Robot-assisted thoracic surgery (RATS) for higher stages non-small cell lung carcinoma (NSCLC) remains controversial. This study reports the feasibility of RATS in patients with stages IIB–IVA NSCLC. A single-institute, retrospective study was conducted with patients undergoing RATS for stages IIB–IVA NSCLC, from January 2015 until January 2020. Unforeseen N2 disease was excluded. Data were collected from the Dutch Lung Cancer Audit database. Conversion rate, radical (R0) resection rate, local recurrence rate and complications were analyzed, as were risk factors for conversion. RATS was performed in 95 patients with NSCLC clinical or pathological stages IIB (N = 51), IIIA (N = 39), IIIB (N = 2) and IVA (N = 3). 10.5% had received neoadjuvant chemoradiotherapy. Pathological staging was T3 in 33.7% and T4 in 34.7%. RATS was completed in 77.9% with a radical resection rate of 94.8%. Lobectomy was performed in 67.4% of the total resections. Conversion was for strategic (18.9%) and emergency (3.2%) reasons. Pneumonectomy (p = 0.001), squamous cell carcinoma (p < 0.001), additional resection of adjacent structures (p = 0.025) and neoadjuvant chemoradiation (p = 0.017) were independent risk factors for conversion. Major post-operative complications occurred in ten patients (10.5%) including an in-hospital mortality of 2.1% (n = 2). Median recurrence-free survival was estimated at 39.4 months (CI 16.4–62.5). Two- and 5-year recurrence-free survival rates were 53.8% and 36.7%, respectively. This study concludes that RATS is safe and feasible in higher staged NSCLC tumors after exclusion of unforeseen N2 disease. It brings new perspective on the potential of RATS in higher stages, dealing with larger and more invasive tumors.

Primary osseous chest wall sarcomas are rare tumours with limited evidence guiding surgical management. This study aimed to evaluate oncological outcomes, complication rates, and prognostic factors associated with survival in a large, single-institution cohort. We retrospectively reviewed 100 patients who underwent chest wall resection for primary osseous sarcoma between 1994 and 2022. Outcomes included overall survival (OS), event-free survival (EFS), local recurrence (LR), distant metastasis (DM), and postoperative complications. The cumulative incidence of LR and DM were estimated using competing risk models. Prognostic factors were analysed with Cox regression. The cohort included 79 patients with chondrosarcoma, eight with osteosarcoma, and 13 with Ewing sarcoma. Negative margins (R0) were achieved in 79%. Reconstruction was performed in 68%, most commonly with mesh. Postoperative complications occurred in 19%. Five-year OS was 79% (70–87%) for the entire cohort, and by subtype: osteosarcoma 38% (4–71%), Ewing sarcoma 67% (41–94%), and chondrosarcoma 85% (77–94%). Recurrence patterns differed, osteosarcoma showed a high 5-year risk of DM (75% (40–100%)), chondrosarcoma predominantly exhibited LR (15% (7–23%)), and Ewing sarcoma both LR (15% (0–36%)) and DM (40% (11–69%)). Notably, grade 1 chondrosarcoma showed metastatic potential, emphasizing that the risk of distant metastasis should also be considered in these low-grade tumours, with a 5-year cumulative incidence of distant metastasis was 11% (95% CI: 0–27%). Tumour size and residual tumour (R1/2) were associated with worse outcomes. Radical resection (R0) remains the most important predictor of survival. 5-year survival differs substantially by subtype (chondrosarcoma 85%, Ewing sarcoma 67% and osteosarcoma 38%), while tumour size is associated with a less favourable prognosis. Individualized reconstructive strategies enable complex resections with acceptable morbidity (19% postoperative complications).

Robot-assisted Thoracic Surgery (RATS) is well-established for complex minimally invasive thoracic surgery. Despite the available literature, robotics for complex advanced NSCLC for re-do surgery remains underexplored. We present a 55-year-old female who underwent esophagectomy with gastric pull-up reconstruction for squamous cell carcinoma (SCC) of the esophagus (cT3N2M0, stage IIIB) after neo-adjuvant concurrent chemoradiation therapy (ypT2N1 stage IIB disease). Six years later, computed tomography (CT) scan showed stage IA Thyroid Transcription Factor-1 (TTF-1) positive adenocarcinoma in the left upper lobe treated by stereotactic radiotherapy. Two years later, a SCC of the right upper lobe (RUL) was found (Fig. 1). Although locoregional therapy was preferred Pembrolizumab® was initiated with curative intent as the tumor demonstrated a high Programmed Death-Ligand 1 (PD-L1) expression. Follow-up CT-scan showed no biological response. Salvage lobectomy was proposed, and patient consent obtained. As demonstrated in the video, RATS provided great exposure to the adhesions, vascularization of the neo-oesophagus and maximal dexterity in difficult spaces. This case demonstrates the value of RATS in complex re-do thoracic surgery after immunotherapy and previous thoracotomy. Robot-Assisted Thoracic Surgery in Re-do Lung Surgery