In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.

Surgical resection is still the standard treatment for early-stage lung cancer. A multimodal treatment consisting of chemotherapy, radiotherapy and/or immunotherapy is advised for more advanced disease stages (stages IIb, III and IV). The role of surgery in these stages is limited to very specific indications. Regional treatment techniques are being introduced at a high speed because of improved technology and their possible advantages over traditional surgery. This review includes an overview of established and promising innovative invasive loco-regional techniques stratified based on the route of administration, including endobronchial, endovascular and transthoracic routes, a discussion of the results for each method, and an overview of their implementation and effectiveness.

Currently, lung transplantation outcome remains inferior compared to other solid organ transplantations. A major cause for limited survival after lung transplantation is chronic lung allograft dysfunction (CLAD). Numerous animal models have been developed to investigate CLAD in order to discover adequate treatments. The murine orthotopic lung transplant model has been further optimized over the last years. However, different degrees of genetic mismatch between donor and recipient mice have been used, applying a single, minor, moderate and major genetic mismatch. This review aims to reassess the existing murine mismatch models and to provide a comprehensive overview, with a specific focus on their eventual histopathologic presentation. This will be crucial to leverage this model and to tailor it according to specific research needs.

Objective: Intravenous (i.v.) chemotherapy for lung cancer is limited by systemic toxicities, reducing the maximum tolerated dose. Selective pulmonary artery perfusion (SPAP) with blood flow occlusion (BFO) is an endovascular loco-regional technique developed to increase local drug concentrations in lung tissue while minimizing systemic exposure. This study compares the pharmacokinetics of gemcitabine and its metabolites between SPAP-BFO and i.v. administration while evaluating safety. Design: Four groups (5 pigs/group) received gemcitabine (1.25 g/m2): i.v. for 30 min, SPAP-BFO 0% (10 min SPAP without BFO), SPAP-BFO 50% (10 min SPAP with 50% BFO), and SPAP-BFO 100% (10 sec SPAP followed by 9 min 50 sec complete BFO). Concentrations of gemcitabine (2′,2′-difluoro-2′-deoxycytidine [dFdC], prodrug) and metabolites (inactive 2′,2′-difluoro-2′-deoxyuridine [dFdU], active 2’,2’-difluoro-2’-deoxycytidine triphosphate [dFdCTP]) were measured in plasma and after 30 min in lung tissue. Results: With SPAP-BFO, no physiological effects nor acute lung damage were observed. Systemic dFdC exposure was significantly higher in the BFO 0% (vs i.v., P < 0.001; vs BFO 100%, P < 0.001) and BFO 50% (vs i.v., P < 0.01; vs BFO 100%, P < 0.01) groups. Lung tissue showed greater dFdCTP exposure with SPAP-BFO 100% over time compared to controls (P < 0.01) and BFO 0% (P < 0.05). At the end of the procedure, mean intracellular dFdCTP concentrations were significantly higher in the BFO 50% (1.43-fold, P < 0.05) and BFO 100% groups (1.95-fold, P < 0.001) compared to i.v. Conclusions: SPAP-BFO with gemcitabine is safe and significantly increases dFdCTP lung concentrations. The SPAP-BFO 100% protocol, which enhances lung dFdCTP levels while reducing systemic exposure, shows the greatest potential and warrants further investigation as an endovascular loco-regional treatment for lung cancer.

Objectives: Selective pulmonary artery perfusion with blood flow occlusion (SPAP-BFO), an experimental endovascular technique, has shown potential to enhance pulmonary drug delivery to the lung. Therefore, it becomes a potential minimally invasive technique for lung cancer and pulmonary metastases. Prior studies predominantly used animal models which do not adequately replicate human vascular anatomy, leaving the clinical feasibility of SPAP-BFO underexplored. To address this gap, we developed a patient-specific 3D model of the human venous system to evaluate the technical feasibility of SPAP-BFO. Methods: A 1:1 scale 3D model of the human venous system was developed and printed based on CT scans of a patient. This model was connected to a perfusion system to simulate blood flow, enabling testing of the catheterization procedure under realistic clinical conditions. Two commercially available balloon catheters, Coda (Cook) and Reliant (Medtronic), were selected based on length and balloon diameter, and their feasibility of reaching and occluding the left and right pulmonary arteries were assessed. Results: The model effectively simulated human anatomy and blood flow, allowing for both visual and fluoroscopic assessment of the procedure. Both Coda and Reliant catheters successfully reached the target location, when introduced via the femoral vein, and occluded the left and right pulmonary arteries without physically blocking contralateral flow or extending beyond the first bifurcation. Conclusions: This patient-specific 3D model provided a valuable platform to evaluate the clinical feasibility of SPAP-BFO. The Coda and Reliant balloon catheters demonstrated effective occlusion of the pulmonary arteries, supporting their potential use in SPAP-BFO procedures.