Giovanni Caffarena

Background: The integration of neoadjuvant and perioperative chemo-immunotherapy (CT-IO) has significantly reshaped the treatment of resectable non-small-cell lung cancer (NSCLC), improving pathological response and survival outcomes. However, its impact on surgical management—particularly robotic-assisted thoracic surgery (RATS)—remains incompletely defined. This review provides a practical overview of current evidence and technical considerations for robotic lung resection following neoadjuvant chemo-immunotherapy. Methods: A narrative review of the literature was performed, focusing on phase III trials, meta-analyses, and surgical series reporting perioperative, oncological, and technical outcomes of minimally invasive—especially robotic—approaches after neoadjuvant or perioperative chemo-immunotherapy. Results: Randomized trials have established CT-IO as a standard treatment option for selected patients with resectable stage II–III NSCLC—although the specific standard varies according to stage, molecular and PD-L1 status, and regulatory approval—significantly improving pathological complete response and event-free survival. However, immune-related fibrosis, nodal scarring, and altered tissue planes increase surgical complexity and intra-postoperative complications. Available evidence, largely retrospective and derived from selected patient populations treated at experienced centers, suggest that RATS is feasible and safe, offering enhanced visualization and dexterity that may facilitate dissection in challenging post-induction settings. Vascular management and lymph node dissection remain critical technical aspects, and early conversion to open surgery, when required, should be regarded as an appropriate safety strategy rather than a complication. Conclusions: RATS after neoadjuvant chemo-immunotherapy appears feasible and promising in selected patients treated at experienced centers, but current evidence does not yet establish it as the preferred approach for all patients. Careful patient selection, adherence to oncological principles, and surgeon experience are essential. Prospective data are needed to define optimal surgical timing and standardize techniques.

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Introduction: Malignant pericardial effusion (MPE) represents a relatively rare complication in various types of solid tumors. Its management is often challenging. One solution can be represented by surgical approaches, including a pericardio-peritoneal window (PPW), which allows draining the fluid into the abdominal cavity. The aim of this study is to investigate the efficacy and long-term outcomes of the PPW procedure as a definitive therapeutic strategy for MPE. Materials and methods: We retrospectively and prospectively observed pre-, peri-, and postoperative data of patients undergoing pericardio-peritoneal window creation from 2010 to December 2023 at the European Institute of Oncology (IEO), including the surgical procedures needed, total and specific postoperative complications, 30-day mortality rate, relapse rate, and the treatment of possible relapses. Results: A total of 44 consecutive patients underwent a pericardio-peritoneal window. In 28 patients (63.8%) PPW was associated with mono or bilateral videothoracoscopy for pleural biopsies/talc poudrage. In 23 cases, pre-operative percutaneous pericardial drainage (usually 1–2 days before surgery) was performed. No intraoperative deaths were observed. The 30-day mortality was 9% (four patients). We observed pericardial effusion recurrence in three patients at two months and in five patients at six months. In only two cases we treated this condition because of a pre-tamponade condition, treated by percutaneous pericardial drainage. The success rate of the PPW regarding pericardial relapse requiring further procedures was 95.5%. Conclusions: Patients presenting with a favorable short-term prognosis benefit from the pericardio-peritoneal window as a safe and effective method for resolving malignant pericardial effusion. Conversely, pericardial drainage is recommended as the most appropriate therapy for those with a less favorable prognosis.

Objectives: Robotic-assisted segmentectomy (RAS) has proven to be safe and feasible for early-stage lung cancer; nonetheless, its oncologic efficacy and long-term outcomes are still debated. We aimed to explore whether RAS could be an alternative to robotic-assisted lobectomy (RAL) in early-stage NSCLC, focusing on long-term outcomes such as 10-year cancer-specific survival (CSS), cumulative rate of relapse (RR), and local recurrence (LR). Methods: Patients undergoing RAS for early-stage NSCLC (clinical stage I) were analyzed from August 2007 to August 2023. A 1:3 propensity score-matched analysis was performed among patients undergoing RAL, based on demographic characteristics and pathological stage. Primary endpoints were CSS, RR, and LR. Results: A total of 40 patients undergoing RAS were retrospectively enrolled. After matching 120 patients undergoing RAL, no significant differences were found in postoperative complications, median operative time, or length of hospital stay. Patients undergoing RAS had comparable 10-year CSS (p = 0.90) and RR (p = 0.99) to those undergoing RAL, whereas 10-year of cumulative incidence of local recurrence (LR) was 11.0% (95% CI: 3.4–23.7%) for RAS patients and 2.8% (95% CI: 0.5–8.9%) for RAL patients (p = 0.08). Additionally, RAL provided a significantly higher number of N1 and N2 lymph node retrievals (p < 0.0001 and 0.06, respectively), as well as a higher number of N2 stations (p = 0.0001). Conclusions: Based on our experiences, even though RAS can ensure excellent long-term outcomes in selected cases of early-stage NSCLC, comparable to RAL, the local recurrence rate was higher in the RAS group.

Objectives: Robotic-assisted segmentectomy (RAS) has proven to be safe and feasible for early-stage lung cancer; nonetheless, its oncologic efficacy and long-term outcomes are still debated. We aimed to explore whether RAS could be an alternative to robot-ic-assisted lobectomy (RAL) in early-stage NSCLC, focusing on long-term outcomes such as 10-year cancer-specific survival (CSS), cumulative rate of relapse (RR), and local recurrence (LR). Methods: Patients undergoing RAS for early-stage NSCLC (clinical stage I) were ana-lyzed from August 2007 to August 2023. A 1:3 propensity score-matched analysis was performed among patients undergoing RAL, based on demographic characteristics and pathological stage. Primary endpoints were CSS, RR, and LR. Results: A total of 40 patients undergoing RAS were retrospectively enrolled. After matching 120 patients undergoing RAL, no significant differences were found in post-operative complications, median operative time, or length of hospital stay. Patients undergoing RAS had comparable 10-year CSS (p=0.90) and RR (p=0.99) to those un-dergoing RAL, whereas 10-year of cumulative incidence of local recurrence (LR) was 11.0% (95% CI: 3.4% – 23.7%) for RAS patients, and 2.8% (95% CI: 0.5% – 8.9%) for RAL patients (p = 0.08). Additionally, RAL provided a significantly higher number of N1 and N2 lymph node retrievals (p < 0.0001 and 0.06, respectively), as well as a high-er number of N2 stations (p = 0.0001). Conclusion: Based on our experiences, even though RAS can ensure excellent long-term outcomes in selected cases of early-stage NSCLC, comparable to RAL, the local recurrence rate was higher in the RAS group.

This study aims to determine whether maximal oxygen consumption (VO2max) or predicted postoperative (ppo)-VO2max could still reliably predict postoperative complications and deaths in lung cancer patients undergoing pneumonectomy and which values could be more reliably considered as the optimal threshold. Methods: We retrospectively collected data of consecutive patients undergoing pneumonectomy for primary lung cancer at the European Oncological Institute (April 2019–April 2023). Routine preoperative assessment included cardiopulmonary exercise testing (CPET) and a lung perfusion scan. We evaluated the morbidity and mortality rates; associations between morbidity, mortality, VO2max, and ppoVO2max values were investigated through ANOVA or Fisher’s exact test as appropriate. Receiver operating characteristic (ROC) curves were applied to further explore the relation between VO2max, ppoVO2max values, and 90-day mortality. Results: The cardiopulmonary morbidity rate was 32.2%; the 30-day and 90-day mortality rates were 2.2% and 6.7%. The PpoVO2max values were significantly lower in patients experiencing cardiopulmonary complications or deaths compared to the whole cohort, whereas VO2max, though showing a trend towards lower values, did not reach statistical significance. A VO2max value threshold of 15 mL/kg/min correlated significantly with 90-day mortality, while a ppoVO2max cut-off of 10 mL/kg/min was significantly associated with cardiopulmonary complications and 30-day and 90-day mortality rates. ROC curve analysis revealed ppoVO2max as a better predictor of 90-day mortality compared to VO2max. Conclusions: CPET and a lung perfusion scan are two key elements for the preoperative evaluation of patients undergoing pneumonectomy, since it provides a holistic assessment of cardiopulmonary functionality. We recommend the routine calculation of ppoVO2max, particularly when adopting a 10 mL/kg/min threshold.

Background: Postoperative physiotherapy is a cornerstone of Enhanced Recovery After Surgery (ERAS) programs, especially following lung resection. Despite its importance, the literature lacks clear recommendations and guidelines, particularly regarding the role of incentive spirometry (IS). This study aims to determine whether incentive spirometry offers additional benefits over early ambulation alone in patients undergoing lung resection for primary lung cancer. Methods: We conducted a retrospective case–control study at the European Institute of Oncology (IEO) involving patients who underwent lung resection from June 2020 to June 2022. Patients were divided into two cohorts: early ambulation alone (control group) and early ambulation with IS (IS group). The primary endpoint was the rate of postoperative pulmonary complications. Secondary endpoints included length of hospital stay and time to chest drain removal. A propensity score-matched analysis was performed based on age, sex, and BMI. Data were compared using Chi-squared and Student’s t-tests as appropriate. Results: A total of 304 patients were included, with 153 in the intervention group and 151 in the control group. After propensity-score matching, 52 patients from each cohort were compared. No significant differences were found between the groups regarding postoperative oxygen requirement, fever, atelectasis, residual pleural space, need for bronchoscopy toilette, and re-hospitalization rate. IS group showed trends toward shorter hospital stays and lower time to chest drain removal, though without reaching statistical significance. Conclusions: IS did not significantly improve postoperative outcomes compared to early ambulation alone in patients undergoing lung resection for primary lung cancer. More extensive, prospective, randomized trials are needed to confirm these findings.