Minimal invasive surgery in locally advanced N2 non-small cell lung cancer

Quality of lymph node dissection and early recurrence in robotic versus thoracoscopic lobectomy for stage N1-2 non-small cell lung cancer: Eleven-year real-world data from a high-volume center

BACKGROUND

The efficacy of lymph node dissection (LND) and oncological outcomes of robot-assisted (RL) versus video-assisted thoracoscopic lobectomy (VL) for non-small cell lung cancer (NSCLC) with nodal involvement remains controversial. This study aims to compare LND quality and early recurrence (ER) rate between RL and VL for stage N1-2 NSCLC patients based on eleven-year real-world data from a high-volume center.

METHODS

Pathologic stage IIB-IIIB (T1-3N1-2) NSCLC patients undergoing RL or VL in Shanghai Chest Hospital from 2010 to 2021 were retrospectively reviewed from a prospectively maintained database. Propensity-score matching (PSM, 1:4 RL versus VL) was performed to mitigate baseline differences. LND quality was evaluated by adequate (≥16) LND and nodal upstaging rates. ER was defined as recurrence occurring within 24 months post-surgery.

RESULTS

Out of 1578 cases reviewed, PSM yielded 200 RL and 800 VL cases. Without compromising perioperative outcomes, RL assessed more N1 and N2 LNs and N1 stations, and led to higher incidences of adequate LND (58.5 % vs. 42.0 %, p < 0.001) and nodal upstaging (p = 0.026), compared to VL. Notably, RL improved perioperative outcomes for patients undergoing adequate LND than VL. Finally, RL notably reduced ER rate (22.0 % vs. 29.6 %, p = 0.032), especially LN ER rate (15.0 % vs. 21.5 %, p = 0.041), and prolonged disease-free survival (DFS; hazard ratio = 0.837, p = 0.040) compared with VL. Further subgroup analysis of ER and DFS within the cN1-2-stage cohort verified this survival benefit.

CONCLUSIONS

RL surpasses VL in enhancing LND quality, reducing ER rates, and improving perioperative outcomes when adequate LND is performed for stage N1-2 NSCLC patients.

Video-Assisted Thoracoscopic Surgery Versus Thoracotomy Following Neoadjuvant Immunochemotherapy in Resectable Stage III Non-Small Cell Lung Cancer Among Chinese Populations: A Multi-Center Retrospective Cohort Study

BACKGROUND

Immune checkpoint inhibitors have revolutionized non-small cell lung cancer (NSCLC) treatment but may pose greater technical challenges for surgery. This study aims to assess the feasibility and oncological effectiveness of video-assisted thoracoscopic surgery (VATS) for resectable stage III NSCLC after neoadjuvant immunochemotherapy.

METHODS

Initial stage IIIA-IIIB NSCLC patients with neoadjuvant immunochemotherapy undergoing either VATS or open lobectomy at 6 medical centers during 2019-2023 were retrospectively identified. Perioperative outcomes and 2-year survival was analyzed. Propensity-score matching (PSM) was employed to balance patient baseline characteristics.

RESULTS

Among the total 143 patients, PSM yielded 62 cases each for VATS and OPEN groups. Induction-related adverse events were comparable between the 2 groups. VATS showed a 14.5% conversion rate. Notably, VATS decreased numeric rating scales for postoperative pain, shortened chest tube duration (5[4-7] vs. 6[5-8] days, P = .021), reduced postoperative comorbidities (21.0% vs. 37.1%, P = .048), and dissected less N1 lymph nodes (5[4-6] vs. 7[5-9], P = .005) compared with thoracotomy. Even when converted, VATS achieves perioperative outcomes equivalent to thoracotomy. Additionally, over a median follow-up of 29.5 months, VATS and thoracotomy demonstrated comparable 2-year recurrence-free survival (77.20% vs. 73.73%, P = .640), overall survival (87.22% vs. 88.00%, P = .738), cumulative incidences of cancer-related death, and recurrence patterns. Subsequent subgroup comparisons and multivariate Cox analysis likewise revealed no statistical difference between VATS and thoracotomy.

CONCLUSION

VATS is a viable and effective option for resectable stage III NSCLC patients following neoadjuvant immunochemotherapy, leading to decreased surgical-related pain, earlier chest tube removal, reduced postoperative complications, and similar survival outcomes compared to thoracotomy.

Robotic versus Open Surgery in Locally Advanced Non-Small Cell Lung Cancer: Evaluation of Surgical and Oncological Outcomes

Locally advanced non-small cell lung cancer (NSCLC) consists of a heterogeneous group, with different pulmonary extension and lymph nodal involvement. Robotic surgery can play a key role in these tumours thanks to its technological features, although open surgery is still considered the gold-standard approach. Our study aims to evaluate the surgical and oncological outcomes of locally advanced NSCLC patients who underwent robotic surgery in a high-volume centre. Data from consecutive patients with locally advanced NSCLC who underwent robotic lobectomy were retrospectively analysed and compared with patients treated with open surgery. Clinical characteristics and surgical and oncological information were evaluated. From 2010 to 2020, 131 patients underwent anatomical lung resection for locally advanced NSCLC. A total of 61 patients were treated with robotic surgery (46.6%); the median hospitalization time was 5.9 days (range 2-27) and the postoperative complication rate was 18%. Open surgery was performed in 70 patients (53.4%); the median length of stay was 9 days (range 4-48) and the postoperative complication rate was 22.9%. The median follow-up time was 70 months. The 5-year overall survival was 34% in the robotic group and 31% in the thoracotomy group. Robotic surgery can be considered safe and feasible not only for early stages but also for the treatment of locally advanced NSCLC.

Minimally Invasive Surgery in Non-Small Cell Lung Cancer: Where Do We Stand?

In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.

Perioperative and Oncological Outcomes of Robotic-Assisted, Video-Assisted Thoracoscopic and Open Lobectomy for Patients with N1-Metastatic Non-Small Cell Lung Cancer: A Propensity Score-Matched Study

(1) Background: Despite the fact that robotic-assisted thoracoscopic lobectomy (RATL) has been prevalently applied for early stage non-small cell lung cancer (NSCLC), its superiorities are still to be fully revealed for patients with metastatic N1 lymph nodes (LNs). We aim to evaluate the advantages of RATL for N1 NSCLC. (2) Methods: This retrospective study identified consecutive pathological N1 NSCLC patients undergoing RATL, video-assisted thoracoscopic lobectomy (VATL), or open lobectomy (OL) in Shanghai Chest Hospital between 2014 and 2020. Further, perioperative and oncological outcomes were investigated. (3) Results: A total of 855 cases (70 RATL, 435 VATL, and 350 OL) were included. Propensity score matching resulted in 70, 140, and 140 cases in the RATL, VATL, and OL groups, respectively. RATL led to (1) the shortest surgical time (p = 0.005) and lowest intraoperative blood loss (p < 0.001); (2) the shortest ICU (p < 0.001) and postsurgical hospital (p < 0.001) stays as well as chest tube duration (p < 0.001); and (3) the lowest morbidities of postsurgical complications (p = 0.016). Moreover, RATL dissected more N1 (p = 0.027), more N1 + N2 (p = 0.027) LNs, and led to a higher upstaging incidence rate (p < 0.050) than VATL. Finally, RATL achieved a comparable 5-year disease-free and overall survival in relation to VATL and OL. (4) Conclusions: RATL led to the most optimal perioperative outcomes among the three surgical approaches and showed superiority in assessing N1 and total LNs over VATL, though it did achieve comparable oncological outcomes in relation to VATL and OL for N1 NSCLC patients.

Efficacy and safety of camrelizumab (a PD‑1 inhibitor) combined with chemotherapy as a neoadjuvant regimen in patients with locally advanced non‑small cell lung cancer

Camrelizumab is a novel programmed cell death protein 1 (PD-1) inhibitor developed in China that exhibits good efficacy in several advanced cancer types, including non-small cell lung cancer (NSCLC); however, its utility as a neoadjuvant regimen in NSCLC remains unclear. Thus, the present study aimed to explore the efficacy and safety of neoadjuvant camrelizumab plus chemotherapy in patients with locally advanced NSCLC. A total of 56 patients with stage IIIA/IIIB resectable NSCLC were analyzed in the present prospective observational study. Amongst the cohort, 31 patients underwent neoadjuvant camrelizumab (200 mg every 2 weeks) plus paclitaxel and carboplatin (PC) chemotherapy, while another 25 cases underwent neoadjuvant PC chemotherapy alone. The pathological response, disease-free survival (DFS) time, overall survival (OS) time and adverse events (AEs) were analyzed. The complete pathological response (25.8 vs. 8.3%; P=0.159) and major pathological response (MPR) (61.3 vs. 37.5%; P=0.080) rates were higher in the camrelizumab plus PC group compared with the findings in the PC group, although the results were not statistically significant. DFS time was significantly prolonged in the camrelizumab plus PC group compared with that in the PC group (P=0.030); however, there was no difference in OS time between these two groups (P=0.251). Following adjustment by multivariate analysis, the camrelizumab plus PC regimen versus the PC regimen alone was independently associated with higher MPR [odds ratio, 5.216; 95% confidence interval (CI), 1.178-23.086; P=0.030], and favorable DFS [hazard ratio (HR), 0.055; 95% CI, 0.007-0.442; P=0.006] and OS (HR, 0.025; 95% CI, 0.002-0.416; P=0.010) times. The most common AEs of the neoadjuvant camrelizumab plus PC regimen were alopecia (51.6%), nausea and vomiting (45.2%), anemia (41.9%) and fatigue (41.9%), the majority of which occurred in patients with grade 1–2 disease. The present results indicated that neoadjuvant camrelizumab plus PC chemotherapy exhibited a superior pathological response and survival profile to PC chemotherapy alone, and was well tolerated in patients with locally advanced NSCLC.

Comparison of the analgesic effect of ultrasound-guided paravertebral block and ultrasound-guided retrolaminar block in Uniportal video-assisted Thoracoscopic surgery: a prospective, randomized study

Background

The optimal modality for postoperative analgesia after uniportal video-assisted thoracoscopic surgery (UVATS) for the treatment of lung cancer has not yet been determined. Both ultrasound-guided paravertebral block (PVB) and retrolaminar block (RLB) have been reported to be successful in providing analgesia after UVATS. However, which block technique provides superior analgesia after UVATS is still unclear. This randomized study was designed to compare the postoperative analgesic effects and adverse events associated with ultrasound-guided PVB and RLB after UVATS.

Methods

Sixty patients with lung cancer were randomized to undergo ultrasound-guided PVB (group P) or ultrasound-guided RLB (group R). In group P, 30 mL of 0.5% ropivacaine was injected at the T3 and T5 levels via ultrasound-guided PVB (15 mL at each level on the operative side). In group R, 30 mL of 0.5% ropivacaine was injected at the T3 and T5 levels via ultrasound-guided RLB (15 mL at each level on the operative side). The primary outcome was the numerical rating scale (NRS) score within 48 h after surgery. The secondary outcomes were total postoperative sufentanil consumption, time to first analgesic request and adverse events.

Results

At 3, 6, 12, 24, 36 and 48 h postoperatively, the NRS score at rest in group P was lower than that in group R (p < 0.05). At 3, 6, 12, 24 and 36 h postoperatively, the NRS score while coughing in group P was lower than that in group R (p < 0.05). The total postoperative sufentanil consumption in group P was significantly lower than that in group R (p < 0.001). Additionally, the time to first analgesic request was longer in group R than in group P (p < 0.0001). The incidence of nausea in group R was higher than that in group P (p < 0.05).

Conclusions

In patients with lung cancer undergoing UVATS, ultrasound-guided PVB with 0.5% ropivacaine provides better analgesia and results in less nausea than ultrasound-guided RLB. Compared with ultrasound-guided RLB, ultrasound-guided PVB seems to be a better technique for analgesia in UVATS.

Trial registration

The name of this study is the Effect And Mechanism Of Ultrasound-guided Multimodal Regional Nerve Block On Acute And Chronic Pain After Thoracic Surgery. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100044060). The date of registration was March 9, 2021.

Robotic Surgery for Non-Small Cell Lung Cancer Treatment in High-Risk Patients

Robotic-assisted pulmonary resection has greatly increased over the last few years, yet data on the application of robotic surgery in high-risk patients are still lacking. The objective of this study is to evaluate the perioperative outcomes in ASA III-IV patients who underwent robotic-assisted lung resection for NSCLC. Between January 2010 and December 2017, we retrospectively collected the data of 148 high-risk patients who underwent lung resection for NSCLC via a robotic approach at our institution. For this study, the prediction of operative risk was based on the ASA-PS score, considering patients in ASA III and IV classes as high-risk patients: of the 148 high-risk patients identified, 146 patients were classified as ASA III (44.8%) and two as ASA IV (0.2%). Possible prognostic factors were also analysed. The average hospital stay was 6 days (8–30). Post-operative complications were observed in 87 (58.8%) patients. Patients with moderate/severe COPD developed in 33 (80.5%) cases post-operative complications, while elderly patients in 25 (55%) cases, with a greater incidence of high-grade complications. No difference was observed when comparing the data of obese and non-obese patients. Robotic surgery appears to be associated with satisfying post-operative results in ASA III-IV patients. Both marginal respiratory function and advanced age represent negative prognostic factors. Due to its safety and efficacy, robotic surgery can be considered the treatment of choice in high-risk patients.