Background: The identification of small lung nodules is challenging during mini-invasive thoracic surgery. Unable to palpate them directly, surgeons have developed several methods to preoperatively localize pulmonary nodules, including the computed tomography-guided positioning of coils or metallic landmarks (hook wire) or bronchoscopic marking. Methods: We present a series of patients scheduled for the video-assisted thoracoscopic sublobar resection of small pulmonary nodules, in which we performed preoperative percutaneous computed tomography (CT)-guided nodule localization through the injection of a mixture of indocyanine green and human albumin. Results: A total of 40 patients underwent a preoperative CT-guided injection of indocyanine green followed by VATS resection within 24 h. Patients tolerated the procedure well, no pain medication was administrated, and no complications were observed during the marking procedure. All pulmonary nodules were easily detected and successfully resected. Conclusion: the near-infrared dye marking solution of indocyanine green (ICG) with diluted human albumin was safe, effective, and easy to perform. The ICG solution has the potential to facilitate the accurate localization and resection of pulmonary nodules during VATS surgery, avoiding the risk of marker displacement/migration.

Background: Tracheal stenosis represents a fearsome complication that substantially impairs quality of life. The recent SARS-CoV-2 pandemic increased the number of patients requiring invasive ventilation through prolonged intubation or tracheostomy, increasing the risk of tracheal stenosis. Study design and methods: In this prospective, observational, multicenter study performed in Lombardy (Italy), we have exanimated 281 patients who underwent prolonged intubation (more than 7 days) or tracheostomy for severe COVID-19. Patients underwent CT scan and spirometry 2 months after hospital discharge and a subsequent clinical follow-up after an additional 6 months (overall 8 months of follow-up duration) to detect any tracheal lumen reduction above 1%. The last follow-up evaluation was completed on 31 August 2022. Results: In the study period, 24 patients (8.5%, CI 5.6–12.4) developed tracheal stenosis in a median time of 112 days and within a period of 200 days from intubation. Compared to patients without tracheal stenosis, tracheostomy was performed more frequently in patients that developed stenosis (75% vs 54%, p = 0.034). Tracheostomy and alcohol consumption (1 unit of alcohol per day) increased risk of developing tracheal stenosis of 2.6-fold (p = 0.047; IC 0.99–6.8) and 5.4-fold (p = 0.002; CI 1.9–16), respectively. Conclusions: In a large cohort of patients, the incidence of tracheal stenosis increased during pandemic, probably related to the increased use of prolonged intubation. Patients with histories of prolonged intubation should be monitored for at least 200 days from invasive ventilation in order to detect tracheal stenosis at early stage. Alcohol use and tracheostomy are risk factors for developing tracheal stenosis.

Background: Lung cancer represents a significant health concern, particularly among the elderly population. With global life expectancy increasing, the number of very elderly patients is rising. Robotic-assisted thoracic surgery (RATS) offers potential advantages over both traditional and video-assisted thoracoscopic surgery (VATS). This study aims to evaluate the feasibility and safety of RATS in very elderly patients (VEP) diagnosed with lung cancer. Methods: This retrospective study included patients who underwent major lung resections using RATS between 2015 and 2022 at two specialized centers. Patients were divided into very elderly patients (VEP, ≥80 years) and non-elderly patients (NEP, <80 years). Demographic, clinical, and surgical data were analyzed. Propensity score matching (PSM) at a 1:3 ratio was performed using clinically relevant variables that were significantly different at baseline to balance the two groups. Results: This study included 340 patients: 28 VEP and 312 NEP. Before PSM, VEP had higher ASA scores, more advanced disease stages, and increased comorbidities. Despite these differences, postoperative outcomes were comparable. Complications occurred in 42.9% of VEP and 29.8% of NEP (p = 0.16), but grade III complications were observed in 14.3% of VEP and 6.4% of NEP (p = 0.12), and grade IV complications were observed in 0% of VEP and 0.9% of NEP (p = not estimable). The mean hospital stay was 4 days in both groups (p = 0.99). Even after PSM (26 VEP vs. 71 NEP), complications, hospital stay, and 90-day mortality (3.9% in VEP, 0% in NEP) were similar. Multivariable analysis identified reduced FEV1 as a predictor of complications, while pathological stage I and lobectomy were associated with a decreased risk of complications, both before and after PSM. Conclusions: RATS is a safe and feasible option for selected very elderly patients with lung cancer, yielding outcomes comparable to younger patients.

Background: Intraoperative localisation of nodal disease in non-small cell lung cancer (NSCLC) can be challenging. Lymph node localisation via radiopharmaceuticals is used in many conditions; we tested the feasibility of this approach in NSCLC. Methods: NSCLC patients were prospectively recruited. Intraoperative peri-tumoral injections of [99mTc]Tc-albumin nanocolloids were performed, followed by removing the tumour and locoregional lymph nodes. These were examined ex vivo with a gamma probe and labelled sentinel lymph nodes (SLNs) if they showed any activity or non-sentinel lymph nodes (nSLNs) if they did not. Thereafter, the surgical field was scanned with the probe; any further radioactive lymph node was removed and labelled as “extra” SLNs (eSLNs). All specimens were sent to histology, and metastatic status was recorded. Results: 48 patients were enrolled, and 290 nodal stations were identified: 179 SLNs, 87 nSLNs, and 24 eSLNs. A total of 44 nodal metastases were identified in 22 patients, with 36 of them (82%) located within SLNs. Patients with nSLNs metastases had at least a co-existing positive SLN. No metastases were found in eSLNs. Conclusions: The technique shows high sensitivity for intraoperative nodal metastases identification. This information could allow selective lymphadenectomies in low-risk patients or more aggressive approaches in high-risk patients.

Background: Surgery represents the gold standard treatment for patients with stage I non-small cell lung cancer (NSCLC); however, up to 30% of those may experience recurrence. This study aims to identify prognostic factors for both early and late recurrence in this subset. Methods: We retrospectively analyzed the data of patients with stage IA-B NSCLC undergoing lung resection from 2013 to 2021 in four major lung cancer centers. Inclusion criteria were intentionally curative resections via either open or mini-invasive approaches plus lymph node dissection and a minimum follow-up of 36 months. Analyzed prognosticators included age, gender, smoking status, comorbidities, radiological appearance, surgical approach, intraoperative complications, pT stage and histologic subtypes. The overall and disease-free survivals and uni- and multivariable Cox regression for recurrence prediction were analyzed. Results: We collected data from 1132 consecutive patients (mean age 68.5 ± 8.8 years, 55.5% males and 20.1% smokers). After a mean follow-up of 57 ± 37 months, 908 (80.2%), patients were still disease-free, while the remaining 224 (19.8%) presented local (n = 86) or distant (n = 138) recurrences; 72 (32.1%) patients experienced reoccurrence within 12 months. The disease-free survival rate was significantly higher in the pT1a stage and in lepidic adenocarcinoma. The multivariable analysis and Cox regression showed that pT>1a (p = 0.001) and non-lepidic subtypes of adenocarcinoma (p < 0.001) were the best predictors of recurrence. Conclusions: Approximately one fifth of patients undergoing radical surgery for stage I NSCLC experienced recurrence within five years. Significant predictors of recurrence were a pT status greater than 1a and non-lepidic subtypes of adenocarcinoma.