各位好！今天与大家分享一篇近期发表在JTCVS上的一篇文献。研究是由MSK胸外科开展，回顾性分析了影响新辅助治疗后成功进行微创手术因素。新辅助治疗后手术难度的衡量仍然是外科医生所关注的热点话题，到底是无他唯熟而已，还是手术难度可能并无规律可言，一起来看看临床数据视角下的思考。
Determinants of successful minimally invasive surgery (MIS) for resectable non-small cell lung cancer (NSCLC) after neoadjuvant therapy
Ngoc-Quynh Chu, MD, Kay See Tan, PhD, Joe Dycoco, MS, Prasad S. Adusumilli, MD, Manjit S. Bains, MD, Matthew J. Bott, MD, Robert J. Downey, MD, Katherine D. Gray, MD, James Huang, MD, James M. Isbell, MD, Daniela Molena, MD, Smita Sihag, MD, Gaetano Rocco, MD, David R. Jones, MD, Bernard J. Park, MD, Valerie W. Rusch, MD
JTCVS 6 August 2024
Objective: MIS (VATS, RATS) for pulmonary resection is standard in early stage NSCLC as it is associated with better perioperative outcomes than thoracotomy. MIS for resection of more advanced NSCLC (Stages IB-IIIB) treated with neoadjuvant therapy has been utilized. However, the determinants of success are not well-defined.
背景：MIS（VATS，RATS）肺切除术是早期非小细胞肺癌的标准手术，因为它比开胸术具有更好的围手术期结局。MIS已用于切除接受新辅助治疗的更晚期非小细胞肺癌（IB-IIIB期）。然而，成功的决定因素并没有明确定义。
Methods: A single institution retrospective review of a prospectively maintained database was conducted, querying for patients with clinical Stage IB-IIIB NSCLC who had resection after neoadjuvant systemic therapy without radiation from 2013-2022. Patients were grouped by surgical approach, open vs. MIS. Successful MIS was defined by no conversion, R0 resection, and no major (≥grade 3) morbidity. Analyses by intent-to-treat assessed outcomes by Wilcoxon rank sum test and Fisher's exact test. (MVA identified variables that contributed to successful MIS resection.
方法：对前瞻性维护的数据库进行了单一机构回顾性审查，查询了2013年至2022年期间在不进行放疗的新辅助系统治疗后接受切除的临床IB-IIIB期非小细胞肺癌患者。患者按手术入路、开放式与MIS进行分组。成功的MIS定义为无转换、R 0切除和无重大（至少3级）发病率。通过Wilcoxon等级和检验和Fisher精确检验，按意向治疗进行分析评估结果。(MVA确定了有助于成功MIS切除术的变量。
Results: Of 627 eligible patients, 360 (57%) had open and 267 (43%) had MIS procedures. Most patients (79.1%) received neoadjuvant platinum-based chemotherapy, and 21.9% were treated with immunotherapy or targeted therapy alone or combined with chemotherapy. Among MIS resections, 179 (67%) were performed by VATS and 88 (33%) by RATS. The conversion rate was 16% (n=43). Successful MIS resection was achieved in 77% of patients. MVA showed that pre-treatment clinical N stage was a significant determinant of success, but not pre-treatment clinical T stage or type of neoadjuvant therapy.
结果：在627名符合条件的患者中，360名（57%）接受了开放手术，267名（43%）接受了MIS手术。大多数患者（79.1%）接受了铂类新辅助化疗，21.9%的患者接受了免疫治疗或靶向治疗，或联合化疗。在MIS切除术中，179例（67%）通过VATS进行，88例（33%）通过RATS进行。转化率为16%（n=43）。77%的患者成功实现了MIS切除。UVA表明，治疗前临床N分期是成功的重要决定因素，但治疗前临床T分期或新辅助治疗类型并非如此。
Conclusion: Following neoadjuvant systemic therapy for clinical stage IB-IIIB NSCLC, MIS resection can be successfully accomplished and should be considered in appropriate patients. Presence of pre-treatment nodal disease is associated with higher odds of conversion, major morbidity, and incomplete resection.
结论：在对临床阶段IB-IIIB非小细胞肺癌进行新辅助系统治疗后，可以成功完成MIS切除术，并应考虑在合适的患者中进行。治疗前淋巴结疾病的存在与中转率较高、主要并发症和不完全切除率有关。
Central Picture: Multivariable analysis of factors that influence success of post-neoadjuvant lung resection by MIS.
Central Message: Pre-treatment nodal disease but not type of neoadjuvant systemic therapy decreases the odds of a successful MIS approach to resection in locally advanced NSCLC.
Perspective Statement: Neoadjuvant therapy, including immunotherapy, is reported to be associated with greater operative complexity which may limit enthusiasm to use minimally invasive surgery (MIS). We show that the success of MIS (by VATS or RATS) is associated with the presence of pre-treatment nodal disease, but not type of neoadjuvant therapy.
1.顺便学习一下最新的nccn指南,随后我们看个片子，这样的患者你认为VATS可以达到R0切除吗？
2.上细节：
首先本文是一项单中心回顾性研究，研究部分新辅助治疗后手术治疗的情况，也反映了MSK主刀医生在新辅助领域的外科习惯。目前也仅有少量研究对手术难度进行定量化分析。
其次，微创与开放的决定性因素从临床经验上讲很多时候取决于术者的经验、术中意外（如血管/支气管损伤）、包绕支气管血管间隙的淋巴结纤维化或钙化程度。本研究从临床分期角度提出术前淋巴结，特别是N1站淋巴结的情况是影响能否顺利实施微创手术的关键性因素。
第三，需要思考的是什么程度的微创≈开放，什么程度的微创>开放，什么情况的微创<开放。围绕手术视频进行的智能外科评估关键就是模块化和客观标准评估。这方便虽然日本外科领域晋升的一大考试就是一刀未减的手术视频，但这么多年来也未见有定量或者半定量的评估方式出现。期待在AI时代能为这个问题的解决带来新的思路。
10.1016/j.jtocrr.2021.100221
3.生物学机制上来看，如何围绕可切除性和治疗相关的手术难度制定合适的outcome仍然需要深入的临床探索。
目录
1. INTRODUCTION
2. METHODS
2.1 Study design and subjects
2.2 Statistical analysis
3. RESULTS
3.1 Study cohort (Figure 1)(Supplemental Figure 1)(Figure 2)(Supplemental Figure 2)
3.2 Open versus MIS approach (Table 1)(Supplemental Table 1)(Supplemental Table 2; Figure 3)
3.3 Success of MIS approach (Supplemental Figure 3)(Supplemental Table 3)(Table 2)(Supplemental Table 5; Figure 4)
3.4 Conversions (Table 3)
4. DISCUSSION
7. Conclusion
— 图表汇总—
3.1 Study cohort
Figure 1. Assembly of the study cohort.
Supplemental Figure 1. Distribution of pre-treatment clinical stage.
Figure 2. (A) Distribution of neoadjuvant therapy types and drug therapies used (B) Annual distribution of surgical approaches during study period.
Supplemental Figure 2. Surgeon experience as illustrated by number of years in practice (from end of training to 2023), number of anatomic lung resections (2013-2022),and percent of total lung resections, anatomic lung resections, and post-induction lung resections performed by MIS. MIS practice, whether by VATS OR RATS, is also defined.
3.2 Open versus MIS approach
Table 1. Pre-operative characteristics of open versus MIS cases
Supplemental Table 1. Post-operative outcomes of open versus MIS cases
Supplemental Table 2. Univariable analysis for MIS Approach
Figure 3. Multivariable analysis for MIS approach.
3.3 Success of MIS approach
Supplemental Figure 3. Distribution of VATS versus RATS approach within the MIS cohort and definition of MIS success.
Supplemental Table 3. Reasons for not successful MIS
Table 2. Pre-operative characteristics of successful versus not successful MIS cases
Supplemental Table 5. Univariable analysis for MIS success
Figure 4. Multivariable analysis for MIS success.
Supplemental Table 4. Post-operative outcomes of successful versus not successful MIS cases
3.4 Conversions
Table 3. Reasons for Conversion
4. DISCUSSION
7. Conclusion
