Michel Gonzalez

Objectives: We evaluated oncological outcomes of anatomical segmentectomy vs. lobectomy in patients with non-small cell lung cancer (NSCLC) ≤ 3 cm with visceral pleural invasion (VPI). Methods: We retrospectively analyzed consecutive patients undergoing anatomical pulmonary resection with systematic mediastinal lymph node dissection for pT2aN0M0 (stage IB) NSCLC with VPI between January 2014 and December 2023 at a single center. To account for baseline differences in treatment allocation, propensity-score overlap weighting was performed, and weighted Cox proportional-hazards models were used to compare overall survival (OS) and recurrence-free survival (RFS). Results: Ninety-two patients (male 48, female 44; median age: 70 years, IQR: 62–77) underwent anatomical resection (lobectomy n = 48; segmentectomy n = 44) for NSCLC stage IB with VPI. VATS was performed in 94.6% of cases. Segmentectomy group had more comorbidities and poorer pre-operative pulmonary function. Complete resection was achieved in all patients. After overlap weighting, baseline characteristics included in the propensity model were well balanced. No statistically significant difference was observed between segmentectomy and lobectomy for OS (HR 0.89, 95% CI 0.33–2.39; p = 0.809) or RFS (HR 0.85 (0.0.36–1.98), p = 0.701). Three-year overlap-weighted OS was 75.3% after segmentectomy and 72.2% after lobectomy; corresponding RFS estimates were 63.8% and 57.9%, respectively. Perioperative outcomes were broadly similar after weighting, although prolonged air leak was less frequent after segmentectomy. Conclusions: After adjustment for measured baseline differences, segmentectomy was not associated with a statistically significant difference in intermediate-term OS or RFS compared with lobectomy in this selected VPI-positive cohort. These findings support further evaluation of segmentectomy in carefully selected VPI-positive patients.

Background: Adequate lymph node evaluation is central to oncologic segmentectomy for early-stage non-small cell lung cancer (NSCLC), yet the quantitative relationship between lymph node yield and survival remains unclear. This study aimed to evaluate the association between regional lymph node yield and overall survival after segmentectomy for early-stage NSCLC. Methods: Using Surveillance, Epidemiology, and End Results (SEER) (2000–2022), we identified patients with NSCLC undergoing anatomical segmentectomy and clinical N0M0 disease with tumors ≤30 mm. Regional lymph node yield (“regional nodes examined”) was analyzed as 0, 1–5, 6–10, and >10 nodes, and continuously using restricted cubic splines. Overall survival (OS) was evaluated with Kaplan-Meier and multivariable Cox regression. Lung cancer-specific death was assessed using Fine-Gray competing-risk models. Results: A total of 2,217 patients met inclusion criteria (median follow-up 58 months), with 783 deaths during follow-up. OS differed significantly across lymph node yield groups (log-rank P10 nodes. In multivariable Cox models, higher yields were independently associated with lower all-cause mortality: 1–5 nodes, hazard ratio (HR) =0.79 [95% confidence interval (CI): 0.67–0.94]; 6–10 nodes, HR =0.55 (95% CI: 0.44–0.70), and >10 nodes, HR =0.40 (95% CI: 0.30–0.52) (all P≤0.006; P for trend vs. ≥70 years) and tumor size strata (T1a–c), without significant interaction. Conclusions: In SEER patients undergoing anatomical segmentectomy for clinical N0M0 NSCLC ≤30 mm, higher regional lymph node yield demonstrated a dose-response association with higher OS and lower lung cancer–specific mortality. These findings support lymph node yield as a pragmatic marker of nodal evaluation during segmentectomy.

Sublobar anatomical resections are increasingly adopted for management of early-stage non-small cell lung cancer (NSCLC), particularly for peripheral tumors ≤2 cm, to maximize parenchymal preservation while maintaining oncologic outcomes comparable to lobectomy. This type of resection is also used for pulmonary metastasectomies or for the treatment of non-malignant lung lesions. This video demonstrates a uniportal video-assisted thoracoscopic surgery (UVATS) technique for anatomical resection of the superior lingular segment (S4), addressing unique anatomical and technical challenges inherent to this procedure. The superior lingular segment (S4) is characterized by deeply situated and variable segmental broncho-vascular structures that demand meticulous hilar dissection and precise identification prior to division. Key technical elements include optimized patient positioning and single-port access, systematic exposure of the hilum, careful isolation and controlled division of the targeted arterial branches and lingular bronchus using vascular staplers or energy devices, and parenchymal division guided by clear intersegmental plane identification. Adjunctive strategies such as selective bronchoscopic inflation/deflation, intravenous indocyanine green (ICG) fluorescence imaging, and use of anatomical landmarks are integrated to accurately delineate the intersegmental plane and to minimize margin compromise. Special attention is given to techniques for handling deeply located vessels to prevent hemorrhage, measures to reduce postoperative air leak, and methods for secure staple-line management to preserve adjacent lung. The uniportal approach offers a minimally invasive, reproducible method for anatomically precise isolated S4 segmentectomy, facilitating parenchymal sparing without sacrificing oncologic principles. Knowledge of segmental anatomy, familiarity with segmental identification tools, and adherence to defined technical steps are essential to safely perform this lung-sparing resection in appropriately selected patients.

The incision matters: survival evidence finally catches up with video-assisted thoracoscopic surgery

Supplementary Figure S5: Impact of HITOC on tumor-infiltrating T cells.

Supplementary Figure S6: Effect of HITOC on PD-1 and CTLA-4 expression by CD4 T cells.

Supplementary Figure S1: Evaluation of the impact of heat adjunct on cisplatin cytotoxicity.

Supplementary Figure S2: Flow cytometry gating.

Supplementary Figure S4: Effect of HITOC on CD4 T cell infiltration in tumors.

Supplementary Table S2: List of antibodies used in the study