3D printing in anatomical lung segmentectomies: A randomized pilot trial.

Objective: This pilot study evaluated the impact of using a 3D printed model of the patient's bronchovascular lung anatomy on the mental workload and fatigue of surgeons during full thoracoscopic segmentectomy. Design: We performed a feasibility pilot study of a prospective randomized controlled trial with 2 parallel arms. All included patients underwent digital 3D visual reconstruction of their bronchovascular anatomy and were randomized into the following two groups: Digital arm (only a virtual 3D model was available) and Digital + Object arm (both virtual and printed 3D models were available). The primary end-point was the surgeons' mental workload measured using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) score. Setting: Between October 28, 2020 and October 05, 2021, we successively investigated all anatomic segmentectomies performed via thoracoscopy in the Thoracic Department of the Montsouris Mutualiste Institute, except for S6 segmentectomies and S4+5 left bi-segmentectomies. Participants: We assessed 102 patients for anatomical segmentectomy. Among the, 40 were randomly assigned, and 34 were deemed analysable, with 17 patients included in each arm. Results: Comparison of the two groups, each comprising 17 patients, revealed no statistically significant difference in primary or secondary end-points. The consultation of the visual digital model was significantly less frequent when a 3D printed model was available (6 versus 54 consultations, p = 0.001). Notably, both arms exhibited high NASA-TLX scores, particularly in terms of mental demand, temporal demand, and effort scores. Conclusion: In our pilot study, 3D printed models and digital 3D reconstructions for pre-operative planning had an equivalent effect on thoracoscopic anatomic segmentectomy for experienced surgeons. The originality of this study lies in its focus on the impact of 3D printing of bronchovascular anatomy on surgeons, rather than solely on the surgical procedure.

Real-world outcomes of lobectomy, segmentectomy, and wedge resection for the treatment of stage c-IA lung carcinoma.

OBJECTIVES: To determine safety and survival outcomes associated with lobectomy, segmentectomy, and wedge resection for early-stage lung cancer by quiring the French population-based registry EPITHOR. METHODS: Retrospective analysis of 19,452 patients with stage c IA lung carcinoma who underwent lobectomy, segmentectomy, or wedge resection between 2016 and 2022 with curative-intent. Main outcomes measures were 90-day mortality and 5-year overall survival estimates. Proportional hazards regression and propensity score matching were used to adjust outcomes for key patient, tumour, and practice environment factors. RESULTS: The treatment distribution was 72.2% for lobectomy, 21.5% for segmentectomy, and 6.3% for wedge. Unadjusted 90-day mortality rates were 1.6%, 1.2% and 1.1%, respectively (P = 0.10). Unadjusted 5-year overall survival estimates were 80%, 78% and 70%, with significant inter-group survival curves differences (P < 0.0001). Multivariable proportional hazards regression showed that wedge was associated with worse overall survival (adjusted hazard ratio [AHR], 1.23 [95% CI, 1.03-1.47]; P = 0.021) compared with lobectomy, while no significant difference was disclosed when comparing segmentectomy to lobectomy (1.08 [0.97-1.20]; P = 0.162). The three-way propensity score analyses confirmed similar 90-day mortality rate for wedge resection and segmentectomy compared with lobectomy (HR: 0.43; 95% CI: 0.16-1.11; P = 0.081 and 0.99; 0.48-2.10; P = 0.998, respectively), but poorer overall survival (1.45; 1.13-1.86; P = 0.003 and 1.31; 1-1.71; P = 0.048, respectively). CONCLUSIONS: Wedge resection was associated with comparable 90-day mortality but lower overall survival when compared to lobectomy. Overall, all types of sublobar resections may not offer equivalent oncologic effectiveness in real-world settings.

Impact of surgical approach on 90-day mortality after lung resection for nonsmall cell lung cancer in high-risk operable patients.

Introduction: Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients. Methods: We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients. Results: Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02-0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30-0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively). Conclusion: By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.

Selective control of transposable element expression during T cell exhaustion and anti-PD-1 treatment.

In chronic infections and cancer, T cells are exposed to prolonged antigen stimulation, resulting in loss of function (or exhaustion) and impairment of effective immunological protection. Exhausted T cells are heterogeneous and include early progenitors (Tpex) and terminally exhausted cells (Tex). Here, we used bulk and single-cell transcriptomics to analyze expression of transposable elements (TEs) in subpopulations of mouse and human CD8+ tumor-infiltrating T lymphocytes (TILs). We show that in mice, members of the virus-like murine VL30 TE family (mostly intact, evolutionary young ERV1s) are strongly repressed in terminally exhausted CD8+ T cells in both tumor and viral models of exhaustion. Tpex expression of these VL30s, which are mainly intergenic and transcribed independently of their closest gene neighbors, was driven by Fli1, a transcription factor involved in progression from Tpex to Tex. Immune checkpoint blockade (ICB) in both mice and patients with cancer increased TE expression (including VL30 in mice), demonstrating that TEs may be applicable as ICB response biomarkers. We conclude that expression of TEs is tightly regulated in TILs during establishment of exhaustion and reprogramming by ICB. Analyses of TE expression on single cells and bulk populations open opportunities for understanding immune cell identity and heterogeneity, as well as for defining cellular gene expression signatures and disease biomarkers.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. METHODS: Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected. RESULTS: A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. CONCLUSION: These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Venous concerns after lingula sparing left upper lobectomy.

Postoperative ischaemia of the lingula is a complication of left upper lobe trisegmentectomy, usually attributed to a twist of the remaining lingula. It can also be related to other factors such as venous interruption. We report 3 cases of reoperation after lingula-sparing left upper lobectomy for suspected ischaemia. None were related to torsion. Accidental injury of the lingular venous drainage or abnormal venous pattern can be the leading cause of these ischaemia.

Upstaged from cT1a-c to pT2a lung cancer, related to visceral pleural invasion patients, after segmentectomy: is it an indication to complete resection to lobectomy?

OBJECTIVES: Segmentectomy may be indicated for T1a-cN0 non-small-cell lung cancer. However, several patients are upstaged pT2a at final pathological examination due to visceral pleural invasion (VPI). As resection is usually not completed to lobectomy, this may raise issue of potential worse prognosis. The aim of this study is to compare prognosis of VPI upstaged cT1N0 patients operated on by segmentectomy or lobectomy. METHODS: Data of patients from 3 centres were analysed. This was a retrospective study, of patients operated on from April 2007 to December 2019. Survival and recurrence were assessed by Kaplan-Meier method and cox regression analysis. RESULTS: Lobectomy and segmentectomy were performed in 191 (75.4%) and in 62 (24.5%) patients, respectively. No difference in 5-year disease-free survival rate between lobectomy (70%) and segmentectomy (64.7%) was observed. There was no difference in loco-regional recurrence, nor in ipsilateral pleural recurrence. The distant recurrence rate was higher (P = 0.027) in the segmentectomy group. Five-year overall survival rate was similar for both lobectomy (73%) and segmentectomy (75.8%) groups. After propensity score matching, there was no difference in 5-year disease-free survival rate (P = 0.27) between lobectomy (85%) and segmentectomy (66.9%), and in 5-year overall survival rate (P = 0.42) between the 2 groups (lobectomy 76.3% vs segmentectomy 80.1%). Segmentectomy was not impacting neither recurrence, nor survival. CONCLUSIONS: Detection of VPI (pT2a upstage) in patients who underwent segmentectomy for cT1a-c non-small-cell lung cancer does not seem to be an indication to extend resection to lobectomy.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected. A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV).

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. METHODS: Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected. RESULTS: A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. CONCLUSION: These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Anatomic lung resection after immune checkpoint inhibitors for initially unresectable advanced-staged non-small cell lung cancer: a retrospective cohort analysis.

Background: Patients with initially unresectable advanced non-small cell lung cancer (NSCLC) might experience prolonged responses under immune checkpoint inhibitors (ICIs). In this setting, Multidisciplinary Tumor Board (MTB) seldomly suggest surgical resection of the primary tumor with the ultimate goal to eradicate macroscopic residual disease. Our objective was to report the perioperative outcomes of patients who underwent anatomic lung resection in these infrequent circumstances. Methods: We set a retrospective multicentric single arm study, including all patients with advanced-staged initially unresectable NSCLC (stage IIIB to IVB) who received systemic therapy including ICIs and eventually anatomical resection of the primary tumor in 10 French thoracic surgery units from January 2016 to December 2020. Coprimary endpoints were in-hospital mortality and morbidity. Secondary endpoints were the rate of complete resection of the pulmonary disease, major pathologic response, risk factors associated with post-operative complications, and overall survival. Results: Twenty-one patients (median age 64, female 62%) were included. Eighteen patients (86%) progressed after first line chemotherapy and received second line ICI. The median time between diagnosis and surgery was 22 months [interquartile range (IQR) 18-35 months]. Minimally-invasive approach was used in 10 cases (48%), with half of these requiring conversion to open thoracotomy. Nine patients (43%) presented early post-operative complications, and one patient died from broncho-pleural fistula one month after surgery. Rates of complete resection of the pulmonary disease and major pathologic response were 100% and 43%, respectively. In univariable analysis, diffusing capacity for carbon monoxide (DLCO) was the only factor associated with the occurrence of postoperative complications (P=0.027). After a median follow-up of 16.0 months after surgery (IQR, 12.0-30.0 months), 19 patients (90%) were still alive. Conclusions: Anatomic lung resections appear to be a reasonable option for initially unresectable advanced NSCLC experiencing prolonged response under ICIs. Nonetheless, minimally invasive techniques have a low applicability and post-operative complications remains higher in patients who had lower DLCO values. The late timing of surgery may also contribute to complications.

Noncanonical splicing junctions between exons and transposable elements represent a source of immunogenic recurrent neo-antigens in patients with lung cancer.

Although most characterized tumor antigens are encoded by canonical transcripts (such as differentiation or tumor-testis antigens) or mutations (both driver and passenger mutations), recent results have shown that noncanonical transcripts including long noncoding RNAs and transposable elements (TEs) can also encode tumor-specific neo-antigens. Here, we investigate the presentation and immunogenicity of tumor antigens derived from noncanonical mRNA splicing events between coding exons and TEs. Comparing human non-small cell lung cancer (NSCLC) and diverse healthy tissues, we identified a subset of splicing junctions that is both tumor specific and shared across patients. We used HLA-I peptidomics to identify peptides encoded by tumor-specific junctions in primary NSCLC samples and lung tumor cell lines. Recurrent junction-encoded peptides were immunogenic in vitro, and CD8+ T cells specific for junction-encoded epitopes were present in tumors and tumor-draining lymph nodes from patients with NSCLC. We conclude that noncanonical splicing junctions between exons and TEs represent a source of recurrent, immunogenic tumor-specific antigens in patients with NSCLC.

The disappearing hook wire: a case report.

Background: The migration of hook wire used for lung nodule localization to the pulmonary artery is an extremely rare complication. We report a case of migration of hook wire used for lung nodule localization to the main pulmonary artery and discuss the management. Case Description: The patient was a 50-year-old female with multiple pulmonary nodules, the largest of which was 7 mm and located in right lower lob. Since the size of the nodules were very small, three computed tomography (CT)-guided percutaneous hook wires were placed to localize the nodules prior to surgery. After entering the thorax, the wires were unable to be located in the right lower lobe and an intraoperative urgent chest CT demonstrated that the markers had migrated to the pulmonary artery. Therefore, the original surgical incision was extended and the superior tip subsegment of the pulmonary artery of the right lung was dissected open and the positioning needle was successfully removed. The patient was recovered without further complication and discharged 5 days later. Conclusions: When the exact location of a hook wire utilized for lung nodule localization cannot be determined, an exhaustive radiographic evaluation is required to determine the wire's specific location. If conditions permit, it is best to remove the hook wire directly using video-assisted thoracoscopic surgery (VATS). With careful perioperative assessment, surgeons can avoid additional complications and further surgery if they encounter a migrated nodule localization wire.

Thoracic surgery in France.

Until recently, thoracic surgery in France was associated with vascular or cardiac surgery. It is now increasingly performed as a specific activity. Training of a thoracic surgeon has a common part with cardiovascular surgery during a 6-year curriculum including theory and practical practice acquired both by simulation and clinical fellowship. There are 343 board-certified surgeons performing thoracic surgery in 147 authorized centers. To be authorized to perform thoracic surgery, these centers must have at least 2 qualified surgeons and perform a minimum of 40 procedures per year for thoracic cancer. The discussion of the cases in a multidisciplinary tumor board (MDTB), validated by a written conclusion, is also mandatory and is a prerequisite for operating on patient for any cancer. All thoracic surgery procedures are recorded in a national database, Epithor. This database gives a precise idea not only of the activity but also of operative data, morbidity, mortality and follow-up. In 2023, participation to Epithor database will be a prerequisite for the certification of thoracic surgeons. Major changes in diagnostic and therapeutic options, development and innovations in video-assisted and robotically-assisted surgery, forthcoming transbronchial approaches will more likely lead to reorganize thoracic surgery with specialized and expert multidisciplinary boards as well as a concentration in high volume centers.

Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety.

OBJECTIVES: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported. METHODS: All voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for 'in-depth analysis'. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad. RESULTS: Of the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%). CONCLUSIONS: The majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them.

Full subcostal subxiphoid robotic-assisted radical thymectomy: preclinical cadaveric study for optimizing patient positioning, table settings, and port configuration.

Robotic subxiphoid transthoracic thymectomy showed several surgical advantages. Nevertheless, the intercostal insertion of trocars may lead to nerve injury with enhanced post-operative pain. Moreover, the dissection of peri-diaphragmatic mediastinal fat may result challenging, in particular on left side, where the presence of the heart precludes the optimal visualization. We describe a preclinical cadaveric study of a novel full subcostal robotic-assisted technique to overcome these limitations. A total subcostal robotic-assisted radical thymectomy was evaluated on a cadaver model using the da Vinci Xi system. The exploratory procedure was divided in two steps: (a) dissection of the thymus gland, except the left mediastinal epi-diaphragmatic fat pad; (b) dissection of the left diaphragmatic mediastinal fat pad avoiding heart compression while perfectly visualizing the left phrenic nerve. Five different setups were explored based on camera and trocars insertions, patient's positioning and table's settings. Both the tasks were accomplished using the novel technique. The subxiphoid insertion of the camera and the position of two robotic arms about 8 cm distally on the subcostal made the most part of mediastinal dissection straightforward. Left peri-diaphragmatic fat pad can be better visualized and dissected positioning the camera in the left subcostal port shifting the instruments on the right side. This may permit a better control of the left phrenic nerve reducing heart compression. Full subcostal robotic-assisted thymectomy resulted feasible in cadaveric model. Clinical trial should be performed to confirm the translational use of this novel technique and the speculated advantages in living model.