Permissible Outcomes of Lobe-Specific Lymph Node Dissection for Elevated Carcinoembryonic Antigen in Non-Small Cell Lung Cancer

Background and Objectives: Lobe-specific nodal dissection (L-SND) is currently acceptable for the dissection of early-stage non-small cell lung cancer (NSCLC) but not for cancers of more advanced clinical stages. We aimed to assess the efficacy of L-SND, compared to systemic nodal dissection (SND). Materials and Methods: We retrospectively collected the clinical data of patients with carcinoembryonic antigen (CEA) abnormality who underwent complete resection of NSCLC via lobectomy or more in addition to either SND or L-SND at two cancer-specific institutions from January 2006 to December 2017. Results: A total of 799 patients, including 265 patients who underwent SND and 534 patients who underwent L-SND, were included. On multivariate analysis, thoracotomy, more than lobectomy, cN1-2, advanced pathological stage, adjuvant treatment, and EGFR or ALK were strongly associated with SND. No significant differences were found in overall survival, disease-free survival, and overtime survival after propensity adjustment (p = 0.09, p = 0.11, and p = 0.50, respectively). There were no significant differences in local (p = 0.16), regional (p = 0.72), or distant (p = 0.39) tumor recurrence between the two groups. Conclusions: SND did not improve the prognosis of NSCLC patients with CEA abnormality. Complete pulmonary resection via L-SND seems useful for NSCLC patients with CEA abnormality.

Uniportal VATS left lower lobectomy: Fissure first technique

This video tutorial describes a left lower lobectomy performed by the uniportal approach. A single 2-cm incision in the lateral chest wall is used as the utility port. The procedure begins with division of the inferior pulmonary ligament and isolation of the inferior pulmonary vein. This patient has densely adherent interlobar nodes, which are then dissected to demonstrate the interlobar pulmonary artery. Then we proceed to divide the anterior part of the fissure after identifying and safeguarding the lingular branches of the pulmonary artery. This step is followed by the division of the posterior part of the fissure after identification of the posterior branches of the pulmonary artery to the upper lobe. Then we identify the basilar trunk and divide it using endostaplers. Other branches of the interlobar artery are clearly identified, and the apicobasal artery is taken separately. This is followed by division of the inferior pulmonary vein and a systematic mediastinal nodal dissection.

288 Impact of Trainee Surgeons Performing Thyroid Procedure on Patient Safety

Introduction Impact of trainee surgeons performing thyroid procedure on patient safety Aim The primary aim was to evaluate the impact of trainee as the principal operator on patient safety in thyroid surgery. Method The data was extracted from a single consultant’s data from 2009 to 2020 in the British Association of Endocrine and Thyroid Surgeons (BAETS) National audit. Multivariable analysis of predictive factors (including trainee primary operator) for temporary and permanent hypocalcaemia was performed. Results There were 507 thyroid cases. After excluding cases with missing data in variables analysed 378 (74.5%) cases were analysed. Vocal cord palsy occurred in 5/378 (1.3%), postoperative bleeding 3/378 (0.8%), temporary hypocalcaemia 68/378 (18.0%) and permanent hypocalcaemia 20/378 (5.3%). Predictive factors analysed included hyperthyroidism 117/378 (31%), retrosternal goitre 33/378 (8%), reoperation, 43/378 (11%), total thyroidectomy 184/378 (49%), nodal dissection 21/378 (6%) and trainee principal operator 15/378 (4%). Multivariable analyses of temporary and permanent hypocalcaemia found only two variables significantly affected incidence of temporary hypocalcaemia were total thyroidectomy (OR 7.82, 95% CI 3.41-17.92, p < 0.001) and nodal dissection (OR 3.53, 95% CI 1.20-10.38, p = 0.02), and for permanent hypocalcaemia these were reoperation (OR 5.05, 95% CI 1.09-23.25, p = 0.04) and total thyroidectomy (OR 5.76, 95% CI 1.35-24.54, p = 0.018). Conclusions There was no evidence that trainee principal operator adversely affected the outcome of thyroidectomy; it is worth noting that only 4% of operations were done by trainees and so this study would support trainees undertaking more thyroidectomies as principal surgeon.

The Evolving Concept of Complete Resection in Lung Cancer Surgery

Different definitions of complete resection were formulated to complement the residual tumor (R) descriptor proposed by the American Joint Committee on Cancer in 1977. The definitions went beyond resection margins to include the status of the visceral pleura, the most distant nodes and the nodal capsule and the performance of a complete mediastinal lymphadenectomy. In 2005, the International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete and uncertain resections for international implementation. Central to the IASLC definition of complete resection is an adequate nodal evaluation either by systematic nodal dissection or lobe-specific systematic nodal dissection, as well as the integrity of the highest mediastinal node, the nodal capsule and the resection margins. When there is evidence of cancer remaining after treatment, the resection is incomplete, and when all margins are free of tumor, but the conditions for complete resection are not fulfilled, the resection is defined as uncertain. The prognostic relevance of the definitions has been validated by four studies. The definitions can be improved in the future by considering the cells spread through air spaces, the residual tumor cells, DNA or RNA in the blood, and the determination of the adequate margins and lymphadenectomy in sublobar resections.

Myoepithelial Carcinoma Arising in a Plasmacytoid Myoepithelioma of the Parotid Gland Synchronized with Melanoma: A Case Report and Review of the Literature

Myoepithelial carcinoma, also known as malignant myoepithelioma, is considered an extremely rare (0.45–1%) malignant salivary gland neoplasm. Approximately 100 cases have been reported in the English-language literature on myoepithelial carcinoma. The majority of the myoepitheliomas described in the literature have been benign, and the malignant counterpart is considered rare (<1%). Such a tumor may appear de novo or rarely develop from a preexisting pleomorphic adenoma (<20%), and in exceedingly rare cases (<0.5%), it has arisen from a benign myoepithelioma (i.e., plasmacytoid myoepithelioma). To our knowledge, no case of myoepithelial carcinoma of the parotid gland arising in a plasmacytoid myoepithelioma synchronized with melanoma has been reported to date. The treatment of myoepithelial carcinoma has been mainly surgical, including wide excision with free margins, with or without nodal dissection. The roles of chemotherapy and radiotherapy have not yet been established. We report a case of myoepithelial carcinoma of the parotid gland arising in a plasmacytoid myoepithelioma synchronized with melanoma in a 40-year-old woman. In our case, a complete response was achieved with surgery followed by adjuvant chemotherapy based on carboplatin and paclitaxel concurrent with radiotherapy.

Four cases of completion lobectomy for locally relapsed lung cancer after segmentectomy

Background Although completion lobectomy is the treatment of choice for local recurrence of non-small cell lung cancer after segmentectomy, few cases have been reported. We report four patients who underwent completion lobectomies for staple line recurrence after segmentectomy for stage I non-small cell lung cancer. Case presentation Three women aged 65, 82, and 81 years underwent completion lower lobectomy after superior segmentectomy of the same lobe for local recurrence of stage I non-small cell lung cancer. A 67-year-old man, who had a tumor recurrence on the staple line after apical segmentectomy with superior mediastinal nodal dissection for stage I non-small cell lung cancer, underwent completion right upper lobectomy. These four patients underwent segmentectomy because of comorbidities or advanced age. Local recurrence was confirmed by computed tomography-guided needle biopsy. The interval between the two operations was 37, 39, 41, and 16 months, respectively. Although minimal hilar adhesion was seen for the three completion lower lobectomies, tight adhesions after apical segmentectomy made completion right upper lobectomy quite difficult to dissect, which led to injury of the superior pulmonary vein. No recurrence was recorded after completion lobectomies for 62, 70, 67, and 72 months, respectively. Conclusions Although completion lobectomy is one of the most difficult modes of resection, among several completion lobectomies, completion lower lobectomy after superior segmentectomy without superior mediastinal nodal dissection was relatively easy to perform because of fewer hilar adhesions.

Eliminating the Burden of Lymphedema in Cancer Patients Requiring Nodal Dissections Using Prophylactic Immediate Lymphatic Reconstruction – A Case Report and Review of the Literature

Immediate lymphatic reconstruction (ILR), performed concurrently with nodal dissection, has shown promise in reducing the rates of lymphedema in patients with various types of cancers. Herein, we detail the case of a 42-year-old patient who underwent nodal dissection in the management of their melanoma. This patient underwent ILR at the time of lymph node dissection of the right axilla and was followed for 24 months. Circumferential measurements of both the operative and non-operative limbs, as well as lymphedema-specific quality of life questionnaire (LYMQOL) data, were collected at each appointment. Our patient developed lymphedema transiently at 3 months which had resolved by the 6-month follow-up and maintained favorable measures of quality of life over the course of 2 years. This novel approach has yet to be implemented as a standard of care in Canada. Such an outcome would be overwhelmingly positive for our cancer population, and on our health-care system overall.