Limited Pulmonary Reserve Research Articles

Bronchial sleeve resections.

Although bronchial sleeve resections were previously defined as an alternative technique to pneumonectomy for patients with limited pulmonary reserve, currently these resections are applied as a standard even in patients having normal pulmonary capacity. Pneumonectomy, itself, is a disease, and sleeve lobectomies can be performed without compromising oncological principles and without causing significant morbidity and mortality. In parallel with the developments in surgical techniques, bronchial sleeve resections can be performed by videothoracoscopic and robotic surgeries. Major complications in sleeve lobectomies are bronchial dehiscence, bronchopleural fistulas, and broncho-arterial fistulas. Late complications are bronchial stenosis and tumor recurrence.

Shoulder and Upper Arm Surgery Anaesthesia with Interscalene Approach of Brachial Block and Sedation versus Same Method Adjunct with Additional Suprascapular Nerve Block: A Randomised Controlled Study

Introduction: Interscalene Brachial Plexus Block (ISBPB) block provides optimal analgesia for shoulder and upper arm surgery. However, higher incidence of phrenic nerve palsy limits the application of ISBPB for patients with limited pulmonary reserve. The Supplemented Suprascapular Nerve Block (SSNB) is a landmark based technique that is believed to block the sensory fibres supplying major part of shoulder joint, as well as, supraspinatus and infraspinatus muscles. Aim: To compare the analgesic effect and duration of sensory block in interscalene versus interscalene with SSNB block for shoulder and upper arm surgery. Materials and Methods: This double-blinded randomised controlled study was conducted in a Tertiary Care Institute, from April 2021 to march 2022. Eighty patients posted for shoulder and upper arm surgery were divided into two equal groups (group A and B). In group A (n=40), 30 mL 0.5% levobupivacaine in ISBPB and in group B (n=40), 15 mL 0.5% levobupivacaine in ISBPB+15 mL 0.5% levobupivacaine in SSNB were administered. Demographic data, sensory and motor block, onset times and durations, time to administer first rescue analgesic, total analgesic requirement, indications of upper arm surgeries, surgical bleeding and surgeon’s satisfaction score, postoperative Visual Analogue Scale (VAS) score were recorded for each patient. Results: The onset and duration of sensory and motor block was significantly faster and longer in group B. Consequently, time to administer first rescue analgesic in group A vs group B (325.88±33.23 vs. 348.34±37.12) minutes were significantly delayed and in lesser in amount in group B respectively. On the other hand, suprascapular block reduced the odds of block-related respiratory (group A vs group B are 14 and 10, respectively) complications. In group B postoperative VAS score at 24 hour was significantly lower (p-value <0.05) than group A was (3.5 vs 4.5). Intraoperative haemodynamic parameters were comparable among two groups throughout the study period. Conclusion: SSNB when supplemented with Interscalene Block (ISB) could be an effective adjunct for shoulder and upper arm surgery. This combination prolongs the sensory blockade duration, reduces requirement of analgesics and side-effects in postoperative period.

Pooled analysis on image-guided moderately hypofractionated thoracic irradiation in inoperable node-positive/recurrent patients with non-small cell lung cancer with poor prognostic factors and severely limited pulmonary function and reserve.

The objective of this study was to investigate the feasibility and efficacy of image-guided moderately hypofractionated thoracic radiotherapy (hypo-IGRT) in patients with non-small cell lung cancer (NSCLC) with poor performance status and severely limited pulmonary function and reserve. Consecutive inoperable patients who had node-positive, stage IIB-IIIC (TNM, 8th edition) or recurrent NSCLC, had an Eastern Cooperative Oncology Group performance status ≥1, and had a forced expiratory volume in 1 second (FEV1 ) ≤1.0 L, had a single-breath diffusing capacity of the lung for carbon monoxide (DLCO-SB) ≤40% and/or on long-term oxygen therapy were analyzed. All patients received hypofractionated IGRT to a total dose of 42.0 to 49.0 Gy/13 to 16 fractions (2.8-3.5 Gy/fraction) (equivalent dose in 2-Gy fractions/biologically effective dose [α/β = 10] = 45.5-55.1 Gy/54.6-66.2 Gy) alone. Patients were monitored closely for nonhematological toxicity, which was classified per National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0. Between 2014 and 2021, 47 consecutive patients with a median age of 72 years (range, 52.2-88 years) were treated. At baseline, the median FEV1 , vital capacity, and DLCO-SB were 1.17 L (range, 0.69-2.84 L), 2.34 L (range, 1.23-3.74 L), and 35% predicted (range, 13.3%-69.0%), respectively. The mean and median planning target volumes were 410.8 cc (SD, 267.1 cc) and 315.4 cc (range, 83.4-1174.1 cc). With a median follow-up of 28.9 months (range, 0.5-90.6 months) after RT, the median progression-free survival (PFS)/overall survival (OS) and 6- and 12-month PFS/OS rates were 10.4 months (95% CI, 7-13.8 months)/18.3 months (95% CI, 9.2-27.4 months), 70%/89.4%, and 38.8%/66%, respectively. Treatment was well tolerated with only 1 case each of grade 3 pneumonitis and esophagitis. No toxicity greater than grade 3 was observed. Patients with inoperable node-positive NSCLC, a poor performance status, and severely limited lung function can be safely and effectively treated with individualized moderately hypofractionated IGRT. The achieved survival rates for this highly multimorbid group of patients were encouraging.

Lobektomi Sonrası Gelişen Ağır ARDS'nin ECMO ile Başarılı Tedavisi

Pneumonia and acute respiratory distress syndrome (ARDS) are highly mortal complications following lobectomy.An effective treatment strategy is necessary in order to cure hipoxemia due to limited pulmonary reserve. Extracorporeal membrane oxygenation (ECMO) is an effective method to deal with hypoxemia; however the data about its use in severe ARDS after lobectomy is limi

The technique of robotic anatomic pulmonary segmentectomy II: left sided segments

Anatomic pulmonary segmentectomy and mediastinal nodal dissection has been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall 5-year survival and the lung cancer-specific 5-year survival following anatomic segmentectomy have been shown to be equivalent to that of lobectomy. Robotic surgical systems have the advantage of magnified, high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. These robotic systems can facilitate the dissection of the bronchovascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible anatomic segmentectomy technique. This is a companion paper to The Technique of Robotic Anatomic Segmentectomy I: Right Sided Segments. This paper outlines the technique of anatomic pulmonary segmentectomy for the left lung: Left Upper Lobe (LUL) Anterior Segment (S3), LUL Apicoposterior Segment (S1 + S2), LUL Lingulectomy (S4, S5), Left Lower Lobe (LLL) Superior Segmentectomy (S6), and LLL Basal Segmentectomy (S7-S10).

The technique of robotic anatomic pulmonary segmentectomy I: right sided segments

Anatomic pulmonary segmentectomy and mediastinal nodal dissection have been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall five-year survival and lung cancer-specific five-year survival following anatomic segmentectomy have been shown to be equivalent to lobectomy. Robotic surgical systems have the advantage of magnified high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. Robotics can facilitate the dissection of the broncho-vascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible technique. The Technique of Robotic Anatomic Segmentectomy Part I outlines a stepwise approach to robotic segmentectomy of S1, S2, S3, S4, S5, S6, and S7-S10 of the right lung. The Technique of Robotic Anatomic Segmentectomy Part II outlines a stepwise approach to robotic segmentectomy to the left lung.

MTE15.01 Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

MTE15.01 Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

P2.16-28 Comparison of Outcomes of VATS Segmentectomy Versus Lobectomy for Non-Small Cell Lung Cancer Using a Propensity Score Matching Analysis

The aim of this study was to compare surgical and oncologic outcomes between thoracoscopic segmentectomy and lobectomy for the patients with non-small cell lung cancer (NSCLC). Between 2009 and 2016, 250 thoracoscopic segmentectomies (Group S) and 1,550 thoracoscopic lobectomies (Group L) were performed in patients with NSCLC in our institute. Indications for segmentectomy were peripherally located tumor with smaller than 2 cm size, or the patients with limited pulmonary reserve and multiple comorbidities. Propensity score matching was conducted using preoperative clinical parameters and 240 patients in each Group S and L were included in the study. Most commonly performed segmentectomies were left upper lobar upper division segmentectomy (26.7%) and right lower lobar superior segmentectomy (17.1%). Operation time and length of hospital stay were comparable between the groups (162.9 ± 52.8 min and 5.7 days in group S vs. 163.2 ± 40.1 min and 8.7 days in group L; P=0.97 and P=0.13, respectively). Although postoperative mortality rates were not different between the two groups (0.8% vs. 0.8%, p=1.0), post-operative complication rate was significantly lower in the group S (11.2% vs. 19.2%, P=0.02). Especially, pulmonary complication rate including pneumonia, ARDS, and prolonged air leakage was significantly lower in the group S (2.5% vs. 8.3%, p<0.01). Postoperative decrease of diffusion capacity (DLco) was significantly lower in the group S (13.1% ± 16.4 vs. 18.2% ± 19.7, P=0.02). Recurrence-free survival (RFS) and overall survival (OS) were not significantly different between patients who underwent lobectomy (5-year RFS, 84.0%; 5-year OS, 90.2%) and segmentectomy (5-year RFS, 89.0%; 5-year OS 88.4%). (Figure 1) Thoracoscopic segmentectomy could achieve excellent early surgical outcomes with lower complication rates and preserved pulmonary function compared to lobectomy without jeopardizing long-term oncologic outcomes.

Endoscopic Valve Removal >180 Days since Implantation in Patients with Severe Emphysema

Background: Valve implantation provides a reversible effective therapy in a selected group of emphysema patients. Knowing predictors for successful therapy, the rate of treatment failure has decreased. Some patients, however, do not benefit, so that the valves may have to be removed. Objectives: To assess implant-related events, complications during valve removal, and clinical outcome after endoscopic procedure. Methods: The data of 76 consecutive emphysema patients who underwent valve removal > 6 months since implantation were collected. Results: Seventy-six patients (mean age 62 years, 54% male) underwent removal of all valves after a mean time of 624 days (193–3,043 days) since implantation. Granulation tissue was observed in 39.5% (30/76) and significant secretion in 34.2% (26/76). In 5.3% (4/76), valve removal was complicated requiring another bronchoscopy in 2 of them. In 5.3% (4/76) of the patients, one valve could not be removed and remained in situ. Bleeding requiring intervention occurred in 3.9% (3/76) during valve removal. Following bronchoscopy, there was a need for antibiotics in 34.2% (26/76), glucocorticosteroids in 1.3% (1/76), and both in 6.6% (5/76) due to productive cough or chronic obstructive pulmonary disease (COPD) exacerbation. Due to respiratory failure, invasive ventilation or noninvasive ventilation was necessary in 2.6% (2/76) and 6.6% (5/76), respectively, following procedure. No statistical significant change in lung function was observed following valve removal. Conclusions: Valve removal after > 6 months since implantation is feasible and associated with an acceptable safety profile. However, close monitoring of these patients with limited pulmonary reserve is recommended with particular attention to COPD exacerbations and respiratory failure.

GR 03.05 Any Roles of Systemic Therapy (Chemotherapy, Targeted Therapy, Immunotherapy) for Early Stage NSCLC with Limited Pulmonary Reserve?

The standard treatment of early stage non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not lobectomy candidates because of severe medical comorbidity including limited pulmonary reserve. During the past decade, stereotactic ablative radiotherapy (SABR) has resulted in local control in excess of 90% of tumors with medically inoperable and operable clinical stage I NSCLC. The local treatment including surgery and SABR is the stand of care for these patients. No definite evidence-based medicine data about the systemic therapy had been reported in this subgroup patients. A systemic therapy approach to the treatment of patients with medically inoperable, early stage NSCLC is not warranted. The management suggestions were unanimously agreed upon based on available literature. Systemic Therapy combined with local treatment could be a good option for these patients. 1. Chemotherapy+ local treatment: It seems that it is not recommended to add chemotherapy to local treatment for those medically inoperable, early stage NSCLC. It is reported that no evidence of an improvement in event-free survival was seen with the addition of weekly gemcitabine at this dose for patients with early stage NSCLC unfit for surgery, although the power of the study was low. 2. Targeted Therapy+ local treatment: No clear data about the targeted therapy for those medically inoperable, early stage NSCLC patients. For those driven gene positive patients, targeted therapy combined with local treatment seems to be a good choice. Some people worried about the combined therapy may increase the potential for pulmonary toxicity in patients with baseline pulmonary dysfunction, however, there is no cases of interstitial lung disease in early stage NSCLC as adjuvant therapy in 2017 ASCO (CTONG 1104). Further studies should be developed for these patients. 3. Immunotherapy + local treatment: The integration of radiation with immunotherapy is a conceptually promising strategy, as radiation has potent immune-modulatory effects and may contribute not only to local control but also augment systemic antitumor immune response. The advent of novel immunotherapy agents affords patients and clinicians therapeutic modalities to improve patient longevity and avenues to study innovative combinations of therapies. Preclinical data and case reports suggest the potential for robust clinical responses in metastatic NSCLC patients using this strategy, but prospective clinical trials evaluating the integration of radiation and immunotherapy are limited. The use of immunotherapy in non-metastatic settings is also intriguing but understudied. Summary: The assessment of treatment options for limited pulmonary reserve patients that requires uniform reporting of comorbidities and outcomes in clinical studies, which often is lacking. Systemic Therapy combined with local treatment could be a good option for these patients. Trials involving systemic therapy for patients with medically inoperable NSCLC should be developed.

Review of the evidence: best analgesic regimen for shoulder surgery.

Multimodal pain management has been advocated in patients experiencing acute pain after surgical procedures due to tissue damage and the subsequent inflammatory response. For patients undergoing shoulder surgeries, studies have definitively shown that interscalene blocks (ISBs) via single-injection or continuous infusion can reduce the total opioid consumption and can lower pain scores after surgery. In some cases, ISBs can be used as the sole anesthetic during shoulder surgeries and spare patients of receiving general anesthesia. However, clinicians should be fully aware of potential pulmonary complications of ISBs and weigh the risk-benefit ratio in patients with limited pulmonary reserve.

P1.08-038 VATS Sub-Lobar Anatomical Pulmonary Resections: Indications and Outcomes in Thoracic Oncological Practice

In patients with limited pulmonary reserve, sub-lobar anatomic pulmonary resection (SLAPR) may have reduced perioperative morbidity and mortality and additionally may better preserve long-term pulmonary function compared to lobectomy. SLAPR may also mitigate the oncological deficiencies of wedge resection. However, the safety and oncological efficacy of video assisted thoracoscopic surgical (VATS) SLAPR has not been well described. We therefore audited our recent experience of VATS SLAPR to evaluate: indications, safety, and oncological outcomes. We retrospectively reviewed a prospectively maintained database to identify all consecutive patients who underwent planned VATS SLAPR with curative intent. Demographics, co-morbidities, indications and treatment outcomes were retrieved, with supplemental chart review where necessary. Seventy seven VATS SLAPRs were performed between December 2010 and May 2016. Median age of patients was 67 (44-83) years and 57% (44/77) were male. The majority (47/77; 61%) of SLAPRs were undertaken for resection of NSCLC. Indications for SLAPR in NSCLC patients included: inadequate pulmonary reserve (DLCO <60% or predicted post-operative DLCO <40%) in 21/47 (44%), excessive (≥2 major) comorbidities in 18/47 (38%), advanced age (≥75 years) in 13/47 (27%) or a combination of these factors precluding lobectomy. In patients with metastatic 22(28%) and benign 8(10%) nodules, indications included proximity to vascular structures or inability to palpate lesion precluding simple wedge resections. Superior segmentectomy (22/77; 28%) and lingula sparing left upper lobectomy (17/77; 22%) were the commonest SLAPRs performed. Seventy one (92%) were completed via VATS. Emergency conversion occurred in one case. Morbidity rate was 30% (23/77) and 30 day mortality rate was 2.5% (2/77). Pre-operative DLCO was not associated with post-operative pulmonary complication (P=0.7) or length of hospital stay (P=0.20). In the NSCLC sub group, all patients were clinically stage I; R0 resection was achieved in 100%. Median of 12(4-27) nodes were excised with a nodal upstaging rate of 25% (12/47) and pathological stage was I in 65%. Median disease free survival (DFS) was 40 months and median overall survival (OS) was not reached. Loco regional recurrence rate was zero. Pre-operative DLCO dichotomized using median did not correlate with OS (P=0.8) or DFS (P=0.29). A variety of VATS SLAPRs may be performed safely with acceptable morbidity and mortality in high risk patients. Complete microscopic resection and adequate nodal dissection can be achieved. Although larger studies and longer follow is needed, our findings suggest that VATS SLAPR achieves comparable oncological outcomes in high risk patients to formal lobectomy.

Clinical and quality of life outcomes following anatomical lung resection for lung cancer in high-risk patients.

BACKGROUND:Surgery remains the gold standard for patients with resectable nonsmall cell lung cancer. Current guidance identifies patients with poor pulmonary reserve to fall within a high-risk cohort. The aim of this study was to determine the clinical and quality of life outcomes of anatomical lung resection in patients deemed high risk based on pulmonary function measurements.METHODS:A retrospective review of patients undergoing anatomical lung resection for nonsmall cell lung cancer between January 2013 and January 2015 was performed. All patients with limited pulmonary reserve defined as predicted postoperative forced expiratory volume in 1 s or transfer factor of the lung for carbon monoxide of <40% were included in the study. Postoperative complications, admission to the Intensive Care Unit, length of stay, and 30-day in-hospital mortality were recorded. The European Organization for Research and Treatment of Cancer quality of life questionnaire lung cancer 13 questionnaire was used to assess quality of life outcomes.RESULTS:Fifty-three patients met the inclusion criteria. There was no in-hospital mortality, and 30-day mortality was 1.8%. No complications were seen in 64% (n = 34), minor complications occurred in 26% (n = 14), while 9% had a major complication (n = 5). Quality of life outcomes were above the reference results for patients with early stage lung cancer.CONCLUSION:Anatomical lung resection can be performed safely in selected high-risk patients based on pulmonary function without significant increase in morbidity or mortality and with acceptable quality of life outcomes. Given that complications following lung resection are multifactorial, fitness for surgery should be thoroughly assessed in all patients with resectable disease within a multidisciplinary setting. High operative risk by pulmonary function tests alone should not preclude surgical resection.

Regional anesthesia for an upper extremity amputation for palliative care in a patient with end-stage osteosarcoma complicated by a large anterior mediastinal mass

Tumor progression during end-of-life care can lead to significant pain, which at times may be refractory to routine analgesic techniques. Although regional anesthesia is commonly used for postoperative pain care, there is limited experience with its use during home hospice care. We present a 24-year-old male with end-stage metastatic osteosarcoma who required anesthetic care for a right-sided above-the-elbow amputation. The anesthetic management was complicated by the presence of a large mediastinal mass, limited pulmonary reserve, and severe chronic pain with a high preoperative opioid requirement. Intraoperative anesthesia and postoperative pain management were provided by regional anesthesia using an interscalene catheter. He was discharged home with the interscalene catheter in place with a continuous local anesthetic infusion that allowed weaning of his chronic opioid medications and the provision of effective pain control. The perioperative applications of regional anesthesia in palliative and home hospice care are discussed.

Cryoablation of a Small Pulmonary Nodule with Pure Ground-Glass Opacity: A Case Report

Treatments for pure ground-glass nodules (GGNs) include limited resection; however, surgery is not always possible in patients with limited pulmonary functional reserve. In such patients, cryoablation may be a suitable alternative to treat a pure GGN. Here, we report our initial experience with cryoablation of a pure GGN that remained after repeated surgical resection in a patient with multiple GGNs. A 5-mm-sized pure GGN in the left lower lobe was cryoablated successfully without recurrence at the 6-month follow-up.

A critical analysis of segmentectomy versus lobectomy for non-small-cell lung cancer

Bao et al. [1] should be commended for completing a thorough and timely meta-analysis to compare the survival outcomes of segmentectomy versus lobectomy for Stage I non-small-cell lung cancer (NSCLC). This analysis represents the first of its kind to distinguish segmentectomies from wedge resections, an important distinction from both an oncological and technical perspective that has been overlooked in previous meta-analyses that compared ‘sublobar resections’ with lobectomy procedures [2, 3]. We concur with the authors that the current literature lacks robust high-level evidence on this topic and a meta-analysis of observational studies may provide insightful guidance for clinicians. Results of this study found that patients who underwent segmentectomy for Stage I, IA and IA (2–3 cm) NSCLC were associated with inferior combined overall survival (OS) and cancer-specifi cs urvival (CSS) outcomes compared with those who underwent lobectomy. However, patients with Stage IA (≤2 cm) NSCLC had no statistically significant difference in survival compared with lobectomy. It is imperative to analyse these results in detail to avoid misleading conclusions. In two of the four analysed subgroups, Stage IA and Stage IA (2–3 cm), OS outcomes were significantly worse after segmentectomy, but CSS was not significant. The combined OS/CSS were significant in both subgroups, and the authors concluded that patients who underwent segmentectomy in these cohorts resulted in inferior outcomes. However, it must be emphasized that patient baseline characteristics between these two treatment groups differed significantly, and patients were often selected for segmentectomies due to significant comorbidities and limited pulmonary reserve prohibiting them from lobectomy procedures [4, 5]. In such cases, differences in OS may be misleading compared with CSS, as patients died due to causes unrelated to NSCLC and the oncological efficacy of their surgical procedures. Hence, worse OS outcomes in the segmentectomy group may be a reflection of their patient characteristics rather than their operative outcome. Similarly, a combined statistic of OS and CSS may overestimate the adverse survival outcomes of segmentectomy procedures. To address the issue of differing patient baseline characteristics, Tsutani et al. [6] recently published a propensity-score analysis involving 481 patients with clinical Stage IA adenocarcinoma who were subsequently matched into 81 pairs according to clinicopathological factors. Results of this study demonstrated no differences in regard to OS and recurrence-free survival at 3 years. In our opinion, it is no longer controversial to perform sublobar resections for patients with NSCLC who are deemed ineligible for lobectomy procedures due to comorbidities or limited pulmonary function. The area of interest lies with the cohort of patients who can tolerate either a segmentectomy or a lobectomy procedure. For this growing patient population who are diagnosed with early stage NSCLC through more aggressive screening programmes, oncological efficacy needs to be balanced with pulmonary preservation and potentially reduced perioperative complications associated with segmentectomy. Future analyses should aim to differentiate data from studies that included ‘compromised’ patients who underwent sublobar resections as a result of their inability to undergo lobectomy, or ‘intentional’ patients who could have tolerated either procedure.

Proton-based stereotactic ablative radiotherapy in early-stage non-small-cell lung cancer.

Stereotactic ablative radiotherapy (SABR), a recent implementation in the practice of radiation oncology, has been shown to confer high rates of local control in the treatment of early stage non-small-cell lung cancer (NSCLC). This technique, which involves limited invasive procedures and reduced treatment intervals, offers definitive treatment for patients unable or unwilling to undergo an operation. The use of protons in SABR delivery confers the added physical advantage of normal tissue sparing due to the absence of collateral radiation dose delivered to regions distal to the target. This may translate into clinical benefit and a decreased risk of clinical toxicity in patients with nearby critical structures or limited pulmonary reserve. In this review, we present the rationale for proton-based SABR, principles relating to the delivery and planning of this modality, and a summary of published clinical studies.

Segmentectomy Versus Wedge Resection for Non-Small Cell Lung Cancer in High-Risk Operable Patients

Patients with early-stage lung cancer and limited pulmonary reserve may not be appropriate candidates for lobectomy. In these situations, sublobar resection (wedge or segmentectomy) is generally performed. Many physicians believe that segmentectomy is superior because it allows for an improved parenchymal margin and nodal sampling. We performed an analysis using operative and pathology reports collected as part of planned data collection for American College of Surgeons Surgical Oncology Group (ACOSG) Z4032. This was a prospective trial in which patients with clinical stage I lung cancer and limited pulmonary function were randomized to sublobar resection with or without brachytherapy. The operative approach (video-assisted thoracic surgery [VATS] vs thoracotomy), extent of resection, and degree of lymph node evaluation were at the discretion of the individual surgeon. The primary aim of this analysis was to compare the parenchymal margin achieved between segmentectomy and wedge resection. Secondary aims included the extent of nodal staging and whether the operative approach (VATS vs open) had an effect on margin status and nodal evaluation. Among 210 patients, 135 (64%) underwent a VATS approach and 75 (36%) a thoracotomy. A segmentectomy was performed in 57 patients (27%) and a wedge resection in 153 patients (73%). There were no significant differences in the degree of nodal upstaging, stations sampled, or parenchymal margin obtained between VATS and thoracotomy. However, significant differences were observed between patients who underwent a segmentectomy and those who underwent a wedge resection with regard to parenchymal margin (1.5 cm vs 0.8 cm, p = 0.0001), nodal upstaging (9% vs 1%, p = 0.006), and nodal stations sampled (3 vs 1, p < 0.0001) . Notably, 41% of patients treated by wedge resection had no nodes sampled at the time of operation compared with 2% of those who underwent segmentectomy (p < 0.0001). In ACOSG Z4032, wedge resection, regardless of the approach, was associated with a smaller parenchymal margin and a lower yield of lymph nodes and rate of nodal upstaging when compared with segmentectomy.

Efficacy of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in evaluating lung cancer recurrence

For patients with non-small cell lung cancer (NSCLC) classified as stage I using the tumor-node-metastasis (TNM) staging system (T1N0M0 or T2N0M0), the standard treatment is complete resection of the affected lobes and associated lymph nodes. However, lung cancer is usually inoperable in elderly patients, mostly because of their poor performance status. In general, resection of these early-stage tumors, typically by lobectomy, has been associated with three-year and five-year survival rates ranging from 60% to 80%. (1,2) Unfortunately, significant complications have been associated with lobectomy in elderly patients or in those with medical comorbidities, such as limited pulmonary reserve and cardiovascular disease. (3-6) With the popularization of CT screening, lung cancers have been increasingly detected at an early stage.

Myocardial Protection Era: From Valve Surgery to Heart Transplantation

Myocardial Protection Era: From Valve Surgery to Heart Transplantation