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The aim of this study was to elucidate the impact of pleural lavage cytology positivity on early recurrence in patients operated on non-small cell lung cancer (NSCLC).
This is a ...multicentre prospective cohort study of 684 patients undergoing an anatomical lung resection for NSCLC between October 2015 and October 2017 at 12 national centres. A pleural lavage was performed before and after lung resection. The association between the different predictors of early recurrence and PLC positivity was performed using univariate and multivariate logistic regression models. A propensity score analysis was performed by inverse probability weighting (IPSW) using average treatment effect (ATE) estimation to analyse the impact of PLC positivity on early recurrence.
Overall PLC positivity was observed in 15 patients (2.2%). After two years, 193 patients (28.2%) relapsed, 182 (27.2%) with a negative PLC and 11 (73.3%) with a positive PLC (p<0.001). Factors associated to early recurrence were adenocarcinoma histology (OR=1.59, 95%CI 1.06–2.38, p=0.025), visceral pleural invasion (OR=1.59, 95%CI 1.04–2.4, p=0.03), lymph node involvement (OR=1.84, 95%CI 1.14–2.96, p=0.013), advanced pathological stage (OR=2.12, 95%CI 1.27–3.54, p=0.004) and PLC positivity (OR=4.14, 95%CI 1.25–16.36, p=0.028). After IPSW, PLC positivity was associated with an increased risk of early recurrence (OR=3.46, 95%CI 2.25–5.36, p<0.001).
Positive pleural lavage cytology was found to be the strongest predictor of early recurrence.
•The intensity of the lymphadenectomy performed by VATS tends to be worse in comparison with the open approach.•A higher percentage of systematic nodal dissection, pN1 and pN2 disease was found in ...the open approach.
To analyse differences in intraoperative nodal assessment in patients undergoing lung cancer resection by thoracotomy and video-assisted thoracoscopy (VATS) in the Spanish Video-Assisted Thoracic Surgery Group (GEVATS).
Prospective multicentre cohort study of anatomic pulmonary resections (n = 3533) performed from December 2016 to March 2018. Main surgical, clinical and oncological variables related with lymphadenectomy were compared according to surgical approach. Corresponding tests for homogeneity were performed. Multiple logistic regression analyses were used to determine the odds ratio (OR) and 95% confidence interval (95%CI). Covariate adjustment using the propensity score (PS) was performed to reduce confounding effects.
After exclusions, 2532 patients were analysed. Systematic nodal dissection (SND) was performed in 65%, with a median of resected/sampled lymph nodes (LN) of 7 (IQR 4–12) and pathologic (p) N2 and uncertain (u) pNu rates of 9.4% and 28.9%, respectively.
At multivariate analysis, the following were associated with thoracotomy (OR; 95%CI): SND (1.4; 1.08–1.96; p = 0.014), staging mediastinoscopy (2.6; 1.59–4.25; p < 0.001), tumor > 3 cm (2.1; 1.66–2.78; p < 0.001), central tumor (2.5; 1.90–3.24; p < 0.001); pN1 (1.8; 1.25–2.67; p < 0.002), pN2 (1.8; 1.18–2.76; p = 0.006), lower FEV1 (0.9; 0.98–0.99; p < 0.001), squamous cell carcinoma (1.5; 1.16–1.98; p = 0.002) and inexperienced surgeons in VATS (compared with > 100 VATS experience) (37.6; 13.55–104.6; p < 0.001). After PS adjustment, SND maintained the OR, but in the limit of signification (1.4; 1–1.98; p = 0.05). Nodal upstaging was significantly higher in the thoracotomy group. Complication rates of SND and no SND were similar.
Thoracotomy was associated with a more thorough lymphadenectomy in GEVATS. Therefore, intraoperative lymph node evaluation performed at VATS should be improved to have better prognostic information and more solid grounds to indicate adjuvant therapy.
Abstract
OBJECTIVES
The relationship between operating time and postoperative morbidity has not been fully characterized in lung resection surgery. We aimed to determine the variables associated with ...prolonged operative times and their influence on postoperative complications after video-thoracoscopic lobectomy.
METHODS
Patients undergoing thoracoscopic lobectomy for lung cancer from December 2016 to March 2018, within the prospective registry of the Spanish Video-Assisted Thoracic Surgery Group were identified. Operating time was stratified by quartiles and complication rates analysed using chi-squared test. Primary outcomes included 30-day overall, pulmonary and cardiovascular complications and wound infection. Multivariable logistic regression analyses were performed to identify variables independently associated with operating time and their influence on the occurrence of postoperative complications.
RESULTS
Data of 1518 cases were examined. The median operating time was 174 min (interquartile range: 130–210 min). Overall morbidity rates significantly increased with surgical duration (20.5% vs 34.4% in the 1st and 4th quartiles, respectively, P < 0.05) and so did pulmonary complications (14.6% vs 26.4% in the 1st and 4th quartiles, respectively, P < 0.05). Differences were not found regarding cardiovascular and wound complications. After multivariable logistic regression analysis, operating time remained as an independent risk factor for overall (odds ratios, 2.05) and pulmonary complications (odds ratios, 2.01). Male sex, predicted postoperative diffusing capacity of the lung for carbon monoxide, number of lymphatic stations harvested, pleural adhesions, fissures completeness, lobectomy site, surgeon seniority, individual video-thoracoscopic surgeon experience and fissureless technique were identified as predictive factors for long operative time.
CONCLUSIONS
Prolonged operating time is associated with increased odds of postoperative complications. Modifiable factors contributing to prolonged operating time may serve as a target for quality improvement.
Abstract
OBJECTIVES
The aim of this study was to know the treatment effect of video-assisted thoracic surgery (VATS) on 90-day mortality after anatomical lung resection based on a nationwide cohort.
...METHODS
This is a multicentre prospective cohort of 2721 anatomical resections for lung cancer from December 2016 to March 2018. Treatment and intention-to-treat (ITT) analyses were performed after inverse probability score weighting and different propensity score matching algorithms. Covariate balance was assessed by standardized mean differences. The estimators reported were the average treatment effect, the average treatment effect on the treated and odds ratios after conditional logistic models with 95% confidence intervals. The unconfoundedness assumption was evaluated by sensitivity analysis for average treatment effect (c-dependence) and average treatment effect on the treated (Γ).
RESULTS
VATS was the initial approach in 1911 patients (70.2%), though 273 cases (14.3%) had to be converted to thoracotomy. Ninety-day mortality rates were: treatment analysis (VATS 1.16% vs open 3.9%, P < 0.001), ITT analysis (VATS 1.78% vs open 3.36%, P = 0.012). After inverse probability score weighting and propensity score matching, in the treatment analysis, VATS meant absolute risk reductions between 2.25% and 2.96% and relative risk reductions between 65% and 70% OR = 0.34 (95% confidence interval 0.15–0.79), all P-values <0.004). However, all the estimators turned out to be non-significant in the ITT analyses. A high sensitivity to unobservable confounders was proved (c-dependence 0.135, Γ = 1.5).
CONCLUSIONS
VATS can reduce the risk of 90-day mortality after anatomical lung resection. However, the implications of conversion to thoracotomy, comparing ITT versus treatment analysis, and the potential impact of hidden bias should deserve further attention in the future.
Although there are multiple retrospective series that have shown a lower rate of complications and postoperative stay in patients operated on by video-assisted thoracic surgery (VATS), there are more discrepancies on the impact that the surgical approach could have on postoperative mortality.
Abstract
The objective of this study was to describe a novel minimally invasive robotic video-assisted approach for lung transplantation, utilizing a minimally invasive technique with a subxiphoid ...incision, in an animal experimentation model. Two left robotic-assisted single lung transplants were performed in sheep using a robotic surgical system. A subxiphoid incision was made, and robotic ports were inserted into the thoracic cavity for dissection and anastomoses of the bronchus, artery, and pulmonary veins. The integrity of anastomoses was evaluated, and procedural details were recorded. Both animals survived the procedure, with a mean duration of 255 min and a mean console time of 201 min. Anastomoses were performed without complications, and the closed-chest approach with a subxiphoid incision proved successful in preventing gas leakage. The novel approach demonstrated improved exposure and workflow compared to existing techniques. The minimally invasive robotic video-assisted approach for lung transplantation utilizing a closed-chest technique with a subxiphoid incision appears safe and feasible in an animal experimentation model. Further studies in the clinical setting are warranted to establish its feasibility and safety in human lung transplantation. This approach has the potential to offer benefits over the traditional Clamshell incision in lung transplantation procedures.
Lung transplantation is considered the gold standard treatment for patients with end-stage lung disease.
The management of patients with advanced non-small cell lung carcinoma (NSCLC) has undergone major changes in recent years. On the one hand, improved sensitivity of diagnostic tests, both ...radiological and endoscopic, has altered the way patients are staged. On the other hand, the arrival of new drugs with antitumoral activity, such as targeted therapies or immunotherapy, has changed the prognosis of patients, improving disease control and prolonging survival. Finally, the development of radiotherapy and surgical and interventional radiology techniques means that radical ablative treatments can be performed on metastases in any location in the body. All of these advances have impacted the treatment of patients with advanced lung cancer, especially in a subgroup of these patients in which all of these treatment modalities converge. This poses a challenge for physicians who must decide upon the best treatment strategy for each patient, without solid evidence for one optimal mode of treatment in this patient population. The aim of this article is to review, from a practical and multidisciplinary perspective, published evidence on the management of oligometastatic NSCLC patients. We evaluate the different alternatives for radical ablative treatments, the role of primary tumor resection or radiation, the impact of systemic treatments, and the therapeutic sequence. In short, the present document aims to provide clinicians with a practical guide for the treatment of oligometastatic patients in routine clinical practice.
After pneumonectomy, the development of a new lung cancer or a recurrence in the residual lung is a challenge. Surgery often is considered contraindicated. The goal of our study is to assess the ...morbidity and mortality of lung resection on a single lung.
All patients who underwent lung resection after pneumonectomy from January 1996 through December 2012 were reviewed.
There were 12 patients (10 men and 2 women). Mean age was 71 years (range, 54-81 years). Mean preoperative FEV1 was 1,470 ml (52%) and preoperative FVC 2,153 ml (61,5%). Subsequent pulmonary resection was performed after a median follow-up of 34,5 months. Wedge resection was performed in all patients. Diagnosis was pulmonary mestastatic lung cancer in 2 patients, metachronous lung cancer in 6, metastatic extrathoracic cancer in 3 and benign nodule in one. Complications occurred in 4 patients (33,4%) while operative mortality was nil.
Lung resection on a single lung is a safe procedure associated with acceptable morbidity and mortality. Careful patient selection is very important.
Lung Resections in Patients with Only One Lung Ramírez Gil, María Elena; Royo Crespo, Íñigo; Rivas de Andrés, Juan José
Archivos de bronconeumología (English ed.)
46, Številka:
2
Journal Article
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