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Recurrence after pulmonary metastasectomy (PM) is frequent, but it is unclear to whom repeated pulmonary metastasectomy (RPM) offers highest benefits. Retrospective analysis of oncological and post-operative outcomes of consecutive patients who underwent PM from 2003 to 2018. Overall survival (OS) and disease-free interval (DFI) were calculated. Cox regression was used to identify variables influencing OS and DFI. In total, 264 patients (female/male: 114/150; median age: 62 years) underwent PM for colorectal cancer (32%), sarcoma (19%), melanoma (16%) and other primary tumors (33%). Pulmonary metastasectomy was approached by video-assisted thoracic surgery (VATS) in 73% and pulmonary resection was realized by non-anatomical resection in 76% of cases. The overall median follow-up time was 33 months (IQR 16–56 months) and overall 5-year survival rate was 62%. Local or distant recurrences were observed in 172 patients (65%) and RPM could be performed in 66 patients (25%) for a total of 116 procedures. RPM was realized by VATS in 49% and pulmonary resection by wedge in 77% of cases. In RPM patients, the 5-year survival rate after first PM was 79%. Post-operative cardio-pulmonary complication rate (13% vs. 12%; p = 0.8) and median length of stay (4 vs. 5 days; p = 0.2) were not statistically different between first PM and RPM. Colorectal cancer (HR 0.56), metachronous metastasis (HR 0.48) and RPM (HR 0.5) were associated with better survival. In conclusion, our results suggest that RPM offers favorable survival rates without increasing post-operative morbidity.

Background Repeated anatomical pulmonary resections in second primary nonsmall‐cell lung cancer (NSCLC) pose significant challenges due to prior surgery. This study evaluates the feasibility and short‐term outcomes of repeated anatomical pulmonary resections for second primary NSCLC. Method We retrospectively reviewed all consecutive cases of repeated anatomical pulmonary resections for second primary NSCLC performed in our institution from January 2014 to December 2023. Results A total of 55 patients (median age 68 years; interquartile range [IQR]: 61.5–72) underwent repeated anatomical pulmonary resections for second primary NSCLC. Adenocarcinoma predominated in both primary (78.2%) and secondary (76.4%) cases. Video‐assisted thoracoscopy (VATS) approach was used in 94.5% and 96.4% for first and repeated resection, respectively (p = 0.647). The extent of pulmonary resection differed between first and repeated resection, with a predominance of lobectomy during first resection (56.4%) and segmentectomy during repeated resection (85.5%, p < 0.001). We did not observe any significant difference in postoperative overall morbidity after first and repeated resection (23.6% vs. 40%, p = 0.065). However, there was an increased incidence of atrial fibrillation (16.4% vs. 0%) and prolonged air leak (> 5 days) after repeated resection (25.5% vs. 5.5%, p = 0.008). The median length of hospital stay was similar after first and repeated resection (5 vs. 5 days, p = 0.089). The three‐year overall survival (OS) was 73% after first resection and 87% after repeated resection. Overall disease recurrence rate was not statistically different between first and repeated resection (1.8% vs. 3.6%, p = 0.558). Conclusion Our series demonstrated that second primary NSCLC can be safely managed by VATS segmentectomy, yielding favorable short‐term survival and low recurrence rates. In 55 patients with second primary nonsmall‐cell lung cancer (NSCLC), repeated anatomical video‐assisted thoracoscopic surgery (VATS) resections—mostly segmentectomies—were safe and effective. Despite a higher rate of air leak and atrial fibrillation, morbidity and length of stay were similar to initial surgery. Three‐year survival reached 87%, with low recurrence. These findings support minimally invasive, parenchyma‐sparing reoperations in selected patients.

Objective: The optimal extent of segmentectomy for clinical T1N0 non-small cell lung cancer (NSCLC) remains unclear. This study compared perioperative and oncological outcomes of video-assisted thoracoscopic surgery (VATS) single segmentectomy (SS) versus multiple segmentectomy (MS) for tumors ≤ 3 cm. Methods: This single center study retrospectively analyzed all consecutive patients who underwent VATS anatomic segmentectomy for cT1N0 NSCLC between 2017 and 2022. Patient demographics, perioperative outcomes, and survival were compared between SS and MS groups. Results: In total, 334 patients underwent pulmonary segmentectomy: single in 211 (63%) and multiple in 123 patients (37%). In the SS group, 83 (39%) were simple and 128 (61%) complex segmentectomies; while in the MS group, 67 (54%) were simple and 56 (46%) were complex. Baseline characteristics were similar between groups. SS was associated with shorter operative time (117 vs. 132 min; p = 0.007), reduced length of drainage (1 vs. 3 days; p < 0.001), reduced hospital stay (5 vs. 6 days; p < 0.001), and lower atrial fibrillation (1.4% vs. 5.7%; p = 0.042). Total mean tumor size was 14.3 mm, with no statistical difference between groups (14.3 vs. 15.5 mm; p = 0.115). Surgical margins were larger in SS (median 13 vs. 11 mm; p = 0.038), while the number of lymph nodes dissected was similar. After a median follow-up of 30 months, no significant differences were observed in overall survival (OS) (94.5% vs. 90.7%) and disease-free survival (DFS) (83.2% vs. 79.1%). Conclusions: SS and MS provide equivalent short-term oncological outcomes in cT1N0 NSCLC ≤ 3 cm. SS may be preferred when adequate margins are achievable, offering equivalent oncologic outcomes with better perioperative recovery.

Background Compared to lobectomy by video-assisted thoracic surgery (VATS), segmentectomy by VATS has a potential higher risk of postoperative atelectasis and air leakage. We compared postoperative complications between these two procedures, and analyzed their risk factors. Methods We reviewed the records of all patients who underwent anatomical pulmonary resections by VATS from January 2014 to March 2018 in two Swiss university hospitals. All complications were reported. A logistic regression model was used to compare the risks of complications for the two interventions. Adjustment for patient characteristics was performed using a propensity score, and by including risk factors separately. Results Among 690 patients reviewed, the major indication for lung resection was primary lung cancer (86.4%) followed by metastasis resection (5.8%), benign lesion (3.9%), infection (3.2%) and emphysema (0.7%). Postoperatively, there were 80 instances (33.3%) of complications in 240 segmentectomies, and 171 instances (38.0%) of complications in 450 lobectomies ( P  = 0.73). After adjustment for the patient’s propensity to be treated by segmentectomy rather than lobectomy, the risks of a complication remained comparable for the two techniques (odds ratio for segmentectomy 0.91 (0.61–1.30), p  = 0.59). Length of hospital stay and drainage duration were shorter after segmentectomy. On multivariate analysis, an American Society of Anesthesiologists score above 2 and a forced expiratory volume in one second below 80% of predicted value were significantly associated with the occurrence of complications. Conclusions The rate of complications and their grade were similar between segmentectomy and lobectomy by VATS.

Background Pulmonary metastasectomy is increasingly performed in selected patients by video-assisted thoracic surgery (VATS) on the base of thin-slice high-resolution CT-Scan (HRCT). This study determines the overall survival and ipsilateral recurrence rate and of patients undergoing after VATS lung metastasectomy. Patients and method Retrospective single institution study of all patients who underwent VATS pulmonary metastasectomy on the base of HRCT with curative intent between 2005 and 2014. Results Seventy-seven patients (41 males, 36 females) underwent VATS pulmonary metastasectomy for solitary ( n  = 63) or multiple ( n  = 14) lung metastases in the context of colorectal carcinoma ( n  = 26), sarcoma ( n  = 17), melanoma ( n  = 16), or other primaries ( n  = 18). Nine patients had bilateral lung metastases and underwent synchronous ( n  = 4) or sequential ( n  = 5) VATS resections. Preoperative CT-guided hook wire localization of the lesions was performed in 65 patients (84 %). The postoperative mortality and morbidity rates were 0 and 5.2 %, respectively. During a mean follow-up time of 24 months (range 1–120 months), tumor progression occurred in 46 patients. Twenty-three patients (30 %) had pulmonary recurrence only, of them, eight patients (10 %) in the operated lungs. Seven of eight patients with recurrence in the operated lungs underwent a second metastasectomy by VATS ( n  = 5) or thoracotomy ( n  = 2). The overall 5-year survival rate was 54 % and without difference between patients without tumor recurrence and those with pulmonary recurrence treated by re-metastasectomy. Conclusion Ipsilateral recurrence remains low after VATS pulmonary metastasectomy guided by preoperative HRCT and can be efficiently treated by re-metastasectomy.

Background Identification of the prognostic factors of recurrence and survival after single pulmonary metastasectomy (PM). Methods Retrospective analysis of all consecutive patients who underwent PM for a single lung metastasis between 2003 and 2018. Results A total of 162 patients with a median age of 64 years underwent single PM. Video-Assisted Thoracic Surgery (VATS) was performed in 83.9% of cases. Surgical resection was achieved by wedge in 73.5%, segmentectomy in 7.4%, lobectomy in 17.9% and pneumonectomy in 1.2% of cases. The median durations of hospital stay and of drainage were 4 days (IQR 3–7) and 1 day (IQR 1–2), respectively. During the follow-up (median 31 months; IQR 15–58), 93 patients (57.4%) presented recurrences and repeated PM could be realized in 35 patients (21.6%) achieved by VATS in 77.1%. Non-colorectal tumour (HR 1.84), age < 70 years (HR 1.77) and previous extra-thoracic metastases (HR 1.61) were identified as prognostic factors of recurrence. Overall survival at 5-year was estimated at 67%. Non-colorectal tumour (HR 2.40) and mediastinal lymph nodes involvement (HR 3.42) were significantly associated with an increased risk of death. Conclusions Despite high recurrence rates after PM, surgical resection shows low morbidity rate and acceptable long-term survival, thus should remain the standard treatment for single pulmonary metastases. Trial registration : The Local Ethics Committee approved the study (No. 2019–02,474) and individual consent was waived.

Background Persistent pain and disability following rib fractures result in a large psycho-socio-economic impact for health-care system. Benefits of rib osteosynthesis are well documented in patients with flail chest that necessitates invasive ventilation. In patients with uncomplicated and simple rib fractures, indication for rib osteosynthesis is not clear. The aim of this trial is to compare pain at 2 months after rib osteosynthesis versus medical therapy. Methods This trial is a pragmatic multicenter, randomized, superiority, controlled, two-arm, not-blinded, trial that compares pain evolution between rib fixation and standard pain medication versus standard pain medication alone in patients with uncomplicated rib fractures. The study takes place in three hospitals of Thoracic Surgery of Western Switzerland. Primary outcome is pain measured by the brief pain inventory (BPI) questionnaire at 2 months post-surgery. The study includes follow-up assessments at 1, 2, 3, 6, and 12 months after discharge. To be able to detect at least 2 point-difference on the BPI between both groups (standard deviation 2) with 90% power and two-sided 5% type I error, 46 patients per group are required. Adjusting for 10% drop-outs leads to 51 patients per group. Discussion Uncomplicated rib fractures have a significant medico-economic impact. Surgical treatment with rib fixation could result in better clinical recovery of patients with uncomplicated rib fractures. These improved outcomes could include less acute and chronic pain, improved pulmonary function and quality of life, and shorter return to work. Finally, surgical treatment could then result in less financial costs. Trial registration ClinicalTrials.gov NCT04745520 . Registered on 8 February 2021.

BackgroundChest malignancies such as non-small cell lung cancer (NSCLC) or pleural mesothelioma (PM) have an ominous prognosis. Photodynamic therapy (PDT) of NSCLC and PM improves patient survival, but the precise underlying mechanism remains unknown. Here, we hypothesized that low-dose PDT (L-PDT) alters the expression of tumor endothelial cell adhesion molecules favoring immune cell recruitment and tumor control. We explored this hypothesis in two mouse models of NSCLC and PM. We validated our findings in 82 PM patient samples.MethodsWe assessed, in C56BL/6 mice bearing 344SQ-NSCLC and in BALB/c mice bearing AB12-PM, how L-PDT (400 μg/kg Visudyne administered intravenously, irradiance: 50 mW/cm2, light dose: 10 J/cm2) affected tumor growth, modulated the tumor immune microenvironment and the expression of endothelial selectin cell adhesion molecule (E-selectin) using real-time multiphoton imaging, immunofluorescence staining and flow cytometry. We then blocked E-selectin, canonical nuclear factor kappa B (NF-κB) pathway or selectively depleted CD8+ lymphocytes with dedicated peptides/antibodies in mouse models to evaluate the effect of L-PDT on tumors. Finally, we assessed in 82 PM patient samples the correlation between vascular E-selectin and CD8+ lymphocyte content by immunofluorescence staining of tissue sections and their association with patient survival.ResultsL-PDT induced vascular E-selectin in both NSCLC and PM, which enhanced granzyme B+/CD3+/CD8+ lymphocyte infiltration and improved tumor control. Blockade of E-selectin or immunodepletion of CD8+ lymphocytes abrogated the L-PDT-mediated cancer regression. Moreover, canonical NF-κB pathway blockade impaired enhanced vascular E-selectin expression and CD8+ T cells infiltration in tumors following L-PDT. In human malignant pleural mesothelioma samples, we found a correlation between vascular E-selectin and CD8+ T cell infiltration, which was associated with improved patient outcome.ConclusionL-PDT remodels the vasculature of chest tumors and favors a cytotoxic immune microenvironment promoting tumor control. This approach could complement current immunotherapy approaches in these malignancies.

We aimed to evaluate whether computed tomography (CT)-derived preoperative sarcopenia measures were associated with postoperative outcomes and survival after video-assisted thoracoscopic (VATS) anatomical pulmonary resection in patients with early-stage non-small cell lung cancer (NSCLC). We retrospectively reviewed all consecutive patients that underwent VATS anatomical pulmonary resection for NSCLC between 2012 and 2019. Skeletal muscle mass was measured at L3 vertebral level on preoperative CT or PET/CT scans to identify sarcopenic patients according to established threshold values. We compared postoperative outcomes and survival of sarcopenic vs. non-sarcopenic patients. A total of 401 patients underwent VATS anatomical pulmonary resection for NSCLC. Sarcopenia was identified in 92 patients (23%). Sarcopenic patients were predominantly males (75% vs. 25%; p < 0.001) and had a lower BMI (21.4 vs. 26.5 kg/m2; p < 0.001). The overall postoperative complication rate was significantly higher (53.2% vs. 39.2%; p = 0.017) in sarcopenic patients and the length of hospital stay was prolonged (8 vs. 6 days; p = 0.032). Two factors were associated with postoperative morbidity in multivariate analysis: BMI and American Society of Anesthesiologists score >2. Median overall survival was comparable between groups (41 vs. 46 months; p = 0.240). CT-derived sarcopenia appeared to have a small impact on early postoperative clinical outcomes, but no effect on overall survival after VATS anatomical lung resection for NSCLC.

Background Solitary pulmonary nodules (SPN) are frequently detected in cancer patients. These lesions are often considered as pulmonary metastases and increasingly treated by non-surgical techniques without histological confirmation. The aim of this study is to determine the histological nature of SPN resected by thoracoscopy and to identify risk factors of malignancy. Methods Single-institution retrospective analysis of all consecutive patients with previously known malignancies who underwent thoracoscopic resection of SPN with unknown diagnosis between 2001 and 2014. Results One hundred and forty cancer patients underwent thoracoscopic resection of a SPN. The resected SPN was benign in 34 patients (24.3%) and malignant in 106 patients. The latter were metastasis in 70 patients (50%) and a primary lung cancer in 36 patients (25.7%). Upon univariate analysis, malignancy was significantly associated with age >60 years, disease-free interval ≥24 months, SPN size >8 mm, upper lobe localization and SUV max  > 2.5 on PET-CT. Upon multivariate analysis, upper lobe localization and SUV max  > 2.5 were associated with malignancy. Smoking was significantly associated with SPN containing primary lung cancer. Conclusion In this series, only 50% of SPN in patients with known malignant disease were pulmonary metastases and 25% had a newly diagnosed NSCLC. Smoking was associated with primary lung cancer but no other predictor was found to allow the distinction between pulmonary metastasis and lung cancer. These results endorse the need of histological confirmation of SPN in patients with previous malignancies to avoid diagnostic uncertainty and suboptimal treatments.