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.

SMARCA4 as a support for the differential diagnosis of poorly differentiated lung carcinomas

Among non-small cell lung cancers (NSCLCs), sarcomatoid carcinomas account for 3%. They are rare tumours with a poor prognosis, classified into three subgroups, namely pleomorphic carcinoma, pulmonary blastoma and carcinosarcoma. In the 5th edition of WHO Classification of Thoracic Tumours more space is given to SMARC4-deficient lung cancers. Although studies on SMARCA4-deficient lung tumours are limited, a small percentage of SMARCA4 loss is present within NSCLCs. This finding is clinically relevant, as the loss of the SMARCA4 gene is associated with a worse prognosis. In our study, we analysed the presence of the main catalytic subunit of the SMARCA4 gene, the BRG1 protein, in 60 sarcomatoid lung tumours. The results of our study show that 5.3% of sarcomatoid carcinomas have BRG1-loss in tumour cells, proving that a non-negligible amount of lung sarcomatoid carcinomas are SMARCA4-deficient. These data open the debate on the necessity of including the detection of SMARCA4 within a standardised immunohistochemical panel.

The evolution of robotic thoracic surgery

Robotic surgery has the features to represent the future of surgery, considering the rapid evolution of its technology and the resulting in the surgical field. In the last years, the robotic technique in thoracic surgery has progressively become widespread in the word, particularly for the treatment of the mediastinal and pulmonary lesions. The development of technology in the robotic system has been associated with the improvement of intraoperative and postoperative results. Due to the satisfying results and increasing experience and confidence with the robotic technique, surgeons are consequently enlarging the surgical indication, moving to increasingly challenging cases. Thoracic robotic surgery is being affirmed as a safe technique also for those complex cases, which in the past were considered a matter solely for open surgery. In fact, robotic surgery is increasingly associated with positive surgical results and guarantees less traumatism and a fast recovery to the patients. These positive results have resulted from the evolution of the technique, which has developed in parallel with the evolution of the technology, exploiting to its best the latest features of the robotic system. These features, such as the fluorescence-detection tool or the robotic stapler, have been aiding the surgeon to maximise the safety and feasibility of the application of the robotic technique to thoracic surgery.