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BackgroundPrevious studies have reported the feasibility and efficacy of thoracoscopic anatomical sublobar resection under three-dimensional computed tomography (3DCT) simulation; however, its long-term outcomes have not been clearly established in primary lung cancer. This study aimed to evaluate the long-term outcomes of this technique.MethodsWe retrospectively reviewed data from 112 consecutive patients with selected clinical stage IA non-small cell lung cancer (NSCLC) who underwent thoracoscopic anatomical sublobar resection from 2004 to 2014. This procedure was planned using preoperative 3DCT simulation to ensure sufficient surgical margins and enabled tailor-made surgery for each patient. Patients who had predominantly ground glass opacity lung cancers underwent anatomical sublobar resection as a curative-intent resection. Other patients who were high-risk candidates for lobectomy underwent anatomical sublobar resection as a compromised limited resection.ResultsOf the 112 cases, 82 had a curative-intent resection, while 30 had a compromised limited resection. Recurrence occurred in only 2 cases (1.8%), both of which were in the compromised limited group. A second primary lung cancer was observed in 5 cases (4.5%). Of the 5 patients, 4 underwent surgery for a second cancer and had no recurrence. The 5-year overall survival, lung cancer-specific overall survival, and recurrence-free survival rates were 92.5%, 100%, and 98.2%, respectively, for all cases; 97.6%, 100%, and 100%, respectively, in the curative-intent group; and 75.8%, 100% and 92.6%, respectively, in the compromised limited group.ConclusionsThoracoscopic anatomical sublobar resection under 3DCT simulation may be an acceptable alternative treatment in selected patients with NSCLC.Trial and clinical registryClinical registration number: IRB No. 2020-98 (Dated: 2020.6.30).

Background Lung segmentectomy is an option for the treatment of noninvasive or minimally invasive lung cancer. For tumors located in the left upper division (LUD), LUD trisegmentectomy (S 1+2  + S 3 ) is frequently performed as a sublobar resection because of its technical simplicity. However, the differences in surgical outcomes between simple and complex segmentectomies remain unclear. Methods We compared the surgical outcomes and frequency of postoperative complications of LUD trisegmentectomy (simple group) with those of complex segmentectomy (other than LUD trisegmentectomy; complex group) for pulmonary lesions using three-dimensional computed tomography between 2010 and 2021. Results In total, 118 patients were included: 65 in the simple group and 53 in the complex group (S 1+2 : 25, S 3 : 15, others: 13). There were no significant differences in surgical time or duration of postoperative chest drainage. However, the blood loss volume was significantly smaller in the complex group than in the simple group (12 vs. 36 mL, p  = 0.023), and major complications tended to occur less frequently in the complex group than in the simple group (3.8 vs. 13.8%, p  = 0.061). Among patients who underwent intentional segmentectomy for primary lung cancer ( n  = 61), major complications were significantly less common in the complex group ( p  = 0.006). Conclusions Complex segmentectomy can be performed safely under the guidance of three-dimensional CT. Complex segmentectomy itself is not a risk factor for postoperative complications when the intersegmental planes are sufficiently recognized and accurately cut.

PurposeTo study the correlation between absorbed perfused liver dose using Y90 radioembolization and degree of hepatocellular carcinoma (HCC) necrosis in liver explants in a multicenter cohort analysisMethodsA retrospective analysis of 45 HCC patients treated between 2014 and 2017 is presented. Inclusion criteria were treatment-naïve solitary HCC ≤ 8 cm and Child-Pugh A liver status using the radiation segmentectomy approach. All patients underwent liver resection or transplantation (LT). Liver explants were examined per institutional routine protocols to assess histopathological viability of HCC. Tumor pathological necrosis was classified into complete (100% necrosis), extensive (> 50% and ≤ 99%) necrosis, and partial (< 50%) necrosis. Absorbed perfused liver doses were estimated using MIRD calculations. Associations between dose and degree of necrosis were studied.ResultsThirty-four (76%) patients underwent LT, and 11 (24%) patients underwent hepatic resection. Median radiation dose was 240 (IQR: 136–387) Gy. Thirty (67%) patients had complete pathologic necrosis (CPN) at explant, while 10 (22%) and 5 (11%) had extensive and partial necrosis, respectively. There were significant differences among perfused liver doses that exhibited partial, extensive, and complete necrosis (p = 0.001). Twenty-four out of twenty-eight (86%) patients who had dose > 190 Gy achieved CPN, while 11/17 (65%) who had < 190 Gy did not (Fisher’s exact test; p = 0.001). Using binary logistic regression, only absorbed radiation dose was significantly associated with CPN (p = 0.01), while tumor size was not (p = 0.35). All patients receiving > 400 Gy exhibited CPN.ConclusionRadiation segmentectomy for early HCC with ablative dosing > 400 Gy results in CPN. This represents the new standard target dose for radiation segmentectomy.

The aim of this study was to evaluate whether 3-dimensional (3D) simulation software is applicable to and useful for anatomic liver segmentectomy and subsegmentectomy. A prospective study of 83 consecutive patients who underwent anatomic segmentectomy or subsegmentectomy using the puncture method was performed. All patients underwent 3D simulation analysis (SA) preoperatively for planning operative procedures. The clinical information acquired by 3D SA and the consistency of virtual and real hepatectomy were evaluated. The time needed for completing 3D SA was 18.3 ± .7 minutes. Three-dimensional SA proposed resection of multiple segments or subsegments in 29 patients (35%). It also helped complement the resection line in 26 patients (31%) who lacked a bold staining area on the liver surface. The volume of segment or subsegment calculated by 3D SA was correlated with the actual resected specimen (R2 = .9942, P < .01). The bordering hepatic veins were clearly exposed in 71 patients (86%), in accordance with completed drawings by 3D SA. Three-dimensional SA showed accurate completed drawings and assisted liver surgeons in planning and executing anatomic segmentectomy and subsegmentectomy.

Background It remains no clear conclusion about which is better between robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for the treatment of patients with non-small cell lung cancer (NSCLC). Therefore, this meta-analysis aimed to compare the short-term and long-term efficacy between RATS and VATS for NSCLC. Methods Pubmed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were comprehensively searched for studies published before December 2020. The quality of the articles was evaluated using the Newcastle-Ottawa Scale (NOS) and the data analyzed using the Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis and sensitivity analysis were conducted. Results A total of 18 studies including 11,247 patients were included in the meta-analyses, of which 5114 patients were in the RATS group and 6133 in the VATS group. Compared with VATS, RATS was associated with less blood loss (WMD = − 50.40, 95% CI -90.32 ~ − 10.48, P  = 0.010), lower conversion rate (OR = 0.50, 95% CI 0.43 ~ 0.60, P  < 0.001), more harvested lymph nodes (WMD = 1.72, 95% CI 0.63 ~ 2.81, P  = 0.002) and stations (WMD = 0.51, 95% CI 0.15 ~ 0.86, P  = 0.005), shorter duration of postoperative chest tube drainage (WMD = − 0.61, 95% CI -0.78 ~ − 0.44, P  < 0.001) and hospital stay (WMD = − 1.12, 95% CI -1.58 ~ − 0.66, P  < 0.001), lower overall complication rate (OR = 0.90, 95% CI 0.83 ~ 0.99, P  = 0.020), lower recurrence rate (OR = 0.51, 95% CI 0.36 ~ 0.72, P  < 0.001), and higher cost (WMD = 3909.87 USD, 95% CI 3706.90 ~ 4112.84, P <  0.001). There was no significant difference between RATS and VATS in operative time, mortality, overall survival (OS), and disease-free survival (DFS). Sensitivity analysis showed that no significant differences were found between the two techniques in conversion rate, number of harvested lymph nodes and stations, and overall complication. Conclusions The results revealed that RATS is a feasible and safe technique compared with VATS in terms of short-term and long-term outcomes. Moreover, more randomized controlled trials comparing the two techniques with rigorous study designs are still essential to evaluate the value of robotic surgery for NSCLC.

Background Harlequin syndrome is characterized by unilateral facial flushing and sweating induced by exercise, heat, and emotion, which is mainly caused by autonomic nervous system impairment. Case presentation A patient underwent thoracoscopic segmentectomy for a tumor located in the apicoposterior segment of the left upper lobe. Within two hours after surgery, the patient developed ipsilateral facial pallor accompanied by contralateral flushing, without any neurological deficits or hemodynamic instability. The symptoms persisted until late at night, and facial erythema resolved spontaneously by the following morning. The patient was discharged on postoperative day 4 without complications. Based on the clinical presentation and temporal association, the condition was diagnosed as Harlequin syndrome secondary to paravertebral nerve block at the corresponding vertebral level. Conclusions When performing paravertebral block for pulmonary resection, the location of the tumor and the involvement of the pleura should be considered. If a patient’s preoperative computed tomography (CT) images are consistent with those of the patient described in this article, paravertebral block administration may induce Harlequin syndrome. Therefore, the nerve block procedure may be adjusted to avoid the corresponding segment to mitigate this risk.

Purpose To verify the correlation between yttrium-90 glass microsphere radiation segmentectomy treatment intensification of hepatocellular carcinoma (HCC) and complete pathologic necrosis (CPN) at liver transplantation. Methods A retrospective, single center, analysis of patients with HCC who received radiation segmentectomy prior to liver transplantation from 2016 to 2021 was performed. The tumor treatment intensification cohort ( n  = 38) was prescribed radiation segmentectomy as per response recommendations identified in a previously published baseline cohort study ( n  = 37). Treatment intensification and baseline cohort treatment parameters were compared for rates of CPN. Both cohorts were then combined for an overall analysis of treatment parameter correlation with CPN. Results Sixty-three patients with a combined 75 tumors were analyzed. Specific activity, dose, and treatment activity were significantly higher in the treatment intensification cohort (all p  < 0.01), while particles per cubic centimeter of treated liver were not. CPN was achieved in 76% ( n  = 29) of tumors in the treatment intensification cohort compared to 49% ( n  = 18) in the baseline cohort ( p  = 0.013). The combined cohort CPN rate was 63% ( n  = 47). ROC analysis showed that specific activity ≥ 327 Bq (AUC 0.75, p  < 0.001), dose ≥ 446 Gy (AUC 0.69, p  = 0.005), and treatment activity ≥ 2.55 Gbq (AUC 0.71, p  = 0.002) were predictive of CPN. Multivariate logistic regression demonstrated that a specific activity ≥ 327 Bq was the sole independent predictor of CPN ( p  = 0.013). Conclusion Radiation segmentectomy treatment intensification for patients with HCC prior to liver transplantation increases rates of CPN. While dose strongly correlated with pathologic response, specific activity was the most significant independent radiation segmentectomy treatment parameter associated with CPN.

Purposes Robot-assisted thoracoscopic (RATS) segmentectomy is becoming increasingly common because of the expanded indications for segmentectomy and the widespread adoption of robotic surgery. The precise division of the intersegmental plane is necessary to ensure oncologic margins from the tumor and to preserve the lung function. In this study, we present a strategy for accurately dividing the intersegmental plane using a robotic stapler and review the surgical outcomes. Methods RATS portal segmentectomy was performed using the Da Vinci Xi system and the intersegmental plane was dissected using a robotic stapler. We evaluated the perioperative outcomes in 92 patients who underwent RATS portal segmentectomy between May 2020 and January 2023. These results were compared with those of 82 patients who underwent complete video-assisted thoracoscopic surgery (CVATS) during the same period. Results The operative and console times were 162 and 97 min, respectively. No intraoperative complications occurred, and postoperative complications were observed in four cases (4.3%). The operative time, blood loss, postoperative complications, and maximum incision size were significantly lower in the RATS group than in the CVATS group. However, RATS requires a significantly higher number of staplers than CVATS. Conclusions The division of the intersegmental plane using a robotic stapler in RATS portal segmentectomy was, therefore, found to be safe and effective.

Background With the popularity of LDCT screening, more and more small lung cancers have been found, and segmentectomy has been widely used because of its advantages in the treatment of early lung cancer, but the feasibility of segmentectomy is still controversial because of the increased complexity of the operation. Especially in complex lung segment surgery, it is more controversial. Preoperative three-dimensional reconstruction (3DR) is one of the effective methods to ensure the smooth operation, but its role in complex segmentectomy has not yet been verified. This article aims to evaluate the value of preoperative three-dimensional reconstruction in complex pulmonary segmentectomy by retrospective analysis of preoperative three-dimensional reconstruction assisted single-port video-assisted thoracoscopic complex pulmonary segmentectomy and comparison of surgical related indicators. Methods The clinical data of patients with lung cancers who underwent single-port thoracoscopic complex segmentectomy ( n  = 299) from August 2015 to February 2019 were retrospectively analyzed, including 156 patients in the preoperative three-dimensional reconstruction group and 143 patients in the non-three-dimensional reconstruction group. Perioperative outcomes were compared between the two groups after comparative propensity score matching analysis (PSM) according to patient age, gender, BMI, lung function, smoking history, major tumor components, and tumor size. Results There were 125 patients in each group after PSM, and the baseline characteristics of patients were comparable. There were no significant differences in age, sex, BMI, smoking history, tumor histology and tumor size between the two groups (all P  > 0.05). Lymph node dissection (9.4 ± 5.1 vs. 10.6 ± 7.0), postoperative drainage volume (510.5 ± 279.4 ml vs. 528.7 ± 379.4 ml), indwelling time of chest tube (2.3 ± 1.1d vs. 2.5 ± 1.6 d), and the incidence of chronic air leaks (0.8% vs. 0.8%), total complications (2.4% vs. 5.6%), 30-day postoperative mortality (0% vs. 0%) were not statistically different between the two groups. The operative time of preoperative 3DR group (178.6 ± 50.5 min vs. 202.1 ± 51.4 min), intraoperative blood loss (47.6 ± 37.9 ml vs. 58.4 ± 36.2 ml) compared with the control group (non-3DR), the difference was statistically significant ( P  < 0.05). Conclusion This is the first study to evaluate the usefulness of preoperative 3D reconstruction in complex segmentectomy. The results showed that the use of preoperative three-dimensional reconstruction for complex pulmonary segmentectomy was a safe and effective method, which could significantly reduce the operation time and blood loss.

Background: Yttrium-90 ([sup.90] Y) radioembolization is increasingly being utilized with curative intent. While single-compartment doses with respect to the perfused volume for the complete pathologic necrosis (CPN) of tumors have been reported, the actual doses delivered to the tumor and at-risk margins that leads to CPN have hitherto not been estimated. We present an ablative dosimetry model that calculates the dose distribution for tumors and at-risk margins based on numerical mm-scale dose modeling and the available clinical CPN evidence and report on the necessary dose metrics needed to achieve CPN following [sup.90] Y-radioembolization. Methods: Three-dimensional (3D) activity distributions (MBq/voxel) simulating spherical tumors were modeled with a 121 × 121 × 121 mm[sup.3] soft tissue volume (1 mm[sup.3] voxels). Then, 3D dose distributions (Gy/voxel) were estimated by convolving 3D activity distributions with a [sup.90] Y 3D dose kernel (Gy/MBq) sized 61 × 61 × 61 mm[sup.3] (1 mm[sup.3] voxels). Based on the published data on single-compartment segmental doses for the resected liver samples of HCC tumors showing CPN after radiation segmentectomy, the nominal voxel-based mean tumor dose (D[sub.mean] [sup.CPN] ), point dose at tumor rim (D[sub.rim] [sup.CPN] ), and point dose 2 mm beyond the tumor boundary (D[sub.2mm] [sup.CPN] ), which are necessary to achieve CPN, were calculated. The single-compartment dose prescriptions to required achieve CPN were then analytically modeled for more general cases of tumors with diameters d[sub.t] = 2, 3, 4, 5, 6, and 7 cm and with tumor-to-normal-liver uptake ratios T:N = 1:1, 2:1, 3:1, 4:1, and 5:1. Results: The nominal case defined to estimate the doses needed for CPN, based on the previously published clinical data, was a single hyperperfused tumor with a diameter of 2.5 cm and T:N = 3:1, treated with a single-compartment segmental dose of 400 Gy. The voxel-level doses necessary to achieve CPN were 1053 Gy for the mean tumor dose, 860 Gy for the point dose at the tumor boundary, and 561 Gy for the point dose at 2 mm beyond the tumor edge. The single-compartment segmental doses necessary to satisfy the criteria for CPN in terms of the mean tumor dose, point dose at the tumor boundary, and the point dose at 2 mm beyond the tumor edge were tabulated for a range of tumor diameters and tumor-to-normal-liver uptake ratios. Conclusions: The analytical functions that describe the relevant dose metrics for CPN and, more importantly, the single-compartment dose prescriptions for the perfused volume needed to achieve CPN are reported for a large range of conditions in terms of tumor diameters (1–7 cm) and T:N uptake ratios (2:1–5:1).