Pulmonary Resection Research Articles

Pulmonary metastasectomy for recurrent metastatic ovarian cancer.

The prognosis of patients with ovarian cancer with lung metastasis is poor; data on pulmonary metastasectomy for such patients are lacking. This study aimed to determine the safety and feasibility of pulmonary resection as part of cytoreductive surgery for recurrent metastatic ovarian cancer. Medical records of patients with ovarian cancer, who underwent pulmonary resection for lung metastasis in our hospital from April 2012 to February 2022, were retrospectively reviewed. Ten patients were included (median age, 53 years). Five patients had metastatic disease limited to the lungs. Additional surgeries included diaphragm resection, partial hepatectomy, para-aortic lymph node dissection, and cytoreduction. We achieved complete cytoreduction for all patients without severe complications, and the 30-day mortality was zero. After a median follow-up of 23 months, four of the patients experienced recurrence. One patient recurred 9 months after the operation and was lost to follow-up at 17 months, two died at 68 and 26 months respectively, one is alive with disease (23 months), and six are alive without recurrence, among whom two have survived for 56 and 124 months. Pulmonary resection for recurrent metastatic ovarian cancer seems safe and feasible, with long-term survival observed in certain patients. Pulmonary metastasectomy can be performed as part of the debulking surgery for selected patients with relapsed metastatic ovarian cancer. Both the patient lost to follow-up and the one who died at 26 months, had two lung metastatic nodules and did not receive postoperative chemotherapy, which might have led to relatively poor prognosis.

Sublobar resection utilizing near-infrared thoracoscopy with intravenous indocyanine green for intralobar pulmonary sequestration: a case report and literature review

BackgroundPulmonary sequestration is a rare pulmonary malformation, with intralobar pulmonary sequestration being the most common subtype. Lobectomy has generally been performed for its treatment, owing to unclear boundaries of the lesion. However, recent reports have introduced lung resection using intravenous indocyanine green (ICG) as a treatment for pulmonary sequestrations.Case descriptionA 34-year-old woman presented with chest pain, and enhanced chest computed tomography (CT) displayed a solid mass of 4.5 × 3.1 cm in the right S10 area. An aberrant artery was found running from the celiac artery through the diaphragm to the thoracic cavity. The patient was diagnosed as having pulmonary sequestration Pryce type III, and surgical resection was performed. Intrathoracic findings demonstrated that the precise area of the pulmonary sequestration could not be clearly identified, and a 5-mm aberrant artery was present in the pulmonary ligament. Following the separation of the aberrant artery, intravenous injection of ICG clearly delineated the border between the normal lung tissue and the pulmonary sequestration. Wedge resection was then performed without any postoperative events, and the pathological diagnosis was also pulmonary sequestration.ConclusionsWe herein reported a case of a patient who underwent sublobar resection for intrapulmonary sequestration using intravenous ICG injection, together with a literature review. Our case suggests that a comprehensive understanding of abnormal vessels and pulmonary vasculature in pulmonary resection for intrapulmonary sequestrations, complemented with the use of ICG, might potentially avoid unnecessary pulmonary resection and enable sublobar surgical resection.

SAT560 A Case of Medullary Thyroid Carcinoma with Increasing Carcinoembryonic Antigen and Stable Calcitonin Levels

Abstract Disclosure: K.N. Youssef: None. L. Salej: None. A. Gavrila-Filip: None. Background: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor arising from the parafollicular or C cells of the thyroid gland that secretes different tumor markers, including calcitonin (CT) and carcinoembryonic antigen (CEA). CT is only produced by parafollicular cells, while CEA is a non-specific marker produced in various normal tissues, such as epithelial cells of the gastrointestinal tract, lung, breast, and prostate. Different benign and malignant conditions are associated with elevated serum CEA levels. Clinical case: A 69 years-old active smoker male with a history of nasal squamous cell carcinoma (SCC) status post resection in the remote past and bilateral pulmonary nodules underwent total thyroidectomy for a thyroid nodule with FNA positive for medullary carcinoma. Surgical pathology revealed a unifocal 1.5 cm medullary carcinoma with clean surgical margins and no lymphadenopathy. Pre-operative studies included an elevated serum CT of 388 pg/mL (normal ≤ 10 pg/mL), normal serum calcium and PTH levels and a normal 24-hour urinary test for pheochromocytoma. Family history was irrelevant, and the RET proto-oncogene test was negative. Initial post-operative serum CT levels were undetectable and CEA levels were normal (0-4 ng/mL). CT levels increased slowly over the next five years and then they remained stable in the range of 32 to 45 pg/mL. Serum CEA started to rise progressively 7 years after the thyroid surgery up to 6.5 pg/mL. Follow-up neck ultrasounds showed no local recurrence or lymphadenopathy. An extensive evaluation was performed to search for possible MTC metastases and other etiologies for the elevated CEA levels. Bone scan was negative. Chest CT scans revealed enlarging small bilateral pulmonary nodules; stable calcified mediastinal lymph nodes were noted, consistent with chronic granulomatous disease. PET-CT scan showed pulmonary nodules, too small to characterize. The patient underwent a left lower pulmonary lobe robotic-assisted wedge resection. Surgical pathology revealed keratinizing SCC, though to represent primary lung SCC versus metastases from his prior nasal SCC. Upper endoscopy and colonoscopy with biopsy were negative for malignancy. On further workup, the patient was diagnosed with prostate adenocarcinoma and underwent surgery followed by external beam radiation with hormonal therapy. Serum CEA levels normalized one year after the prostate cancer treatment. Serum CT levels remained stable. Conclusion: In patients with MTC who show increasing serum CEA and stable CT levels during follow-up after the initial treatment, it is important to exclude other etiologies before concluding that this change is related to a progression of the medullary cancer. Reference: Carcinoembryonic Antigen. Kankanala VL, Mukkamalla SKR.2022 Jan 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Presentation Date: Saturday, June 17, 2023

The significance of digital drainage devices on standardization of air leak management after pulmonary resection

The significance of digital drainage devices on standardization of air leak management after pulmonary resection

Pulmonary coccidioidomycosis complicated by nontuberculous mycobacterial pulmonary diseases with a literature review.

Following endobronchial examination, a young mine supervisor was treated with antibiotics for a pulmonary nontuberculous mycobacterial infection for approximately 1 year. However, a review of the radiological findings, which had not been previously assessed, revealed a different possibility. Accordingly, pulmonary resection was performed, enabling histopathological analysis, which showed numerous yeast-like fungi. Given the history of a stay in the southwestern United States for 2 months in 2009, 8 years previously, coccidioidomycosis was strongly suspected and the diagnosis was subsequently confirmed by serology and polymerase chain reaction testing of the excised specimen. Here, we report an educational case emphasizing the importance of meticulous medical history-taking and awareness of endemic mycoses in other countries in the context of globalization.

Unplanned reoperation after pulmonary surgery: Rate, risk factors and early outcomes at a single center

BackgroundUnplanned reoperation is a potential risk factor for worse prognoses and reflects the quality of surgical treatment. This study compared the short-term outcomes between patients with and without reoperation and identified clinical factors predicting reoperation within 90 days following pulmonary surgery. MethodsConsecutive patients undergoing pulmonary resection from January 2012 to August 2021 at our institution were retrospectively reviewed. Clinical and operation-related data were collected and analyzed. Kaplan‒Meier, Cox hazard proportional regression, and propensity score matching were adopted for prognostic evaluation. ResultsA total of 90263 patients were included: 247 (0.27%) patients required reoperation within 90 days. Patients undergoing unplanned reoperation had higher mortality and more postoperative complications than the nonreoperation group. Reoperation within 24 h was associated with reduced odds of mortality relative to reoperation beyond 24 h. Independent risk factors for unplanned reoperation were male sex, benign lung disease, specific surgical locations, lobectomy, and pneumonectomy. A history of smoking, pulmonary tuberculosis, intraoperative pleural adhesion, and postoperative complications were also identified as predisposing factors. The most common complication was hemorrhage in 75.7% (187 of 247). ConclusionOur study found that unplanned reoperation was a rare but serious event that increased the risk of postoperative complications and mortality. We identified several risk factors that could be used to stratify patients according to their reoperation risk and suggest that high-risk patients should receive more intensive monitoring and preventive measures. Moreover, our study indicated that reoperating within 24 h could improve the outcomes for patients who needed reoperation.

Respect the Middle Lobe: Perioperative Risk of Bilobectomy Compared With Lobectomy and Pneumonectomy

BackgroundIn some cases of right-sided lung cancer, tumor extension, bronchial involvement, or pulmonary artery infiltration may necessitate bilobectomy. Although the middle lobe is believed to represent a fraction of total lung function, the morbidity and mortality associated with bilobectomy is not well described. MethodsWe retrospectively identified patients in The Society of Thoracic Surgeons Database who underwent lobectomy, bilobectomy, or pneumonectomy for lung cancer from 2009 to 2017. The primary outcome was 30-day perioperative mortality. We performed propensity matching by patient demographics, comorbidities, and perioperative variables for each surgical type against bilobectomy and ran Cox proportional hazard models. Secondary outcomes of 30-day morbidity and mortality of upper vs lower bilobectomy were also compared. ResultsWithin the study period 2911 bilobectomy, 65,506 lobectomy, and 3370 pneumonectomy patients met the inclusion criteria. Patients undergoing pneumonectomy and bilobectomy had fewer comorbidities than lobectomy patients. After propensity matching 30-day mortality of bilobectomy was comparable with left pneumonectomy (hazard ratio [HR], 1.35; 95% CI, 0.95-1.91; P = .09) and significantly worse than left (HR, 0.40; 95% CI, 0.29-0.56; P < .0001) or right (HR, 0.43; 95% CI, 0.31-0.59; P < .0001) lobectomy. Bilobectomy was associated with a survival advantage compared with right pneumonectomy (HR, 2.54; 95% CI, 1.72-3.74; P < .0001). Thirty-day morbidity was higher for bilobectomy compared with lobectomy, and upper bilobectomy had a significant unadjusted 30-day mortality advantage compared with lower bilobectomy (98.3% vs 97%, P = .04). ConclusionsThe morbidity and mortality of bilobectomy is significantly worse than lobectomy and is comparable with left pneumonectomy. The addition of middle lobectomy to a pulmonary resection is not without risk and should be carefully considered during preoperative risk stratification.

The process and safety of removing chest tubes 4 to 12 hours after robotic pulmonary lobectomy and segmentectomy

ObjectiveChest tubes cause pain and morbidity. MethodsThis is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery. ResultsBetween January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 (P < .001). Forty patients (6.8%) were discharged home on postoperative day 1 with a chest tube. Sixteen patients (2.7%) had post–chest tube removal increasing pneumothorax and subcutaneous emphysema; none required tube reinsertion. There was no 30-day or 90-day mortality. Twelve patients (2%) had an outpatient thoracentesis for effusion within 60 days. Twenty patients (3.3%) were readmitted, none seemingly related to effusions. Nonsmokers (P = .04) and segmentectomy (P = .001) were associated with chest tube removal within 4 to 12 hours of surgery. ConclusionsChest tubes can be safely removed within 4 to 12 hours after robotic segmentectomy and lobectomy. Factors associated with successful early chest tube removal are nonsmoking, segmentectomy, and team members becoming comfortable with the process.

Discussion to: Postoperative day 1 discharge following robotic thoracoscopic pulmonary anatomic resections in the era of enhanced recovery protocol: A single-institution experience

Discussion to: Postoperative day 1 discharge following robotic thoracoscopic pulmonary anatomic resections in the era of enhanced recovery protocol: A single-institution experience

Nomogram combining clinical and radiological characteristics for predicting the malignant probability of solitary pulmonary nodules measuring ≤ 2 cm.

At present, how to identify the benign or malignant nature of small (≤ 2 cm) solitary pulmonary nodules (SPN) are an urgent clinical challenge. This retrospective study aimed to develop a clinical prediction model combining clinical and radiological characteristics for assessing the probability of malignancy in SPNs measuring ≤ 2 cm. In this study, we included patients with SPNs measuring ≤ 2 cm who underwent pulmonary resection with definite pathology at Qilu Hospital of Shandong University from January 2020 to December 2021. Clinical features, preoperative biomarker results, and computed tomography characteristics were collected. The enrolled patients were randomized at a ratio of 7:3 into a training cohort of 775 and a validation cohort of 331. The training cohort was used to construct the predictive model, while the validation cohort was used to test the model independently. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors. The prediction model and nomogram were established based on the independent risk factors. The receiver operating characteristic (ROC) curve was used to evaluate the identification ability of the model. The calibration power was evaluated using the Hosmer-Lemeshow test and calibration curve. The clinical utility of the nomogram was also assessed by decision curve analysis (DCA). A total of 1,106 patients were included in this study. Among them, the malignancy rate of SPNs was 85.08% (941/1,106). We finally identified the following six independent risk factors by logistic regression: age, carcinoembryonic antigen, nodule shape, calcification, maximum diameter, and consolidation-to-tumor ratio. The area under the ROC curve (AUC) for the training cohort was 0.764 (95% confidence interval [CI]: 0.714-0.814), and the AUC for the validation cohort was 0.729 (95% CI: 0.647-0.811), indicating that the prediction accuracy of nomogram was relatively good. The calibration curve of the predictive model also demonstrated a good calibration in both cohorts. DCA proved that the clinical prediction model was useful in clinical practice. We developed and validated a predictive model and nomogram for estimating the probability of malignancy in SPNs measuring ≤ 2 cm. With the application of predictive models, thoracic surgeons can make more rational clinical decisions while avoiding overtreatment and wasting medical resources.

Recent Advances in Perioperative Immunotherapies in Lung Cancer.

Several clinical trials have been revolutionizing the perioperative treatment of early-stage non-small cell lung cancer (NSCLC). Many of these clinical trials involve cancer immunotherapies with antibody drugs that block the inhibitory immune checkpoints programmed death 1 (PD-1) and its ligand PD-L1. While these new treatments are expected to improve the treatment outcome of NSCLC patients after pulmonary resection, several major clinical questions remain, including the appropriate timing of immunotherapy (neoadjuvant, adjuvant, or both) and the identification of patients who should be treated with neoadjuvant and/or adjuvant immunotherapies, because some early-stage NSCLC patients are cured by surgical resection alone. In addition, immunotherapy may induce immune-related adverse events that will require permanent treatment in some patients. Based on this fact as well, it is desirable to select appropriate patients for neoadjuvant/adjuvant immunotherapies. So far, data from several important trials have been published, with findings demonstrating the efficacy of adjuvant atezolizumab (IMpower010 trial), neoadjuvant nivolumab plus platinum-doublet chemotherapy (CheckMate816 trial), and several perioperative (neoadjuvant plus adjuvant) immunotherapies (AEGEAN, KEYNOTE-671, NADIM II, and Neotorch trials). In addition to these key trials, numerous clinical trials have reported a wealth of data, although most of the above clinical questions have not been completely answered yet. Because there are so many ongoing clinical trials in this field, a comprehensive understanding of the results and/or contents of these trials is necessary to explore answers to the clinical questions above as well as to plan a new clinical trial. In this review, we comprehensively summarize the recent data obtained from clinical trials addressing such questions.

TPVB and general anesthesia affects postoperative functional recovery in elderly patients with thoracoscopic pulmonary resections based on ERAS pathway.

Thoracic surgery is easy to cause various perioperative complications, especially in elderly patients, due to their physical weakness and physiological function degeneration. Postoperative cognitive dysfunction is a common complication in elderly patients undergoing thoracic surgery. This study focuses on exploring the effects of thoracic paravertebral block (TPVB) combined with general anesthesia on postoperative functional recovery in elderly patients undergoing thoracoscopic radical resection for lung cancer based on enhanced recovery after surgery (ERAS) pathway. A total of 104 patients aged 60 years or older undergoing thoracoscopic radical resection of lung cancer were randomized into the combination group (n = 52) and the control group (n = 52). Patients in the control group were given general anesthesia alone, while patients in the combination group were given TPVB combined with general anesthesia. All patients applied the ERAS model for the perioperative intervention. Hemodynamic indices (heart rate [HR] and mean arterial pressure [MAP]) before anesthesia (T0), 5 min after thoracoscopic trocar placement (T1), at extubation (T2), 30 min after extubation (T3), and 6 h after the surgery (T4), postoperative analgesia, preoperative and postoperative serum pain stress factors (5-hydroxytryptamine [5-HT], prostaglandin E2 [PGE2], cortisol [Cor], substance P [SP], and norepinephrine [NE]), tumor markers (CYFRA21-1, CEA, and CA50), inflammatory factors (IL-6, TNF-α, and c-reactive protein (CRP)), lung function indicators (forced vital capacity [FVC] and forced expiratory volume in the first second [FEV1]), 6 min walking distance (6MWD), clinical recovery indicators, hospitalization status, and postoperative complications in patients between both groups were compared. Compared with the control group, patients in the combination group had lower HR and MAP at T1-T4 time points, less intraoperative doses of remifentanil and propofol, less patient-controlled interscalene analgesia compression number 24 h after the surgery, lower visual analogue scale scores 24 h after the surgery, shorter hospitalization time, postoperative off-bed time, postoperative chest tube removal time, postoperative first feeding time and gastrointestinal function recovery time, reduced postoperative serum levels of 5-HT, PGE2, Cor, SP, NE, CYFRA21-1, CEA, CA50, IL-6, TNF-α, and CRP, decreased complications, and higher FVC, FEV1, and 6MWD. Based on the ERAS pathway, TPVB combined with general anesthesia in thoracoscopic surgery for lung cancer in elderly patients can effectively reduce the patients' hemodynamic fluctuations, alleviate postoperative pain, accelerate the recovery process, and reduce complications.

Magnusiomyces Capitatus Lung Nodule in a Patient with Nasopharyngeal and Hepatocellular Carcinoma.

Magnusiomyces capitatus is a dimorphic yeast commonly isolated from the environment and was uncommonly reported as a disease in Asia. It may cause invasive infection in patients with hematological malignancies, especially those with neutropenia, and resulting in high mortality. Herein, we reported a man with nasopharyngeal carcinoma and hepatocellular carcinoma suffered from intermittent fever after pulmonary nodules resection. The histopathology showed yeast-like fungal elements. For further identification, we extracted the tissue DNA from formalin-fixed paraffin-embedded tissue and M. capitatus was confirmed using polymerase chain reaction amplification and sequencing of the ITS region of ribosomal DNA. After a 4-week amphotericin B and flucytosine treatment, his condition recovered well and then was followed by a 3-month oral fluconazole treatment. There was no evidence of recurrence within one year. Our case highlights that nucleic acids obtained from formalin-fixed tissue could be a feasible identification method, especially in those whose culture results are unavailable.

The essential role of non-steroidal anti-inflammatory drugs in pain control following robotic thoracoscopic lung resections.

Enhanced recovery after thoracic surgery (ERATS) protocols use a combination of analgesics for pain control. We investigated the effect of non-steroidal analgesic drugs (NSAIDs) on pain control by comparing patient levels and opioid requirements after robotic pulmonary resections. We retrospectively analyzed our prospectively maintained institutional database for elective, opioid-naïve robotic thoracoscopic pulmonary resections. All patients received postoperative NSAIDs unless contraindicated or at the discretion of the attending surgeons. Our original protocol (ERATS-V1) was modified to optimize opioid-sparing effect without affecting pain control (ERATS-V2). Demographics, operative outcomes, and postoperative opioid dispensed [morphine milligram equivalent (MME)] were collected. A total of 491 patients (147 ERATS-V1; 344 ERATS-V2) were included in this study. There was no difference in patient characteristics or operative outcomes between ERATS cohorts. Protocol optimization was associated with a 2- to 10-fold reduction of postoperative opioid use without compromising pain control. In ERATS-V1 cohort, there was no difference in pain levels and opioid requirements with NSAID usage. In ERATS-V2 cohort, while pain levels were similar, higher in-hospital opioid consumption was observed in no-NSAID subgroup {MME: 20.5 [interquartile range (IQR), 4.8-40.5] vs. 12.0 (IQR, 2.0-32.2), P=0.0096, schedule II: 14.2 (IQR, 3.0-36.4) vs. 6.8 (IQR, 1.4-24.0), P=0.012} as well as total postoperative schedule II opioid requirement [17.8 (IQR, 3.0-43.5) vs. 8.8 (IQR, 1.5-30), P=0.032]. The opioid-sparing effect of NSAIDs was observed only in optimized ERATS patients. Modifications of our pre-existing ERATS was associated with a significant reduction of opioid consumption without affecting pain levels. This revealed the role of NSAIDs in postoperative pain management otherwise masked by excessive opioids use.

Mortality and failure-to-rescue major complication trends after lung cancer surgery between 2005 and 2020: a nationwide population-based study

ObjectivesTo estimate the evolution of quality indicators (30-day mortality and failure-to-rescue) inpatients who underwent lung cancer surgery in France over the past 15 years and to study the potential influencing...

Combined indocyanine green and medical glue enables stable and precise position in animal studies: promising for fluorescence-guided pulmonary ground glass nodule resection.

Accurate preoperative localization of pulmonary nodules is crucial for surgical treatment. The use of indocyanine green (ICG) for localization is prone to thoracic contamination and spread, resulting in the eventual failure of localization. By using medical glue combined with ICG, we can accurately and permanently locate various tissues in animal study, which can provide evidences for clinical translations. A series of medical glue and ICG volume ratios of 2:3, 3:3, 4:3, 6:3, and 9:3 were mixed and injected immediately into subcutaneous tissues of BALB/c nude mice; either medical glue or ICG was injected singly in the control group. Fluorescence intensity over time and boundary sharpness were investigated to determine the optimal ratio. Then, fluorescence guided resection of tissue was performed ex vivo on the pig intestine utilizing optimal ratio. Further, localization agents with the optimal ratio were injected into the organs of living mice, and fluorescence imaging for accurate positioning was performed 24 hours later. The localization agents with a volume ratio of 4:3 showed the best boundary sharpness and the strongest photostability. With the guidance of fluorescence navigation, the marked tissues were accurately separated and removed from the surrounding tissue both on mice and on pig intestines. In the organs of living mice, the localization agents (ratio 4:3) realized accurate positioning of marked tissues. Additionally, the medical glue limited the diffusion of ICG, promising to enable more stable and precise positioning of the nodules during surgery. The combination of ICG and medical glue presents a superior approach when compared to the individual use of either ICG or medical glue. This technique offers enhanced precision and durability and sealed the wound, thereby mitigating the risk of pneumothorax following puncture procedures. This innovative technique optimizes the properties of medical adhesive to augment tissue density while harnessing the real-time fluorescent endoscopic marking capabilities of ICG during surgical interventions. By employing this innovative technique, it holds significant promise for augmenting the accuracy of pulmonary nodule localization in thoracoscopic surgery within future clinical applications.

Impact of travel distance on receipt of indicated adjuvant therapy in resected non–small cell lung cancer

ObjectiveWe have previously demonstrated the negative impact of travel distance on adherence to surveillance imaging guidelines for resected non–small cell lung cancer (NSCLC). The influence of patient residential location on adherence to recommended postoperative treatment plans remains unclear. We sought to characterize the impact of travel distance on receipt of indicated adjuvant therapy in resected NSCLC. MethodsWe performed a single-institution, retrospective review of patients with stage II-III NSCLC who underwent upfront pulmonary resection, 2012-2016. Clinicopathologic and operative/perioperative details of treatment were collected. Travel distance was measured from patients' homes to the operative hospital. Our primary outcome was receipt of adjuvant systemic or radiotherapy. Travel distance was stratified as <100 or >100 miles. Multivariable logistic regression was performed. ResultsIn total, 391 patients met inclusion criteria, with mean age of 65.9 years and fairly even sex distribution (182 women, 49.2%). Most patients were Non-Hispanic White (n = 309, 83.5%), and most frequent clinical stage was II (n = 254, 64.9%). Indicated adjuvant therapy was received by 266 (71.9%), and median distance traveled was 209 miles (interquartile range, 50.7-617). Multivariate analysis revealed that longer travel distance was inversely associated with receipt of indicated adjuvant therapy (odds ratio, 0.13; 95% confidence interval, 0.06-0.26; P < .001). In addition, Black patients were less likely to receive appropriate treatment (odds ratio, 0.05; 95% confidence interval, 0.02-0.15; P < .001). ConclusionsTravel distance >100 miles negatively impacts the likelihood of receiving indicated adjuvant therapy in NSCLC. Indications for systemic therapy in earlier staged disease are rapidly expanding, and these findings bear heightened relevance as we aim to provide equitable access to all patients.

New method for delineation of the intersegmental line in a deflated lung.

Preoperative three-dimensional (3D) computed tomography (CT) images have been widely used as surgical guides in lung surgery; however, the lungs tend to be deflated during surgery. Discrepancies between the preoperatively constructed 3D image and the intraoperative view of the deflated lungs often require preoperative and/or intraoperative marking methods for sublobar pulmonary resection. We have developed a lung deflation simulation algorithm in which 3D CT images of the deflated lungs can be predicted only based on the preoperative CT taken in an inflated phase of respiration. Using this system, we conducted a preliminary study to retrospectively compare the intersegmental line predicted by our lung deflation simulation algorithm with the intersegmental line delineated by the intravenous administration of indocyanine green. Sixteen patients who underwent unilateral segmentectomy between January 1, 2020, and June 30, 2022, were included in the study. The identified intersegmental lines were confirmed intraoperatively using indocyanine green. These actual intersegmental lines were compared with those delineated on 3D images using the lung deflation simulation algorithm. Of the 16 patients who underwent pulmonary segmentectomy, the consistency of these intersegmental lines was in complete agreement in twelve patients, partial agreement in three patients, and disagreement in one patient. The concordance rate of the intersegmental lines was 75%. The lung deflation simulation algorithm provides a new surgical guide in addition to the currently utilized ones. Continuous innovation might lead to a less invasive surgical technique for delineating the intersegmental line.

Extracorporeal life support use in limited lung function: a narrative review.

In thoracic surgery, different modalities of extracorporeal life support (ECLS) can be used for cardiorespiratory support in complex scenarios. Decades of learning in clinical practice and physiology associated with technological development led to a great variety of ECLS technologies available. Thoracic surgery procedures with difficult or impossible single lung ventilation may still be performed using different ECLS modalities. The aim of this review is to describe the use of ECLS, with its different modalities, as a solution to perform complex surgeries in a patient with difficult or impossible single lung ventilation. A literature review was conducted using the terms "extracorporeal life support pulmonary resection" and "extracorporeal life support thoracic surgery", and articles were selected according to defined criteria. To support lung function during thoracic surgery, the most efficient and popular variety of ECLS is venovenous extracorporeal membrane oxygenation. Lung resection on a single lung after pneumonectomy, surgery in a patient with severe hypercapnia and/or low respiratory reserve, carinal and airway surgery, and severe thoracic trauma are the main examples of situations where ECLS may be the solution to provide a safe surgical environment in patients who cannot tolerate single lung ventilation. Multidisciplinarity, selection of patients and careful surgical planning are cornerstones in defining the situations that may benefit from ECLS support. Knowledge on techniques of ECLS are essential for every thoracic surgeon. Although rarely used, these techniques of cardiorespiratory support should be considered when planning complex cases with difficulties in ventilation and emergent situations.

486. FOR SYNCHRONOUS ESOPHAGEAL CARCINOMA AND PULMONARY LESION: IS IT APPROPRIATE TO PERFORM COMBINED RESECTION?

Abstract Background Reports on esophageal cancer with concurrent lung lesion cases are rare and mostly individual cases. Furthermore, the safety and feasibility of combined resection for patients with synchronous pulmonary lesions and esophageal cancer had always been a controversial topic. In the current study, we retrospectively analyzed the clinical data of patients who underwent simultaneous surgical resection for esophageal cancer with concurrent lung lesions, and explored their clinical characteristics, treatment outcomes, especially postoperative complications and prognosis. Method Patients who underwent esophagectomy between February 2009 and December 2022 were retrospectively reviewed at our center, and those with combined lung resection at the same setting were matched in a 1:1 propensity score matched (PSM) ratio to esophagectomy-alone patients. The main postoperative complications (including pneumonia, anastomotic leakage, pleural effusion, and other complications) and overall survival were compared. Results Of the 7152 esophagectomies, 222 cases of combined resection for synchronous pulmonary lesion (including 105 pneumatoceles, 71 benign nodules, and 46 malignant nodules) were eligible, and 1:1 ratio PSM esophagectomy-alone patients were matched. Wedge resection was the most frequent procedures (181, 81.5%). No significant differences were found in the incidence of postoperative complication between combined resection and esophagectomy-alone: pneumonia (21.2% vs. 20.7%), anastomotic leakage (7.2% vs. 6.3%), pleural effusion (15.3% vs. 13.1%). Moreover, different type of pulmonary lesions and extent of pulmonary resection also unaffected the incidence of postoperative complications. Survival analysis showed no significant difference for combined surgery or esophagectomy-alone. Conclusion In this large sample size study, combined resection dose not elevate the incidence of postoperative complications and weaken the overall survival for patients with synchronous esophageal carcinoma and pulmonary lesion. Therefore, for patients with clinically diagnosed esophageal cancer combined with lung lesions requiring surgery, the risk of concurrent resection may be acceptable.