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Background: Lungsco01 is the first study assessing the real benefits and the medico-economic impact of video-thoracoscopy versus open thoracotomy for non-small cell lung cancer in the French context. Methods: Two hundred and fifty nine adult patients from 10 French centres were randomised in this prospective multicentre randomised controlled trial, between July 29, 2016, and November 24, 2020. Survival from surgical intervention to day 30 and later was compared with the log-rank test. Total quality-adjusted-life-years (QALYs) were calculated using the EQ-5D-3L®. For medico-economic analyses at 30 days and at 3 months after surgery, resources consumed were valorised (€ 2018) from a hospital perspective. First, since mortality was infrequent and not different between the two arms, cost-minimisation analyses were performed considering only the cost differential. Second, based on complete cases on QALYs, cost-utility analyses were performed taking into account cost and QALY differential. Acceptability curves and the 95% confidence intervals for the incremental ratios were then obtained using the non-parametric bootstrap method (10,000 replications). Sensitivity analyses were performed using multiple imputations with the chained equation method. Results: The average cumulative costs of thoracotomy were lower than those of video-thoracoscopy at 30 days (€9,730 (SD = 3,597) vs. €11,290 (SD = 4,729)) and at 3 months (€9,863 (SD = 3,508) vs. €11,912 (SD = 5,159)). In the cost-utility analyses, the incremental cost-utility ratio was €19,162 per additional QALY gained at 30 days (€36,733 at 3 months). The acceptability curve revealed a 64% probability of efficiency at 30 days for video-thoracoscopy, at a widely-accepted willingness-to-pay threshold of €25,000 (34% at 3 months). Ratios increased after multiple imputations, implying a higher cost for video-thoracoscopy for an additional QALY gain (ratios: €26,015 at 30 days, €42,779 at 3 months). Conclusions: Given our results, the economic efficiency of video-thoracoscopy at 30 days remains fragile at a willingness-to-pay threshold of €25,000/QALY. The economic efficiency is not established beyond that time horizon. The acceptability curves given will allow decision-makers to judge the probability of efficiency of this technology at other willingness-to-pay thresholds. Trial registration: NCT02502318. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The aim of this study was to describe the epidemiology of patients undergoing diagnostic and/or curative surgical pulmonary resections for lung opacities suspected of being localized primary lung cancers without preoperative tissue confirmation. METHODS We performed a single-centre retrospective study of a prospectively implemented institutional database of all patients who underwent pulmonary resection between January 2010 and December 2020. Patients were selected when surgery complied with the Fleischner society guidelines. We performed a multivariable logistic regression to determine the preoperative variables associated with malignancy. RESULTS Among 1392 patients, 213 (15.3%) had a final diagnosis of benignancy. We quantified futile parenchymal resections in 29 (2.1%) patients defined by an anatomical resection of >2 lung segments for benign lesions that did not modified the clinical management. Compared with patients with malignancies, patients with benignancies were younger (57.5 vs 63.9 years, P  < 0.001), had lower preoperative risk profile (thoracoscore 0.4 vs 2.1, P  < 0.001), had a higher proportion of wedge resection (50.7% vs 12.2%, P  < 0.01) and experienced a lower burden of postoperative complication (Clavien–Dindo IV or V, 0.4% vs 5.6%, P  < 0.001). Preoperative independent variables associated with malignancy were (adjusted odd ratio [95% confident interval]) age 1.02 [1.00; 1.04], smoking (year-pack) 1.005 (1.00; 1.01), history of cardiovascular disease 2.06 [1.30; 3.30], history of controlled cancer 2.74 [1.30; 6.88] and clinical N involvement 4.20 [1.11; 37.44]. CONCLUSIONS Futile parenchymal lung resection for suspicious opacities without preoperative tissue diagnosis is rare (2.1%) while surgery for benign lesions represented 15.3% and has a satisfactory safety profile with very low postoperative morbi-mortality. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES To compare outcomes at 12 months between video-assisted thoracic surgery (VATS) and open thoracotomy (OT) in patients with non-small-cell lung cancer (NSCLC) using real-world evidence. METHODS We did a nationwide propensity-matched cohort study. We included all patients who had a diagnosis of NSCLC and who benefitted from lobectomy between 1 January 2015 and 31 December 2017. We divided this population into 2 groups (VATS and OT) and matched them using propensity scores based on patients' and hospitals' characteristics. Unplanned readmission, mortality, complications, length of stay and hospitalization costs within 12 months of follow-up were compared between the 2 groups. RESULTS A total of 13 027 patients from 180 hospitals were included, split into 6231 VATS (47.8%) and 6796 OT (52.2%). After propensity score matching (5617 patients in each group), VATS was not associated with a lower risk of unplanned readmission compared with OT [20.7% vs 21.9%, hazard ratio 1.03 (0.95–1.12)] during the 12-months follow-up. Unplanned readmissions at 90 days were mainly due to pulmonary complications (particularly pleural effusion and pneumonia) and were associated with higher mortality at 12 months (13.4% vs 2.7%, P  < 0.0001). CONCLUSIONS VATS and OT were both associated with high incidence of unplanned readmissions within 12 months, requiring a better identification of prognosticators of unplanned readmissions. Our study highlights the need to improve prevention, early diagnosis and treatment of pulmonary complications in patients with VATS and OT after discharge. These findings call for improving the dissemination of systematic perioperative care pathway including efficient pulmonary physiotherapy and rehabilitation. [ABSTRACT FROM AUTHOR]

These results should stimulate an accurate follow-up of patients following a first resection for lung cancer and a systematic meticulous assessment for operability in case of ipsilateral metachronous lung cancer. Keywords: Surgical outcome; Ipsilateral anatomical resection; Non-small-cell lung cancer; Pulmonary lobectomy; Overall survival EN Surgical outcome Ipsilateral anatomical resection Non-small-cell lung cancer Pulmonary lobectomy Overall survival 1 2 2 04/04/23 20230301 NES 230301 The standard of care in operable patients with early-stage lung cancer is surgery, consisting of anatomical parenchymal resection with systematic lymph node dissection. They conducted a multicentre retrospective study of a cohort of 6293 patients from 23 institutes over a 7-year period (2012-2018), identifying 51 patients who underwent ipsilateral redo lung resections for a new primary lung cancer. [Extracted from the article]

OBJECTIVES: Large-cell neuroendocrine carcinoma (LCNC) is a rare tumour characterized by aggressive biological behaviour and poor prognosis. Due to its rarity and the lack of randomized clinical trials, the best treatment is still under debate. Some recent reports indicate that adjuvant chemotherapy (CT) may have a beneficial effect on survival. Our goal was to evaluate this finding using a large series of patients with neuroendocrine tumours obtained from the European Society of Thoracic Surgeons database. METHODS: Data for 400 patients with LCNC operated on in 14 thoracic surgery institutions worldwide between 1992 and 2014 were collected retrospectively. Overall survival was the primary endpoint; we used a multivariable Cox regression model to evaluate which clinical variables may influence patient outcomes; we also focused on the possible prognostic role of adjuvant CT. A propensity score (PS) analysis using the inverse probability of treatment weighting was also carried out. RESULTS: The 3- and 5-year survival rates were 54.1% and 45%, respectively. With the multivariable model, we found that increasing age, Eastern Cooperative Oncology Group Performance Status >2 and advanced TNM stage were indicators of poor prognosis. Weak evidence of a higher overall survival in patients receiving adjuvant CT (adjusted hazard ratio 0.73; 95% confidence interval: 0.56–0.96, P = 0.022) was observed. CONCLUSIONS: A trend towards benefit from adjuvant CT has been observed in patients with LCNC. Although surgical procedures remain the mainstay of curative options, combination with other treatments (e.g. neoadjuvant CT/radiotherapy) should be evaluated by future studies. [ABSTRACT FROM AUTHOR]

OBJECTIVES Nutritional assessment is not included yet as a major recommendation in lung cancer guidelines. The purpose of this study was thus to assess the influence on surgical outcome of the nutritional status of patients with primary lung cancer undergoing lobectomy. METHODS We queried Epithor, the national clinical database of the French Society of Thoracic and Cardiovascular Surgery, and identified a retrospective cohort of 19 635 patients having undergone lobectomy for a primary lung cancer in the years 2005–11. Their nutritional status was categorized according to the WHO definition: underweight (BMI < 18.5): 857 patients (4.4%), normal (18.5 ≤ BMI < 25): 9391 patients (47.8%), overweight (25 ≤ BMI < 30): 6721 patients (34.2%), obese (BMI ≥ 30): 2666 patients (13.6%). Operative mortality, pulmonary, cardiovascular, infectious and surgical complications rates were collected and analysed for these various BMI groups. RESULTS In the normal-weight category, operative mortality, pulmonary, surgical, cardiovascular and infectious complications rates were 2.7, 14.6, 13.8, 5.5 and 4.1%, respectively. When compared with that of normal BMI patients, adjusted operative mortality was significantly lower in overweight (2.3%; odd ratio (OR): 0.72 [95% confidence interval (CI): 0.59–0.89]; P = 0.002) and obese patients (1.9%, OR: 0.54 [95% CI: 0.40–0.74]; P < 0.001), and significantly higher in underweight patients (4.1%, OR: 1.89 [95% CI: 1.30–2.75]; P = 0.001). Underweight patients experienced significantly more pulmonary (21.1%; P < 0.001), surgical (23.2%; P < 0.001) and infectious (5.1%; P = 0.05) complications (P < 0.0001). Among surgical complications, prolonged air leaks (17.6%; P < 0.001) and bronchial stump dehiscence (1.5%; P = 0.001) were significantly more frequent in underweight patients than in normal BMI patients. Obesity was not associated with increased incidence of postoperative complications, except for arrhythmia (5.6%; P < 0.05), deep venous thrombosis and pulmonary embolism (1.5%; P = 0.005). Moreover, a statistical protective effect of obesity was observed regarding surgical complications (7.1%; P < 0.001). CONCLUSIONS Despite having an increased risk of some postoperative cardiovascular complications, obese patients should undergo surgical standard of care therapy for appropriately stage-specific lung cancer. In underweight patients, in addition to preoperative rehabilitation including a nutritional program, attention should be given to aggressive prophylactic respiratory therapy in the perioperative period, and specific intraoperative actions to prevent prolonged air leaks and bronchial stump dehiscence. [ABSTRACT FROM AUTHOR]

Background: Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications. Methods: Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results. Results: In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n = 13, and herpesvirus simplex, n = 1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p = 0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications. Conclusions: When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications. [Copyright &y& Elsevier]

Bronchial sleeve resection is an uncommon thoracic surgical procedure. Under specific conditions, patients can be selected to undergo a sleeve resection of the main bronchus with complete parenchymal preservation. The left main bronchus is longer than the contralateral bronchus, therefore left endobronchial tumours can be localized at the proximal end of the bronchus or distally, near the secondary carina. Bronchial anastomosis in these 2 situations requires different approaches. We present the surgical technique of left main bronchus resection with complete preservation of lung parenchyma through a hemi-clamshell incision (proximal tumour) or posterolateral thoracotomy (distal tumour). [ABSTRACT FROM AUTHOR]

Simple Summary: It is commonly believed that obesity increases the risk of cancers and lowers the possibility of cure of patients with proven cancers. In recent years, this traditional view has been challenged by the hypothesis of an 'obesity paradox', which refers to a better prognosis in obese patients with some specific cancers, compared to normal/underweight patients. In this study, we assessed, in a nationwide dataset, the prognostic role of preoperative BMI on postoperative outcomes in patients undergoing curative lung resection for non-small-cell lung cancer (NSCLC) and found that BMI is a strong and independent predictor of long-term survival. Obesity could have a protective effect in patients with lung cancer. We assessed the prognostic role of preoperative BMI on survival in patients who underwent lung resection for NSCLC. A total of 54,631 consecutive patients with resectable lung cancer within a 15-year period were extracted from Epithor (the French Society of Thoracic and Cardiovascular Surgery database). Patient subgroups were defined according to body mass index (BMI): underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2), and obese (BMI ≥ 30 kg/m2). Underweight was associated with lower survival (unadjusted HRs 1.24 (1.16–1.33)) compared to normal weight, whereas overweight and obesity were associated with improved survival (0.95 (0.92–0.98) and 0.88 (0.84–0.92), respectively). The impact of BMI was confirmed when stratifying for sex or Charlson comorbidities index (CCI). Among patients with obesity, a higher BMI was associated with improved survival. After adjusting for period of study, age, sex, WHO performance status, CCI, side of tumor, extent of resection, histologic type, and stage of disease, the HRs for underweight, overweight, and obesity were 1.51 (1.41–1.63), 0.84 (0.81–0.87), and 0.80 (0.76–0.84), respectively. BMI is a strong and independent predictor of survival in patients undergoing surgery for NSCLC. [ABSTRACT FROM AUTHOR]

• Induction treatment improve survival in lung cancer with chest wall involvement. • Induction therapy improve complete resection of tumor invading the chest wall. • Induction chemoradiotherapy is an overall survival prognostic factor. According to a nation-based study, we intend to report the data of the patients operated on for lung cancer invading the chest wall, taking into consideration the completion of induction chemotherapy (Ind_CT), induction radiochemotherapy (Ind_RCT) or no induction therapy (0_Ind). All patients with a primary lung cancer invading the chest wall who underwent radical resection from 2004 to 2019 were included. Superior sulcus tumors were excluded. Overall, 688 patients were included: 522 operated without induction therapy, 101 with Ind_CT and 65 with Ind_RCT. Postoperative 90-day mortality was 10.7% in the 0_Ind group, 5.0% in the Ind_CT group, 7.7% in the Ind_RCT group (p = 0.17). Incomplete resection rate was 14.0% in the 0_Ind group, 6.9% in the Ind_CT group, 6.2% in the Ind_RCT group (p = 0.04). In the 0_Ind group, 70% of the patients received adjuvant therapies. Overall survival (OS) analysis disclosed the best long-term outcomes in the Ind_RCT group (5-year OS probability: 56.5% versus 40.0% and 40.5% for 0_Ind and Ind_CT groups, respectively; p = 0.035). At multivariable analysis, Ind_RCT (HR = 0.571; p = 0.008), age > 60 years old (HR = 1,373; p = 0.005), male sex (HR = 1.710; p < 0.001), pneumonectomy (HR = 1.368; p = 0.025), pN2 status (HR = 1.981; p < 0.001), ≥3 resected ribs (HR = 1.329; p = 0.019), incomplete resection (HR = 2.284; p < 0.001) and lack of adjuvant therapy (HR = 1.959; p < 0.001) were associated with OS. Ind_CT was not associated with survival (HR = 0.848; p = 0.257). Induction chemoradiation therapy seems to improve survival. Therefore, the present results should be confirmed by a prospective randomized trial testing the benefit of induction radiochemotherapy for NSCLC invading the chest wall. [ABSTRACT FROM AUTHOR]

Background Colorectal cancer (CRC) is the third most diagnosed cancer worldwide, with up to 25% of patients who will develop metastases. Pulmonary metastases (PMs) resection for CRC might improve long-term survival, but the selection criteria for patients who would benefit remain unclear. The aim of this study was to identify preoperative predictive factors in patients eligible for this surgical strategy. Materials and methods We retrospectively reviewed data of patients from five thoracic surgery departments who underwent PM resection for CRC with intent to cure between 2005 and 2010. Univariate and multivariate analyses were performed to identify predictive factors influencing long-term survival and recurrence after pulmonary resection. Results Three hundred fifty-four patients were eligible. Forty-eight patients had pulmonary recurrence (13.5%). Thirty-day postoperative mortality was 0.3% ( n = 1). Five- and 8-y overall survival (OS) were 64.3 ± 3.99% and 60.72 ± 4.5%, respectively. In univariate analysis, 5-y OS was significantly associated with an American Society of Anesthesiologists score of 1 ( P = 0.02), a low number of PM ( P = 0.001), and single wedge resection ( P = 0.00001). In multivariate analysis, an American Society of Anesthesiologists score of 3 or higher ( P = 0.05), two or more PMs ( P = 0.034) and pneumonectomy ( P = 0.021) were significant predictors of a poor outcome. In univariate analysis, 5-y cumulative recurrence was significantly associated with the absence of mediastinal lymph node dissection ( P = 0.01). Conclusions Given its high 5-y OS with low postoperative morbidity, thus allowing repeat surgical management, resection of PM could be performed. Resection of PM could improve long-term survival. [ABSTRACT FROM AUTHOR]

Summary: Lung cancer remains the main leading cancer-related cause of death in the world. For early-stage tumor, surgery stands out as the best curative option offering the greatest chance for cure. Despite improvement of per- and postoperative management, surgery continues to carry a high morbidity with a significant mortality. Among postoperative complications, respiratory failures (nosocomial pneumonia and acute respiratory distress syndrome) are currently the most frequent and serious, as well as being the primary cause of hospital death, after a lung resection for cancer. Because infectious etiologies have been highly incriminated in the development of these pulmonary complications, microbial airways colonizations (AWCs) are supposed to be an essential first step in the pathogenesis of these failures occurring in hospitalized and chronically ill individuals. These patients fulfill all the predisposing factors to bronchial colonizations and are particularly exposed to the development of respiratory failures in the postoperative setting, when secretion clearance and cough reflex are impaired. Under immunosuppressive conditions, AWC should act in a manner that increases its ability to stimulate microorganisms and increase the risks of superimposed infections. Few studies have addressed the problem of AWCs in patients submitted for lung cancer surgery. Because of several limitations, especially the lack of exhaustive microbiological studies, the conclusions that can be reached remain inconclusive. This review aims to report the existing literature on this critical and controversial issue, focusing on their specific incidence, their predisposing factors, their correlation with development of respiratory failures, and, in turn, the reliability of the current antibiotic prophylaxis for their prevention. [Copyright &y& Elsevier]

Abstract: Background: Stump dehiscence after pneumonectomy is a cause of morbidity and mortality in patients treated for non-small-cell lung carcinoma. Surgical repair remains the treatment of choice but can be postponed or contraindicated. Bronchoscopic techniques may be an option with curative intent or as a bridge towards definitive surgery. The aim of the study is to evaluate the efficacy and the outcome of a new customised covered conical self-expandable metallic stent in the management of large bronchopleural fistulas complicating pneumonectomies. Methods: A case series using chart review of non-operable patients presenting with large bronchopleural fistulas (>6mm) post-pneumonectomies as a definitive treatment with curative intent for non-small-cell lung carcinomas and requiring the use of a dedicated conical shaped stent in two tertiary referral centres. Results: Seven patients presenting large post-pneumonectomy fistulas (between 6 and 12mm) were included. Cessation of the air leak and clinical improvement was achieved in all the patients after stent placement. Stent-related complications (two migrations and one stent rupture) were successfully managed using bronchoscopic techniques in two patients and surgery in one. Mortality, mainly related to overwhelming sepsis, was 57%. Delayed definitive surgery was achieved successfully in three patients (43%). Conclusions: This case series assesses the short-term clinical efficacy of a new customised covered conical self-expandable metallic stent in the multidisciplinary management of large bronchopleural fistulas complicating pneumonectomies in patients deemed non-operable. Long-term benefits are jeopardised by infectious complications. [ABSTRACT FROM AUTHOR]