Adjuvant Therapy-Free Strategy for Stage IB to IIIA Non-Small-Cell Lung Cancer Patients After Radical Resection Based on Longitudinal Undetectable Molecular Residual Disease: Prospective, Multicenter, Single-Arm Study (CTONG 2201).

BACKGROUND: The utility of circulating tumor DNA to monitor molecular residual disease (MRD) has been clinically confirmed to predict disease recurrence in non-small cell lung cancer (NSCLC) patients after radical resection. Patients with longitudinal undetectable MRD show a favorable prognosis and might not benefit from adjuvant therapy. PATIENTS AND METHODS: The CTONG 2201 trial is a prospective, multicenter, single-arm study (ClinicalTrials.gov identifier, NCT05457049), designed to evaluate the hypothesis that no adjuvant therapy is needed for patients with longitudinal undetectable MRD. Pathologically confirmed stage IB-IIIA NSCLC patients who have undergone radical resection will be screened. Only patients with 2 consecutive rounds of undetectable MRD will be enrolled (first at days 3-10, second at days 30 ± 7 after surgery), and admitted for imaging and MRD monitoring every 3 months without adjuvant therapy. The primary endpoint is the 2-year disease-free survival rate for those with longitudinal undetectable MRD. The recruitment phase began in August 2022 and 180 patients will be enrolled. CONCLUSIONS: This prospective trial will contribute data to confirm the negative predictive value of MRD on adjuvant therapy for NSCLC patients. CLINICAL TRIAL REGISTRATION: NCT05457049 (CTONG 2201).

Mutational Pattern in Multiple Pulmonary Nodules Are Associated With Early Stage Lung Adenocarcinoma.

The clinical significance of mutation in multiple pulmonary nodules is largely limited by single gene mutation-directed analysis and lack of validation of gene expression profiles. New analytic strategy is urgently needed for comprehensive understanding of genomic data in multiple pulmonary nodules. In this study, we performed whole exome sequencing in 16 multiple lung nodules and 5 adjacent normal tissues from 4 patients with multiple pulmonary nodules and decoded the mutation information from a perspective of cellular functions and signaling pathways. Mutated genes as well as mutation patterns shared in more than two lesions were identified and characterized. We found that the number of mutations or mutated genes and the extent of protein structural changes caused by different mutations is positively correlated with the degree of malignancy. Moreover, the mutated genes in the nodules are associated with the molecular functions or signaling pathways related to cell proliferation and survival. We showed a developing pattern of quantity (the number of mutations/mutated genes) and quality (the extent of protein structural changes) in multiple pulmonary nodules. The mutation and mutated genes in multiple pulmonary nodules are associated with cell proliferation and survival related signaling pathways. This study provides a new perspective for comprehension of genomic mutational data and might shed new light on deciphering molecular evolution of early stage lung adenocarcinoma.

Uniportal complete video-assisted thoracoscopic surgery lobectomy with partial pulmonary arterioplasty for lung cancer with calcified lymph node.

Now, more and more complete video-assisted thoracoscopic surgery (cVATS) surgeons are capable of performing lobectomy by uniportal approach. However, concerns regarding the safety of uniportal procedures for complex cases such as neoadjuvant chemotherapy, bronchial sleeves or vascular reconstructions still remains. As experience with uniportal VATS has increased, its application toward more technically demanding operations has also expanded. This article describes a uniportal cVATS left upper lobectomy with partial pulmonary arterioplasty for lung cancer with calcified lymph nodes. In order to reduce the risk of bleeding, we looped the left main pulmonary artery and applied two-stage maneuvering for left upper lobe (LUL) bronchus, cut the bronchus at the distal end and close the stump using a stapler at the end, which are conducive to maximal safety.

Uniportal complete video-assisted thoracoscopic lobectomy with systematic lymphadenectomy.

Video-assisted thoracoscopic surgery (VATS) has permeated our thoracic surgical practice and now will develop in depth towards a next level of minimally invasive surgery (MIS). Irrespective of generation gaps and diversified perception within thoracic community, more and more surgical teams are adapting to the uniportal lobectomy. This video demonstrates a case undergoing uniportal VATS lobectomy with systematic lymphadenectomy for lung cancer. We here describe our technique for uniportal approach by using a combination of double-jointed and endoscopic instruments to combat the four major obstacles: (I) interference of the thoracoscope, stapler and the instrumentation in and out of the thoracic cavity? (II) whether the field of vision is enough or not without the other 1-3 ports to improve the exposure? (III) the optimal stapler introduction angle especially for upper and middle lobes resection? (IV) more importantly, the oncologic validity of uniportal procedures as well as the reduction of postoperative morbidity? We believe, uniportal VATS lobectomy with systematic lymphadenectomy is technically safe and feasible and alternative approach to conventional thoracoscopic lobectomy in lung cancer treatment. The issues of patient acceptability, the cosmetic and oncologic results, and cost-effectiveness remain to be determined in the future through multi-institution randomized controlled trials and long-term follow-up.

Biportal complete video-assisted thoracoscopic lobectomy and systematic lymphadenectomy.

The video-assisted thoracoscopic approach (VATS) for lobectomy of non-small-cell lung cancer (NSCLC) has not been standardized. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out via only two incisions. This video demonstrates a case undergoing biportal complete VATS (biportal cVATS) right upper lobectomy and systematic lymphadenectomy. Here we describe our technique of biportal approach by using a combination of conventional and endoscopic instruments. As our experience gained, we consider the knacks of biportal cVATS lobectomy imply two radical changes of perspectives from the traditional triportal technique. One fundamental step is how to achieve satisfactory exposure in the case of single utility incision for multiple instruments to insert. Another technical tip that should be taken into account is how to introduce staplers conveniently without the third posterior port. Optimization of the whole procedures is critical for accomplishing anatomic hilar vascular, bronchial, and lymphatic dissection via two ports. In conclusion, biportal cVATS lobectomy for lung cancer is a safe and reliable procedure that can achieves good postoperative results without oncological compromise.

Thoracoscopic management for bronchiectasis with non-tuberculous mycobacterial infection.

BACKGROUND: Non-tuberculous mycobacteria (NTM) have emerged as important opportunistic pathogens of the human being in recent years. Patients with pre-existing bronchiectasis are susceptible to NTM. However, information about its occurrence among bronchiectatic patients in Shenzhen, China is lacking and its impact on the course of bronchiectasis following surgical intervention is unknown. This preliminary study aimed to investigate the prevalence of NTM in bronchiectasis that required surgery in our center, evaluate the role of intraoperative routine screening for NTM, and summarize our initial experience in thoracoscopic management for bronchiectatic patients with NTM. METHODS: A retrospective analysis of clinical, microbiological data of our bronchiectatic patients with NTM over 5 years was made and 40 patients with bronchiectasis were studied to determine the role of intraoperative routine screening for NTM. RESULTS: The prevalence of NTM in this population of patients with bronchiectasis in our center was 6.7% (7/105). The diagnostic yield of the 40 intraoperative specimens was 7.5% (3/40). Of the 7 patients with bronchiectasis and NTM, 3 patients developed postoperative wound infections. All were cured with chemotherapy for 8 - 12 months along with vigorous surgical debridement. Another patient had a slow growth of mycobacteria involving double lungs and the right thoracic cavity and recovered after chemotherapy for nearly 14 months and tube drainage. The affected tissue was completely resected in the remaining 3 patients with no operative mortality and postoperative morbidity, and routine intraoperative screening for NTM was initiated in these patients. CONCLUSIONS: NTM is not uncommon in bronchiectatic patients which deserves surgeons' utmost attention. Routine intraoperative screening for NTM identified otherwise unsuspected patients has shown favorable outcomes. Thoracoscopic management for bronchiectasis with NTM is technically feasible although its role remains to be defined.