Management of calcified hilar lymph nodes during thoracoscopic lobectomies: avoidance of conversions

N1-positive non-small cell lung cancer: surgeons' perspective before undertaking a major resection

Among various reasons for a rise in surgical referrals for locally advanced non-small cell lung cancer, few are improved clinical-pathological staging, better understanding of oncological driver mutation, and aggressive neoadjuvant treatment options. These cases with positive ipsilateral bronchopulmonary lymph nodes are intriguing subset where multiple treatment options have been explored to improve disease-free survival. Targeted neoadjuvant therapy followed by surgical resection is becoming a new norm and surgeons are referred these complex cases. This narrative review is highlighting the importance of proper preoperative staging, contemporary practices in surgical decision-making, and procedural aspect of hilar node dissection.

Handling benign interlobar lymphadenopathy during thoracoscopic lobectomy

The presence of calcified or inflammatory lymph nodes between the target bronchus and pulmonary artery is a huge challenge when performing thoracoscopic lobectomy as it may frequently result in tearing of the vessel, and massive bleeding. Herein, we describe a simple strategy in which thoracoscopic lobectomy was safely completed in similar cases. After fissure dissection, the target pulmonary artery was exposed by more than two‐thirds of its circumference. A needle was passed across the nodes and the target vessel was closed with a proximal and distal suture. After dissection of lymphadenopathies, the target bronchus was exposed, and stapled. This strategy was applied with success to complete right lower lobectomies for cancer in three patients. No complications occurred during the operation. Only one patient had persistent air leaks that spontaneously ceased 11 days later. Final pathology showed pN0 disease in all cases.

The prognosis of stage I non-small cell lung cancer with visceral pleural invasion and whole pleural adhesion after video-assisted thoracoscopic lobectomy: A single center retrospective study

Background

In cases of peripheral lung cancer with visceral pleural invasion and severe pleural adhesion, the question arises as to whether video-assisted thoracoscopic surgery (VATS) is a safe operation. The purpose of this study was to evaluate whether whole pleural adhesion is a risk factor for recurrence of cancer when performing VATS lobectomy for stage I non-small cell lung cancer (NSCLC) with visceral pleural invasion.

Methods

From 2010 to 2018, 123 consecutive patients who were diagnosed as stage I NSCLC with visceral pleural invasion and who underwent VATS lobectomy, were reviewed retrospectively. Those patients with partial pleural adhesion were excluded. The prognoses of the patients in the whole pleural adhesion group were compared with those of the non-adhesion group.

Results

The clinicopathological characteristics were not found to differ between the two groups, with the exception of age. The mean age of the whole pleural adhesion group was found to be greater than that of the non-adhesion group (70.6 vs. 64.4, P=0.002). The 5-year recurrence-free survival rates for the whole pleural adhesion group and the non-adhesion group were 64.8% and 70.9% respectively, and they were not statistically different (P=0.545). In multivariate analysis, the extent of lymph node dissection (hazard ratio =13.854, P=0.023) was a significant risk factor for recurrence. Whole pleural adhesion was not a risk factor for recurrence.

Conclusions

Whole pleural adhesion was not a risk factor for recurrence after VATS lobectomy in stage I NSCLC with visceral pleural invasion. However, the extent of lymph node dissection was identified as an important prognostic factor.