Clinical utility of psoas muscle volume in assessment of sarcopenia in patients with early-stage non-small cell lung cancer.

PURPOSE: Sarcopenia influences postoperative outcomes of patients with non-small cell lung cancer (NSCLC). Imaging tools for evaluating and diagnosing sarcopenia have developed, and a novel method of psoas volume index (PVI) obtained by measuring bilateral psoas major muscle volume has been reported. However, the relationship between sarcopenia based on PVI and clinical outcomes has not been fully investigated for patients with early-stage NSCLC. This study aimed to clarify the utility of PVI values in assessing the relationshipe between sarcopenia and clinical outcomes. METHODS: This study included 645 patients with stage I-II NSCLC who underwent curative lung resection between 2012 and 2017. Bilateral psoas major muscle volumes were calculated semi-automatically using a three-dimensional workstation. The cutoff value of PVI for defining sarcopenia was < 60.5 cm3/m3 for men and < 43.6 cm3/m3 for women. RESULTS: The avrage time to obtaine PVI was only 25 s with the 3D system, and interobserver agreements for evauating sarcopenia on PVI was 1. A total of 159 patients (24.7%) were preoperatively diagnosed with sarcopenia. On multivariate analysis, sarcopenia was an independent prognostic factor for overall survival (OS, p < 0.001), recurrence-free survival (RFS, p < 0.001), and lung cancer-specific survival (LCS, p < 0.001). The 5-year OS, RFS, and LCS were significantly worse in sarcopenic patients than non-sarcopenic patients (88.8 vs. 72.4%, p < 0.001; 80.1 vs. 65.0%, p < 0.001; 92.4 vs. 78.9%, p < 0.001, respectively). CONCLUSION: Sarcopenia diagnosed using PVI is an independent prognostic predictor of OS, RFS, and LCS in early-stage NSCLC.

Assessment of emphysema severity as measured on three-dimensional computed tomography images for predicting respiratory complications after lung surgery.

OBJECTIVES: Emphysema is one of the main causes of respiratory complications in patients operated on for lung cancer. We have used three-dimensional computed tomography (3D CT) for surgical simulations, as well as for depicting emphysematous areas as low attenuation areas (LAAs) and visual scores based on the Goddard classification (Goddard score), which is a visual scale of the area of vascular disruption and LAA for each lung field. This study aimed to investigate the effectiveness of the 3D CT function for assessing emphysema severity and its association with respiratory complications. METHODS: The study included 504 lung cancer patients who had preoperative 3D CT from October 2010 to March 2015. Goddard score and LAA% (LAA/total lung volume) were measured using 3D CT data. The relationship between respiratory complications and independent variables was investigated. RESULTS: Postoperative respiratory complications were observed in 69 (13.6%) patients. The receiver operating characteristic curves for respiratory complications determined using the Goddard score and LAA% dichotomized at each cut-off level (1 and 0.7%, respectively) showed that the events were observed in 32% of the patients with a Goddard score ≥1 and in 25% of the patients with an LAA% ≥0.7. On multivariable analyses, the Goddard score was significantly correlated with postoperative respiratory complications (P < 0.001). CONCLUSIONS: Preoperative measurement of the Goddard score and LAA% using 3D CT in patients with lung cancer, particularly with the coexistence of emphysema, was beneficial for predicting postoperative respiratory complications.

Cost-Benefit Performance Simulation of Robot-Assisted Thoracic Surgery As Required for Financial Viability under the 2016 Revised Reimbursement Paradigm of the Japanese National Health Insurance System.

PURPOSE: To discuss the cost-benefit performance (CBP) and establish a medical fee system for robotic-assisted thoracic surgery (RATS) under the Japanese National Health Insurance System (JNHIS), which is a system not yet firmly established. METHODS: All management steps for RATS are identical, such as preoperative and postoperative management. This study examines the CBP based on medical fees of RATS under the JNHIS introduced in 2016. RESULTS: Robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) now receive insurance reimbursement under the category of use of support devices for endoscopic surgery ($5420 and $3485, respectively). If the same standard amount were to be applied to RATS, institutions would need to perform at least 150 or 300 procedures thoracic operation per year to show a positive CBP ($317 per procedure as same of RALP and $130 per procedure as same of RAPN, respectively). CONCLUSION: Robotic surgery in some areas receives insurance reimbursement for its "supportive" use for endoscopic surgery as for RALP and RAPN. However, at present, it is necessary to perform da Vinci Surgical System Si (dVSi) surgery at least 150-300 times in a year in a given institution to prevent a deficit in income.

Cost-Benefit Performance of Robotic Surgery Compared with Video-Assisted Thoracoscopic Surgery under the Japanese National Health Insurance System.

BACKGROUND: Medical economics have significant impact on the entire country. The explosion in surgical techniques has been accompanied by questions regarding actual improvements in outcome and cost-effectiveness, such as the da Vinci(®) Surgical System (dVS) compared with conventional video-assisted thoracic surgery (VATS). OBJECTIVE: To establish a medical fee system for robot-assisted thoracic surgery (RATS), which is a system not yet firmly established in Japan. METHODS: This study examines the cost benefit performance (CBP) based on medical fees compared with VATS and RATS under the Japanese National Health Insurance System (JNHIS) introduced in 2012. RESULTS: The projected (but as yet undecided) price in the JNHIS would be insufficient if institutions have less than even 200 dVS cases per year. Only institutions which perform more than 300 dVS operations per year would obtain a positive CBP with the projected JNHIS reimbursement. CONCLUSION: Thus, under the present conditions, it is necessary to perform at least 300 dVS operations per year in each institution with a dVS system to avoid financial deficit with current robotic surgical management. This may hopefully encourage a downward price revision of the dVS equipment by the manufacture which would result in a decrease in the cost per procedure.

High-quality 3-dimensional image simulation for pulmonary lobectomy and segmentectomy: results of preoperative assessment of pulmonary vessels and short-term surgical outcomes in consecutive patients undergoing video-assisted thoracic surgery†.

OBJECTIVES: The aim of this study was to evaluate the effectiveness of 3-dimensional computed tomography (3D-CT) software in short-term surgical outcomes and the assessment of variations of pulmonary vessel branching patterns on performing video-assisted thoracic surgery (VATS). METHODS: The study included 179 consecutive patients who had undergone VATS anatomical lung resection, of which 172 were lobectomies (96%) and 7 were segmentectomies (4%), from May 2011 through January 2013. There were 124 patients (69%) in whom 3D-CT was performed and 55 patients (31%) who had not undergone 3D-CT. Observed actual pulmonary vessel branching patterns by intraoperative findings or footage were compared with the 3D image findings. Various surgical outcomes, including the occurrence of postoperative complications, in this study defined as those of Grade 2 or above under the Clavien-Dindo classification system, and total operative time, were retrieved from available clinical records. RESULTS: Among the 124 patients with preoperative 3D imaging, there were 5 (4%) conversions from VATS to thoracotomy. The incidence rate of patients with postoperative complications was 8% (n = 10), and there were no 30-day or 90-day mortalities. Pulmonary artery (PA) branches were precisely identified for 97.8% (309 of 316) of branches on 3D images, and the sizes of the seven undetected branches (five in the right upper lobe, two in the left upper lobe) ranged from 1 to 2 mm. The 3D images accurately revealed 15 cases (12%) of anomalous or unusual PA branches and 5 cases (4%) of variant pulmonary veins. Multivariate logistic regression analysis of the association with postoperative complications and operative time in 165 lung cancer patients demonstrated that male gender was the only statistically significant independent predictor of complications (risk ratio: 5.432, P = 0.013), and patients without 3D imaging tended to have operative complications (risk ratio: 2.852, P = 0.074), whereas conducting the 3D-CT (risk ratio: 2.282, P = 0.021) as well as intraoperative bleeding amount (risk ratio: 1.005, P = 0.005) had significant association with operative time. CONCLUSIONS: High-quality 3D-CT images clearly revealed the anatomies of pulmonary vessels, which could play important roles in safe and efficient VATS anatomical resection.