Thoracoscopic segmentectomy for trans-fissure ground-glass opacity.

OBJECTIVES: The trans-fissure ground-glass opacity (GGO) is a special category of lesions, with a diameter always exceeding 2 cm. It is located on a fused fissure, 'seizing' 2 neighbouring lobes simultaneously. The segmentectomy for the trans-fissure GGO is never reported. METHODS: Between August 2016 and December 2022, patients operated with a trans-fissure GGO were included. The patients' backgrounds and surgical data were summarized. All procedures were performed with the help of preoperative three-dimensional computed tomography bronchography and angiography. RESULTS: A total of 84 patients were included. The selection criteria included a consolidation tumour ratio <50% and a lesion size >2 and ≤3 cm. Thirty-six patients were operated with lobectomy + wedge (the traditional method group) and 48 patients were operated with anatomical segmentectomy + function-preserving sublobectomy (the new method group). The median operative time was 87 min in the traditional group and 98 min in the new method group, and the median blood loss was 60 ml in the traditional group and 70 ml in the new method group. The median duration of hospital stays was 4 days in the traditional group and 2 days in the new method group. In the traditional method group, there was 1 case of postoperative air leakage and 5 cases of haemoptysis. In the new method group, 2 cases of postoperative air leakage were identified. The median size of the tumour in the resected segment was 2.6 cm in the traditional group and 2.5 cm in the new method group. The median margin was 2.5 cm in the traditional group and 3.3 cm in the new method group. CONCLUSIONS: The trans-fissure GGO could be safely resected en bloc by segmentectomy with a well-designed surgical procedure and appropriate preoperative planning.

Natural Sequential Collapse Method: A Common Technique to Identify the Intersegmental Plane.

The natural sequential collapse method (NSCM) can be employed during surgery to reduce the duration of segmentectomy. This method avoids inflating the lung by rapidly blocking vessels within the tumor basin. It is important to note that the color of the lungs should be used to determine the surgical procedure. The NSCM is efficient and straightforward in revealing the intersegmental plane.

Prevalence and anatomical characteristics of medial-basal segment in right lung.

OBJECTIVES: The anatomic features and surgical techniques focusing on the right medial-basal segment (RS7) are few reported. This study aimed to accurately define the new nomenclature and classifications of B7 anatomy, elucidate its prevalence and anatomical characteristics and summarize the surgical outcomes. METHODS: Between August 2019 and February 2022, 5023 patients were admitted for pulmonary nodules. Their chest computed tomography images were obtained. All of the images were reconstructed in 3 dimensions. The RS7 were screened according to their new definition and statistically analysed for their anatomical characteristics. RESULTS: The bronchovascular anatomy of S7 can be newly classified into 6 types: B7a type, B7p type, B7o type, B7t type, BX7a type and BX7t type. The B7 anterior to the inferior pulmonary vein (IPV) was B7a (a, anterior) (3617/5023, 72%). The B7 posterior to IPV was B7p (p, posterior) (306/5023, 6.1%). The B7 over IPV was B7o (o, over) (904/5023, 18%). The B7 through IPV was B7t (t, through) (7/5023, 0.14%). An abnormal origin of B7 was named the BX7 type. The BX7 anterior to IPV sharing a common trunk with B8 was named BX7a (a, anterior) (176/5023, 3.5%). The BX7 through IPV originated from B10 and was named BX7t (t, through) (13/5023, 0.26%). 0.2% (12/5023) of patients had the nodules in RS7 and underwent RS7 surgery. CONCLUSIONS: The variation pattern of B7 is far more complex than expected. The results of this study can help surgeons better understand S7 and perform segmentectomies more accurately.

Superior mesenteric artery syndrome following lung cancer surgery: A case report.

INTRODUCTION AND IMPORTANCE: Superior mesenteric artery syndrome (SMAS) is a rare medical condition resulting from vascular compression of the third part of the duodenum in the angle between the aorta and the superior mesenteric artery, leading to partial or complete intestinal obstruction and causing a series of symptoms. We now introduce a case of SMAS after lung cancer surgery, which was unique in that it was most likely caused by weight loss after surgery. CASE PRESENTATION: A 58-year-old male patient gradually developed severe nausea, vomiting, and weight loss after lung cancer surgery. A diagnosis of SMAS was made after the computed tomography of the abdomen was performed. The patient's symptoms were relieved after immediate placement of a nasojejunal nutrition tube for gastrointestinal decompression and enteral nutrition support. CLINICAL DISCUSSION: SMAS is rare and the symptoms are not specific, the clinical diagnosis of it is mostly confirmed by imaging. The presence of SMAS should be considered as a possibility when recurrent nausea and vomiting occur after lung surgery that excludes the above-mentioned causes. CONCLUSION: The signs and symptoms of SMAS are usually non-specific, which leads to misdiagnosis in all probability. SMAS should be considered when unexplained significant weight loss accompanied by recurrent nausea and vomiting happens to postoperative patients.

Functional Preserving Sublobectomy: A Novel Method for Sublobectomy.

We introduce a new method for sublobectomy. It utilizes the easiness and rapidity of wedge resection, and the accuracy and functional preserving of anatomical segmentectomy. It can preserve lung function with less sacrifice of lung parenchyma.

Glutathione peroxidase 2 overexpression promotes malignant progression and cisplatin resistance of KRAS­mutated lung cancer cells.

Kirsten rat sarcoma viral oncogene homolog (KRAS) aberrations frequently occur in patients with lung cancer. Oncogenic KRAS is characterized by excessive reactive oxygen species (ROS) accumulation, thus, ROS detoxification may contribute to KRAS­driven lung tumorigenesis. In the present study, the influence of glutathione peroxidase 2 (GPX2) on malignant progression and cisplatin resistance of KRAS­driven lung cancer was explored. The RNA sequencing data from TCGA lung cancer samples and GEO database were downloaded and analyzed. The effects of GPX2 on KRAS­driven lung tumorigenesis were evaluated by western blotting, cell viability assay, soft agar assay, Transwell assay, tumor xenograft model, flow cytometry, BrdU incorporation assay, transcriptome RNA sequencing, luciferase reporter assay and RNA immunoprecipitation. In the present study, GPX2 was upregulated in patients with non­small cell lung carcinoma (NSCLC), and positively correlated with poor overall survival. Ectopic GPX2 expression facilitated malignant progression of KRASG12C­transformed BEAS­2B cells. Moreover, GPX2 overexpression promoted growth, migration, invasion, tumor xenograft growth and cisplatin resistance of KRAS­mutated NSCLC cells, while GPX2 knockdown exhibited the opposite effects. GPX2 overexpression reduced ROS accumulation and increased matrix metalloproteinase­1 (MMP1) expression in KRAS­mutated NSCLC cells. In addition, GPX2 was directly targeted by miR­325­3p, while MMP1 knockdown or miR­325­3p overexpression partially abrogated the effects of GPX2 in NSCLC cells. In conclusion, the results indicated that GPX2 facilitated malignant progression and cisplatin resistance of KRAS­driven lung cancer, and inhibition of GPX2 may be a feasible strategy for lung cancer treatment, particularly in patients with active KRAS mutations.

Thoracoscopic Anatomical Enucleation of GGO.

BACKGROUND: Enucleation was commonly used in the surgery of the eye or prostate. The implication in the treatment of GGO is never reported. METHODS: In this multimedia article, we described a thoracoscopic enucleation of GGO between S7 and S8 in the right lower lobe. According to the pre-operative 3D-CTBA, few bronchovascular structures were passing through the border of RS7 and RS8-a primarily pulmonary parenchyma region. Therefore, an enucleation of GGO is feasible with a low risk of injuring adjacent structures. The main utility incision and observing port were inserted in the fourth and seventh intercostal space in the anterior axillary line. Two assistant incisions were made in the seventh intercostal space in the mid-axillary line and the ninth intercostal space in the posterior axillary line. The GGO is invisible and unpalpable, so it cannot be located intraoperatively. The surgery was initiated by dividing the lung parenchyma alongside the anatomic landmark of A7 on the left. On the right, the common trunk of A8-10 was dissected until A8 was identified. The last anatomic landmark is V8b, which lies posteriorly. The lung parenchyma was dissected by electrocautery hook along with the A7, A8, and V8b to the diaphragmatic surface. Using an electrocautery hook during dissection is preferable, whose terminal is sharper and more flexible. The ultrasonic scalpel is not recommended. A glove is utilized for the specimen retrieval to avoid implantation metastasis. RESULTS: The operative time was 0.5 h with an estimated blood loss of 10 ml. With no chest tube, the patient was discharged on postoperative day 1. The final pathological finding was minimally invasive adenocarcinoma (pTmiN0M0). DISCUSSION: Considering the natural history and excellent prognosis of GGO, the safe margin is the primary concern for GGO resection.1,2 We use the anatomic landmark to secure a safe margin in enucleation. Besides, dissection of the anatomic intersegmental plane by electrocautery (but not by stapling) reduces unfavorable recurrent local failure at the margin and allows full expansion of the preserved adjacent segments to result in maximal pulmonary function.3.

Thoracoscopic right middle lobe subsegmentectomy: A single-center, retrospective review.

Objective: The right middle lobe subsegmentectomy (including multisubsegmentectomy and subsubsegmentectomy) has never been reported. This study aimed to describe a thoracoscopic right middle lobe subsegmentectomy. Methods: This retrospective study included 94 patients who underwent thoracoscopic right middle lobe subsegmentectomy between August 2018 and February 2021. All procedures were performed with the help of the preoperative 3-dimensional computed tomography bronchography and angiography. Results: Ninety-four patients underwent thoracoscopic right middle lobe subsegmentectomy. The median operative time was 56 minutes (range, 35-86 minutes) and median blood loss was 86 mL (range, 50-150 mL). The median duration of chest tube retention was 2.5 days (range, 1-4 days). There were neither cases of postoperative right middle lobe torsion nor instances of perioperative death. The median size of the tumor in the resected segment was 1.3 cm (range, 1.1-1.8 cm). The median margin was 3.3 cm (range, 2.9-4.3). There were 88 cases of lung cancer and 6 cases of benign lesions. The median number of N1 lymph nodes sampled was 3 (range, 2-4). No lymph node involvement was observed postoperatively. No recurrence or mortality was observed during the median follow-up period of 26 months (range, 6-36 months). Conclusions: Thoracoscopic right middle lobe subsegmentectomy is feasible and safe. It may be valuable to preserve the lung parenchyma in patients with noninvasive lung cancer, multiple lung cancer, and benign diseases. Long-term lung function, survival, and cancer-free data are being collected.

Boyden's triad in the left lung: an interesting phenomenon.

OBJECTIVES: Boyden's triad of the right lung was first proposed in 2021. Here, we report 5 cases of this malformation found in the left lung. METHODS: A total of 5280 patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography between January 2019 and January 2021, prior to surgery; 5 cases of this malformation were identified in the left lung. Bronchovascular patterns were analysed in each patient. RESULTS: The incidence rate of Boyden's triad in the left lung was 0.1%. This malformation was further divided into B3 on B4+5 type and B3 on B4 type. In B3 on B4+5 type, B3 was shifted downwards on the common trunk of B4+5, and A3 arose from the common trunk of A4+5 running alongside B3. In B3 on B4 type, B3 was shifted downwards on B4. A4 and A5 appeared separately. A3 arose from A4, running alongside B3; A5 arose from the common trunk of A8 - 10, and there was also an extraordinary 'posterior vein' (V. post): V1+2c. The incidence of V. post was 0.17%. An additional 'fissure' lies longitudinally between S1+2 and S3+4+5, nearly perpendicular to the oblique fissure, dividing the upper lobe into 'two lobes'. CONCLUSIONS: The B3 downwards-shifting malformation can be found on both lungs, and this is the first description of Boyden's triad in the left lung; it appears to be much rarer than that in the right lung, with some accompanying unique variations.

Emergence of transient intersegmental plane by pulmonary circulation single-blocking: is it the true intersegmental plane?

We report the transient intersegmental plane formed by circulation single-blocking, which is consistent with the true intersegmental plane, and its formation principles, characteristics and potential applications.

Boyden's triad: the past, present and future.

OBJECTIVES: The B3 downwards-shifting malformation was first proposed by Boyden in 1950. Here, we report 14 cases of this malformation in the right lung and the first case of segmentectomy for this malformation. METHODS: All patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography (3D-CTBA) between January 2019 and January 2020, prior to surgery. A consecutive 2356 patients were included, and 14 cases of this malformation were identified; bronchovascular patterns were analysed in each patient. RESULTS: The incidence of this malformation was 0.6%. It was further divided into 3 types: over downwards-shift, partial downwards-shift and normal downwards-shift. The normal downwards-shift type was the most common (8/14), where B3 shifted downwards completely to merge with B4 + 5. In the partial downwards-shift (5/14), only part of the B3 shifted. In the over downwards-shift type (1/14), both B3 and B1b shifted downwards. A bifurcated right upper lobe （RUL) bronchus (B1 defective) was observed in 3 cases. The incidence of V1a, V1b, V2a, V2b, V2c, V3a, V3b and V3c was 100% (14/14). The incidence rates of A1, A3a and A3b were 100% (14/14). The incidence of A2 rec and A2 asc was 92.9% (13/14) and 71.4% (10/14), respectively. CONCLUSIONS: The B3 downwards-shifting malformation or 'Boyden's triad' is a rare anomaly. Anatomical exploration of this malformation is important for surgery.

A novel localization technique for peripheral ground glass opacity using geometric parameters measured on CT images.

BACKGROUND: Currently no optimal localization technique has been established for localization of ground glass opacity (GGO). We aimed to introduce a localization technique using geometric localization for peripheral GGO. METHODS: We delineated the location of pulmonary GGO using geometric method which was similar with localization of a point in a spatial coordinate system. The localization technique was based on the anatomical landmarkers (ribs or intercostal spaces, capitulum costae and sternocostal joints). The geometric parameters were measured on preoperative CT images and the targeted GGO could be identified intraoperatively according to the parameters. We retrospectively collected the data of the patients with peripheral GGOs which were localized using this method and were wedge resected between June 2019 and July 2020. The efficacy and feasibility of the localization technique were assessed. RESULTS: There were 93 patients (male 34, median = 55 years) with 108 peripheral GGOs in the study. All the targeted GGOs were successfully wedge resected in the operative field with negative surgical margin at the first attempt. For each GGO, the localization parameters could be measured in 2-4 min (median = 3 min) on CT images before operation, and surgical resection could be completed in 5-10 min (median = 7 min). A total of 106 (98.15%) GGOs achieved sufficient resection margin. No complications and deaths occurred related to the localization and surgical procedure. CONCLUSIONS: The localization technique can achieve satisfactory localization success rate and good safety profile. It can provide an easy-to-use alternative to localize peripheral GGO.

Intrapulmonary lymph node (stations 13 and 14) metastasis in peripheral non-small cell lung cancer.

ABSTRACT: It remains unknown whether dissecting the intrapulmonary lymph nodes (stations 13 and 14) when resecting peripheral non-small cell lung cancer (NSCLC) is necessary for accurate tumor node metastasis (TNM) staging. This study investigated intrapulmonary lymph node dissection (stations 13 and 14) on the pathological staging of peripheral NSCLC and the metastatic pattern of the lymph nodes.This retrospective study included patients with primary peripheral NSCLC who underwent radical dissection between January 2013 and December 2015. The clinical data of patients and examination results of intrapulmonary stations 12, 13, and 14 lymph nodes were analyzed.Of 3019 resected lymph nodes in a total of 234 patients (12.9/patient), 263 (8.7%) had metastasis. Ninety-nine patients had lymph node metastasis (42.3%): 40 (17.1%) were N1, 11 (4.7%) were N2, 48 (20.5%) were both N1 and N2, and 135 (57.7%) had no N1 or N2 metastasis. Sixteen (6.8%) patients had metastasis of stations 13 and/or 14. Metastasis in N1 positive patients of stations 10, 11, 12, 13, and 14 were 2.7%, 10.5%, 9.8%, 10.4%, and 8.5%, respectively. Missed detection without station 13 and 14 dissection was up to 6.8% (16/234).Dissection of stations 13 and 14 could be helpful for the identification of lymph node metastasis and for the accurate TNM staging of primary NSCLC.

Non-energy devices to dissect recurrent laryngeal nerve lymph nodes of non-small cell lung cancer under video-assisted thoracic surgery.

BACKGROUND: Systematic nodal dissection plays a crucial role in improving survival and staging in resectable non-small cell lung cancer (NSCLC) patients but at the cost of increasing the occurrence of recurrent laryngeal nerve injury. Technology should be improved to protect the recurrent laryngeal nerve (RLN) during surgery. METHODS: NSCLC patients who underwent video-assisted thoracic surgery (VATS) surgical treatment by the same surgeon at our hospital from January 2016 to December 2017 were included as the research subjects and were divided into an energy-device group and a non-energy-device group. Their procedures included anatomic pulmonary resection, normative N1 dissection, and systemic N2 dissection. RESULTS: The rate of metastatically involved recurrent laryngeal nerve lymph nodes (RLNLNs) was 5.19% (39/752). Dissection device, side of primary, FEV1, operative time and BMI were independent predictors of recurrent laryngeal nerve injury (RLNI) (hazard ratio (HR) = 3.576, 95% confidence interval (CI): 1.490-8.583, P = 0.004; HR = 0.175, 95% CI: 0.072-0.424, P = < 0.001; HR = 3.008, 95% CI: 1.30-6.927, P = 0.010; HR = 0.328, 95% CI: 0.136-0.794, P = 0.013; HR = 0.344, 95%CI: 0.147-0.801, P = 0.013, respectively). Patients in the non-energy-device group had significantly less RLNI than the energy-device group (P = 0.016) and nearly half of the non-thermal RLNI recovered in 2 weeks (P = 0.025) whereas most thermal RLNI required 3 months for recovery. CONCLUSIONS: Every station of RLNLN had some degree of cancer metastasis in NSCLC patients and when dissecting RLNLNs, dissection device was an independent and artificially controlled predictor of RLNI. Using a non-energy device is a feasible method to protect the RLN as well as an improved recovery time of RLNI.

Vein or artery-first resection in right middle lobe segmentectomy: which preserves more lung?

We report the thoracoscopic RS5 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method and confirmed that the segmental plane visualized by vein-first resection is slightly narrower than the traditional artery-first resection.

The VVBA method for thoracoscopic right middle lobe segmentectomy.

The right middle lobe segments (RS4 and RS5) are very small and the technique for segmentectomy is rarely reported. Here, we report 3 cases of thoracoscopic RS4 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method. The VVBA method for thoracoscopic segmentectomy is a simple, safe, and effective procedure for RS4 segmentectomy with clear procedural steps. It overcomes the difficulty in manipulation of incomplete lung fissures and simplifies the surgical procedures.

Analysis of the variation pattern in left upper division veins and establishment of simplified vein models for anatomical segmentectomy.

BACKGROUND: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) is a powerful tool to analyze pulmonary anatomy. We used 3D-CTBA to analyze variations of the pulmonary veins of the left upper division (LUD) and created a simplified LUD vein model. METHODS: Between January 2019 and October 2019, 124 patients with left-sided pulmonary lesions were admitted and underwent 3D-CTBA prior to surgery. We reviewed the anatomical variations of the LUD veins in these patients using 3D-CTBA images and classified them according to their position in relation to the bronchus. To facilitate this process, the same nomenclature as that used to describe the veins of the right upper lobe (RUL) is used for the LUD. RESULTS: The pattern of LUD veins could be classified into three forms: an anterior + central form, an anterior form and a central form. For the central form, V 1+2 a, V 1+2 b, V 1+2 c and V 1+2 d drained into V. cent. For the anterior form, V 1+2 d drained into V. ant. The anterior + central form could be further classified into three subtypes (V abc, V ab and V a). CONCLUSIONS: This is the first report to categorize the pattern of veins in the LUD. This may facilitate the creation of simplified models for use in pre-operative planning for segmentectomy.

Application of large-scale targeted sequencing to distinguish multiple lung primary tumors from intrapulmonary metastases.

The effective differentiation between multiple primary lung tumors (MPs) and intrapulmonary metastases (IMs) in patients is imperative to discover the exact disease stage and to select the most appropriate treatment. In this study, the authors was to evaluate the efficacy and validity of large-scale targeted sequencing (LSTS) as a supplement to estimate whether multifocal lung cancers (MLCs) are primary or metastatic. Targeted sequencing of 520 cancer-related oncogenes was performed on 36 distinct tumors from 16 patients with MPs. Pairing analysis was performed to evaluate the somatic mutation pattern of MLCs in each patient. A total of 25 tumor pairs from 16 patients were sequenced, 88% (n = 22) of which were classified as MPs by LSTS, consistent with clinical diagnosis. One tumor pair from a patient with lymph node metastases had highly consistent somatic mutation profiles, thus predicted as a primary-metastatic pair. In addition, some matched mutations were observed in the remaining two paired ground-glass nodules (GGNs) and classified as high-probability IMs by LSTS. Our study revealed that LSTS can potentially facilitate the distinction of MPs from IMs. In addition, our results provide new genomic evidence of the presence of cancer invasion in GGNs, even pure GGNs.

A rare case of lung squamous cell carcinoma coexisting with pulmonary MALT lymphoma presenting as a progressive pGGN.

Pulmonary extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) presenting as a progressive pure ground-glass nodule (GGN) coexisting with lung squamous cell carcinoma has not been reported. A 65-year-old male presented with a progressive lung GGN in the left upper lobe identified six and a half years ago but showed no symptoms. The patient had a history of tuberculosis, squamous cell carcinoma, and stomach MALT lymphoma. The patient was diagnosed with lung squamous cell carcinoma coexisting with pulmonary MALT lymphoma through computed tomography (CT)-guided lung biopsy. A progressive lung GGN presenting in a patient with squamous cell carcinoma does not always indicate multiple primary lung adenocarcinoma, especially when given a specific medical history. The development of MALT lymphoma in the lung presenting as GGNs suggests a possible association between these two entities.

[Advances in Identification of Intersegmental Plane during Pulmonary Segmentectomy].

With the popularity of computed tomography (CT) scan in recent years, early stage lung cancer has been discovered in large numbers of patients and pulmonary segmentectomy has been widely used clinically. Identification of the intersegmental plane is one of the key steps in pulmonary segmentectomy, and current methods for identifying the intersegmental plane are numerous and have their own advantages and disadvantages. We will review relevant methods to help the clinical practice.
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