate the effects of these characteristics. Univariate analyses identified imaging features with inter-group differences. A multivariate analysis was conducted to screen independent risk factors for FS upgrade, after which a logistic regression prediction model was established and a receiver operating characteristic (ROC) curve was plotted.

RESULTS

The consistency rate of FS with FP was 84.19%. 26.67% of the patients with non-IAC FS diagnosis were upgraded to IAC. The predictive model's Area Under Curve (AUC) is 0.785. Consolidation tumor ratio (CTR) ≤ 0.5 and smaller nodule diameter are associated with the underestimation of IAC in FS.

CONCLUSION

CT imaging has the capacity to effectively detect patients at risk of upstaging during FS.

Differential efficacy of segmentectomy and wedge resection in sublobar resection compared to lobectomy for solid-dominant stage IA lung cancer: a systematic review and meta-analysis

BACKGROUND

Currently, the impact of sublobar resection versus lobectomy on the prognosis of solid-dominant stage IA lung cancer is contradictory in different studies, which requires further exploration.

METHODS

The authors analyzed 26 studies, including one randomized controlled trial and retrospective cohort studies. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using fixed-effects or random-effects models based on heterogeneity levels.

RESULTS

The analysis included 12 667 patients, with 3488 undergoing sublobar resections and 9179 receiving lobectomies. The overall analysis revealed no statistically significant difference in overall survival (OS) (HR=1.28, 95% CI: 0.98-1.69) between sublobar resection and lobectomy, but lobectomy was associated with better recurrence-free survival (RFS) (HR=1.39, 95% CI: 1.10-1.75). Subgroup analyses revealed that, for tumors with a diameter ≤2 cm, sublobar resection versus lobectomy showed no significant difference in OS but sublobar resection had lower RFS. For 2-3 cm tumors, both OS and RFS were significantly lower in the sublobar resection group. When consolidation-to-tumor ratio (CTR) ranged from 0.5 to <1, OS did not differ significantly, but RFS was significantly lower in sublobar resection. Lung cancers with CTR=1 showed significantly lower OS and RFS in the sublobar resection group. Segmentectomy provided similar OS and RFS compared to lobectomy, while wedge resection had a detrimental effect on patient prognosis. However, wedge resection may have provided comparable outcomes for patients aged 75 years or older.

CONCLUSION

Our findings suggest that segmentectomy and lobectomy yield similar oncological outcomes. However, compared to lobectomy, wedge resection is associated with a poorer prognosis. Nevertheless, for elderly patients, wedge resection is also a reasonable surgical option.

A gene-based score for the risk stratification of stage IA lung adenocarcinoma

OBJECTIVE

We aim to molecularly stratify stage IA lung adenocarcinoma (LUAD) for precision medicine.

METHODS

Twelve multi-institution datasets (837 cases of IA) were used to classify the high- and low-risk types (based on survival status within 5 years), and the biological differences were compared. Then, a gene-based classifying score (IA score) was trained, tested and validated by several machine learning methods. Furthermore, we estimated the significance of the IA score in the prognostic assessment, chemotherapy prediction and risk stratification of stage IA LUAD. We also developed an R package for the clinical application. The SEER database (15708 IA samples) and TCGA Pan-Cancer (1881 stage I samples) database were used to verify clinical significance.

RESULTS

Compared with the low-risk group, the high-risk group of stage IA LUAD has obvious enrichment of the malignant pathway and more driver mutations and copy number variations. The effect of the IA score on the classification of high- and low-risk stage IA LUAD was much better than that of classical clinicopathological factors (training set: AUC = 0.9, validation set: AUC = 0.7). The IA score can significantly predict the prognosis of stage IA LUAD and has a prognostic effect for stage I pancancer. The IA score can effectively predict chemotherapy sensitivity and occult metastasis or invasion in stage IA LUAD. The R package IAExpSuv has a good risk probability prediction effect for both groups and single stages of IA LUAD.

CONCLUSIONS

The IA score can effectively stratify the risk of stage IA LUAD, offering good assistance in precision medicine.

Sublobar resection is not always superior for early-stage lung cancer in high-risk patients

OBJECTIVES

The phase III trial, Japan Clinical Oncology Group 0802, illustrated the superiority of sublobar resection for early-stage lung cancer in terms of overall survival, with more non-lung cancer-related deaths after a lobectomy. The advantages of sublobar resection may be more pronounced in high-risk patients. The goal of this study was to elucidate the prognoses of high-risk patients.

METHODS

Patients with a risk of being ineligible for Japan Clinical Oncology Group 0802 for general conditions were classified as the high-risk group, and those who were not at risk of being ineligible were classified as the normal-risk group. Overall survival and prognostic factors were analysed in the high-risk group.

RESULTS

There were 254 (19.4%) and 1054 patients in the high- and normal-risk groups, respectively. Five-year survival rates were 94.5% and 79.1% in the normal-risk and high-risk groups, respectively (P < 0.001). More patients in the high-risk group died of lung cancer (P < 0.001) and non-lung cancer deaths (P < 0.001) than patients in the normal-risk group.In the high-risk group, 151 lobectomies and 103 sublobar resections were performed. There was no significant difference in the numbers of lung cancer deaths and of non-lung cancer deaths between the procedures. Stratified survival analyses showed that the diffusing capacity of the lungs for carbon monoxide  < 40% tended to favour sublobar resection; being female and having a high carcinoembryonic antigen level tended to favour a lobectomy.

CONCLUSIONS

Sublobar resection is not always superior for early-stage lung cancer. Even in such cases, the surgical method should be determined by taking into consideration the patient's background and lung cancer surveillance.

Preoperative pulmonary nodule localization: A comparison of hook wire and Lung-pro-guided surgical markers

In minimally invasive thoracoscopic surgery, for solitary pulmonary nodules (SPNs) far from the pleura, it is difficult to resected by only relying on imaging data, and effective preoperative localization can significantly improve the success rate of surgery. Therefore, preoperative localization is particularly important for accurate resection. Here, we compare the value of a novel Lung-pro-guided localization technique with Hook-wire localization in video-assisted thoracoscopic surgery.

METHOD

In this study, 70 patients who underwent CT-guided Hook-wire localization and Lung-pro guided surgical marker localization before VATS-based SPNs resection between May 2020 and March 2021 were analyzed, and the clinical efficacy and complication rate of the two groups were compared.

RESULT

Thirty-five patients underwent Lung-pro guided surgical marker localization, and 35 patients underwent CT-guided Hook-wire localization. The localization success rates were 94.3% and 88.6%, respectively (p = 0.673). Compared with the puncture group, the locating time in the Lung-pro group was significantly shorter (p = 0.000), and the wedge resection time was slightly shorter than that in the puncture group (P = 0.035). There were no significant differences in the success rate of localization, localization complications, intraoperative blood loss, postoperative hospital stay, and the number of staplers used.

CONCLUSION

The above studies show that the Lung-pro guided surgical marker localization and the CT-guided Hook-wire localization have shown good safety and effectiveness. However, the Lung-pro guided surgical marker localization may show more safety than the Hook-wire and can improve the patient's perioperative experience.

Three-dimensional imaging anatomical research and clinical implications of V1 +2 d in the left upper lung

BACKGROUND

To investigate the distribution pattern of V1+2 d in the left superior pulmonary vein and its clinical significance.

METHODS

A retrospective analysis was conducted using three-dimensional computed tomographic bronchography and angiography (3D-CTBA) data from 500 lung cancer patients. Statistical analyses were performed to evaluate the incidence and drainage patterns of the three sub-branches of V1+2 d, namely V1+2 d1, V1+2 d2 and V1+2 d3. Furthermore, clinical data from 10 patients' lesions involving V1+2 d were reviewed to illustrate the impact of adjacency to V1+2 d on the surgical approach.

RESULTS

The incidences of V1+2 d1, V1+2 d2 and V1+2 d3 were 100%, 76.4% and 100% respectively. The relative interlobar distribution sizes of B3 a and B1+2 c and the left upper division (LUD) vein type influenced the incidence of V1+2 d2 (p < 0.05; p < 0.001). V1+2 d2 predominantly occurred in B3 a = B1+2 c and B1+2 c > B3 a patterns. V1+2 d2 was entirely absent in the B3 a > B1+2 c pattern. V1+2 d2 exhibited a higher incidence in both the central vein (CV) type and the noncentral vein (NCV) type when compared to the semi-central vein (SCV) type (100% vs. 100% vs. 64.8%). The most prevalent venous drainage pattern was the three sub-branches of V1+2 d constituting a major trunk to drain (41.2%). All 10 cases with lesions involving V1+2 d successfully underwent sublobar resection with no complications, and the surgical margin was ≥2 cm.

CONCLUSIONS

The three sub-branches of V1+2 d exhibit a high incidence with diverse distribution patterns, yet a discernible pattern exists. For inter- or multi-intersegmental nodules involving V1+2 d, combined segmentectomy and subsegmentectomy or combined subsegmentectomy can ensure the safe margin.

A Shift in Paradigm: Selective Lymph Node Dissection for Minimizing Oversurgery in Early Stage Lung Cancer

Systematic lymph node dissection has been widely accepted and turned into a standard procedure for lung cancer surgery. In recent years, the concept of "minimal invasive surgery (MIS)" has greatly changed the surgical paradigm of lung cancer. Previous studies revealed that excessive dissection of lymph nodes without metastases had uncertain clinical benefit. Meanwhile, it leads to the elevated risk of postoperative complications including chylothorax and laryngeal nerve injury. In addition, dissection of nonmetastatic lymph nodes may disturb systematic immunity, resulting in the secondary effect on primary tumor or latent metastases. The past decades have witnessed the innovative strategies such as lobe-specific lymph node dissection and selective lymph node dissection. On the basis of evolution of lymph node dissection strategy, we discuss the negative effects of excessive nonmetastatic lymph node dissection and summarize the recent advances in the optimized dissection strategies, hoping to provide unique perspectives on the future directions.

Molecular screening reveals Variolin B as a multitargeted inhibitor of lung cancer: a molecular docking-based fingerprinting and molecular dynamics simulation study

Lung Cancer is the topmost death causing cancer and results from smoking, air pollution, cigar, exposure to asbestos or radon-like substances, and genetic factors. The cases of Lung Cancer in south Asian developing nations are being seen most due to heavy pollution and unbalanced lifestyle and putting a considerable burden on healthcare systems. The Food and Drug Administration of the USA has approved almost 100 drugs against SCLC and NSLC and a few drugs that are given to minimise the side effect of anticancer drugs. However, the drugs are shown to be resistant at significantly higher stages and non-affective on cancerous cells and have long-term side effects due to designing the drug by keeping one protein/gene target while designing or repurposing the drugs. In this study, we have taken five main lung cancer protein targets- Nerve growth factor protein (1SG1), Apoptosis inhibitor survivin (1XOX), Heat shock protein (3IUC), Protein tyrosine phosphate (3ZM3), Aldo-keto reductase (4XZL) and screened the complete prepared Drug Bank library of 155888 compounds and identified Variolin B (DB08694) as a multitargeted inhibitor against lung cancer using HTVS, SP and XP sampling algorithms followed by MM\GBSA calculation to sort the best pose. Variolin B is a natural marine antitumor and antiviral compound, so we analysed the ADMET properties and interaction patterns and then simulated all five P-L complexes for 100 ns in water using the NPT ensemble to check its selves against lung cancer. The docking results, ADMET and fingerprints have shown a good performance, and RMSD and RMSF results were with least deviation and fluctuations (<2Å) and produced a huge contact with other residues making the complex stable. The complexes initially fluctuated and deviated due to changes in the solute medium and sudden heat and stabilise after a few ns. However, extensive experimental validation is required before human use.Communicated by Ramaswamy H. Sarma.

Treatment strategies for malignant pulmonary nodule: beyond lobectomy. Point-counterpoint

PURPOSE OF REVIEW

Technological advancement in low-dose computed tomography resulted in an increased incidental discovery of early-stage lung cancer and multifocal ground glass opacity. The demand for parenchyma-preserving treatment strategies is greater now than ever. Pulmonary ablative therapy is a groundbreaking technique to offer local ablative treatment in a lung-sparing manner. It has become a promising technique in lung cancer management with its diverse applicability. In this article, we will review the current development of ablative therapy in lung and look into the future of this innovative technique.

RECENT FINDINGS

Current literature suggests that ablative therapy offers comparable local disease control to other local therapies and stereotactic body radiation therapy (SBRT), with a low risk of complications. In particular, bronchoscopic microwave ablation (BMWA) has considerably fewer pleural-based complications due to the avoidance of pleural puncture. BMWA can be considered in the multidisciplinary treatment pathway as it allows re-ablation and allows SBRT after BMWA.

SUMMARY

With the benefits which ablative therapy offers and its ability to incorporate into the multidisciplinary management pathway, we foresee ablative therapy, especially BMWA gaining significance in lung cancer treatment. Future directions on developing novel automated navigation platforms and the latest form of ablative energy would further enhance clinical outcomes for our patients.

Optimal resection strategies for small-size lung cancer: Is a wedge enough? Is lobectomy too much?

Recently published large multicenter prospective clinical trials have demonstrated that sublobar resection is noninferior to lobectomy, the traditional treatment of choice, for peripherally located early-stage lung cancer. Most clinical trials and several retrospective studies published to date have used the consolidation-to-tumor ratio to define the indication for sublobar resection, as it is well known that the size of the solid portion seen on high-resolution computed tomography is highly correlated with pathologic invasiveness. However, it is difficult to accurately predict pathologic features that may increase the risk of locoregional recurrence, such as specific adenocarcinoma subtypes or spread through air spaces, based on imaging characteristics alone, and the location of the nodule also should be considered one of the important factors in obtaining an adequate parenchymal resection margin. In this article, we summarize the results of the most recently published clinical trials related to sublobar resection and discuss various factors that should be considered for optimal candidate selection for sublobar resection.

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.