Anatomical resection using a robotic approach in patients with thoracic deformities presents several challenges, including port placement. We present two patients with thoracic deformities-one without (Case 1) and one with (Case 2) specific port placements-focusing on difficulties such as limited visibility and restricted motion of the robotic arm.

Background: We investigated the clinical efficacy of complex segmentectomy for non-small cell lung cancer (NSCLC) adjacent to the intersegmental plane between S6 and the basal segments. Methods: Between 2009 and 2023, 135 patients with clinical stage IA NSCLC adjacent to the intersegmental plane in the lower lobe were retrospectively evaluated. We identified the intersegmental plane using three-dimensional (3D) image analysis systems and measured the distance (X) from the intersegmental plane to the tumor’s caudal side. Tumor location was classified into four: group A: located in S6, 10≤ X <20 mm; group B: located in S6, 0< X <10 mm; group C: on the plane (X=0); and group D: located in the basal segments. Clinicopathological characteristics, perioperative outcomes, and recurrence patterns were compared between S6 (n=123) and complex (n=12) segmentectomy. Results: Tumor distribution was 43 (32%) in group A, 35 (26%) in group B, 15 (11%) in group C, and 42 (31%) in group D. Complex segmentectomy was performed more frequently in group D (58% vs. 28%, p=0.03). Pure-solid tumors were more frequent in the complex segmentectomy group (42% vs. 20%, p = 0.07). Operative time was longer in complex segmentectomy than that in S6 segmentectomy (142 vs. 132 min, p=0.07); however, postoperative complications were similar between the two procedures (grade ≥3: 8% vs. 11%). Local recurrence occurred in three patients, which was exclusive to S6 segmentectomy. Conclusions: Complex segmentectomy may be considered in selected cases to secure adequate surgical margins based on preoperative three-dimensional evaluation.

The effectiveness and safety of cryoablation for lung cancer treatment has been gaining interest. This report presents a case of robotic portal right upper lobectomy for a second recurrence post-cryoablation, with valuable pathological findings. A 58-year-old male patient was referred to our hospital for lung cancer recurrence post-cryoablation, and he underwent robotic portal right upper lobectomy and mediastinal lymph node dissection. Microscopically, papillary adenocarcinoma, fibrosis, and a foreign body reaction were observed. The patient was diagnosed with local recurrence of adenocarcinoma following cryoablation.

OBJECTIVES:We evaluated the significance of spread through alveolar space (STAS) as a predictor of cancer recurrence in epidermal growth factor receptor (EGFR)-mutated pathological stage IA lung adenocarcinomas. METHODS:Between 2011 and 2020, data from 856 patients with surgically resected pathological stage IA EGFR-mutated lung adenocarcinoma were evaluated to investigate the oncological and prognostic roles based on the presence of STAS. The cumulative incidence of recurrence (CIR) was estimated using the Fine-Gray test. Survival outcomes were assessed using Kaplan-Meier analysis and log-rank tests. RESULTS:Seventy patients (8.2%) were STAS-positive, demonstrating a higher proportion of larger tumor size, lymphovascular invasion, nonlepidic predominant lesions, and the Ex19 subtype (P < .001). Postoperative cancer recurrence was significantly higher in the STAS-positive group (total: 18.6% vs. 5.7%, P < .001; locoregional: 10.0% vs. 3.8%, P = .015; distant: 15.7% vs. 3.7%, P < .001). Both CIR and recurrence-free survival (RFS) differed significantly according to the presence of STAS (5y-CIR: 14.4% vs. 4.2%, P < .001; 5y-RFS: 83.2% vs. 91.8%, P = .001). Multivariate analysis revealed that the presence of STAS (P = .028), lymphovascular invasion (P = .020), pathologic tumor size (P = .036), and absence of a lepidic component (P < .001) were independent significant factors for CIR. When combined with STAS, these factors further increased recurrence prediction (STAS and absence of a lepidic component, 5y-CIR: 26.8% vs. 4.0%, P < .001; STAS and larger tumor size, 18.1% vs. 4.3%, P < .001; STAS and lymphovascular invasion, 27.1% vs. 4.5%, P < .001). CONCLUSIONS:STAS is an important risk factor for predicting postoperative cancer recurrence in EGFR-mutated pathological stage IA lung adenocarcinomas.

Objective:The study objective was to evaluate the feasibility and technical considerations of pulmonary resection after coronary artery bypass grafting, with emphasis on procedures ipsilateral to an internal thoracic artery graft and the role of preoperative 3-dimensional imaging. Methods:We retrospectively reviewed 75 patients who underwent pulmonary resection after coronary artery bypass grafting between January 2008 and April 2024. Thirty-eight patients underwent pulmonary resection on the same side as internal thoracic artery grafting. Preoperative 3-dimensional reconstructed coronary or contrast-enhanced computed tomography was used to delineate graft anatomy in 23 patients. Results:Left internal thoracic artery grafts were present in 24 left-sided resections and right internal thoracic artery grafts in 14 right-sided resections. Surgical approaches included thoracotomy (n = 35) and robot-assisted thoracic surgery (n = 3); procedures comprised lobectomy (n = 19), segmentectomy (n = 8), and wedge resection (n = 11). Adhesions between the lung and bypass graft were observed in 26 patients (68.4%); 24 patients underwent successful adhesiolysis, and 2 patients required partial lung resection with selective preservation of a thin parenchymal layer adjacent to the graft while otherwise completing the planned lobectomy. No intraoperative graft injuries or postoperative myocardial infarctions occurred. Prolonged air leak was more frequent in right-sided procedures (21.4% vs 0%; P = .043). The 30-day mortality rate was 0%, and the 90-day mortality rate was 5.4%. Conclusions:Pulmonary resection after coronary artery bypass grafting is feasible but technically demanding and requires meticulous preoperative planning and careful intraoperative judgment, particularly during adhesiolysis near patent grafts. Preoperative 3-dimensional imaging provides supportive anatomical guidance for graft localization but should be regarded as adjunctive rather than outcome proven. In cases of dense adhesions, avoiding forceful adhesiolysis and selectively preserving a thin parenchymal layer adjacent to the graft, while otherwise completing the planned lobectomy, may represent a pragmatic graft-preserving strategy that maintains oncologic adequacy when negative margins are achieved.

INTRODUCTION: Carcinoembryonic antigen (CEA) is one of the most widely used tumor markers in clinical practice. In non-small cell lung cancer, elevated preoperative serum CEA levels have been reported to be associated with a poor prognosis. CASE PRESENTATION: A 43-year-old man with primary lung cancer of the right upper lobe was referred to our hospital. Initial blood tests revealed a markedly elevated serum CEA level of 1160.0 ng/mL. Chest CT identified a 55-mm tumor in the right hilar region, with enlargement of the right hilar and prevascular (#3a) lymph nodes (c-T3N2M0, Stage IIIB according to the Union for International Cancer Control tumor-node-metastasis classification, 8th edition). The patient underwent a type A extended sleeve lobectomy and pulmonary vein transposition. However, due to suspected pulmonary venous return failure, a right completion pneumonectomy was performed on POD 7. The patient's serum CEA levels returned to the normal range within 2 months postoperatively. He has remained recurrence-free for more than 4 years since the surgery. CONCLUSIONS: This case highlights that upfront surgery may be a valid treatment option in selected patients with c-Stage IIIA or IIIB disease, even in the presence of an abnormally high preoperative serum CEA level.

Objective: Extended robotic-assisted thoracic surgery (E-RATS) involving combined resection of adjacent structures remains uncommon, and consolidated reports are limited. This study aimed to describe our institutional early experience with E-RATS and evaluate perioperative outcomes, including the role of hybrid techniques. Methods: We retrospectively reviewed a prospectively maintained database of patients who underwent planned E-RATS between January 2017 and October 2024. E-RATS was defined as robotic pulmonary resection combined with bronchoplasty, pulmonary arterioplasty, or resection of adjacent structures. A hybrid approach was defined as planned use of a small thoracotomy solely for pulmonary artery clamping and/or chest wall resection, with all other procedures performed robotically. Patients converted to full thoracotomy were excluded. Perioperative outcomes were analyzed descriptively. Results: Eighteen patients (1.4% of 1276 robotic resections) were included. Procedures comprised bronchoplasty (n = 9), pulmonary arterioplasty (n = 6), and combined resection of the chest wall, diaphragm, or pericardium. Median operative time was 255 minutes, and median blood loss was 10 mL. Major postoperative complications (Clavien-Dindo grade ≥III) occurred in 4 patients (22%). Postoperative pain was assessed using a numerical rating scale on postoperative day 1 and is reported descriptively. All resections achieved negative margins, and no 90-day mortality was observed. Conclusions: In this single-institution early experience, extended robotic-assisted thoracic surgery, including selected hybrid procedures, was technically feasible and associated with acceptable perioperative outcomes. These findings provide descriptive and educational insight into the application of robotic-assisted techniques for selected complex thoracic resections.

As of 2017, robotic surgery accounted for less than 1% of lung cancer operations. The adoption of robotic surgery for lung cancer has rapidly increased, now comprising over 15% of such procedures. Juntendo University initiated robotic thoracic surgery in 2017 and currently performs approximately 250 robotic surgeries annually, including 150 for lung cancer. While robotic surgery offers advantages such as a three-dimensional field of view and enhanced dexterity through multi-jointed instruments, managing intraoperative complications-particularly bleeding-has been considered a limitation. To address these challenges, our hospital has implemented optimized operating room layouts, conducted emergency thoracotomy simulations, and developed safe surgical protocols. In recent years, the precision of robotic systems has enabled minimally invasive approaches to complex procedures. We have successfully performed advanced surgeries using robotic or robot-assisted techniques, including bronchoplasty, pulmonary artery reconstruction, deep lymph node dissection, and operations involving severe adhesions that are typically difficult with conventional minimally invasive methods. With continued advancements in robotic surgery, a growing number of patients are expected to benefit from minimally invasive treatment options.

To identify the high-risk subgroup of outcomes following upfront surgery for clinical (c)-N1 stage II non-small cell lung cancer (NSCLC). Between 2009 and 2022, 140 patients underwent upfront lung resection of more than one lobe with mediastinal lymphadenectomy for cN1 stage II NSCLC. The subjects of this retrospective study were 129 of these patients, whose cN1 node was confirmed pathologically as metastasis after surgery. “Continuous cN1” was an N1 node directly involving the primary tumor. Disease-free survival (DFS) and overall survival (OS) were estimated using log-rank tests. Continuous cN1 was detected in 55 patients (43

Gastroparesis is a rare complication of thoracic surgery, defined as delayed gastric emptying without mechanical obstruction. Gastroparesis may worsen outcomes; however, data after lung resection are scarce. We aimed to determine the incidence, perioperative factors, and course of postoperative gastroparesis after anatomical lung resection for lung cancer. We retrospectively reviewed records of 1623 adult patients who underwent anatomical lung resection (2018–2022). Gastroparesis was defined as postoperative upper gastrointestinal symptoms with radiographic gastric dilatation without mechanical obstruction. Univariate comparisons were performed using the Wilcoxon rank-sum or Fisher’s exact tests. Because of the infrequency of events, an exploratory multivariate analysis was conducted using Firth-penalized logistic regression with pre-specified covariates (clinical stage, lesion laterality, and extent of lymph node dissection). Eight patients developed postoperative gastroparesis (0.49

A 77-year-old woman presented with a right upper lobe tumor invading the chest wall. She was diagnosed with squamous cell carcinoma (cT4N1M0) and underwent right upper lobectomy with en bloc resection of the chest wall extending from the second intercostal space to the fifth rib. On postoperative day 6, the patient’s consciousness deteriorated, and brain computed tomography (CT) confirmed pneumocephalus. Surgical closure of the cerebrospinal fluid fistula was performed on postoperative day 7. The cerebrospinal fluid leak was successfully controlled using an erector spinae muscle flap. The patient was discharged eight days after reoperation, neurologically intact.

Robot-assisted thoracoscopic surgery is challenging in cases with complete pleural adhesions. To date, no previous reports have addressed this issue. We evaluated the surgical outcomes of robot-assisted anatomical lung resection in patients with complete pleural adhesions. Among 810 patients who underwent robot-assisted anatomical lung resection at our institute between 2017 and 2024, we retrospectively investigated 24 (3.0

Lobectomy and lymph node dissection have long been the standard surgical procedures for clinical stage IA lung cancer, based on a randomized trial published in 1995. That randomized trial showed better overall survival (OS) and recurrence-free survival (RFS) with lobectomy than with limited resection (segmentectomy or wide wedge resection) for clinical T1N0 non-small cell lung cancer. In addition, a three-fold higher rate of locoregional recurrence after limited resection was observed. However, recent advances in diagnostic imaging, such as thin-section computed tomography (TSCT), have improved the accuracy of clinical staging and the assessment of ground-glass opacity (GGO) in lung cancer, which is now recognized as being associated with less invasive pathology and a favorable prognosis. Subsequently, to evaluate the efficacy of sublobar resection for early-stage lung cancer, three major JCOG trials (JCOG0802/WJOG4607L, JCOG0804/WJOG4507L, and JCOG1211) were conducted. These studies stratified patients according to the consolidation-to-tumor ratio (CTR) on preoperative TSCT findings. These studies have recently disclosed their results, and they support the efficacy of sublobar resection, although several questions remain in daily clinical practice. In this perspective article, we summarize the current status and optimal surgical strategy for early-stage lung cancer based on these randomized controlled trials and discuss future perspectives, including the potential expansion of segmentectomy to larger or node-positive lung tumors.

To evaluate the efficacy and safety of postoperative pleurodesis using OK-432, focusing on patients with idiopathic interstitial pneumonia (IIP). This retrospective cohort study included patients who underwent OK-432 pleurodesis following pulmonary resection. We reviewed clinical characteristics, radiological evidence of IIP, operative findings, postoperative air leak volume, pleurodesis details, morbidity, and mortality; then we compared the outcomes of patients with vs. those without IIP, and analyzed the predictors of ≥Grade II complications. Pleurodesis was performed in 361 patients, including 67 (19

This study aimed to examine the influence of ground-glass opacity (GGO) on the prognosis of epidermal growth factor receptor (EGFR)-mutated pathological (p)-stage IB non-small cell lung cancer (NSCLC). Between 2009 and 2021, 115 patients underwent complete anatomical lung resection with mediastinal lymphadenectomy for p-stage IB non-squamous NSCLC harboring common EGFR mutations. The patients were classified into the part-solid and pure-solid arms based on the presence of GGO components. The median follow-up time was 70.2 months. Sixty-seven patients (58

We experienced two cases of lung cancer in teenagers. Case 1 involved a 17-year-old never-smoking girl with no medical history. Chest computed tomography revealed a 9 × 7 mm ground-glass nodule in the left lung. Case 2 involved an 18-year-old man with no smoking history but bilateral pneumothorax. Chest computed tomography showed a 13 × 11 mm ground-glass nodule in the right lung. In both cases, thoracoscopic wedge resection was performed, and the tumours were pathologically diagnosed as adenocarcinoma in situ. There was no evidence of recurrence for 2 years in Case 1, and for 1.5 years in Case 2.

The importance of complex robotic lung resection should increase because of growing experience with robotic surgery worldwide. However, there have been no reports on robotic portal pulmonary arterioplasty because clamping the main pulmonary artery without thoracotomy is challenging. A 67-year-old female patient who was clinically diagnosed with lung adenocarcinoma cT1bN2M0 stage IIIA underwent induction chemo-immunotherapy, which resulted in a conventional and metabolically partial response. Subsequently, robotic portal right upper sleeve lobectomy with pulmonary arterioplasty was performed using a combination of bulldog clamp forceps and a cotton tape to clamp the main pulmonary artery.

Objective: Clinical stage IA non-small cell lung cancer (NSCLC) showing a pure- solid appearance on computed tomography is associated with a worse prognosis. This study aimed to develop and validate machine-learning models using preoperative clinical and radiomic features to predict overall survival (OS) in clinical stage IA pure-solid NSCLC. Methods: Patients who underwent lung resection for NSCLC between January 2012 and December 2020 were reviewed. The radiomic features were extracted from the intratumoral and peritumoral regions on computed tomography. The machine- learning models were developed using random survival forest and eXtreme Gradient Boosting (XGBoost) algorithms, whereas the Cox regression model was set as a benchmark. Model performance was assessed using the integrated time- dependent area under the curve (iAUC) and validated by 5-fold cross-validation. Results: In total, 642 patients with clinical stage IA pure-solid NSCLC were included. Among 3748 radiomic and 34 preoperative clinical features, 42 features were selected. Both machine-learning models outperformed the Cox regression model (iAUC, 0.753; 95% confidence interval [CI], 0.629-0.829). The XGBoost model showed a better performance (iAUC, 0.832; 95% CI, 0.779-0.880) than the random survival forest model (iAUC, 0.795; 95% CI, 0.734-0.856). The XGBoost model showed an excellent survival stratification performance with a significant OS difference among the low-risk (5-year OS, 100.0%), moderate low-risk (5-year OS, 88.5%), moderate high-risk (5-year OS, 75.6%), and high-risk (5-year OS, 41.7%) groups (P < .0001). Conclusions: A radiomics-based machine-learning model can preoperatively and accurately predict OS and improve survival stratification in clinical stage IA pure- solid NSCLC.