Minimally Invasive Thoracic Surgery 3.0: Lessons Learned From the History of Lung Cancer Surgery

Prediction of the pathological subtypes by intraoperative frozen section for patients with cT1N0M0 invasive lung adenocarcinoma (ECTOP-1015): a prospective multicenter study

BACKGROUND

This study aims to assess the diagnostic accuracy of the intraoperative frozen section (FS) in determining the pathological subtypes among patients diagnosed with cT1N0M0 invasive lung adenocarcinoma.

MATERIALS AND METHODS

This was a prospective, multicenter (seven centers in China) clinical trial of Eastern Cooperative Thoracic Oncology Projects (ECTOP-1015). Patients with cT1N0M0 invasive lung adenocarcinoma were enrolled in the study. Pathological images obtained from FS and final pathology (FP) were reviewed by at least two pathologists. The primary endpoint was the concordance between FS and FP diagnoses. The interobserver agreement for identifying pathological subtypes on FS was evaluated among three pathologists.

RESULTS

A total of 935 patients were enrolled. The best sensitivity of diagnosing the predominant subtype was 78.2% in the evaluation of the acinar pattern. The presence of an acinar pattern diagnosed by FS was an independent factor for the concordance between FS and FP ( P =0.007, 95% confidence interval: 2.332-4.736). Patients with tumor size >2 cm measured by pathology showed a better concordance rate for the predominant subtype (81.6% vs. 74.6%, P =0.023). The presence of radiological ground glass opacity component did not affect the diagnosis accuracy of FS for the predominant subtype (concordance rate: 76.4% vs. 75.2%, P =0.687). Patients with ground glass opacity component showed better accuracy of the identification in the presence of lepidic pattern-predominant adenocarcinoma (82.1% vs. 71.0%, P =0.026). Substantial agreement between the FS diagnosis from three pathologists for the predominant pathological pattern was revealed with κ=0.846.

CONCLUSIONS

This is the largest prospective trial evaluating FS diagnosing pathological subtype in cT1N0M0 invasive lung adenocarcinoma. A favorable concordance in the assessment of the pathological subtypes between FS and FP was observed, indicating the feasibility of utilizing accurate intraoperative pathological diagnoses from FS in guiding surgical strategies. A combination of radiology could improve the precision of FS.

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.

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.

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.

Changing profile of lung cancer clinical characteristics in China: Over 8-year population-based study

Background

Although examinations and therapies for bronchial lung cancer, also called lung cancer (LC), have become more effective and precise, the morbidity and mortality of LC remain high worldwide. Describing the changing profile of LC characteristics over time is indispensable. This study aimed to understand the changes in real-world settings of LC and its characteristics in China.

Methods

In this study, 119,785 patients were enrolled from 2012 to 2020 in the Shanghai Pulmonary Hospital. The patients' medical records were extracted from the hospital's database. Demographic characteristics, general clinicopathological information, and blood coagulation indices at the initial diagnoses were analyzed using the Kruskal-Wallis, Nemenyi, chi-squared, and Bonferroni tests. Changes in demographic characteristics during the 8-year study period, namely dynamic changes among different stages and different pathological types, were evaluated.

Results

The percentages of female (from 38.50% [323/839] in 2012 to 48.29% [5112/10,585] in 2020) and non-smoking LC (from 69.34% [475/685] to 80.48% [8055/10,009]) patients increased significantly during the study period, with a trend toward a younger age at diagnosis (from 3.58% [30/839] to 8.99% [952/10,585]). Over the study period, the proportion and absolute number of lung adenocarcinoma cases increased (from 67.97% [433/637] to 76.31% [6606/8657]) while the proportion of lung squamous cell carcinoma decreased (from 21.19% [135/637] to 12.08% [1046/8657]). Comprehensive driver gene mutation examination became more common, and epidermal growth factor receptor (EGFR) mutation occurred more frequently in female vs. male (62.03% [12793/20625] vs. 29.90% [8207/27,447]) and non-smoking vs. smoking (53.54% [17,203/32,134] vs. 23.73% [3322/13,997]) patients (both P < 0.001). The distribution of the common driver genes differed among different stages of LC. EGFR mutation was detected most frequently at each stage, and other driver gene alterations were more common in advanced stages (P <0.001). The combination of chemotherapy, targeted therapy, and immunotherapy, as a comprehensive management regimen, gradually became predominant over the study period (P < 0.001). A hypercoagulable state was shown in advanced-stage LC patients and patients with the anaplastic lymphoma kinase fusion, indicated by significantly elevated levels of d-dimer, fibrinogen, and fibrinogen degradation products.

Conclusions

This study comprehensively depicted the changing characteristics of Chinese LC patients over an 8-year period to provide preliminary insights into LC treatment.Trial registration: ClinicalTrials.gov, NCT05423236.

Uniportal versus multiportal nonintubated thoracoscopic anatomical resection for lung cancer: A propensity-matched analysis

BACKGROUND/PURPOSE

No studies have compared between uniportal and multiportal nonintubated thoracoscopic anatomical resection for non-small cell lung cancer (NSCLC). We aimed to compare short- and long-term postoperative outcomes concerning these two methods.

METHODS

Our retrospective dataset comprised patients with NSCLC who underwent uniportal or multiportal nonintubated thoracoscopic anatomical resection between January 2011 and December 2019. The primary outcome was recurrence-free survival. Propensity scores were matched according to age, sex, body mass index, pulmonary function, tumor size, cancer stage, and surgical method.

RESULTS

In total, 1130 such patients underwent nonintubated video-assisted thoracoscopic surgery (VATS), and 490 consecutive patients with stage I-III NSCLC underwent nonintubated anatomical resection, including lobectomy and segmentectomy (uniportal, n = 158 [32.3%]; multiportal, n = 331 [67.7%]). The uniportal group had fewer dissected lymph nodes and lymph node stations. In paired group analysis, the uniportal group had shorter operation durations (99.8 vs. 138.2 min; P < 0.001), lower intensive care unit (ICU) admission rates and ICU admission intervals (7.0% vs. 27.8%; P < 0.001), and shorter postoperative hospital stays (4.1 days vs. 5.2 days; P < 0.001). The most common postoperative complication was prolonged air leaks. No surgical mortality was observed. The multiportal group had higher complication rates for grades ≥ II NSCLC; however, this difference was not significant (4.4% vs. 1.3%, respectively; P = 0.09).

CONCLUSION

Nonintubated uniportal VATS for anatomical resection had better results for some perioperative outcomes than multiportal VATS. Oncological outcomes such as recurrence-free and overall survival remained uncompromised, despite fewer dissected lymph nodes.

Selective Mediastinal Lymph Node Dissection Strategy for Clinical T1N0 Invasive Lung Cancer: A Prospective, Multicenter, Clinical Trial

INTRODUCTION

We aimed to prospectively evaluate our previously proposed selective mediastinal lymph node (LN) dissection strategy for peripheral clinical T1N0 invasive NSCLC.

METHODS

This is a multicenter, prospective clinical trial in China. We set six criteria for predicting negative LN stations and finally guiding selective LN dissection. Consolidation tumor ratio less than or equal to 0.5, segment location, lepidic-predominant adenocarcinoma (LPA), negative hilar nodes (stations 10-12), and negative visceral pleural invasion (VPI) were used separately or in combination as predictors of negative LN status in the whole, superior, or inferior mediastinal zone. LPA, hilar node involvement, and VPI were diagnosed intraoperatively. All patients actually underwent systematic mediastinal LN dissection. The primary end point was the accuracy of the strategy in predicting LN involvement. If LN metastasis occurred in certain mediastinal zone that was predicted to be negative, it was considered as an "inaccurate" case.

RESULTS

A total of 720 patients were enrolled. The median number of LN dissected was 15 (interquartile range: 11-20). All negative node status in certain mediastinal zone was correctly predicted by the strategy. Compared with final pathologic findings, the accuracy of frozen section to diagnose LPA, VPI, and hilar node metastasis was 94.0%, 98.9%, and 99.6%, respectively. Inaccurate intraoperative diagnosis of LPA, VPI, or hilar node metastasis did not lead to inaccurate prediction of node-negative status.

CONCLUSIONS

This is the first prospective trial validating the specific mediastinal LN metastasis pattern in cT1N0 invasive NSCLC, which provides important evidence for clinical applications of selective LN dissection strategy.

The Uncomfortable Truth: Open Thoracotomy versus Minimally Invasive Surgery in Lung Cancer: A Systematic Review and Meta-Analysis

For decades, lung surgery in thoracic cancer has evolved in two ways: saving more parenchyma and being minimally invasive. Saving parenchyma is a fundamental principle of surgery. However, minimally invasive surgery (MIS) is a matter of approach, so it has to do with advances in surgical techniques and tools. For example, MIS has become possible with the introduction of VATS (video-assisted thoracic surgery), and the development of tools has extended the indication of MIS. Especially, RATS (robot-assisted thoracic surgery) improved the quality of life for patients and the ergonomics of doctors. However, the dichotomous idea that the MIS is new and right but the open thoracotomy is old and useless may be inappropriate. In fact, MIS is exactly the same as a classic thoracotomy in that it removes the mass/parenchyma containing cancer and mediastinal lymph nodes. Therefore, in this study, we compare randomized-controlled trials about open thoracotomy and MIS to find out which surgical method is more helpful.

Advances in Surgical Techniques for Lung Cancer

Thoracic surgery for non-small cell lung cancer has evolved tremendously in the past two decades. Improvements have come on multiples fronts and include a transition to minimally invasive techniques, an incorporation of neoadjuvant treatment, and a greater utilization of sublobar resection. These advances have reduced the morbidity of thoracic surgery, while maintaining or improving long-term survival. This review highlights major advances in the surgical techniques of lung cancer and the keys to optimizing outcomes from a surgical perspective.

The evolving landscape of thoracic surgical oncology

The history of Thoracic Surgical Oncology warrants attribution to the strong foundational contributions of the past. Current surgical approaches and techniques along with newer systemic therapies are the product of iterative modifications to prior successes. Progress also fosters traditional thinking to be challenged and other classic topics to be revisited with a contemporary perspective. Cumulatively, past and present clinical and scientific efforts point toward a promising future in the evolving landscape of Thoracic Surgical Oncology.

Robotic approach has improved outcomes for minimally invasive resection of mediastinal tumors

BACKGROUND

The optimal minimally invasive surgical (MIS) approach to mediastinal tumors is unknown. There are limited reports comparing the outcomes of resection with robotic-assisted and video-assisted thoracoscopy (RATS vs VATS). We hypothesized that patients who underwent RATS would have improved outcomes.

METHODS

The National Cancer Database was queried for all patients who underwent MIS for any mediastinal tumor from 2010-2016. Patients were determined to have an adverse composite outcome if they had any of the adverse perioperative outcomes; conversion to open procedure, 90-day mortality, 30-day readmission, and positive pathologic margins. Secondary outcomes of interest were length-of-stay (LOS) and overall survival. Multivariable logistic regression was used to assess likelihood of having a composite adverse outcome based on surgical approach.

RESULTS

856 patients were included: 402 (47%) underwent VATS and 454 (53%) underwent RATS. RATS resections were associated with fewer conversions (4.9% vs 14.7%, p<0.001), fewer positive margins (24.3% vs 31.6%, p=0.02), shorter LOS (3.8d vs 4.3d, p=0.01) and less composite adverse events (36.7% vs 51.3%, p<0.001). Multivariate analysis showed RATS (OR 0.44, p<0.001) was independently associated with decreased likelihood of composite adverse outcome, even among tumors >4 cm (OR 0.45, p=0.001). Overall survival was similar between the two groups.

CONCLUSIONS

Among patients who underwent MIS for a mediastinal tumor, RATS had fewer adverse outcomes than VATS, even for tumors ≥4 cm. These data suggests that RATS may be the preferred technique for patients who are candidates for minimally invasive resection of mediastinal tumors.

The concept of broad exposure facilitates uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection

Background

Systematic lymph node dissection is an important part of radical resection for lung cancer. Insufficient incision of the mediastinal pleura results in a tapered or tunnel-like operation surface, which increases the difficulty of uniportal video-assisted thoracoscopic mediastinal lymph node dissection. The objective of this study was to report our concept of broad exposure and investigate the efficacy and safety of this concept in uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection.

Methods

We retrospectively analyzed the clinical data of the 204 non-small cell lung cancer patients who underwent uniportal video-assisted thoracoscopic surgery for anatomical lobectomy and systematic lymph node dissection following the concept of broad exposure. SPSS 23.0 software was used for statistical analysis.

Results

All operations were completed under uniportal video-assisted thoracoscopic surgery following the concept of broad exposure. The median surgery time was 102 (range, 76–285) minutes and the median blood loss was 50 (range, 20–900) milliliters. The median chest tube duration time was 2 (range, 1–6) days, the median postoperative hospital duration time was 5 (range, 4–10) days. The median number of dissected lymph node stations and dissected lymph nodes were 8 (range,6–9) and 15(range,12–19), respectively. The median number of dissected mediastinal lymph nodes stations and dissected mediastinal lymph nodes were 5(range,3–6) and 11(range,10–15), respectively. The up-staging rate of N staging was 6.86%. The postoperative complication rate was 10.29% and there was no perioperative death.

Conclusions

According to our results, it’s effective and safe to perform uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection following the concept of broad exposure. This new concept not only emphasizes sufficient exposure, but also focuses on protection of important tissues.

Lung cancer screening: who pays? who receives?-the Chinese perspective

The National Lung Screening Trial (NLST) revealed that low-dose computed tomography (LDCT) screening reduced lung cancer mortality by 20.0%. In China, LDCT is very cheap and easy to access. As a result, LDCT screening is not limited to "high-risk" population defined by the NLST trial. The results of LDCT screening in China are also quite different from that in Western countries. LDCT detected lung cancer in a significant proportion of young, female and non-smokers in China. There is also a higher proportion of adenocarcinoma (ADC), a lower proportion of squamous cell carcinoma, and a higher proportion of early-stage 0/I disease among LDCT-detected lung cancer in China. The issue of overdiagnosis and overtreatment is discussed. Finally, we call the global attention to clarify the etiology of lung cancer in young female non-smokers.

Remote monitoring of patient recovery following lung cancer surgery: a messenger application approach

Background

Repeated assessment of patient recovery after discharge is challenging. This study used a popular messenger application to remotely collect patient self-reported symptoms and their severity so as to monitor patient recovery and identify the factors affecting the recovery of symptoms following lung cancer surgery.

Methods

This prospective observational study was conducted at a single tertiary lung cancer center in China between November 2018 and June 2019. Participants received demonstration videos and repeated symptom surveys regarding pain and cough severity (assessed using numeric rating scores of 0–10 for pain and 0–6 for cough) at 2, 4, 6, 8, and 12 weeks after discharge via a smartphone program bound to the WeChat application. Patients who responded to at least 3 of the 5 post-discharge surveys were included in this study. The data were analyzed to investigate the symptom recovery and its related factors.

Results

Of the 826 patients enrolled, 589 (71.3%) responded to at least three surveys. The average pain score reduced from 4.1±2.5 at 2 weeks to 2.2±2.0 at 12 weeks (P<0.001). Factors associated with higher pain severity included the female gender, age over 60 years, thoracotomy, longer operation time (>90 minutes), and prolonged chest tube drainage (>7 days). The average cough score decreased from 2.34±1.30 at 2 weeks to 1.93±1.26 at 12 weeks (P<0.001). Being female and a prolonged operation time (>90 min) were related to increased cough severity. Sublobar resection and limited lymphadenectomy may contribute to lower cough severity post-surgery.

Conclusions

The messenger application-based remote monitoring successfully collected post-discharge symptom information and identified factors associated with recovery following lung surgery.

Surgery for pre- and minimally invasive lung adenocarcinoma

OBJECTIVE

Adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) are the pre- and minimally invasive forms of lung adenocarcinoma. We aimed to investigate safety results and survival outcomes following different types of surgical resection in a large sample of patients with AIS/MIA.

METHODS

Medical records of patients with lung AIS/MIA who underwent surgery between 2012 and 2017 were retrospectively reviewed. Clinical characteristics, surgical types and complications, recurrence-free survival, and overall survival were investigated.

RESULTS

A total of 1644 patients (422 AIS and 1222 MIA) were included. The overall surgical complication rate was significantly lower in patients receiving wedge resection (1.0%), and was comparable between patients undergoing segmentectomy (3.3%) or lobectomy (5.6%). Grade ≥ 3 complications occurred in 0.1% of patients in the wedge resection group, and in a comparable proportion of patients in the segmentectomy group (1.5%) and the lobectomy group (1.5%). There was no lymph node metastasis. The 5-year recurrence-free survival rate was 100%. The 5-year overall survival rate in the entire cohort was 98.8%, and was comparable among the wedge resection group (98.8%), the segmentectomy group (98.2%), and the lobectomy group (99.4%).

CONCLUSIONS

Sublobar resection, especially wedge resection without lymph node dissection, may be the preferred surgical procedure for patients with AIS/MIA. If there are no risk factors, postoperative follow-up intervals may be extended. These implications should be validated in further studies.

The safety and feasibility of three-dimension single-port video-assisted thoracoscopic surgery for the treatment of early-stage lung cancer

Background

Video-assisted thoracoscopic surgery (VATS) has been widely used in the lung resections. Reports regarding three-dimension (3D) single-port VATS are very limited. The purpose of this study is to evaluate the perioperative outcomes of 3D single-port VATS in a single medical center.

Methods

Totally 523 clinical stage I lung cancer patients underwent surgical resection through VATS operation between September 2016 and October 2017 in our single institution were retrospectively collected and 374 were enrolled. The comparison between 3D single-port VATS and conventional VATS (c-VATS), single-port VATS was conducted focusing on intraoperative and postoperative outcomes. Continuous and categorical variables were analyzed through SPSS software.

Results

The 3D singe-port VATS demonstrated no significant difference neither on the intraoperative outcomes including the operative time and the intraoperative blood loss nor the postoperative outcomes including the length of drainage duration and postoperative complications when against c-VATS and single-port VATS. Besides, 3D singe-port VATS elucidated comparable ability of lymph node dissection with c-VATS in subgroup analysis (P=0.192), both of which were better than single-port VATS group (P<0.001). What’s more, the rate of conversion as well as hospital stays of 3D single-port group were also comparable. In subgroup analysis, 3D singe-port VATS also elucidated its safety and feasibility when dealing with routine thoracic surgeries including lobectomy and segmentectomy.

Conclusions

3D single-port VATS, integrating the advantages of single-port VATS and three-dimensional vision of 3D VATS, is a safe and feasible technique and is promising for next-generation thoracoscopic surgery.

Inequalities in access to minimally invasive general surgery: a comprehensive nationwide analysis across 20 years

Background

Minimally invasive surgery (MIS) has profoundly changed standards of care and lowered perioperative morbidity, but its temporal implementation and factors favoring MIS access remain elusive. We aimed to comprehensibly investigate MIS adoption across different surgical procedures over 20 years, identify predictors for MIS amenability and compare propensity score-matched outcomes among MIS and open surgery.

Methods

Nationwide retrospective analysis of all hospitalizations in Switzerland between 1998 and 2017. Appendectomies (n = 186,929), cholecystectomies (n = 57,788), oncological right (n = 9138) and left hemicolectomies (n = 21,580), rectal resections (n = 13,989) and gastrectomies for carcinoma (n = 6606) were included. Endpoints were assessment of temporal MIS implementation, identification of predictors for MIS access and comparison of propensity score-matched outcomes among MIS and open surgery.

Results

The rates of MIS increased for all procedures during the study period (p ≤ 0.001). While half of all appendectomies were performed laparoscopically by 2005, minimally invasive oncological colorectal resections reached 50% only by 2016. Multivariate analyses identified older age (p ≤ 0.02, except gastrectomy), higher comorbidities (p ≤ 0.001, except rectal resections), lack of private insurance (p ≤ 0.01) as well as rural residence (p ≤ 0.01) with impaired access to MIS. Rural residence correlated with low income regions (p ≤ 0.001), which themselves were associated with decreased MIS access. Geographical mapping confirmed strong disparities for rural and low-income areas in MIS access. Matched outcome analyses revealed benefits of MIS for length of stay, decreased surgical site infection rates for MIS appendectomies and cholecystectomies and higher mortality for open cholecystectomies. No consistent morbidity or mortality benefit for MIS compared to open colorectal resections was observed.

Conclusion

Unequal access to MIS exists in disfavor of older and more comorbid patients and those lacking private insurance, living in rural areas, and having lower income. Efforts should be made to ensure equal MIS access regardless of socioeconomic or geographical factors.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08123-0) contains supplementary material, which is available to authorized users.

Clinical application and mechanism of traditional Chinese medicine in treatment of lung cancer

Lung cancer is a malignant tumor characterized by a rapid proliferation rate, less survivability, high mortality, and metastatic potential. This review focuses on updated research about the clinical application of traditional Chinese medicine (TCM) as an adjuvant therapy to lung cancer treatment and the mechanisms of TCM effect on lung cancer in vitro and in vivo. We summarized the recent 5 years of different research progress on clinical applications and antitumor mechanisms of TCM in the treatment of lung cancer. As a potent adjuvant therapy, TCM could enhance conventional treatments (chemotherapy, radiation therapy, and epidermal growth factor receptors [EGFRs] tyrosine kinase inhibitors [TKIs]) effects as well as provide synergistic effects, enhance chemotherapy drugs chemosensitivity, reverse drug resistance, reduce adverse reactions and toxicity, relieve patients’ pain and improve quality of life (QOL). After treating with TCM, lung cancer cells will induce apoptosis and/or autophagy, suppress metastasis, impact immune reaction, and therapeutic effect of EGFR-TKIs. Therefore, TCM is a promisingly potent adjuvant therapy in the treatment of lung cancer and its multiple mechanisms are worthy of an in-depth study.

Uniportal versus multiportal video-assisted thoracoscopic anatomical resection for NSCLC: a meta-analysis

Background

Uniportal video-assisted thoracoscopic surgery (U-VATS) has recently emerged as an alternative procedure for non-small cell lung cancer (NSCLC); however, whether U-VATS has advantages over multiportal VATS (M-VATS) remains unknown.

Methods

We performed a systematic review of two databases (Pubmed and Web of Science) to search comparative studies of U-VATS and M-VATS anatomical pulmonary resection for NSCLC. Operative time, blood loss, number of resected lymph nodes, drainage duration, length of postoperative stay, pain in postoperative day 1(POD1) and conversion rates were retrieved to estimate the comparison of outcomes. A subgroup analysis stratified by study type (propensity-matched analysis and randomized-controlled trial versus non-propensity matched analysis) was performed.

Result

A total of 20 studies with 4142 patients were included in this meta-analysis. U-VATS was performed on 1869 patients, whereas the other 2173 patients underwent M-VATS. This meta-analysis showed that there was no significant difference in operative time (U-VATS: 146.48 ± 55.07 min versus M-VATS: 171.70 ± 79.40 min, P = 0.81), blood loss (74.49 ± 109.03 mL versus 95.48 ± 133.67 mL, P = 0.18), resected lymph nodes (17.28 ± 9.46 versus 18.31 ± 10.17, P = 0.62), conversion rate (6.18% versus 4.34%, P = 0.14), drainage duration (3.90 ± 2.94 days versus 4.44 ± 3.12 days, p = 0.09), length of postoperative stay (6.16 ± 4.40 days versus 6.45 ± 4.80 days, P = 0.22), and pain in POD1 (3.94 ± 1.68 versus 3.59 ± 2.76, p = 0.07). Subgroup analysis showed the value of PSM and RCT group consistency with overall value.

Conclusion

This up-to-date meta-analysis shows that the perioperative outcomes of U-VATS and M-VATS anatomical pulmonary resection are equivalent. In addition, the differences in long-term outcomes of these two approaches are still unclear. Thoracic surgeons should pay more emphasize on providing high-quality and personalized surgical care for patients, to improve the survival ultimately.

Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment

Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.

Segment Location and Ground Glass Opacity Ratio Reliably Predict Node-Negative Status in Lung Cancer

BACKGROUND

Although selective mediastinal lymph node dissection based on lobe-specific nodal metastasis has been proposed for non-small cell lung cancer, controversy remains over its validity. We hypothesized that different segments within the same lobe might have different patterns of lymph node metastasis.

METHODS

Data on 2749 invasive non-small cell lung cancer patients who underwent pulmonary resection with systematic lymph node dissection from April 2008 to December 2015 were retrospectively analyzed. The segment location and consolidation tumor ratio were identified using preoperative computed tomography scans.

RESULTS

None of the 151 tumors with consolidation tumor ratio ≤ 0.5 had lymph node involvement. None of the 333 tumors located in apical segments had inferior mediastinal lymph node metastasis. When the analysis was limited to patients without hilar nodes involvement, only 7 out of 740 (0.9%) peripheral upper lobe tumors had inferior mediastinal lymph node metastasis. Interestingly, all these 7 tumors showed visceral pleural invasion. If hilar nodes were negative, superior mediastinal lymph node metastasis was not present for lower lobe ground glass opacity lesions. Among patients with left lower lobe tumors, if hilar nodes were negative, station 4L lymph node metastasis was not found in superior-segment or basal-segment tumors, and station 5/6 lymph node involvement was always absent in basal-segment tumors.

CONCLUSIONS

Segment location, ground glass opacity proportion, and absence of hilar lymph nodes involvement are reliable predictors of node-negative status in specific mediastinal regions. Based on these findings, we propose a new selective mediastinal lymph node dissection strategy for non-small cell lung cancer.

Results of low-dose computed tomography as a regular health examination among Chinese hospital employees

OBJECTIVE

Lung cancer is traditionally more prevalent in the elderly patients, men, and smokers. However, as low-dose computed tomography (LDCT) is increasingly popular, we hypothesized the disease spectrum might change.

METHODS

LDCT was performed as a part of regular health examinations in 8392 of 15,686 employees from 6 hospitals in different regions of China in 2012 to 2018. Clinicopathologic characteristics, including age, sex, smoking status, radiologic features, tumor histology, and pathologic stage, were retrospectively analyzed.

RESULTS

LDCT incidentally detected lung cancer (pathologically confirmed) in a total of 179 (2.1%) hospital employees. The lung cancer detection rate was significantly greater in female than male (2.5% vs 1.3%, P = .001) patients. There was also a greater detection rate among nonsmokers than smokers, although statistical significance was not reached (2.2% vs 1.4%, P = .092). The lung cancer detection rate was 1.0% in the "age ≤40 years" group, 2.6% in the "40 < age ≤55 years" group, and 2.9% in the "age >55 years" group (P < .001). Among the hospital employees with lung cancer, 171 (95.5%) presented as ground-glass opacity, 177 (98.9%) were lung adenocarcinoma, 170 (95.0%) were early stage 0/IA, and 177 (98.9%) received curative surgical resection as the initial treatment. After a median follow-up of 38 months, no disease recurrence or death was observed among these patients.

CONCLUSIONS

LDCT detected lung cancer in a significant proportion of young, female, and nonsmoking employees. The vast majority of these lung cancers were early stage, with extremely good prognosis.

Comprehensive circular RNA profiling identifies CircFAM120A as a new biomarker of hypoxic lung adenocarcinoma

Background

Hypoxia is crucial in the initiation and progression of tumor metastasis. Circular RNAs (CircRNAs) comprise a novel group of non-coding, RNase R resistant and regulatory RNAs which are generated by 'back-splicing' processes. However, the characterization and function of circRNAs in hypoxic cancer cells remain unknown.

Methods

High throughput RNA-seq assay was performed in lung adenocarcinoma cells (A549) under either normoxic or hypoxic conditions. Bioinformatic analysis of differentially expressed circRNAs was conducted and their target genes were predicted and partially confirmed.

Results

Hypoxia increased the expression of hypoxia-inducible factor 1 alpha (HIF-1α) and its downstream genes in A549 cells and enhanced cell migration ability. Comprehensive analysis of global circRNAs expression profiles of A549 identified a total of 558 circRNAs candidates, among which 65 circRNAs were differentially expressed (35 upregulated and 30 downregulated) in hypoxic cancer cells. The difference in their circRNA expressions were compared by computational analysis and circRNA-miRNA networks were constructed. We further characterized one circRNA (hsa_circ_0008193) derived from the FAM120A gene and renamed it as circFAM120A. The expression of circFAM120A, as validated by reverse transcription polymerase chain reaction, was significantly downregulated in both hypoxic A549 and lung cancer tissue from patients with lymph node metastasis. Gene ontology (GO) enrichment analysis and KEGG pathway analysis revealed that circFAM120A may participate in lung cancer development.

Conclusions

CircRNAs profiles were altered in lung adenocarcinoma under hypoxia and circFAM120A may have the potential to be a new biomarker of lung adenocarcinoma hypoxia.

Delayed recovery following thoracic surgery: persistent issues and potential interventions

PURPOSE OF REVIEW

Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges.

RECENT FINDINGS

Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes.

SUMMARY

Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.

Factors during training which predict future use of minimally invasive thoracic surgery

Background

While minimally invasive thoracic surgery (MIS) has increased nationwide over the years, most patients undergoing lung and esophageal resections still undergo an open approach. We performed a national survey to analyze factors associated with a propensity to perform MIS after completing a cardiothoracic training program.

Materials and methods

Cardiothoracic surgery trainees in 2 or 3-year programs from 2010 to 2016 were sent an online survey regarding the numbers and types of cases performed during training and current practice patterns as attending surgeons. Comfort level with MIS was also assessed. Responses were recorded and analyzed using SPSS.

Results

One hundred thirty-six trainees responded, with a mean of 121 lobectomies (30-250) and 40 esophagectomies (8-110) performed during training. Mean minimally invasive lobectomy and esophagectomy rates during training were 53% and 30% respectively. A greater ratio of MIS procedures performed during training correlated with a higher rate performed as an attending (lobectomies, p = 0.04; esophagectomies, p = 0.01) and a greater comfort level with performing these procedures (lobectomies, p = 0.01 and esophagectomies, p < 0.01).

Conclusions

Based on these results, performing a greater ratio of minimally invasive lobectomies and esophagectomies during fellowship training increases the likelihood of performing them as an attending.

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Trainees who perform more minimally invasive procedures as trainees are more likely to do so as attendings.

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Trainees who perform many open lobectomies do not necessarily convert to minimally invasive approaches as attendings.

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Trainees who perform many esophagectomies are less likely to convert as attendings.

3D convolutional neural network for differentiating pre-invasive lesions from invasive adenocarcinomas appearing as ground-glass nodules with diameters ≤3 cm using HRCT

Background

Identification of pre-invasive lesions (PILs) and invasive adenocarcinomas (IACs) can facilitate treatment selection. This study aimed to develop an automatic classification framework based on a 3D convolutional neural network (CNN) to distinguish different types of lung cancer using computed tomography (CT) data.

Methods

The CT data of 1,545 patients suffering from pre-invasive or invasive lung cancer were collected from Fudan University Shanghai Cancer Center. All of the data were preprocessed through lung mask extraction and 3D reconstruction to adapt to different imaging scanners or protocols. The general flow for the classification framework consisted of nodule detection and cancer classification. The performance of our classification algorithm was evaluated using a receiver operating characteristic (ROC) analysis, with diagnostic results from three experienced radiologists.

Results

The sensitivity, specificity, accuracy, and AUC (area under the ROC curve) values of our proposed automatic classification method were 88.5%, 80.1%, 84.0%, and 89.2%, respectively. The results of the CNN classification method were compared to those of three experienced radiologists. The AUC value of our method (AUC =0.892) was higher than those of all radiologists (radiologist 1: 80.5%; radiologist 2: 83.9%; and radiologist 3: 86.7%).

Conclusions

The 3D CNN-based classification algorithm is a promising tool for the diagnosis of pre-invasive and invasive lung cancer and for the treatment choice decision.