Stéphane Renaud

Surgery is the standard of care for eligible patients with localized or stage IIIA locally advanced non-small cell lung cancer (NSCLC) current guidelines recommend the most conservative surgeries possible. The aim of this study was to bring new real-world data on resected NSCLC epidemiology, management, and survival outcomes in patients with resected non-metastatic NSCLC. This is a descriptive, non-interventional, national, retrospective claims study using data from the French National Hospitalization Database (PMSI) describing the management of patients with non-metastatic NSCLC who underwent a first lung resection (LR) between 2015 and 2019. Patients with LR performed in 2015 were followed from LR until the last registered hospital care or in-hospital death. Five-year disease-free survival (DFS [i.e., time from LR to first recurrence or death]) and overall survival (OS) were assessed. The rate of patients with non-metastatic NSCLC and a first LR between 2015 and 2019 increased by an average of 4.5% per year (8,688 in 2015 vs. 10,330 in 2019). Lobectomy (79.8% vs. 84.9%) and video-assisted thoracoscopic surgery (29.6% vs. 46.4%) became more frequent. Five-year DFS was 33.7% [95%CI 29.8-37.6%] following infralobar resection, 52.3% [51.0-53.5%] after lobectomy, 42.3% [36.9-47.5%] after bilobectomy, and 33.6% [30.0-37.2%] after pneumonectomy. Respective five-year OS from LR were 58.4% [54.1–62.4], 70.2% [69.0-71.3], 59.3% [53.7–64.4], and 46.3% [42.3–50.2]. This study highlights the increasing trend toward conservative and less invasive surgeries in resected NSCLC. Type of LR can be used as an indirect marker of disease expansion, with poorer survival outcomes in case of extensive surgeries.

Background: Systematic lymph node dissection (SLND) is currently the gold standard for lung cancer surgery. However, this is not the case for breast cancer or melanoma, where sentinel lymph node (SLN) identification is routine. The SLN could be a possible surrogate for the pathological status of the other lymph nodes, but there is limited data in the literature for lung cancer surgery. The main objective of this study was to evaluate pathological concordance between the SLN and the complete lymphadenectomy.Methods: In this retrospective study, we reviewed all cases of localized lung cancer that had benefited from our SLN identification protocol and underwent surgery (segmentectomy or lobectomy) between December 2020 and December 2023. We examined the pathological status of the SLN and the rest of the lymph node dissection to assess the pathological concordance rate.Results: After exclusion, 106 patients with localized stage I-IIA non-small cell lung cancer and suspected node negative disease (N0) were included in our study. Of these 106 patients, 96 had a pN0 SLN (90.6%) and 10 had a positive SLN (pN+), resulting in an upstaging rate of 9.4%. All patients with a pN0 SLN were also pN0 for the rest of the lymph node dissection, corresponding to a pathological concordance rate of 100%. Disease-free survival was statistically lower in the pN+ SLN group than in the pN0 SLN group (p<0.0001).Conclusion: We demonstrated a 100% pathological concordance between SLN when it is cancer-free and the rest of the lymph nodes in the lymph node dissection, suggesting that the SLN is a good indicator of the overall pathological status of the other lymph nodes in the thorax.

Management of acute and chronic pain after thoracic surgery for pulmonary resection or thymectomy remains a challenge for both thoracic surgeons and anesthesiologists. Advances in minimally invasive robotic procedures have made subcostal outside-the-cage (OTC) resections possible, but the procedure’s pain benefits have not been previously measured. A single-center cohort was consented to undergo robotic-assisted thoracoscopic surgery (RATS) with an OTC or transthoracic (TT) approach. On every post-operative day (POD), patients were asked to complete the visual analog scale (VAS) of pain, assigning a score of 0–10 with higher scores equaling higher pain intensity. Additionally, patients’ opioid consumption was recorded and classified using morphine equivalent dose (MED). Descriptive statistics of demographics, Mann–Whitney, and Chi-squared tests were performed in a matched analysis. Altogether, 50 OTC patients and 50 TT patients were included. For each group, 1 pneumonectomy, 19 lobectomies, 10 segmentectomies, and 20 thymectomies were performed. Between groups, most were male (n = 54; p = 0.42) and there were no differences in American Society of Anesthesiologists scores (p = 0.51), or tobacco consumption (p = 0.45). Patients who received an OTC approach experienced significantly lower pain scores on POD-0 (p = 0.001), POD-1 (p < 0.001), and POD-2 (p < 0.001). POD-3 OTC VAS scores were not different from those of the TT group (p = 0.09). Similarly, MED was lower for the OTC group on POD-0 (p < 0.001), POD-1 (p = 0.03), and POD-3 (p = 0.03). The RATS-OTC approach results in a more rapid decrease in self-reported pain by the patient as well as significantly lower levels of MED.

Background: The widespread deployment of screening programs has increased the number of suspected pulmonary nodules diagnosed. The main objective of this retrospective study was to evaluate the concordance between needle-based confocal laser endomicroscopy (nCLE) image patterns and pathology reports. Methods: In this retrospective study, we reviewed all cases of endobronchial navigational bronchoscopy (ENB) performed using the nCLE system as a guide for injecting a dye marker or for biopsy of a lung nodule. All surgeries were performed at the Thoracic Surgery Department, University Hospital Nancy, France, between June and October 2023. All navigation procedures were performed under general anesthesia by a senior resident supervised by a senior surgeon, and endobronchial positioning assistance was provided by using the nCLE probe. Results: A total of 30 patients were included in this study. The median size of the suspicious lesions was 16 mm [interquartile range (IQR), 13 mm]. The average time the nCLE system was in contact with the lesion was 5 minutes (IQR, 5 minutes). In 22/30 patients, dark, enlarged pleomorphic cells were visualized, and for one patient, a mix of dark clusters and dark enlarged pleomorphic cells was visualized, leading to a diagnosis of cancer in 22/23 patients (95.6%). For five patients, dark clusters were visualized, resulting in a diagnosis of cancer in 100% of patients. Pathology was performed for 6/30 patients/21 (20%) by endobronchial biopsy and for 24 patients by surgical resection of the suspicious lesion (80%). Conclusions: By retrospectively analyzing the nCLE lung cancer criteria published by Wijmans et al. in 2019, we observed 95.6% and 100% positive diagnoses according to the images visualized during the assistance of positioning. We believe that this type of technology could be used in the future for endobronchial analysis of suspected lesions and eventually for replacing frozen section analysis. However, the diagnostic value of this system needs to be confirmed, particularly for benign lesions.

Background: Mapping of the pulmonary lymphatic system by near-infrared (NIR) fluorescence imaging might not always identify the first lymph node relay. The aim of this study was to determine the clinicopathologic factors allowing the identification of sentinel lymph nodes (SLNs) by NIR fluorescence imaging in thoracic surgery for non-small-cell lung cancer (NSCLC). Methods: We conducted a retrospective review of 92 patients treated for suspected or confirmed cN0 lung cancer with curative intent who underwent an intraoperative injection of indocyanine green (ICG) either by direct peritumoral injection or by endobronchial injection using electromagnetic navigational bronchoscopy (ENB). After exclusion of patients for technical failure, benign disease and metastasis, we analyzed the clinicopathologic findings of 65 patients treated for localized-stage NSCLC, comparing the group with identification of SLNs (SLN-positive group) with the group without identification of SLNs (SLN-negative group). Results: Forty-eight patients (73.8%) were SLN-positive. Patients with SLN positivity were more frequently female (50%) than the SLN-negative patients were (11.8%) (p = 0.006). The mean value of diffusing capacity for carbon monoxide (DLCO) was lower among the patients in the SLN-negative group (64.7% ± 16.7%) than the SLN-positive group (77.6% ± 17.2%, p < 0.01). The ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FCV) was higher in the SLN-positive group (69.0% vs. 60.8%, p = 0.02). Patients who were SLN-negative were characterized by a severe degree of emphysema (p = 0.003). There was no significant difference in pathologic characteristics. On univariate analyses, age, female sex, DLCO, FEV1/FVC, degree of emphysema, and tumor size were significantly associated with SLN detection. On multivariate analysis, DLCO > 75% (HR = 4.92, 95% CI: 1.27–24.7; p = 0.03) and female sex (HR = 5.55, 95% CI: 1.25–39.33; p = 0.04) were independently associated with SLN detection. Conclusions: At a time of resurgence in the use of the sentinel lymph node mapping technique in the field of thoracic surgery, this study enabled us to identify, using multivariate analysis, two predictive factors for success: DLCO > 75% and female sex. Larger datasets are needed to confirm our results.

OBJECTIVES: Although segmentectomy is steadily increasing in early-stage non-small-cell lung cancer, recurrence in the ipsilateral lobe is also increasing. Completion lobectomy (CL) is a challenging procedure that has already been described in a few studies using video-assisted thoracic surgery or thoracotomy. In this study, we aimed to show the feasibility and safety of robot-assisted thoracic surgery in cases of CL. METHODS: Among 2073 major resections performed between January 2018 and september 2022 in the Department of Thoracic Surgery at Nancy University Regional Hospital, we retrospectively included patients who underwent CL by robot-assisted thoracic surgery after previous segmentectomy for non-small-cell lung cancer. Data and perioperative results were described and analysed. RESULTS: Seventeen patients underwent CL with a median recurrence time after previous segmentectomy of 18 months [interquartile range (IQR): 12]. Four patients (23.5%) had a pulmonary artery injury that was controlled, and no conversion to open thoracotomy was needed. The operative time was 150 min (IQR: 20), and blood loss was 300 ml (IQR: 150). The median postoperative chest tube duration was 2 days (IQR: 1), and the length of hospital stay was 3 days (IQR: 3), with no postoperative deaths. CONCLUSIONS: Completion lobectomy is a challenging procedure due to severe adhesions surrounding vessels, which potentially could cause higher rate of PA bleeding than conventional surgeries. With experienced team and surgeons, CL with robotic surgery may be reported as a safe and feasible procedure.

Occult micrometastases can be missed by routine pathological analysis. Mapping of the pulmonary lymphatic system by near-infrared (NIR) fluorescence imaging can identify the first lymph node relay. This sentinel lymph node (SLN) can be analyzed by immunohistochemistry (IHC), which may increase micrometastasis detection and improve staging. This study analyzed the feasibility and safety of identifying SLNs in thoracic surgery by NIR fluorescence imaging in non-small cell lung cancer (NSCLC). This was a prospective, observational, single-center study. Eighty adult patients with suspected localized stage NSCLC (IA1 to IIA) were included between December 2020 and May 2022. All patients received an intraoperative injection of indocyanine green (ICG) directly in the peri tumoural area or by electromagnetic navigational bronchoscopy (ENB). The SLN was then assessed using an infrared fluorescence camera. SLN was identified in 60 patients (75%). Among them, 36 SLNs associated with a primary lung tumor were analyzed by IHC. Four of them were invaded by micrometastases (11.1%). In the case of pN0 SLN, the rest of the lymphadenectomy was cancer free. The identification of SLNs in thoracic surgery by NIR fluorescence imaging seems to be a feasible technique for improving pathological staging.

Renal cell carcinoma (RCC) remains a public health issue and seems to be increasing. A significant proportion of RCC patients will develop pulmonary metastasis at some point in their evolution. In this review, we aimed to update the surgical management of pulmonary metastases as well as systemic therapy, including targeted therapies, according to recent data in the literature. We retrospectively reviewed studies evaluating the benefit of pulmonary metastasectomy in RCC patients and evaluating the place of different chemotherapies, targeted therapies and immunotherapies through November 1, 2019. Several retrospective studies have shown the benefit of pulmonary metastasectomy in metastatic RCC (mRCC), most in a situation with only pulmonary metastases. According to the prognostic criteria of the IMDC risk model, the patient is classified into a prognostic group to identify the best systemic treatment. With the development of targeted therapies, the modalities are multiple and may involve tyrosine kinase inhibitors/checkpoint inhibitors and soon vaccine therapy or CAR-T cells. At the local level, in patients who cannot benefit from surgery, stereotactic radiotherapy or radiofrequency has a place to be considered. Although there is a lack of a randomized study, pulmonary metastasectomy appears to be feasible and effective. The place and modalities of systemic therapies in the era of targeted therapies remain to be more clearly defined.