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Assistência Perioperatória , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/etiologia , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Europa (Continente) , Neoplasias Torácicas/cirurgia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Anticoagulantes/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia , Fatores de RiscoRESUMO
OBJECTIVES: The aim of this study was to assess the self-reported current dyspnoea and perioperative changes of dyspnoea in long-term survivors after minimally invasive segmentectomy or lobectomy for early-stage lung cancer. METHODS: Cross-sectional telephonic survey of patients alive and disease-free as of March 2023, with pathologic stage IA1-2, non-small-cell lung cancer, assessed 1-5 years after minimally invasive segmentectomy or lobectomy (performed from January 2018 to January 2022). Current dyspnoea level: Baseline Dyspnoea Index score <10. Perioperative changes of dyspnoea were assessed using the Transition Dyspnoea Index. A negative Transition Dyspnoea Index focal score indicates perioperative deterioration in dyspnoea. Mixed effect models were used to examine demographic, medical and health-related correlates of current dyspnoea and changes in dyspnoea level. RESULTS: A total of 152 of 236 eligible patients consented or were available to respond to the telephonic interview(67% response rate): 90 lobectomies and 62 segmentectomies. The Baseline Dyspnoea Index score was lower (greater dyspnoea) in lobectomy patients (median 7, interquartile range 6-10) compared to segmentectomy (median 9, interquartile range 6-11), P = 0.034. 70% of lobectomy patients declared to have a current dyspnoea vs 53% after segmentectomy, P = 0.035. 82% of patients after lobectomy reported a perioperative deterioration in their dyspnoea compared to 57% after segmentectomy, P = 0.002. Mixed effect logistic regression analysis adjusting for patient-related factors and time elapsed from operation showed that segmentectomy was associated with a reduced risk of perioperative dyspnoea deterioration (as opposed to lobectomy) (Odds ratio (OR) 0.31, P = 0.004). CONCLUSIONS: Our findings may be valuable to inform the shared decision-making process by complementing objective data on perioperative changes of pulmonary function.
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Carcinoma Pulmonar de Células não Pequenas , Dispneia , Neoplasias Pulmonares , Pneumonectomia , Autorrelato , Humanos , Dispneia/etiologia , Masculino , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Neoplasias Pulmonares/cirurgia , Feminino , Idoso , Pessoa de Meia-Idade , Estudos Transversais , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estadiamento de NeoplasiasRESUMO
The Society of Thoracic Surgeons Workforce on Evidence-Based Surgery provides this document on management of pleural drains after pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in 5 specific areas: (1) choice of drain, including size, type, and number; (2) management, including use of suction vs water seal and criteria for removal; (3) imaging recommendations, including the use of daily and postpull chest roentgenograms; (4) use of digital drainage systems; and (5) management of prolonged air leak. To formulate the consensus statements, a task force of 15 general thoracic surgeons was invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of 2 rounds of voting until 75% agreement on the statements was reached. A total of 13 consensus statements are provided to encourage standardization and stimulate additional research in this important area.
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Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/patologia , Neoplasias Pulmonares/patologia , Estadiamento de Neoplasias , Pneumonectomia/efeitos adversos , Terapia CombinadaRESUMO
OBJECTIVES: Robotic-assisted thoracic surgery (RATS) is increasingly used in our specialty. We surveyed European Society of Thoracic Surgeons membership with the objective to determine current status of robotic thoracic surgery practice including training perspectives. METHODS: A survey of 17 questions was rolled out with 1 surgeon per unit responses considered as acceptable. RESULTS: A total of 174 responses were obtained; 56% (97) were board-certified thoracic surgeons; 28% (49) were unit heads. Most responses came from Italy (20); 22% (38) had no robot in their institutions, 31% (54) had limited access and only 17% (30) had full access including proctoring. Da Vinci Xi was the commonest system in 56% (96) centres, 25% (41) of them had dual console in all systems, whereas RATS simulator was available only in half (51.18% or 87). Video-assisted thoracic surgery (VATS) was the most commonly adopted surgical approach in 81% of centres (139), followed by thoracotomy in 67% (115) and RATS in 36% (62); 39% spent their training time on robotic simulator for training, 51% on robotic wet/dry lab, which being no significantly different to 46-59% who had training on VATS platform. There was indeed huge overlap between simulator models or varieties usage; 52% (90) reported of robotic surgery not a part of training curriculum with no plans to introduce it in future. Overall, 51.5% (89) responded of VATS experience being helpful in robotic training in view of familiarity with minimally invasive surgery anatomical views and dissection; 71% (124) reported that future thoracic surgeons should be proficient in both VATS and RATS. Half of the respondents found no difference in earlier chest drain removal with either approach (90), 35% (60) reported no difference in postoperative pain and 49% (84) found no difference in hospital stay; 52% (90) observed better lymph node harvest by RATS. CONCLUSIONS: Survey concluded on a positive response with at least 71% (123) surgeons recommending to adopt robotics in future.
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The treatment landscape of resectable early-stage non-small cell lung cancer (NSCLC) is transforming due to the approval of novel adjuvant and neoadjuvant systemic treatments. The European Medicines Agency (EMA) recently approved adjuvant osimertinib, adjuvant atezolizumab, adjuvant pembrolizumab, and neoadjuvant nivolumab combined with chemotherapy, and the approval of other agents or new indications may follow soon. Despite encouraging results, many unaddressed questions remain. Moreover, the transformed treatment paradigm in resectable NSCLC can pose major challenges to healthcare systems and magnify existing disparities in care as differences in reimbursement may vary across different European countries. This Viewpoint discusses the challenges and controversies in resectable early-stage NSCLC and how existing inequalities in access to these treatments could be addressed.
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The treatment landscape of resectable early-stage non-small cell lung cancer (NSCLC) is set to change significantly due to encouraging results from randomized trials evaluating neoadjuvant and adjuvant immunotherapy, as well as adjuvant targeted therapy. As of January 2024, marketing authorization has been granted for four new indications in Europe, and regulatory approvals for other study regimens are expected. Because cost-effectiveness and reimbursement criteria for novel treatments often differ between European countries, access to emerging developments may lead to inequalities due to variations in recommended and available lung cancer care throughout Europe. This Series paper (i) highlights the clinical studies reshaping the treatment landscape in resectable early-stage NSCLC, (ii) compares and contrasts approaches taken by the European Medicines Agency (EMA) for drug approval to that taken by the United States Food and Drug Administration (FDA), and (iii) evaluates the differences in access to emerging treatments from an availability perspective across European countries.
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Background: Dyspnoea is common following surgical resection for non-small cell lung cancer (NSCLC). The effects range from reduced quality of life to impact on adjuvant therapy outcomes. Currently, dyspnoea beyond the immediate postoperative phase and risk factors are not well characterised. We hope to assess the evolution of patient-reported dyspnoea after anatomic lung resection and associated factors. Methods: Single-centre cohort study with analysis on data collected longitudinally of 131 patients undergoing anatomic lung resections for NSCLC between September 2014 and December 2018. The European Organization for Research and Treatment Lung Cancer-specific Quality of Life Questionnaire Dyspnoea Scale was used to measure dyspnoea before and after surgery. Multivariable regression analysis was used to identify factors associated with clinically meaningful perioperative changes in dyspnoea at 6-12 months. Results: Mean Dyspnoea Scale scores preoperatively and 6-12 months after resection were 12.6 (standard deviation 17.4) and 17.9 (standard deviation 20.5), respectively. Of all patients 31% experienced a clinically meaningful increase in dyspnoea, defined as >10 points between Dyspnoea Scale scores preoperatively and at 6-12 months. Comparatively, 71% of patients without preoperative symptoms of dyspnoea developed a clinically meaningful increase of dyspnoea postoperatively. After adjusting the analysis for baseline factors and preoperative Dyspnoea Scale score, female sex remained the only patient factor associated with increased postoperative dyspnoea at 6-12 months after surgery (P=0.046). A total of 34% of patients reported increased dyspnoea after lobectomies and 9% after segmentectomies (P=0.014). Segmentectomy (as opposed to larger resections) was the only surgical factor associated with lower risk of increased dyspnoea (P=0.057). Conclusions: A clinically meaningful increase in dyspnoea is frequent after lung resection. Postoperative evolution of dyspnoea is non-predictable using objective baseline factors highlighting the importance of patient reported symptoms and involvement in clinical consultation.
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Background: Chest dynamic digital radiography (DDR) is used as a supplementary tool for the routine pulmonary function test (PFT); however, its potential as a novel standard PFT method has yet to be explored. Therefore, the present study aimed to investigate the correlation between the change in the projected lung area (ΔPLA) and forced vital capacity (FVC) using chest DDR, and to establish a DDR-FVC estimation model and a predictive value model for the ΔPLA. Methods: In total, 139 participants who underwent chest DDR and the PFT in the same period at The First Affiliated Hospital of Guangzhou Medical University from April 2022 to February 2023 were prospectively included in the study. The patients' age, gender, height, and weight measurements were recorded. Additionally, the ΔPLA was measured, and the IWS workstation software was used for automated outlining and calculation. Subsequently, a correlation analysis and regression analysis models were employed to examine the relationship between the ΔPLA, FVC, and individual physiological characteristics. Additionally, an independent sample t-test was used to determine whether there were any significant differences between the normal and abnormal FVC groups. Results: The 139 participants were grouped according to the results of the ratio of measured/predicted FVC values (FVC%pred); those with an FVC%pred ≥80%, were allocated to the normal FVC group, and those with an FVC%pred <80% were allocated to the abnormal FVC group. The correlation coefficient was >0.8 in the full sample; the ΔPLA showed a significant linear correlation with the measured FVC value [r=0.81, 95% confidence interval (CI): 0.75-0.86, P<0.001]. There was a significant difference in the ΔPLA between the normal and abnormal FVC groups. With the ΔPLA, age, gender, height, and weight as predictor variables, the following DDR-FVC estimation model was established: DDR-FVC estimation model = -0.997 + 1.35×10-4 × ΔPLA + 0.017 × height - 0.014 × age + 0.249 × gender (1 for male and 0 for female) [adjusted R2 (adj. R2)=0.731, F=94.615, P<0.001]. The following formula was used to determine the predictive value of the ΔPLA: Predictive value of ΔPLA = -12,504.287 + 173.185 × height + 62.971 × weight - 84.933 × age (adj. R2=0.393, F=20.453, P<0.001). Conclusions: There was a linear correlation between the ΔPLA measured by biphasic chest DDR and the FVC. A model for estimating the FVC was established based on the ΔPLA, which allows the FVC to be assessed by the ΔPLA measured by biphasic chest DDR. A predictive value model for the ΔPLA was also established to provide ΔPLA reference values for assessment and comparison.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Cirurgiões , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Pneumonectomia , Estadiamento de Neoplasias , Estudos RetrospectivosRESUMO
OBJECTIVES: Ventilatory efficiency [minute ventilation-to-carbon dioxide output slope (VE/VCO2 slope)] can be measured at sub-maximal workload during cardiopulmonary exercise test. The aim of this study is to assess the association between VE/VCO2 slope and outcome after lung cancer resections. METHODS: Retrospective, single-centre analysis on all patients undergoing lung resection for cancer (April 2014-August 2022) and with a preoperative cardiopulmonary exercise test. VE/VCO2 slope >40 was chosen as high-risk threshold. Logistic regression analysis was used to test the association of VE/VCO2 slope and several patient- and surgery-related factors with 90-day mortality. RESULTS: A total of 552 patients were included (374 lobectomies, 81 segmentectomies, 55 pneumonectomies and 42 wedge resections). Seventy-four percent were minimally invasive procedures. Cardiopulmonary morbidity was 32%, in-hospital/30-day mortality 6.9% and 90-day mortality 8.9%. A total of 137 patients (25%) had a slope of >40. These patients were older (72 vs 70 years, P = 0.012), had more frequently coronary artery disease (17% vs 10%, P = 0.028), lower carbon monoxide lung diffusion capacity (57% vs 68%, P < 0.001), lower body mass index (25.4 vs 27.0 kg/m2, P = 0.001) and lower peak VO2 (14.9 vs 17.0 ml/kg/min, P < 0.001) than those with a lower slope. The cardiopulmonary morbidity among patients with a slope of >40 was 40% vs 29% in those with lower slope (P = 0.019). Ninety-day mortality was 15% vs 6.7% (P = 0.002). The 90-day mortality of elderly patients with slope >40 was 21% vs 7.8% (P = 0.001). After adjusting for peak VO2 value, extent of operation and other patient-related variables in a logistic regression analysis, VE/VCO2 slope retained a significant association with 90-day mortality. CONCLUSIONS: VE/VCO2 slope was strongly associated with morbidity and mortality following lung resection and should be included in the functional algorithm to assess fitness for surgery.
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Insuficiência Cardíaca , Neoplasias Pulmonares , Humanos , Idoso , Teste de Esforço/métodos , Neoplasias Pulmonares/cirurgia , Dióxido de Carbono , Estudos Retrospectivos , Consumo de Oxigênio , Pulmão , Pneumonectomia , Insuficiência Cardíaca/cirurgia , PrognósticoRESUMO
OBJECTIVES: The aim of this study was to assess variations in surgical stage distribution in 2 centres within the same UK region. One centre was covered by an active screening program started in November 2018 and the other was not covered by screening. METHODS: Retrospective analysis of 1895 patients undergoing lung resections (2018-2022) in 2 centres. Temporal distribution was tested using Chi-squared for trends. A lowess curve was used to plot the proportion of stage 1A patients amongst those operated over the years. RESULTS: The surgical populations in the 2 centres were similar. In the screening unit (SU), we observed a 18% increase in the proportion of patients with clinical stage IA in the recent phase compared to the early phase (59% vs 50%, P = 0.004), whilst this increase was not seen in the unit without screening. This difference was attributable to an increase of cT1aN0 patients in the SU (16% vs 11%, P = 0.035) which was not observed in the other unit (10% vs 8.2%, P = 0.41). In the SU, there was also a three-fold increase in the proportion of sublobar resections performed in the recent phase compared to the early one (35% vs 12%, P < 0.001). This finding was not evident in the unit without screening. CONCLUSIONS: Lung cancer screening is associated with a higher proportion of lung cancers being detected at an earlier stage with a consequent increased practice of sublobar resections.
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OBJECTIVES: The objective of this study is to compare in a real-world series the short- and long-term results of segmentectomy and lobectomy for peripheral clinical stage IA non-small-cell lung cancer (NSCLC). METHODS: Single-centre cohort study including a series of consecutive patients undergoing minimally invasive segmentectomy or lobectomy for peripheral (outer third of the lung) clinical stage IA NSCLC (January 2017-August 2022). Propensity score case matching analysis generated 2 matched groups of patients undergoing segmentectomy or lobectomy. Short-term (morbidity and mortality) and long-term [overall survival and event-free survival (EFS)] outcomes were compared between the 2 matched groups. EFS was calculated by including death resulting from any cause and any recurrence as events. RESULTS: Propensity score generated 118 pairs of patients undergoing minimally invasive segmentectomy or lobectomy. The median follow-up was 30 months (95% confidence limits (CL) 4-64). The median postoperative length of stay was 4 days in both groups. Ninety-day mortality was similar (segmentectomy 2.5% versus lobectomy 1.7%, P = 1). Three-year overall survival [segmentectomy 87% (76-93) versus lobectomy 81% (72-88), P = 0.73] and EFS [segmentectomy 82% (72-90) versus lobectomy 78% (68-84), P = 0.52] did not differ between the groups. Loco-regional recurrence rate [segmentectomy 4.2% (5/118) versus lobectomy 9.3% (11/118), P = 0.19] was similar despite a lower nodal upstaging [segmentectomy 3.4% (4/118) versus lobectomy 14% (17/118), P = 0.005]. The occurrence of compromised resection margins (pR1 or pR uncertain) was similar between the groups [segmentectomy 7.6% (9/118) versus lobectomy 9.3% (11/118), P = 0.81]. CONCLUSIONS: This observational series confirms the non-inferiority of segmentectomy compared to lobectomy in treating peripherally located stage IA NSCLC.
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OBJECTIVES: There is a lack of evidence on whether perioperative outcomes differ in obese patients after video-assisted thoracic surgery (VATS) or open lobectomy. We queried the European Society of Thoracic Surgeons database to assess morbidity and postoperative length of hospital stay in obese patients submitted to VATS and open pulmonary lobectomy for non-small-cell lung cancer. METHODS: We collected all consecutive patients from 2007 to 2021 submitted to lobectomy through VATS or thoracotomy with a body mass index greater than or equal to 30. An intention-to-treat analysis was carried out. Primary outcomes were morbidity rate, mortality and postoperative length of stay (LOS). Differences in outcomes were assessed through univariable, multivariable-adjusted and propensity score-matched analysis. RESULTS: Out of a total of 78 018 patients submitted to lung lobectomy, 13 999 cases (17.9%) were considered in the analysis, including 5562 VATS lobectomies and 8437 thoracotomy lobectomies. The VATS group showed a lower complication rate (23.2% vs 30.2%, P < 0.001), mortality (0.8% vs 1.5%, P < 0.001) and postoperative LOS (median 5 vs 7 days, P < 0.001). After propensity score matching, the VATS approach confirmed a lower complication rate (24.7% vs 29.7%, P = 0.002) and postoperative LOS (median 5 vs 7 days, P < 0.001). Moreover, these results were consistently observed when analyzing the severe obese subgroup (body mass index 35-39.9) and morbid obese subgroup (body mass index ≥40). CONCLUSIONS: In obese patients with non-small cell lung cancer, VATS lobectomy was found to be associated with improved postoperative outcomes than open lobectomy. Consequently, it should be considered the approach of choice for the Obese population.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Cirurgiões , Humanos , Carcinoma Pulmonar de Células não Pequenas/complicações , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/cirurgia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodos , Toracotomia/efeitos adversos , Toracotomia/métodos , Complicações Pós-Operatórias , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Obesidade/complicações , Obesidade/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Screening for lung cancer with low radiation dose computed tomography has a strong evidence base, is being introduced in several European countries and is recommended as a new targeted cancer screening programme. The imperative now is to ensure that implementation follows an evidence-based process that will ensure clinical and cost effectiveness. This European Respiratory Society (ERS) task force was formed to provide an expert consensus for the management of incidental findings which can be adapted and followed during implementation. METHODS: A multi-European society collaborative group was convened. 23 topics were identified, primarily from an ERS statement on lung cancer screening, and a systematic review of the literature was conducted according to ERS standards. Initial review of abstracts was completed and full text was provided to members of the group for each topic. Sections were edited and the final document approved by all members and the ERS Science Council. RESULTS: Nine topics considered most important and frequent were reviewed as standalone topics (interstitial lung abnormalities, emphysema, bronchiectasis, consolidation, coronary calcification, aortic valve disease, mediastinal mass, mediastinal lymph nodes and thyroid abnormalities). Other topics considered of lower importance or infrequent were grouped into generic categories, suitable for general statements. CONCLUSIONS: This European collaborative group has produced an incidental findings statement that can be followed during lung cancer screening. It will ensure that an evidence-based approach is used for reporting and managing incidental findings, which will mean that harms are minimised and any programme is as cost-effective as possible.
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Neoplasias Pulmonares , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Detecção Precoce de Câncer/métodos , Etiquetas de Sequências Expressas , Achados Incidentais , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Screening for lung cancer with low radiation dose computed tomography has a strong evidence base, is being introduced in several European countries and is recommended as a new targeted cancer screening programme. The imperative now is to ensure that implementation follows an evidence-based process that will ensure clinical and cost effectiveness. This European Respiratory Society (ERS) task force was formed to provide an expert consensus for the management of incidental findings which can be adapted and followed during implementation. METHODS: A multi-European society collaborative group was convened. 23 topics were identified, primarily from an ERS statement on lung cancer screening, and a systematic review of the literature was conducted according to ERS standards. Initial review of abstracts was completed and full text was provided to members of the group for each topic. Sections were edited and the final document approved by all members and the ERS Science Council. RESULTS: Nine topics considered most important and frequent were reviewed as standalone topics (interstitial lung abnormalities, emphysema, bronchiectasis, consolidation, coronary calcification, aortic valve disease, mediastinal mass, mediastinal lymph nodes and thyroid abnormalities). Other topics considered of lower importance or infrequent were grouped into generic categories, suitable for general statements. CONCLUSIONS: This European collaborative group has produced an incidental findings statement that can be followed during lung cancer screening. It will ensure that an evidence-based approach is used for reporting and managing incidental findings, which will mean that harms are minimised and any programme is as cost-effective as possible.