Learning Curve of Robotic Lobectomy for the Treatment of Lung Cancer: How Does It Impact on the Autonomic Nervous System of the Surgeon?

OBJECTIVE: Our purpose is to define the learning curve for robot-assisted thoracoscopic surgery lobectomy by reporting the experience of a single surgeon. MATERIAL AND METHODS: We progressively collected the data concerning the surgical performance of a single male thoracic surgeon, from the beginning of his robotic activity as first operator from January 2021 to June 2022. We evaluated several pre-, intra- and postoperative parameters concerning patients and intraoperative cardiovascular and respiratory outcomes of the surgeon, recorded during surgical interventions, in order to evaluate his cardiovascular stress. We used cumulative sum control charts (CUSUM) to analyze the learning curve. RESULTS: A total of 72 lung lobectomies were performed by a single surgeon in this period. Analyzing the CUSUM of several parameters, the inflection point identifying the transition beyond the surgeon learning phase was reached at cases 28, 22, 27 and 33 when considering operating time, mean heart rate, max heart rate and mean respiratory rate, respectively. CONCLUSIONS: The learning curve for robotic lobectomy seems to be safe and feasible with a correct robotic training program. The analysis of a single surgeon from the beginning of his robotic activity demonstrates that confidence, competence, dexterity and security are achieved after about 20-30 procedures, without compromising efficiency and oncological radicality.

Prospective evaluation of EBUS-TBNA specimens for programmed death-ligand 1 expression in non-small cell lung cancer patients: a pilot study.

OBJECTIVE: EBUS-TBNA cytological sampling is routinely performed for pathological diagnosis, mediastinal staging, and molecular testing in lung cancer patients. EBUS-TBNA samples are not formally accepted for testing programmed death-ligand 1 (PD-L1) expression. The objective of the study was to compare the feasibility, reproducibility, and accuracy of PD-L1 expression assessment in cytological specimens and histological samples. METHODS: We prospectively collected histological (transbronchial forceps biopsy) and cytological (EBUS-TBNA) samples from peribronchial neoplastic lesions during an endoscopic procedure at the same target lesion for the pathological diagnosis and molecular assessment of stage IV non-small cell lung cancer (NSCLC). RESULTS: Fifteen patients underwent the procedure. Adequate cytological samples (at least 100 neoplastic cells) were obtained in 12 cases (92.3%). Assessment of PD-L1 expression was similar between histological and cytological samples (agreement rate = 92%). Sensitivity and diagnostic accuracy of EBUS-TBNA cytological specimens were 88.9% and 100%, respectively. CONCLUSIONS: The evaluation of PD-L1 expression in EBUS-TBNA cytological specimens is feasible and presents good reproducibility when compared with routine histological samples. EBUS-TBNA cytological samples could be used for the assessment of PD-L1 expression in patients with NSCLC as a minimally invasive approach in stage IV NSCLC cancer patients.

Prospective evaluation of EBUS-TBNA specimens for programmed death-ligand 1 expression in non-small cell lung cancer patients: a pilot study / Avaliação prospectiva de espécimes obtidos por meio de EBUS-TBNA quanto à expressão de programmed death-ligand 1 em pacientes com câncer pulmonar de células não pequenas: um estudo piloto

ABSTRACT Objective: EBUS-TBNA cytological sampling is routinely performed for pathological diagnosis, mediastinal staging, and molecular testing in lung cancer patients. EBUS-TBNA samples are not formally accepted for testing programmed death-ligand 1 (PD-L1) expression. The objective of the study was to compare the feasibility, reproducibility, and accuracy of PD-L1 expression assessment in cytological specimens and histological samples. Methods: We prospectively collected histological (transbronchial forceps biopsy) and cytological (EBUS-TBNA) samples from peribronchial neoplastic lesions during an endoscopic procedure at the same target lesion for the pathological diagnosis and molecular assessment of stage IV non-small cell lung cancer (NSCLC). Results: Fifteen patients underwent the procedure. Adequate cytological samples (at least 100 neoplastic cells) were obtained in 12 cases (92.3%). Assessment of PD-L1 expression was similar between histological and cytological samples (agreement rate = 92%). Sensitivity and diagnostic accuracy of EBUS-TBNA cytological specimens were 88.9% and 100%, respectively. Conclusions: The evaluation of PD-L1 expression in EBUS-TBNA cytological specimens is feasible and presents good reproducibility when compared with routine histological samples. EBUS-TBNA cytological samples could be used for the assessment of PD-L1 expression in patients with NSCLC as a minimally invasive approach in stage IV NSCLC cancer patients.

RESUMO Objetivo: A amostragem citológica por meio de EBUS-TBNA é realizada rotineiramente para diagnóstico anatomopatológico, estadiamento mediastinal e teste molecular em pacientes com câncer de pulmão. As amostras obtidas por meio de EBUS-TBNA não são formalmente aceitas para testar a expressão da proteína programmed death-ligand 1 (PD-L1, ligante de morte celular programada 1). O objetivo do estudo foi comparar a viabilidade, reprodutibilidade e precisão da avaliação da expressão de PD-L1 em espécimes citológicos e amostras histológicas. Métodos: Foram coletadas prospectivamente amostras histológicas (obtidas por meio de biópsia transbrônquica com pinça) e citológicas (obtidas por meio de EBUS-TBNA) de lesões neoplásicas peribrônquicas durante um procedimento endoscópico na mesma lesão-alvo para o diagnóstico anatomopatológico e avaliação molecular de câncer pulmonar de células não pequenas (CPCNP) em estágio IV. Resultados: Quinze pacientes foram submetidos ao procedimento. Amostras citológicas adequadas (pelo menos 100 células neoplásicas) foram obtidas em 12 casos (92,3%). A expressão de PD-L1 nas amostras histológicas e citológicas foi semelhante (taxa de concordância = 92%). A sensibilidade e precisão diagnóstica das amostras citológicas obtidas por meio de EBUS-TBNA foram de 88,9% e 100%, respectivamente. Conclusões: A avaliação da expressão de PD-L1 em espécimes citológicos obtidos por meio de EBUS-TBNA é viável e apresenta boa reprodutibilidade quando comparada com amostras histológicas rotineiras. Amostras citológicas obtidas por meio de EBUS-TBNA podem ser usadas para avaliar a expressão de PD-L1 como uma abordagem minimamente invasiva em pacientes com CPCNP em estágio IV.

Platypnea-orthodeoxia syndrome after pulmonary wedge resection in a patient with severe scoliosis.

Platypnea-orthodeoxia is a rare syndrome characterized by dyspnoea and arterial desaturation, exacerbated by an upright position and relieved when the subject is recumbent. We report on a unique case of a patient with severe scoliosis who presented with several episodes of arterial desaturation after right pulmonary wedge resection.

When Less Is More: EBUS-TBNA for the Diagnosis of Pleural Lesions.

The investigation of pleural lesions is challenging. Thoracoscopic pleural biopsies are often the chosen approach for diagnosis and, in case of malignancy, for disease staging and palliation pleurodesis. Minimally invasive techniques represent a valid option in patients that cannot undergo surgery, minimizing the risks related to more aggressive procedures. Here we report the case of a 63-year-old man with computed tomography evidence of paratracheal pleural thickening that was successfully sampled with endobronchial ultrasound-guided transbronchial needle aspiration. This technique should be considered for the diagnosis of pleural lesions adjacent to the main airway; it represents a safer, better tolerated, and less invasive alternative to operation.

Diagnostic and Therapeutic Implications of Pulmonary Lymphoma Associated With Nodular Amyloidosis.

Pulmonary localization of B-cell lymphoma associated with deposits of amyloid material is a rare finding in the thoracic disease spectrum. This report describes a rare case of nodular pulmonary amyloidosis in a 50-year-old patient. He underwent left upper lobectomy for mucosa-associated lymphoid tissue lymphoma that originated from bronchial lymphoid tissue.

A 10-year single-center experience on 708 lung metastasectomies: the evidence of the "international registry of lung metastases".

INTRODUCTION: The International Registry of Lung Metastases defined a new staging system based on identified prognostic factors for long-term survival after metastasectomy. The aim of our study was to confirm the validity of the International Registry of Lung Metastases classification system in patients who underwent curative lung metastasectomy in a single center. METHODS: We retrospectively reviewed 575 patients who underwent 708 lung metastasectomies from January 1998 to October 2008. Complete curative pulmonary resections were performed in 490 cases (85%). Three hundred seventy-two patients developed lung metastases from epithelial tumors, 80 from sarcomas, 27 from melanomas, and 11 from germ cell tumors. The mean disease-free interval (DFI) was 46.6 months. Open surgical resection was performed in 479 patients. One hundred eighty-five patients had a single-lung metastasis. Lymph node dissection was performed in 353 cases. RESULTS: After a mean follow-up of 34 months, 247 patients (43%) had died. Multivariate analysis disclosed that completeness of resection (p < 0.0001), patients with germ cell tumors (p = 0.04), and DFI ≥36 months (p = 0.01) were also associated with a better prognosis. The actuarial survival after complete metastasectomy was 74% at 2 years and 46% at 5 years. CONCLUSIONS: We confirmed completeness of surgery, histology, and DFI ≥36 months as independent prognostic factors. Number of metastases, presence of lymph node metastases, surgical approach, and number of metastasectomies did not statistically influence long-term survival.