OBJECTIVES:Neoadjuvant chemo-immunotherapy is associated with oncologic benefits in patients undergoing resection for locally advanced non-small cell lung cancer (NSCLC). We assessed patient-reported physical and psychological symptoms following neoadjuvant chemo-immunotherapy and surgery compared to stage-equivalent patients who were operated during the same period without neodjuvant treatment. METHODS:All consecutive patients submitted to lung resection for clinical stage II and III NSCLC between March 2023 and December 2024 and alive at the time of the interview were approached for the study. Their patient-reported symptoms were assessed using the Non-Small Cell Lung Cancer Symptom Assessment Questionnaire (NSCLC-SAQ) and their psychological distress was assessed using the Hospital Anxiety and Depression Scale (HADS). RESULTS:Of the 138 patients initially screened, 82 completed the survey. Median time from surgery to the interview was 13.9 months. There was no difference in total NSCLC-SAQ score between patients undergoing upfront surgery (S) and surgery after neoadjuvant chemo-immunotherapy (CT-IO) (P = .64). Chemo-immunotherapy was not independently associated with total NSCLC-SAQ score after multivariable regression analysis. The average anxiety and depression scores were also similar between the 2 groups. Finally, a similar proportion of patients in the 2 groups reported to have symptoms similar or better than before starting treatment. CONCLUSIONS:Our findings show in a real clinical practice setting that neoadjuvant chemo-immunotherapy is not negatively associated with patient-reported physical or psychological symptoms in the medium to long-term follow-up compared to surgery alone. These results can be used as information tool during patients' counselling.

Background: Neoadjuvant chemoimmunotherapy is now a standard approach for resectable stage II-III non-small cell lung cancer (NSCLC), demonstrating improved pathological response and survival. However, its safety in physiologically high-risk surgical patients is unclear, as these groups are underrepresented in trials. This study compares 30-day and 90-day mortality and oncological outcomes of neoadjuvant chemoimmunotherapy followed by surgery versus upfront surgery within a high-risk multidisciplinary team (MDT) cohort. Methods: A retrospective single-centre study was performed, including consecutive high-risk MDT patients undergoing resection for stage II -III NSCLC between January 2022 and December 2025. High-risk status was defined by established physiological, cardiopulmonary, and comorbidity criteria. Patients were stratified into neoadjuvant chemoimmunotherapy followed by surgery (Chemo-IO; n = 33) or upfront surgery (n = 57). The primary outcome was 30-day mortality. Secondary outcomes included 90-day mortality, R0 resection rate, and length of hospital stay. Inverse probability of treatment weighting (IPTW) based on propensity scores was used to balance baseline differences between groups. Results: Ninety patients were included. Patients receiving neoadjuvant therapy had a greater comorbidity burden (Charlson Comorbidity Index 3.2 ± 1.5 vs. 1.4 ± 1.7, p < 0.001) and more advanced disease (stage III: 57.6% vs. 29.8%, p = 0.014). Thirty-day mortality was 0% in the Chemo-IO group and 1.8% following upfront surgery. After IPTW adjustment, neoadjuvant therapy was not associated with increased perioperative mortality. Ninety-day mortality was similar between groups (3.0% vs. 3.5%; IPTW OR 0.91, 95% CI 0.05-15.39, p = 0.948). R0 resection rates were numerically higher following Chemo-IO (87.9% vs. 78.9%; IPTW OR 3.42, 95% CI 0.71-16.59, p = 0.127). Median hospital stay was identical in both cohorts (6 days), with no significant difference after weighting (p = 0.722). Conclusions: Neoadjuvant chemoimmunotherapy appears safe and feasible in carefully selected high-risk patients with resectable stage II-III NSCLC. Despite greater comorbidity burden and more advanced disease, short-term perioperative outcomes were not compromised, while a trend towards improved R0 resection rates was observed. These findings support the consideration of multimodal treatment strategies within high-risk MDT pathways.

BACKGROUND The increasing use of segmentectomy for early-stage peripheral non-small cell lung cancer (NSCLC) raises questions about its oncologic adequacy compared to lobectomy, particularly for tumours with high-risk features. This study aims to compare oncologic outcomes between segmentectomy and lobectomy for clinical stage IA1-2 peripheral NSCLC, stratified by radiological tumour risk. METHODS This retrospective single-center study analyzed 527 patients with peripheral NSCLC ≤2 cm who underwent either lobectomy (n=240), or segmentectomy (n=287) from January 2017 to December 2024. High-risk tumours were defined as cT1b, solid-dominant, and hypermetabolic (SUVmax>2.5). Primary endpoints included 4-year overall survival (OS) and event-free survival (EFS). Cox regression analysis was performed to identify independent predictors of EFS. RESULTS High-risk tumours comprised 122 lobectomies (51%) and 73 segmentectomies (25%). For low-risk tumours, there was no significant difference in 4-year OS or EFS (OS: lobectomy 85% versus segmentectomy 84% p=0.74); (EFS: lobectomy 75% versus segmentectomy 72%, p=0.74).For high-risk tumours, 4-year OS or EFS were also not different after lobectomy or segmentectomy (OS: lobectomy 80% versus segmentectomy 68%, p=0.18); (EFS: lobectomy 72% versus segmentectomy 60%, p=0.33). In the IPW-adjusted Cox proportional hazards model, lobectomy was not independently associated with improved EFS (HR 0.86, 95% CI 0.59-1.25, p=0.43). CONCLUSIONS Segmentectomy demonstrates oncologically equivalent outcomes compared to lobectomy for both low-risk and high-risk clinical stage IA1-2 peripheral NSCLC. These findings support the oncological safety of segmentectomy as an alternative to lobectomy in appropriately selected patients with small peripheral NSCLC, even in the high-risk tumour subset.

OBJECTIVES:The oncological role of anatomic segmentectomy in early-stage non-small-cell lung cancer (NSCLC) remains under active investigation. We sought to identify predictors of recurrence following segmentectomy in patients with clinical stage IA1-2 NSCLC. METHODS:We retrospectively analysed consecutive patients who underwent segmentectomy for clinical stage IA1-2 pathologically confirmed NSCLC between 2017 and 2024. Event-free survival (EFS), overall survival (OS), and recurrence patterns were assessed. Cox regression and competing risk models were applied to determine factors associated with adverse outcomes. RESULTS:A total of 287 patients were included. Four-year OS and EFS were 80% (95% confidence interval [CI], 73-87) and 69.5% (95% CI, 61-77), respectively. Recurrence occurred in 31 patients (10.8%), predominantly loco-regional (n = 26, 9.1%). Patients with resection margins <5 mm had significantly higher rates of loco-regional recurrence compared with those with wider margins (20.3% vs 5.8%, P < .001). On competing risk analysis, a short margin (<5 mm) was independently associated with recurrence (P = .009). Poorer EFS was also observed in patients with hypermetabolic tumours on positron emission tomography (PET) (standardized uptake value maximum [SUVmax] > 2.5 vs ≤2.5: 60% [95% CI, 48-70] vs 81% [95% CI, 69-89]; P = .0001) and in pure solid tumours compared with those with a subsolid component (61% [IQR, 45-74] vs 73% [IQR, 62-81]; P = .039). CONCLUSIONS:Adequate resection margins are critical to reduce loco-regional recurrence after segmentectomy for stage IA NSCLC. PET avidity and tumour morphology further stratify recurrence risk. Careful preoperative planning and tailored surgical strategies are essential to ensure oncologically sound resections.

This study evaluated real-world surgical outcomes following neoadjuvant nivolumab in combination with chemotherapy in a multicentre national cohort of patients operated for stage II-IIIB nonsmall cell lung cancer (March 2023-May 2024). Surgical and pathological outcomes were assessed. Of the 130 patients who started the neoadjuvant treatment, 93% proceeded to surgery. 90-days postoperative mortality was 5.8%. Pathologic complete response occurred in 31.4% of patients without significant differences between clinical stages. Background: To evaluate the real-world surgical and pathological outcomes following neoadjuvant nivolumab in combination with chemotherapy in a multicentre national cohort of patients. Methods: Retrospective analysis on consecutive patients treated in three tertiary referral hospitals in UK with neoadjuvant chemotherapy and immunotherapy (nivolumab) for stage II-IIIB nonsmall cell lung cancer (March 2023-May 2024). Surgical and pathological outcomes were assessed. Results: 130 patients started neoadjuvant treatment. 121 patients (93.1%) were able to proceed to surgery. 62% of patients had surgery more than 6 weeks after completion of the last neoadjuvant cycle. 91 operations (75.2%) were started using a minimally invasive approach with a conversion rate of 18.7%. The most frequent resection was lobectomy in 85% of patients. 30-and 90-days postoperative mortality rates were 3.3% and 5.8%. The pCR occurred in 38 patients (31.4% of the surgical patients), MPR in 57 patients (47.1% of the surgical patients). The incidence of pCR (P = .90) and MPR (P = .66) were similar in patients with clinical stage II and III. pCR rate was higher in patients with PD-L1 >= 50% compared to those with PD-L1 <50% (41.9% vs. 25.6%, P = .066). A higher pCR (44.7% vs. 23%, P = .012) and MPR (66% vs. 35.1%, P = .001) in squamous vs. non-squamous histology tumors. Conclusions: The use of neoadjuvant chemo-ICI in the real clinical practice is safe and effective. The pathological response rates parallel those reported in trials and appear consistent across stages. Our findings provide real world data from a public healthcare system which will be valuable to inform multidisciplinary treatment selection for locally advanced resectable NSCLC. Clinical Lung Cancer, Vol. 26, No. 3, 253-261 (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Objectives: Our objective was to assess the incidence and reason of last-minute cancellations before surgery for lung cancer and their association with outcomes. Methods: Retrospective analysis on all consecutive patients booked for elective lung cancer surgery from January 2017 through December 2022 in a single centre. Last-minute cancellation: a cancellation occurring within the last 24 h from the planned operation. Cancellation categories: process-related and patient-related. The short-term and long-term outcomes of patients who experienced a last-minute cancellation were analysed. Results: 197 patients of 1587 (12%) had a last-minute cancellation: 156 (79%) were process-related and 41 (21%) were patient-related. Three percent (5/156) of patients cancelled for process reasons did not receive surgery versus 39% (16/41) of those cancelled for patient-related reasons, P < 0.0001. The 90-day mortality rates of cancelled and non-cancelled patients were similar (4.6% vs 4.7%, P = 1). Five-year overall survival of patients with cancellation was 58% (95% confidence interval 49-66) vs 69% (95% confidence interval 66-71) of those without cancellations, P = 0.022. Among those who had a cancellation, the 5-year overall survival of those with process-related cancellations was 61% (52-60) vs 35% (14-58) of those with patient-related cancellations (adjusted P value for multiple comparisons = 0.14). Cox regression analysis showed that surgery cancellations within the last 24 h for patient-related (hazard ratio 1.87, 95% confidence interval 1.02-3.42, P = 0.043) reasons remained a factor associated with poorer overall survival after adjusting for clinical stage, type of operation and patient-related variables. Conclusions: Implementing the patient's preoperative clinical evaluation to reduce the occurrence of related last-minute cancellations might mitigate its negative impact on survival.

Background This study aims to develop an predictive model for surgical complexity after neoadjuvant chemoimmunotherapy. Methods This is real clinical practice study of consecutive patients undergoing surgery after neoadjuvant nivolumab and chemotherapy for locally advanced lung cancer (April 23, 2023 through December 24, 2024). Surgical complexity was graded by the operating surgeon using a 4-dimension published score. An operation was defined as complex if at least 1 of the dimensions scored severely more complex than a standard lobectomy. Logistic regression analysis was used to test the association of several patient- and tumor-related factors with the presence of a complex procedure. The model was constructed by proportionally weighing the regression coefficients. Results The analysis included 65 patients. The most frequent procedure was lobectomy (86%), of which 28 cases (43%) were classified as complex. Complex procedures were longer (median 228 minutes vs 180 minutes; P = .003) and were more frequently converted to thoracotomy (48% vs 6.7%, P = .001). Logistic regression analysis showed that absence of radiologic nodal response to neoadjuvant treatment (score, 1 point; regression coefficient, 2.4; P = .007), pretreatment cN2 stage (score 1 point; regression coefficient, 2.1; P = .024), and programmed death-ligand 1 ≥50% (score 1 point; regression coefficient, 1.67; P = .012) were independent predictors of a complex procedure. The final predictive surgical complexity model ranged from 0 to 3. The proportion of complex operations significantly increased with the higher risk scores (ie, 0% in patients with no risk factors, to 100% in those with all 3 risk factors, P < .001). Conclusions The proposed model can assist to efficiently planning lung cancer surgery in the neoadjuvant setting and for patient counseling.

Background We aimed to assess the outcome of patients who were stage-eligible for neoadjuvant chemo-immunotherapy but did not start the treatment and received surgery upfront. Methods All consecutive patients undergoing lung resection with or without prior neoadjuvant chemo-immunotherapy (nivolumab) for clinical stage II and III NSCLC (April 2023 through December 2024) were included in this analysis. The main reasons for not receiving the neoadjuvant treatment were described. Subgroup analyses were performed to assess outcomes by presence of neoadjuvant treatment. Results 129 patients were included. 47 % received neoadjuvant nivolumab in combination with platinum-based chemotherapy (IO group), whereas 53 % did not receive neoadjuvant treatment and proceeded to surgery upfront (S group). There was no difference in minimally invasive approach between procedures performed after neoadjuvant treatment and those without (75 % vs. 73.9 %, p = 0.88).Neoadjuvant treatment was not associated with increased risk of postoperative cardiopulmonary complications (IO = 35 % vs. S = 38 %, p = 0.75) or prolonged hospital stay (IO = 5 days vs. S = 6, p = 0.24). The most frequent reason for not starting neoadjuvant treatment was the lack of adequate tissue sampling for molecular testing or diagnosis/nodal staging confirmation (32 %), followed by the presence of actionable genetic alterations (16 %), patient choice (11.5 %) and underlying immune-related disease (11.5 %). Conclusions A large proportion of patients who could qualify for neoadjuvant systemic anticancer treatment never started it. Our findings may inform future discussions on how to improve the treatment pathway of patients with NSCLC and candidates to neoadjuvant or perioperative immunotherapy.

OBJECTIVES:To evaluate the real clinical practice surgical outcomes following neoadjuvant nivolumab in combination with chemotherapy in a multicentre European cohort of patients. METHODS:Retrospective analysis on consecutive patients treated in 6 tertiary referral hospitals in Europe with neoadjuvant chemotherapy and immunotherapy (nivolumab) for stage II-IIIB non-small cell lung cancer (March 2023-December 2024). Surgical and pathological outcomes were assessed. RESULTS:A total of 340 patients started neoadjuvant treatment. Three hundred seventeen patients (93.2%) were able to proceed to surgery. Forty-seven percent of patients had surgery more than 6 weeks after completion of the last neoadjuvant cycle. Two hundred eight operations (66%) were started using a minimally invasive approach with a conversion rate of 18%. The most frequent resection was lobectomy in 86% of patients. Ninety-day postoperative mortality rate was 2.5%. The pathologic complete response occurred in 95 patients (30% of the surgical patients), major pathologic response in 167 patients (52.7% of the surgical patients). The incidence of pathologic complete response (P = .78) and major pathologic response (P = .26) were similar in patients with clinical stage II and III. Pathologic complete response rate was higher in patients with programmed death-ligand 1 (PD-L1) ≥ 50% compared to those with PD-L1 < 50% (37.5% vs 27.2%, P = .082). A higher pathologic complete response (39% vs 23%, P = .004) and major pathologic response (66% vs 45%, P = .001) were observed in squamous vs non-squamous histology tumours. CONCLUSIONS:The use of neoadjuvant nivolumab in association with platinum-based chemotherapy in the real clinical practice is safe and effective. Our real clinical practice data represent valuable information to be used during multidisciplinary treatment selection for clinical stage II and III resectable non-small cell lung cancer and shared decision-making.

OBJECTIVES The aim of this study was to assess the self-reported current dyspnoea and perioperative changes of dyspnoea in long-term survivors after minimally invasive segmentectomy or lobectomy for early-stage lung cancer. METHODS Cross-sectional telephonic survey of patients alive and disease-free as of March 2023, with pathologic stage IA1-2, non-small-cell lung cancer, assessed 1-5 years after minimally invasive segmentectomy or lobectomy (performed from January 2018 to January 2022). Current dyspnoea level: Baseline Dyspnoea Index score <10. Perioperative changes of dyspnoea were assessed using the Transition Dyspnoea Index. A negative Transition Dyspnoea Index focal score indicates perioperative deterioration in dyspnoea. Mixed effect models were used to examine demographic, medical and health-related correlates of current dyspnoea and changes in dyspnoea level. RESULTS A total of 152 of 236 eligible patients consented or were available to respond to the telephonic interview(67% response rate): 90 lobectomies and 62 segmentectomies. The Baseline Dyspnoea Index score was lower (greater dyspnoea) in lobectomy patients (median 7, interquartile range 6-10) compared to segmentectomy (median 9, interquartile range 6-11), P = 0.034. 70% of lobectomy patients declared to have a current dyspnoea vs 53% after segmentectomy, P = 0.035. 82% of patients after lobectomy reported a perioperative deterioration in their dyspnoea compared to 57% after segmentectomy, P = 0.002. Mixed effect logistic regression analysis adjusting for patient-related factors and time elapsed from operation showed that segmentectomy was associated with a reduced risk of perioperative dyspnoea deterioration (as opposed to lobectomy) (Odds ratio (OR) 0.31, P = 0.004). CONCLUSIONS Our findings may be valuable to inform the shared decision-making process by complementing objective data on perioperative changes of pulmonary function.

Background To evaluate the real-world surgical and pathological outcomes following neoadjuvant nivolumab in combination with chemotherapy in a multicentre national cohort of patients. Methods Retrospective analysis on consecutive patients treated in three tertiary referral hospitals in UK with neoadjuvant chemotherapy and immunotherapy (nivolumab) for stage II-IIIB non-small cell lung cancer (March 2023-May 2024). Surgical and pathological outcomes were assessed. Results 130 patients started neoadjuvant treatment. 121 patients (93.1%) were able to proceed to surgery. 62% of patients had surgery more than 6 weeks after completion of the last neoadjuvant cycle. 91 operations (75.2%) were started using a minimally invasive approach with a conversion rate of 18.7%. The most frequent resection was lobectomy in 85% of patients. 30- and 90-days postoperative mortality rates were 3.3% and 5.8%.The pCR occurred in 38 patients (31.4% of the surgical patients), MPR in 57 patients (47.1% of the surgical patients). The incidence of pCR (p=0.90) and MPR (p=0.66) were similar in patients with clinical stage II and III. pCR rate was higher in patients with PD-L1≥50% compared to those with PD-L1<50% (41.9% vs. 25.6%, p=0.066). A higher pCR (44.7% vs. 23%, p=0.012) and MPR (66% vs. 35.1%, p=0.001) in squamous vs. non-squamous histology tumours. Conclusions The use of neoadjuvant chemo-ICI in the real clinical practice is safe and effective. The pathological response rates parallel those reported in trials and appear consistent across stages. Our findings provide real world data from a public healthcare system which will be valuable to inform multidisciplinary treatment selection for locally advanced resectable NSCLC. Mini-abstract This study evaluated real-world surgical outcomes following neoadjuvant nivolumab in combination with chemotherapy in a multicentre national cohort of patients operated for stage II-IIIB non-small cell lung cancer (March 2023-May 2024). Surgical and pathological outcomes were assessed. Of the 130 patients who started the neoadjuvant treatment, 93% proceeded to surgery. 90-days postoperative mortality was 5.8%. Pathologic complete response occurred in 31.4% of patients without significant differences between clinical stages.

Epithelial-mesenchymal transition (EMT) may increase the malignant potential of tumours and may be induced by chemotherapy agents including platinum and pemetrexed (cis/pem). Non-epithelial malignant pleural mesothelioma (MPM) has a significantly poorer survival than epithelial MPM. We aimed to evaluate whether EMT occurred in MPM after induction cis/pem and whether this reduced survival.

The advent of helical high-resolution CT scanners, the application of screening programs and the follow-up of patient with oncological history, led to an increasing number of diagnosis of small pulmonary nodule (less than 10 mm in maximum diameter), partially solid nodule or completely ground glass ones. Their management is controversial. Excisional biopsy by mean of video-assisted thoracic surgery is often a viable choice but to locate these lesions intraoperatively can be impossible without the aid of preoperative or intraoperative localization techniques. In this brief review we will analyze the benefit of adopting localization techniques prior to pulmonary resection for small pulmonary lesions and face the advantages and problems with the main techniques described in the literatures.

OBJECTIVES: There has been declining interest in cardiothoracic surgery amongst medical graduates. This survey examines the exposure of British medical students to cardiothoracic surgery in various settings and its relationship with students' interest in the speciality. METHODS: A questionnaire composed of 14 quantitative and qualitative items was distributed amongst 162 medical students. The survey included questions on demographics, interest in cardiothoracic surgery, mechanisms of exposure to the speciality and desire to pursue a career in cardiothoracic surgery before and after exposure. RESULTS: Amongst the surveyed students, 71.0% reported exposure to cardiothoracic surgery as part of their medical school curricula and 24.7% reported extracurricular exposure. Of the students, 46.7% reported clinical exposure. Overall, 27.1% of students reported interest in a career in cardiothoracic surgery, which was higher amongst students who had curricular (29.6%), clinical (35.5%) or extracurricular exposure (50.0%). Amongst interested students, 43.2% engaged in extracurricular cardiothoracic activities compared with 16.1% of students not interested in pursuing the speciality. Confidence in career choice after exposure increased more in interested students (20.4%) than not interested students (1.6%). Students rated exposure and mentorship as the most important factor in promoting a career in cardiothoracic surgery. CONCLUSIONS: Medical students with an interest in cardiothoracic surgery are more likely to organize independent attachments in the speciality and attend extracurricular events; however, many students might fail to identify cardiothoracic surgery as an area of interest because of the lack of exposure at medical school.

We present the case of a 74-year-old man with Stage IIa pulmonary adenocarcinoma, for which he underwent a robotic right middle lobectomy. A 4-armed, 5-port approach was used. Four intercostal ports were created above the ninth rib using the Cerfolio’s technique. The subxiphoid port was created in the midline, 5 cm down from the xiphisternum. The robot offers higher image quality, depth perception and improved articulation of the instruments, allowing for more accurate dissection and stitching. The usage of a subxiphoid utility port reduces the clashing between instruments, offers a good angle for stapling and provides a direct view of the instruments entering into the chest. Specimen removal through the subxiphoid port may reduce postoperative pain and enhance patient recovery. The use of the subxiphoid approach as a utility port for robotic surgery is promising and may be a suitable replacement for the traditional utility port.

Background Subcentimetre pulmonary nodules can be challenging to locate either during video-assisted thoracoscopic surgery (VATS) or by open techniques. In an era of increasing computed tomography scan availability the number of nodules that are identified that are suspicious for malignancy is rising, and thoracic surgeons require a reliable method to locate these nodules intraoperatively. Methods Our aim was to evaluate, for the first time in the UK, resection of pulmonary nodules using radioactive dye labelling. Local research ethics approval was obtained and the study was submitted to the Integrated Research Application System (IRAS). All data were prospectively collected in our dedicated thoracic surgical database and analyzed at the conclusion of the study. This represents a consecutive series of patients, from January 2016 and until April 2017, who underwent this procedure at our institution: James Cook University Hospital, Middlesbrough, United Kingdom. The primary outcome measured was successful resection rate of the target nodules. Results Twenty-three patients underwent radiolabeled excision of pulmonary nodules, their average age was 61 years (range, 28-79 years), 13 women and 10 men. The average maximum diameter of the nodule was 8 mm (range, 3-16 mm). All patients underwent successful excision of the target lesion (success rate 100%). One patient (4.3%) sustained pneumothorax following the CT-guided injection of the radio-labelled dye and this required chest drainage prior to general anesthesia. Conclusions We conclude that technetium guided pulmonary nodule resection is a very reliable method for localization and resection of subcentimetre nodules which may be otherwise be difficult to identify.