Comparison of lobectomy performed through Toumai® surgical robot and da Vinci surgical robot in early-stage non-small cell lung cancer: a retrospective study of early perioperative results.

Background: Robotic-assisted thoracic surgery (RATS) is a safe and efficient minimally invasive thoracic approach compared to thoracotomy. Today, almost all thoracic procedures can be performed by RATS. In recent years, the Chinese government has issued some policies to support the development of domestic surgical robots, leading to the development of the Toumai® surgical robot system. This study aimed to explore the application of the Toumai® surgical robot in performing lobectomy for early-stage non-small cell lung cancer (NSCLC), and to compare its safety, surgical effect, and advantages or disadvantages compared with the mature da Vinci robotic surgical system. Methods: Patients with early-stage NSCLC undergoing robotic-assisted lobectomy in our center between November 2021 and December 2021 were enrolled in the study; Surgeries were performed through the Toumai® surgical robot and the da Vinci robotic system. Anatomical lobectomy and systematic lymph node (LN) dissection were conducted in all patients. Baseline and perioperative outcomes were analyzed to compare the two methods. Results: The combined 19 patients from the Toumai® group (n=9) and the da Vinci group (n=10) were enrolled and eligible for analyses. They had similar baseline characteristics, tumor characteristics, clinical stage, and pathological stage. Conversion to thoracotomy was not observed, and the operation time {95 minutes [interquartile range (IQR), 86.5-136.5 minutes] vs. 86 minutes (IQR, 81-102 minutes), P=0.178} and other perioperative outcomes were comparable in the two groups. There was no significant difference in the number of dissected LNs and lymphatic stations between both groups. Conclusions: The application of Toumai® surgical robot in lobectomy was preliminarily shown to be safe and effective. Compared with the mature da Vinci robotic surgery system, Toumai® surgical robot had similar technical and surgical advantages, highlighting its suitability as an optional method for the new generation of robotic-assisted thoracoscopic surgery.

Comparison of perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic right upper lobectomy in non-small cell lung cancer.

BACKGROUND: Robotic-assisted thoracic surgery (RATS) has been widely used in the treatment of lung cancer. The perioperative outcomes of right upper lobectomy (RUL) using RATS and video-assisted thoracic surgery (VATS) were retrospectively investigated and compared. We aimed to summarize a single-center experience of RATS and 4-port unidirectional VATS in RUL, and to discuss the safety and the essentials of the surgery. METHODS: We retrospectively analyzed the 685 with non-small cell lung cancer (NSCLC) patients who underwent minimally invasive RUL in our center by the same surgical group from January 2015 to December 2019. Both RATS and VATS were performed with three ports with utility incision. The 685 participants were divided into RATS (335 cases) and VATS (350 cases) groups according to surgical method. Baseline characteristics and perioperative outcomes including dissected lymph nodes, postoperative duration of drainage, postoperative hospital stay, and incidence of postoperative complications were compared between the groups. RESULTS: In the 685 patients enrolled, the baseline characteristics were comparable, and no postoperative 30-day mortality or intraoperative blood transfusion were observed. Compared with VATS, RATS had less surgical duration (90.22±12.16 vs. 92.68±12.26 min, P<0.001), less length of stay (4.71±1.37 vs. 5.26±1.56 days, P<0.001), and decreased postoperative duration of drainage (3.49±1.15 vs. 4.09±1.57 days, P<0.001). No significant difference was observed in the lymph nodes dissection, blood loss, conversion rate and morbidities. The cost of RATS was much higher than VATS (85,329.41±12,893.44 vs. 68,733.43±14,781.32 CNY, P<0.001). CONCLUSIONS: Robot assisted RUL had similar perioperative outcomes compared to VATS RUL lobectomy using similar three port with utility incision technique. The advantages of RATS included finer dissection of lymph node, relatively less operation time, earlier chest tube removal and discharge.

Robotic-assisted thoracic surgery reduces perioperative complications and achieves a similar long-term survival profile as posterolateral thoracotomy in clinical N2 stage non-small cell lung cancer patients: a multicenter, randomized, controlled trial.

BACKGROUND: Our previous study demonstrated the safety and short-term efficacy of robotic-assisted thoracic surgery (RATS) in clinical N2 (c-N2) stage non-small cell lung cancer (NSCLC) patients. From this, the present study was devised, in which the follow-up time and sample size were both extended to explore the long-term efficacy and potential benefit in survival of RATS compared with lobectomy in c-N2 stage NSCLC patients. METHODS: Patients with c-N2 NSCLS were randomly assigned in a 1:1 ratio to accept operation through thoracotomy or RATS. The da Vinci Surgical System (Si/Xi) was applied in the RATS group, while conventional lobectomy with a rib-spreading incision was applied in the posterolateral thoracotomy group. Primary endpoint was defined as disease free survival and overall survival (OS) of all recruited patients. RESULTS: Compared with posterolateral thoracotomy group (N=72), the RATS group (N=76) had a reduced blood loss (P<0.001), decreased drainage duration (P=0.002), and decreased postoperative pain visual analog score (all P<0.001), but increased overall cost (P<0.001). Meanwhile, no difference in the other postoperative complications (such as air leakage, subcutaneous emphysema, atrial fibrillation etc.) was found between the RATS group and the posterolateral thoracotomy group (all P>0.05). Regarding long-term outcome, no difference in disease-free survival (DFS; P=0.925) or OS (P=0.853) was observed between the RATS group and posterolateral thoracotomy group. Subgroup analyses and multivariable Cox regression analyses also found no difference in DFS or OS between the RATS group and posterolateral thoracotomy groups. CONCLUSIONS: RATS reduced intraoperative bleeding, drainage duration, postoperative pain, and achieved similar long-term survival outcomes compared with posterolateral thoracotomy in c-N2 stage NSCLC patients. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR-INR-17012777.

Perioperative crizotinib in a patient with stage IIIB ALK-positive non-small cell lung cancer: a case report.

We present a case of a 43-year-old female patient with clinical stage IIIB (T3N2M0) anaplastic lymphoma kinase (ALK)-positive adenocarcinoma of the lung. Surgery was not performed initially because of multiple mediastinal lymph nodes invasion, although the mass was technically resected. With the assessment of upfront multidisciplinary consultation, administration of neoadjuvant crizotinib was selected to induce the downstaging and facilitate the subsequent surgical treatment. After 10 weeks of neoadjuvant crizotinib treatment, a partial response was achieved and the tumor could be radically resected. There were no sever toxic effects and treatment-related surgical delay during the whole neoadjuvant crizotinib therapy. The patient then successfully underwent video-assisted single port thoracoscopic right upper lobectomy and lymphadenectomy. Concurrent chemotherapy and radiotherapy were applied postoperatively. Perioperative targeted therapy demonstrated good curative effect in this case, and no recurrence was observed at the clinic 8 months after surgery. In this case, the safety and effectiveness of neoadjuvant crizotinib and subsequent surgery are preliminarily proved. We here intend to investigate the optimal setting of neoadjuvant targeted therapy combined with minimally invasive surgery and postoperative adjuvant therapy, inspire more potential targeted treatment based schedules and to apply these strategies in treating patients with locally advanced mutant-positive non-small cell lung cancer (NSCLC).

Gli promotes tumor progression through regulating epithelial-mesenchymal transition in non-small-cell lung cancer.

INTRODUCTION: Lung cancer is the leading causes of cancer-related deaths globally. The most frequent histologic type of lung cancer is non-small-cell lung cancer (NSCLC). NSCLC often undergo epithelial-mesenchymal transition (EMT). The components that control this process are thus promising therapeutic targets. MATERIALS AND METHODS: Gli/EMT protein expression levels were examined by western blot in paired NSCLC patient tissues and NSCLC cell lines. Functional analyses were performed to investigate SHH/Gli signaling and EMT in NSCLC cell lines. MTS cell viability, luciferase reporter, and western blot assays were performed to analyze pathway activity, while wound healing and transwell assays were executed to measure cell migration and invasion. RESULTS: Higher Gli1 expressions were detected in tumor samples than in paired normal tissues. Differential expression of EMT biomarkers and activation of p-AKT were observed in tumor tissues. N-Shh stimulation of cells significantly increased reporter activity in NSCLC cell lines, while Gli-i treatment of transfected cells showed less relative reporter activity. When subjected to both Gli-i and N-Shh treatment, NSCLC cell lines continued to demonstrate decreased Gli transcriptional activity. Gli inhibition is associated with decreased expression level of p-AKT, N-cadherin and Vimentin. Knockdown of both Gli1 and Gli2 showed decreased EMT, migrative and invasive ability. Cells stimulated by N-Shh demonstrated greater mobility. In addition, AKT-i treated cells also demonstrated inhibited EMT activity. CONCLUSIONS: This study provides evidence for aberrant upregulation of the Gli signaling pathway and a strong association between expression of Gli versus AKT and EMT markers in NSCLC.

Perioperative outcomes of radical lobectomies using robotic-assisted thoracoscopic technique vs. video-assisted thoracoscopic technique: retrospective study of 1,075 consecutive p-stage I non-small cell lung cancer cases.

BACKGROUND: Robotic thoracoscopic surgery was first done in mainland China in 2009 and has gained popularity in the past few years. Here, we present the largest Chinese series of robotic lobectomy for early-stage non-small cell lung cancer (NSCLC) to date. We aimed to compare the perioperative outcomes of our three-arm robotic-assisted lobectomy (RAL3) and video-assisted lobectomy (VAL) for p-stage I NSCLC and report the approach of the robotic anatomic lobar resections of our center. METHODS: We retrospectively collected and analyzed the data of 1075 stage I NSCLC patients who underwent minimally invasive lobectomies (237 RAL3 cases and 838 VAL cases) by the same surgical team from May 2013 to April 2016. Propensity score matching (PSM) was used to minimize the bias between the two groups. Perioperative outcomes were analyzed. RESULTS: Compared to the VALs, the RAL3s had more retrieved lymph nodes (LNs) (9.70 vs. 8.45, P=0.000), less POD1 drain (230.91 vs. 279.79 mL, P=0.001), shorter chest tube duration (3.84 vs. 4.33 d, P=0.003) and shorter postoperative length of stay (4.97 vs. 5.45 d, P=0.004), but a higher cost (¥93,244.84 vs. ¥67,055.82, P=0.000). No significant difference was observed between the RAL3 and VAL groups concerning the average skin-to-skin time (90.84 vs. 92.25 min, P=0.624), conversion rate (1.3% vs. 0.87%, P=1.000) and prolonged postoperative hospital stay (PPHS) rate (3.0% vs. 4.3%, P=0.694). CONCLUSIONS: This study confirms that RAL3 is a safer and more effective technique than VAL for the treatment of early-stage NSCLC.

Comparison of robotic-assisted lobectomy with video-assisted thoracic surgery for stage IIB-IIIA non-small cell lung cancer.

BACKGROUND: With the rapid development of surgical technics and instruments, more and more locally advanced non-small cell lung cancer (NSCLC) patients are being treated by minimally invasive surgery (MIS), including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS). The aim of this retrospective study was to compare the perioperative and long-term outcomes of patients who underwent lobectomy by these two surgical approaches. METHODS: We performed a retrospective review of the prospectively collected database of our hospital to identify patients with clinical stage IIB-IIIA NSCLC who underwent video-assisted thoracoscopic or robotic lobectomy. Perioperative outcomes, recurrence, and overall survival (OS) were compared. RESULTS: From January 2014 to January 2017, there were at total of 121 patients, including 36 robotic lobectomy patients and 85 VATS lobectomy patients. One patient (2.8%) in the RATS group and 5 patients (5.9%) in the VATS group were converted to thoracotomy (P=0.79). No perioperative death was observed in both groups. The postoperative morbidity was similar between the two groups (13.9% for RATS vs. 15.3% for VATS; P=0.84). Robotic lobectomy was associated with a shorter length of postoperative hospital stay (4 vs. 5 d, P<0.01) and more counts of lymph nodes harvested (13 vs. 10, P<0.01). The median disease-free survival (DFS) for the RATS and VATS groups were 31.1 and 33.8 months, respectively. The corresponding 3-year DFS was 40.3% in the RATS group and 47.6% in the VATS group (P=0.74). The 3-year OS was 75.7% in RATS and 77.0% in the VATS group (P=0.75). CONCLUSIONS: For selected NSCLC patients with lymph node involvement, robotic lobectomy is safe and effective with a low complication rate and similar long-term outcome compared with VATS lobectomy. Moreover, the robotic approach resulted in shorter postoperative length of stay and greater lymph node assessment.

Robot-assisted thoracoscopic surgery versus thoracotomy for c-N2 stage NSCLC: short-term outcomes of a randomized trial.

BACKGROUND: Safety and short-term efficacy of robot-assisted thoracoscopic surgery (RATS) for early-stage non-small cell lung cancer (NSCLC) have been previously proven; however, RATS for N2 stage NSCLC was barely evaluated. The aim of this randomized controlled trial (RCT) was to explore the short-term outcome of RATS for cN2 stage NSCLC. METHODS: Total of 113 patients who were diagnosed with clinically single cN2 stage NSCLC were enrolled and randomly assigned to RATS and thoracotomy groups. The patients in RATS group were treated by lobectomy and mediastinal lymph node dissection using the da Vinci Surgical System, while the patients in thoracotomy group underwent lobectomy and mediastinal lymph node dissection from. And, short-term outcomes were analyzed statistically. RESULTS: The data from 108 subjects (58 in RATS and 55 in thoracotomy groups) were eligible for analyses. Five patients who received robot-assisted lobectomy initially was converted intraoperatively to open operation due to extensive pleural adhesion and equipment issues. And, one subject underwent robot-assisted surgery was died preoperatively due to pulmonary embolism. Compared with thoracotomy, RATS was associated with less intraoperative blood loss (86.3±41.1 vs. 165.7±46.4 mL, P<0.001), median chest duration (4 vs. 5, P<0.01), visual analog scores at postoperative day one to five (P<0.001), and slightly fewer incidence of postoperative complications. Also, both surgical approaches revealed comparable drainages and nodal harvest. The cancer residual margins occurred in one subject in RATS group and three patients in thoracotomy group (P=0.56). However, overall cost of subjects underwent RATS was higher than those received thoracotomy (100,367±19,251 vs. 82,002±20,434, P<0.001). CONCLUSIONS: Present study proves that the feasibility and safety of RATS lobectomy to treat patients with cN2 stage NSCLC, and it should be superior to thoracotomy due to lesser intraoperative blood loss.

Continuous 389 cases of Da Vinci robot-assisted thoracoscopic lobectomy in treatment of non-small cell lung cancer: experience in Shanghai Chest Hospital.

BACKGROUND: To analyze the perioperative indexes of 389 patients with non-small cell lung cancer in single center after robot-assisted thoracoscopic (RATS) lobectomy, and to summarize the surgical key points in robotic lobectomy. METHODS: The clinical data of 389 stage I non-small cell lung cancer patients who underwent RATS lobectomy from May 2013 to December 2016 were retrospectively analyzed. Among them, there were 261 females (67.1%) and 128 males (32.9%); aged from 20-76 years old, with a mean age of 55.01 years; with ASA I in 106 cases, ASA II in 267 cases and ASA III in 16 cases; with BMI from 16.87-34.05, averaged at 23.09±2.79. The largest tumor in preoperative chest CT measurement was 0.3-3.0 cm, ranging from 1.29±0.59 cm; with stage Ia in 153 cases, stage Ib in 148 cases, stage Ic in 32 cases, stage IIb in 26 cases and stage IIIa in 30 cases; including 380 adenocarcinomas and 9 squamous carcinomas. RESULTS: The operating time was 46-300 min, averaged at 91.51±30.80 min; with a blood loss of 0-100 mL in 371 cases (95.80%), 101-400 mL in 12 cases (3.60%) and >400 mL in 2 cases (0.60%); there were 4 (1.2%) conversions to thoracotomy, in which 2 patients had massive hemorrhage and 2 patients had extensive dense adhesion; there was no mortality during operation and perioperatively. The drainage on the first day after operation was 0-960 mL, averaged at 231.39±141.87 mL; the postoperative chest tube was placed for 2-12 d, averaged at 3.96±1.52 d; the postoperative hospital stay was 2-12 d, averaged at 4.96±1.51 d, with postoperative hospital stay >7 d in 12 cases (3.60%). The postoperative air leakage was the main reason (35 cases, 9%) for prolonged hospital stay, and there was no re-admitted case within 30 days. All the patients underwent systemic lymph node dissection. The total cost of hospitalization was 60,389.66-134,401.65 CNY, averaged at 93,809.23±13,371.26 CNY. CONCLUSIONS: The application of Da Vinci robot surgery system in resectable non-small cell lung cancer is safe and effective, and could make up for the deficiencies of traditional thoracoscopic surgery. The number and level of robot surgery in our center have reached international advanced level, but the relatively expensive cost has become a major limitation in limiting its widespread use. With continuous improvements in robotic technology, its scope of application will be wider, which will inevitably bring new insights in lung surgical technology.

Tumor invasiveness defined by IASLC/ATS/ERS classification of ground-glass nodules can be predicted by quantitative CT parameters.

BACKGROUND: To investigate the potential value of CT parameters to differentiate ground-glass nodules between noninvasive adenocarcinoma and invasive pulmonary adenocarcinoma (IPA) as defined by IASLC/ATS/ERS classification. METHODS: We retrospectively reviewed 211 patients with pathologically proved stage 0-IA lung adenocarcinoma which appeared as subsolid nodules, from January 2012 to January 2013 including 137 pure ground glass nodules (pGGNs) and 74 part-solid nodules (PSNs). Pathological data was classified under the 2011 IASLC/ATS/ERS classification. Both quantitative and qualitative CT parameters were used to determine the tumor invasiveness between noninvasive adenocarcinomas and IPAs. RESULTS: There were 154 noninvasive adenocarcinomas and 57 IPAs. In pGGNs, CT size and area, one-dimensional mean CT value and bubble lucency were significantly different between noninvasive adenocarcinomas and IPAs on univariate analysis. Multivariate regression and ROC analysis revealed that CT size and one-dimensional mean CT value were predictive of noninvasive adenocarcinomas compared to IPAs. Optimal cutoff value was 13.60 mm (sensitivity, 75.0%; specificity, 99.6%), and -583.60 HU (sensitivity, 68.8%; specificity, 66.9%). In PSNs, there were significant differences in CT size and area, solid component area, solid proportion, one-dimensional mean and maximum CT value, three-dimensional (3D) mean CT value between noninvasive adenocarcinomas and IPAs on univariate analysis. Multivariate and ROC analysis showed that CT size and 3D mean CT value were significantly differentiators. Optimal cutoff value was 19.64 mm (sensitivity, 53.7%; specificity, 93.9%), -571.63 HU (sensitivity, 85.4%; specificity, 75.8%). CONCLUSIONS: For pGGNs, CT size and one-dimensional mean CT value are determinants for tumor invasiveness. For PSNs, tumor invasiveness can be predicted by CT size and 3D mean CT value.