Segmentectomy vs. Lobectomy in stage IA non-small cell lung cancer: A systematic review and meta-analysis of perioperative and survival outcomes.

While recent randomized controlled trials (RCT) have suggested superior overall survival (OS) outcomes with segmentectomy over lobectomy, questions remain regarding the comparability of these surgical procedures for treating early-stage non-small cell lung cancer (NSCLC). This systematic review and meta-analysis aimed to synthetize existing evidence and to compare the survival outcomes observed for stage IA NSCLC following segmentectomy or lobectomy. 40 studies (38 observational, 2 RCTs) encompassing 103,926 patients were analyzed. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrences, harvested lymph nodes, postoperative morbidity, and length of hospital stay. Risk of bias was assessed using established tools, and evidence certainty was evaluated using GRADE. Non-RCTs showed an OS HR of 1.10 (95 % CI: 0.94-1.30, p = 0.24) with low certainty, contrasting with RCTs' HR of 0.82 (95 % CI: 0.66-1.02, p = 0.7) with moderate certainty. Local recurrences exhibited OR 1.40 (95 % CI: 0.94-2.08, p = 0.09) in non-RCTs with low certainty, and RR 1.61 (95 % CI: 1.12-2.31, p = 0.01) in RCTs with low certainty. Non-RCTs showed DFS HR 1.13 (95 % CI: 0.95-1.34, p = 0.18) with low certainty, while RCTs yielded HR 1.00 (95 % CI: 0.85-1.18, p = 0.97) with moderate certainty. Lobectomy resulted in more harvested lymph nodes. Postoperative morbidity and length of hospital stay did not differ significantly. While definitive evidence for OS, DFS, and postoperative outcomes differences was inconclusive, a potential increase in local recurrences following lobectomy was noted. Further well-designed studies are warranted to enhance evidence and inform clinical practice in stage I lung cancer surgery.

Correction: Outcomes of Patients With Early and Locally Advanced Lung Cancer: Protocol for the Italian Lung Cancer Observational Study (LUCENT).

[This corrects the article DOI: 10.2196/57183.].

Outcomes of Patients With Early and Locally Advanced Lung Cancer: Protocol for the Italian Lung Cancer Observational Study (LUCENT).

BACKGROUND: Lung cancer, predominantly non-small cell lung cancer (NSCLC), remains a formidable challenge, necessitating an in-depth understanding of evolving treatment paradigms. The Italian Lung Cancer Observational Study (LUCENT) addresses this need by investigating the outcomes of patients with early and locally advanced lung cancer in Italy. OBJECTIVE: With a focus on real-world data and patient registries, this study aims to provide comprehensive insights into clinical, psychosocial, and economic impacts, contributing to informed decision-making in health care. METHODS: LUCENT is a prospective observational multicenter cohort study enrolling patients eligible for minimally invasive manual, robot-assisted, or traditional open surgery. The study will develop a web-based registry to collect longitudinal surgical, oncological, and socioeconomic outcome data. The primary objectives include performance assessment through the establishment of national benchmarks based on risk-adjusted outcomes and processes of care indicators. The secondary objectives encompass economic and psychosocial impact assessments of innovative technologies and treatment pathways. The multicenter design ensures a diverse and representative study population. RESULTS: The evolving landscape of NSCLC treatment necessitates a nuanced approach with consideration of the dynamic shifts in therapeutic strategies. LUCENT strives to fill existing knowledge gaps by providing a platform for collecting and analyzing real-world data, emphasizing the importance of patient-reported outcomes in enhancing the understanding of the disease. By developing a web-based registry, the study not only facilitates efficient data collection but also addresses the limitations of traditional methods, such as suboptimal response rates and costs associated with paper-and-pencil questionnaires. Recruitment will be conducted from January 01, 2024, to December 31, 2026. Follow-up will be performed for a minimum of 2 years. The study will be completed in the year 2028. CONCLUSIONS: LUCENT's potential implications are substantial. Establishing national benchmarks will enable a thorough evaluation of outcomes and care processes, guiding clinicians and policymakers in optimizing patient management. Furthermore, the study's secondary objectives, focusing on economic and psychosocial impacts, align with the contemporary emphasis on holistic cancer care. Insights gained from this study may influence treatment strategies, resource utilization, and patient well-being, thereby contributing to the ongoing refinement of lung cancer management. TRIAL REGISTRATION: ClinicalTrials.gov NCT05851755; https://clinicaltrials.gov/study/NCT05851755. ISRCTN 67197140; https://www.isrctn.com/ISRCTN67197140. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/57183.

Safety and Efficacy of Salvage Surgery after Treatment With Immune-Checkpoint Adjuvant Inhibitors for Advanced Non-Small Cell Lung Cancer: A Multicentric Study.

OBJECTIVE: In advanced non-small cell lung cancer (NSCLC), immune-checkpoint inhibitors (ICIs) can achieve significant clinical responses. This raises the question of whether to consider salvage surgery as a curative treatment option. Few case series reported encouraging results in terms of pathological response. However, intraoperative risk and postoperative morbidity have been highlighted. This study aims to assess the safety and feasibility of surgery after ICIs administration and to evaluate its effectiveness on the final pathological examination. METHODS: We retrospectively identified stages III-IVA NSCLC consecutive patients who underwent surgery with radical intent after ICIs at three National Centers (2016-2022). Before treatment, all patients were considered unresectable by a multidisciplinary discussion. After surgery, pathological response was evaluated according to the International Association for the Study of Lung Cancer (IASLC) recommendation. RESULTS: Thirty-one patients were included; pretreatment clinical stage was: IIIA in 4 patients (10%), IIIB in 13 (42%), IIIC in 3 (13%), and IVA in 11 (35%). Median treatment duration was four cycles. Only anatomical resections were performed, with lobectomy that represent the main type of resection (22 patients, 74%). A minimally invasive approach was performed in 10 patients (32%), with a conversion rate of 0%. Postoperative complications were observed in eight patients (25%). Complete pathologic response (CPR) and major pathologic response (MPR) were 48% and 16%, respectively. Two and 3-years survival were 88%. CONCLUSIONS: Based on our experience, salvage surgery of advanced NSCLC treated with ICIs confirm his feasibility and safety in responder patients. Moreover, it is associated with low morbidity, high CPR rate, and satisfying medium-term survival.

Optimal planning and management strategies for minimally invasive lung segmentectomies: an international Delphi consensus report.

OBJECTIVES: CALGB140503/JCOG0802 RCTs comparing lobectomy with sublobar resection in stage IA NSCLC have confirmed the non-inferiority of segmentectomy. Additional insight is needed to improve preoperative work-up and intraoperative strategies to increase safety and promote the dissemination of minimally invasive segmentectomy (MIS). A Delphi panel study assessed the level of consensus among surgeons for the planning and management of MIS. METHODS: Twenty-one expert lung surgeons represented academic institutions, major teaching hospitals, and community hospitals from Europe, North America, and Asia. A 3-round Delphi methodology was used to analyse the answers of each panellist. Recognizing that questions with fewer response options have a higher consensus probability due to limited variability, weighted consensus thresholds were modified based on the number of response options. RESULTS: The 21 panellists responded to all 3 rounds of questions. Based on the most robust consensus (94.4%), 3D chest CT reconstructions are recommended only when planning complex segmentectomies. Surgeons should perform 3D reconstructions chest CT scans (consensus = 83.3%). The most effective and safest technique is image-guided VATS in a hybrid operating room (consensus = 83.3%). Dyes with intravenous administration are the safest technique for identifying the intersegmental plane during MIS (consensus = 72.2%). Augmented/mixed reality will probably not immediately help reduce perioperative complications (consensus = 72.2%). CONCLUSIONS: This Delphi consensus supports 3D reconstructions and preoperative pulmonary nodule localization before complex MIS. These recommendations should be considered when allocating resources to improve MIS's safety and oncologic efficacy for patients with small, early-stage lung cancers.

The Role of Adjuvant Chemotherapy in pN1 (IIB/IIIA) NSCLC Patients Who Undergo Pneumonectomy: Is It Still Justified in the Modern Era?

INTRODUCTION: We aimed to assess our 25-year experience in order to evaluate the role of adjuvant chemotherapy in patients who undergo pneumonectomy for pN1 NSCLC. MATERIALS AND METHODS: We retrospectively reviewed the outcomes and medical records of patients undergoing pneumonectomy for NSCLC with pathological diagnosis of pN1, excluding all patients who underwent neoadjuvant treatment. We compared patients treated with adjuvant chemotherapy with patients who did not undergo neoadjuvant treatment during a follow-up soon after surgery. Gray's test was used to assess differences in the cumulative incidence of relapse or CSS between the different groups. Kaplan-Meier methods were used for drawing overall survival (OS) plots. In order to assess differences in survival between the groups, the log-rank test was used. The cumulative incidence of relapse, CSS, and OS were calculated at 1, 2, 3, 4, and 5 years of follow-up. RESULTS: The 30-day and 90-day mortality rates of our cohort were 6% and 11,6%. Excluding the first three months after surgery (deaths linked to postoperative comorbidity), after 5 years we found no significant differences between the two cohorts (adjuvant CT and no adjuvant CT) in terms of the overall survival (OS) (p: 0.31), cancer-specific survival (CSS) (p: 0.59), disease-free survival (DFS) (p: 0.94), and relapse rate (p: 0.76). CONCLUSIONS: Patients with pN1 NSCLC that was completely resected through pneumonectomy and radical lymphadenectomy may represent a particular cohort, which could be strictly followed up without adjuvant chemotherapy.

1000 Robotic-assisted lobectomies for primary lung cancer: 16 years single center experience.

OBJECTIVE: This study aimed at describing our high-volume single center experience in robotic-assisted thoracic surgery (RATS) to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve. METHODS: We retrospectively analyzed data from 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach between May 2007 and May 2023. RESULTS: Nine-hundred ninety-seven patients (99.7 %) underwent lobectomy, whereas 3 (0.03 %) patients bilobectomy. Conversion rate to open surgery was 3.7 %. Minor complications occurred in 213 (21.3 %) patients, major complications in 29 patients (2.9 %). The 30-day and 90-day operative mortality was 0 % and 0.1 %, respectively. The median number of N1 + N2 stations resected was 5 (range 0-9), with a median number of 17 of N1 + N2 lymph nodes resected (range 0-55). The oncological outcome was evaluated only on the subgroup of patients (n = 895) with non-small cell lung cancer. Pathological lymph node upstaging from cN0 to pN1/pN2 was evident in 147 patients (17.3 %): 9 % from cN0 to pN1 and 7.1 % from cN0 to pN2. With a median follow-up of 3.9, 5-year OS and DFS were respectively 89.3 % and 83.6 % for stage I, 74 % and 66.5 % for stage II, and 61 % and 36.4 % for stage IIIA. CONCLUSIONS: Better vision and excellent instrument maneuverability of the robotic surgical system allowed excellent results in terms of early, adequate oncological outcome comparable to open surgery literature data, and acceptable learning curve. ULTRAMINI ABSTRACT: 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach have been analyzed with the aim to describe our high-volume single center experience, and to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve.

Bridging the divide: addressing discrepancies between clinical guidelines, policy guidelines, and biomarker utilization.

OBJECTIVES: This paper aims to identify and address gaps in cancer treatment and diagnosis within European health services, focusing specifically on discrepancies between clinical guidelines and policy guidelines. It seeks to highlight how the underutilization of advanced diagnostic techniques recommended by medical societies contributes to missed opportunities for improving patient outcomes. METHODS: A comprehensive analysis was conducted across multiple European countries to assess the compliance and integration of clinical guidelines with the availability of advanced diagnostic technologies. Secondary data related to clinical and policy guidelines in cancer care were collected and analyzed. Key indicators of adoption and utilization of next-generation sequencing and liquid biopsy were examined to evaluate their impact on health service efficiency and patient care. RESULTS: The analysis revealed significant discrepancies between the recommendations of medical societies regarding advanced diagnostic techniques and their adoption in health policy decisions across Europe. Country-specific assessments indicated varying levels of alignment between clinical guidelines and the availability of advanced diagnostics. These findings underscored missed opportunities for optimizing patient care and health service efficiency through better alignment and integration of clinical guidelines with policy decisions. CONCLUSIONS: This study concludes that there is a critical need for health policy decision-makers to prioritize the adoption of clinical guidelines in resource allocation and health service organization. Greater attention to the recommendations of medical societies regarding advanced diagnostic techniques could significantly enhance diagnostic accuracy, treatment efficacy, and overall patient outcomes in cancer care. The paper advocates for policy reforms that acknowledge and leverage the potential benefits of advanced diagnostics in improving health service performance and patient-centered care across Europe.

Revamping Non-Small Cell Lung Cancer Treatments in Stages II and III: Preparing Healthcare for Cutting-Edge Immuno-Oncology Regimens.

Non-small cell lung cancer (NSCLC) poses a significant challenge in clinical oncology, necessitating continual refinement of treatment approaches in stages II and III. Recent advancements have highlighted the potential of neoadjuvant therapy in optimising patient outcomes. Biomarker testing guides neoadjuvant therapy decisions, including epidermal growth factor receptor (EGFR) mutation and programmed death-ligand 1 (PD-L1) expression testing. Neoadjuvant therapy aims to improve oncological outcomes by treating micrometastatic disease and assessing tumour response before surgery. Disease-free survival is a surrogate endpoint for overall survival in both neoadjuvant and adjuvant settings. Multidisciplinary collaboration is crucial for individualised treatment planning and optimising patient care. The management of NSCLC requires a comprehensive approach, integrating expertise across disciplines and tailoring treatment strategies to individual patient needs. Neoadjuvant therapy shows promise in improving long-term outcomes, with biomarker testing guiding treatment decisions. Challenges such as defining borderline resectability and differentiating pseudoprogression highlight the need for ongoing research and collaboration.

Pneumonectomy for broncho-pulmonary carcinoids: a single centre analysis of surgical approaches and patient outcomes.

Background: Pneumonectomy is a radical surgical procedure associated with significant morbidity and mortality. Its application in the context of pulmonary neuroendocrine tumours, including carcinoid tumours, requires meticulous preoperative planning and intraoperative precision. This study aims to assess the safety and efficacy of pneumonectomy in the management of these rare and challenging neoplasms. Methods: A retrospective analysis of patients who underwent pneumonectomy for pulmonary carcinoid tumours at our institution over a specified period was conducted. Data regarding patient demographics, tumour characteristics, surgical techniques, intraoperative complications, perioperative management, and long-term outcomes were collected and analysed. Results: Between March 2001 and October 2022, 21 patients (7 male, 14 female) with carcinoid tumours underwent pneumonectomy on a total of 459 surgical operations for carcinoid. Preoperative bronchoscopic procedures were conducted in 90.4% of cases, leading to histological diagnoses for most. The median hospital stay was eight days, with no reported perioperative deaths. Median follow-up after surgery was 73 months, with a five-year overall survival of 65.4 months. Recurrences occurred in 28.6% of cases, primarily in atypical carcinoids. Conclusion: Despite the rarity of bronchial carcinoids, pneumonectomy is effective for low-grade malignancies, demonstrating positive short-and long-term outcomes. Radical lymph node dissection is fundamental in pathological staging and overall survival.

How General and Inflammatory Status Impacts on the Prognosis of Patients Affected by Lung Cancer: State of the Art.

Pulmonary cancer is often associated with systemic inflammation and poor nutritional status and these two aspects are strongly correlated and related to the scarce infiltration of a tumor by immune cells. We reviewed all English literature reviews from 2000 to 2024 from PubMed, Scopus and Google Scholar, including original articles, review articles, and metanalyses. We excluded non-English language articles and case reports/case series. Generally speaking, nutritional and inflammatory status largely affect medium and long-term prognosis in lung cancer patients. A correct stratification of patients could improve their preoperative general functional nutritional and inflammatory status, minimizing, therefore, possible treatment complications and improving long-term prognosis.

Prognostic Factors and Clinical Outcomes of Surgical Treatment of Major Thoracic Trauma.

BACKGROUND: Major thoracic trauma represents a life-threatening condition, requiring a prompt multidisciplinary approach and appropriate pathways for effective recovery. While acute morbidity and mortality are well-known outcomes in thoracic-traumatized patients, long-term quality of life in patients surviving surgical treatment has not been widely investigated before. METHODS: Between November 2016 and November 2023, thirty-two consecutive patients were operated on because of thoracic trauma. Age, sex, comorbidities, location and extent of thoracic trauma, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), Organ Injury Scale (OIS), intra and extrathoracic organ involvement, mechanism of injury, type of surgical procedure, postoperative complications, ICU and total length of stay, immediate clinical outcomes and long-term quality of life-by using the EQ-5D-3L scale and Numeric Rate Pain Score (NPRS)-were collected for each patient Results: Results indicated no significant difference in EQOL.5D3L among patients with thoracic trauma based on AIS (p = 0.55), but a significant difference was observed in relation to ISS (p = 0.000011). CONCLUSIONS: ISS is correlated with the EQOL.5D3L questionnaire on long-term quality of life, representing the best prognostic factor-in terms of long-term quality of life-in patients surviving major thoracic trauma surgical treatment.

Comprehensive Pulmonary Rehabilitation for Patients with Malignant Pleural Mesothelioma: A Feasibility Pilot Study.

Malignant pleural mesothelioma (MPM) represents a significant health burden, with limited treatment options and poor prognosis. Despite advances in pharmacological and surgical interventions, the role of rehabilitation in MPM management remains underexplored. This study aims to assess the feasibility of a tailored pulmonary rehabilitation intervention addressing physical and respiratory function in MPM patients. A prospective pilot study was conducted on surgically treated MPM patients referred to a cardiopulmonary rehabilitation service. The intervention comprised multidisciplinary educational sessions, physical rehabilitation, and respiratory physiotherapy. Feasibility was evaluated based on dropout rates, adherence to the rehabilitation program, safety, and patient-reported outcomes. Twelve patients were initially enrolled, with seven completing the study. High adherence to physical (T1: 93.43%, T2: 82.56%) and respiratory (T1: 96.2%, T2: 92.5%) rehabilitation was observed, with minimal adverse events reported. Patient satisfaction remained high throughout the study (GPE scores at T1: 1.83 ± 1.17; T2: 2.0 ± 1.15), with improvements noted in physical function, pain management, and health-related quality of life. However, some issues, such as time constraints and lack of continuous supervision, were reported by participants. This pilot study demonstrates the feasibility and potential benefits of a tailored pulmonary rehabilitation intervention in MPM patients. Despite its promising outcomes, further research with larger samples is warranted to validate its efficacy and integrate rehabilitation as a component into the multidisciplinary management of MPM.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.

BACKGROUND: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.