XXIII. Nádory hrudníku, plic, průdušek a pleury

XXIII/48. Naše zkušenosti se značením subplerurálních plicních ložisek směsí patentní modři a jodové kontrastní látky pod CT navigovanou kontrolou s následnou videotorakoskopickou (VTS) klínovitou resekcí. Retrospektivní studie. Pohled intervenčního radiologa

Červeňák V.1, Chovanec Z.2, Berková A.2, SOUČKOVÁ L.3, VANÍČEK J.1

1 Klinika zobrazovacích metod LF MU a FN u sv. Anny v Brně, 2 I. chirurgická klinika LF MU a FN u sv. Anny v Brně, 3 Český národní uzel Evropské sítě infrastruktur klinického výzkumu (CZECRIN), Brno

Východiska: Subpleurálně uložená ložiska v plicním parenchymu nejsou perioperačně chirurgem viditelná. K jejich vizualizaci, popřípadě vizualizaci oblasti, ve které se nacházejí, je možno použít několik technik. Příkladem je implantace radiokontrastních drátků či spirálek do oblasti zájmu pod CT navigovanou kontrolou nebo použití lipiodolu a jeho následná verifikace skiaskopicky pod C-ramenem perioperačně. Potažmo je možnost použití perioperačního ultrazvuku, jehož výtěžnost je vzhledem ke vzdušnosti plicního parenchymu omezená. Jako další možnost je značení pomocí barvy. Na našem pracovišti jsme zavedli právě metodu značení pomocí barvy, a to směsí Patent Blue a jodové kontrastní látky pod CT kontrolou. Značení bylo prováděno v den plánované operace za přítomnosti hrudního chirurga. V prvním kroku bylo provedeno kontrolní CT vyšetření plic pacienta s následným provedením značení 0,5 ml směsi jodové kontrastní látky a patentní modře (1 ml Omnipaque 350 mg I/ml a 2 ml Patent Blue V Sodium Injection 2,5%) v lokální anestezii. Poté bylo provedeno kontrolní CT s porovnáním lokalizace značeného ložiska a kontrastní látky a posouzení komplikací značení. Následně byl pacient transferován na operační sál a odoperován. Cíl: Cílem naší studie bylo v první fázi (radiologické) zhodnotit úspěšnost a proveditelnost značení oblasti plicního parenchymu se subpleurálním ložiskem. Byla vyhodnocena úspešnost značení v korelaci s peroperační viditelností označeného okrsku a periprocedurální komplikace při značení. Rovněž bylo cílem ověření možnosti zavedení této metody do rutinní praxe. Výsledky: Zkoumaný soubor obsahuje 63 pacientů, kterým bylo provedeno značení celkem na 63 (100 %) ložiscích. Z celkového počtu bylo značení viditelné na 58 (92,06 %), rozpité bylo na 2 (3,17 %), neviditelné na 3 (4,76 %) ložiscích a 1 (1,58 %) ložisko bylo označeno na jiném místě, než se nacházelo. Celkově tedy metoda selhala u 6 (9,52 %) subjektů. Z celkového počtu 63 (100 %) ložisek se u 1 (1,58 %) vyskytla komplikace hematom a u 8 (12,69 %) komplikace PNO. Závěr: Metoda značení subpleurálně uložených plicních ložisek pod CT kontrolou směsí Patent Blue a kontrastní látky se jeví jako bezpečná a efektivní metoda s minimem periprocedurálních komplikací. Poskytuje chirurgovi možnost přesné vizualizace označeného okrsku plicního parenchymu pro extraanatomickou resekci pomocí VATS. Nutná je úzká spolupráce radiologa a chirurga.

XXIII/85. Fine-tuning surgical oncology by MERATS trial

Horváth T.

Department of Surgery, University Hospital Brno, Faculty of Medicine, and Masaryk University Brno, Czech Republic

Purpose: Exact dialogue of progress with tradition in the surgery of the lung. Chartered guideline of European Journal of Cardio-Thoracic Surgery [1] is used to seeking for new solutions in pulmonary surgical oncology. The exploration of the arguments of authorities, personal experience, partners dissimilarity and local requirements is intended. Results: All phases of pulmonary surgical oncology are discussed in the trial: A) preoperative; B) admission; C) perioperative; D) postoperative. Every item of the protocol enables implementation of authentic decision: 1) yes; 0) no; 2) adjusted; 3) other. The individual solutions in any particular component of guideline emerging from individual experience and educational background of the attending operating surgeon are recorded into common coded database. These are available for all study participants treat each other as equals. This way of individual independent decisions making is connected with genuine feedback, and open to any critical opinion. Discretionary research and publication of every individual item is realizable. Conclusion: The analysis of the outcomes will provide authentic data for precise arrangement medical and organizational. The research can find change tack for balanced universal recommendations.

The author belongs to MERATS group 202306: CZ: Thoracic surgeons of University Hospital Brno, University Hospital of St. Anne, Masaryk Memorial Cancer Institute, Centre for Cardiovascular and Transplantation Surgery Brno, SurgalClinic Brno, Bata Hospital Zlín, SK: University Hospital Martin; University Hospital Banská Bystrica.

References: [1] Batchelor TJ, Rasburn NJ, Abdelnour-Berchtold E et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). European Journal of Cardio-Thoracic Surgery 2019; 55 (1): 91–115.

XXIII/86. Transcervical lobectomy

Zielinski M.

Department of Thoracic Surgery, Pulmonary Hospital “Odrodzenie” Zakopane, Poland

Objective: The aim of the study is a description of surgical technique of uniportal transcervical video-assisted thoracoscopic surgery (VATS) for pulmonary lobectomy. Material and methods: Operative technique: we used a collar neck incision (transcervical) of an average length 5–8 cm. The manubrium of the sternum is elevated with a hook connected to the Zakopane II frame (Aesculap-Chifa, BBraun, Nowy Tomyśl, Poland). The first step is a transcervical extended mediastinal lymphadenectomy (TEMLA), for improved staging and possible improved survival. The nodes removed during TEMLA undergo intraoperative imprint cytology examination. In case of no metastasis, a uniportal VATS lobectomy through the neck follows. Ventilation of the operated lung is disconnected and the pleural cavity is entered by opening of the mediastinal pleura. Pleural adhesions, if present are managed with electrocautery. The branches of the pulmonary artery and vein are sequentially dissected and managed with endostaplers or vascular clips. The lobar bronchus and the fissures are divided with endostaplers and the resected lobe is removed in an endobag. Results: There were 40 patients operated on in the period 1. 2. 2016–30. 6. 2023. There were four conversions – in one patient with left lower lobe tumor, we had to convert to uniportal VATS left lower lobectomy due to extensive adhesions. In one patient undergoing right lower lobectomy and the other patient undergoing left lower lobectomy, there were conversions to thoracotomy because of the bleeding from the pulmonary artery. In the last patients, conversion to thoracotomy was done due to the technical difficulties. There was one postoperative death (cardiac infarct) and complications occurred in four patients. The mean operative time was 185 min (135–385 min) for the whole TEMLA procedure with imprint cytology and lobectomy and 138 min (130–140 min) for the last 10 operations. Conclusions: A uniportal transcervical video-assisted thoracoscopic surgery (VATS) approach for pulmonary lobectomy combined with transcervical extended mediastinal lobectomy (TEMLA) provides an opportunity for radical pulmonary resection and superradical extensive mediastinal lymphadenectomy.

XXIII/87. Spontaneous ventilation with double lumen tube intubation is mission impossible! Or is it still possible?

Szabo Z.

Institut of Surgical Research University of Szeged, Hungary

Background and objective: Traditionally intubated, ventilated general anaesthesia with muscle relaxant and positive pressure one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections for all patients. An adequate analgesia technique (regional or epidural) allows VATS to be performed in anesthetized patients and the potential adverse effects related to general anaesthesia and mechanical one lung ventilation can be avoided but combination of spontaneous respiration and double-lumen tube intubation can be avoided the main disadvantageous factors of general and also the non-intubated techniques. Results: The mechanical one-lung ventilation time could be reduced by this technique with > 75% using the beneficial effects of spontaneous ventilation to ensure safe anesthesiological and surgical conditions, similar to gold standard methods. Conclusion: The combination of spontaneous ventilation with double lumen tube intubation, method seems to be suitable for reducing these risk factors, which may serve as an alternative for patients not suitable for the non-intubated technique in the near future.

XXIII/88. Role of anesthesiology in lung cancer programme in National Taiwan University Cancer Center

Cheng Y.

National Taiwan University Cancer Center Taipei, Taiwan

A rapid progress and growing on precise thoracic operations for lung cancers has been developed. In newly opened National Taiwan University Cancer Center (NTUCC), OR CT room and hybrid OR have made the surgeon, the anaesthesiologist, and the radiologist work as a close team. However, there remains extreme necessity for precision on preoperative diagnosis, staging, and making strategy before treating lung cancers with rapidly developed target therapy, gene therapy, etc. Bilateral sampling or tumors near mediastinum are unfavourable in transcutaneous CT-guided biopsy. More amount of tissue is also expected for gene analysis. In recent years, more interventional pulmonology teams have set up to meet those goals. Besides bronchoscopic examinations and trans-bronchial needle aspiration (TBNA), bronchoscopic interventions (BIs), combining with echography, CAT scan, and navigation, have benefits for precise interventions for diagnosis, staging, treatment, and palliative interventions. Consequently, more time, more flexible and stable interventional fields with variable probes are necessary for BIs. A complete anaesthetic team joined the BI team after setting a hybrid bronchoscopy room from November 2019 in NTUCC. As anaesthetic management are challenging with BIs with open, shared, manipulated airways, the backup system is also crucial for catastrophic complications such as massive bleeding with BIs. Therefore, our hybrid bronchoscopic room was set up near the OR and shared with the same PACU care. In addition to the pulmonologist, anaesthesiologist, radiologist, our pathologist joins the BI team to achieve higher yield rate by rapid on-site examination (ROSE). Up to date, more than 2,000 BIs have been performed for diagnosis, staging, treatment, and follow-up including 120 tracheobronchial tumor excision. The average BI time was about 60 minutes. More than 60% of patients received EBUS-TBB/transbronchial cryobiopsy. According to the experience in non-intubated VATS, we developed non-intubated BIs (NIBIs) to provide the full flexibility of variable larger probes or cryotherapy for complete operability. EEG-guided total intravenous anesthesia is induced with spontaneous breathing. Airway or oxygenation are supported with either supraglottic airways (iGel) or high flow nasal oxygen (HFNO). Bronchoscopic spray of local anaesthetic from vocal cords to bilateral bronchioles are routinely performed before starting BIs. In our retrospective analysis, use of cryoprobes remain to be the most risky of tracheobronchial bleeding and resuscitation. Intraprocedural desaturation (SPO2 < 90%) and hypotension (SBP < 90 mmHg) occurred in about 20% and 30% of patients during BIs with suction and balloon compression for bleeding, respectively. However, more than 96% of OPD patients discharged from OPD with limited adverse effects. NIBIs provide patients a comfortable and safe experience with rapid recovery. With close collaboration between bronchoscopists, surgeons, radiologists, anaesthesiologists, and pathologists, we have built a new program for patients with lung pathology with higher yield rate on preoperative diagnosis and staging and less mediastinoscopy. Bronchoscopic tracheobronchial tumor excision or removal of granulations after airway stents could be performed repeatedly to maintain patients’ life quality. Hybrid bronchoscopy room and our team in NTUCC makes BIs more powerful to meet the variable goals precisely. However, anaesthesia for BIs remains the most risky and challenging. The location, the setting, and the quick availability of all support team including ECMO should be put into before BI room construction. Our experience showed that non-intubated BIs is routinely doable and safe with limited complications.

XXIII/89. Role of surgery in lung cancer programme at NTU Cancer Center

Lin M. W.

National Taiwan University Hospital Taipei, Taiwan

Low-dose computed tomography (CT) screening has recently increased the detection rate of early-stage lung cancer. The surgical techniques and policies for managing screen-detected early-stage lung cancer are different from those for advanced lung cancer. Over the past decade, various innovative tumor localization methods and surgical management policies have been developed specifically for these patients. During this session, I will share our institution’s experience regarding to screen-detected lung nodule localization techniques. Additionally, I will present the studies related to the surgical policies of sublobar resection at our institute. These novel techniques and surgical policies have the potential to assist physicians in the management of screen-detected early-stage lung cancer.

XXIII/90. Spontaneous ventilation thoracic surgery European view

Furak J.

Albert Szent-Gyorgyi Medical School University of Szeged, Hungary

To reduce this surgical stress and the systemic inflammation (SI), video-assisted thoracoscopic surgery (VATS) as a minimally invasive procedures can be applied, and additionally on the anesthesiology side the non-intubated thoracic surgery (NITS) was developed. In the early 2000’s a group in Tor Vergata University, Rome published their first results regarding awake non-intubated patients, and in 2014, Gonzales-Rivas performed the first non-intubated uniportal video assisted lobectomy. Despite the advantage of the NITS on the postoperative results, this procedure was not widely accepted, because of the objection of the anesthesia. To exclude the “unsafe” airway, the most criticized point of the NITS, the spontaneous ventilation combined with double lumen tube intubation (SVI) technique was developed in our clinic. Between 26. 1. 2017 and 30. 11. 2018, 160 NITS operations were performed in our clinic, including 100 VATS NITS lobectomies: the operative time was 94.1 (55–170) min, the drainage time was 3.4 (1–22) days, the prolonged air leak was 10%, and the numbers of removed mediastinal lymph nodes were 11 (3–31). Surgical conversion rate to thoracotomy was 7.5%. As an oncological advantage of the NITS, during the adjuvant treatment the grade 1–2 toxicity and the grade 4 neutropenia were significantly less after NITS than in relaxed cases. Between 3. 11. 2020 and 26. 3. 2021, 155 SVI surgeries were performed, with 58 VATS SVI lobectomies. The SVI procedure was complete with 3–5 PEEP and O₂ supply in 73.7%. In 13.1% of the cases, additional pressure support ventilation was necessary to keep the normal gas exchanges, and in 13.1%, relaxation was necessary.

XXIII/91. The IASLC lung cancer staging project – towards the 9th edition of the TNM Classification

Rami-Porta R.

Hospital Universitari Mútua Terrassa Barcelona, Spain

The staging project of the International Association for the Study of Lung Cancer (IASLC) has spanned for > 25 years, and has been in charge for the revisions of the tumour, node and metastasis (TNM) classification of lung cancer, epithelial thymic tumours and pleural mesothelioma. At the time of this writing, the members of the IASLC Staging and Prognostic Factor Committee (SPFC) and the biostatisticians of Cancer Research and Biostatistics (CRAB) are finalizing the revisions towards the 9^th edition of the TNM classifications of these thoracic malignancies due to be published in 2024 [1]. For the revision of the TNM classification of lung cancer, 87,043 evaluable patients were collected from around the world: 73,197 (84%) with non-small cell lung cancer (NSCLC), 5,530 (6%) with small cell lung cancer and 8,316 (10%) with other types of lung cancer, including carcinoid tumours and lung cancers with multiple lesions. In addition, nearly 10,000 patients with NSCLC have information on molecular data [2]. Regarding the T component of the classification, the analyses already performed have confirmed the 8^th edition categories and descriptors with the 9^th edition database. Specific analyses to explore whether there are prognostic differences among the T3 descriptors, namely chest wall/parietal pleura vs other T3 descriptors, did not find any significant differences. Finally, the survival analysis in those patients who had received induction therapy compared with that of those who had undergone upfront resection showed that pathologic (p) T categories after induction therapy (ypT) had worse prognosis than the same pT category with no induction. This will not affect the T categories or their descriptors, but it is a useful information to refine postoperative prognosis for those patients who undergo induction treatment. For the N component, the analyses of the 9^th edition database have confirmed the prognostic relevance of clinical and pathologic quantification of nodal disease based on the number of involved nodal stations; and the worse prognosis of ypN compared with pN. This will not affect the N categories, either, but will allow the refinement of postoperative prognosis for those patients undergoing induction therapy. The new analyses on the M component have confirmed the prognostic relevance of the number and location of extrathoracic metastases that suggest some changes in the 8^th edition M categories. In conclusion, in the 9^th edition lung cancer TNM, most likely there will be no changes in the T categories; there might be some changes in the N categories depending on the number of involved nodal stations; and some small change in the M categories is likely to happen.

References: [1] Rami-Porta R, Goldstraw P, Asamura H. Commemorating the silver anniversary of the international association for the study of lung cancer international workshop on intrathoracic stagingJ Thorac Oncol 2021; 16 (6): 902–905. [2] Asamura H, Nishinura KK, Giroux DJ et al. IASLC Lung Cancer Staging Project: The New Database to Inform Revisions in the Ninth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol 2023; 18 (5): 564–575.

XXIII/116. Časná detekce plicního karcinomu prostřednictvím proteinových biomarkerů ve vydechovaném vzduchu

Hajdúch M.1, Václavková J.1, Vrbková J.1, Holub D.1, Fischer O.2, Bendová M.1, Kultan J.2, Turčáni P.3, Jakubec P.2, Džubák P.1

1 Ústav molekulární a transakční medicíny, LF UP v Olomouci, 2 Klinika plicních nemocí a tuberkulózy LF UP a FN Olomouc, 3 Centrum pneumologie a intervenční bronchologie, MOÚ Brno

Karcinom plic je v ČR jedním z nejčastějších typů karcinomu, a především u žen počet diagnostikovaných případů stále roste. Karcinom plic je obvykle spojován se špatnou prognózou a krátkou dobou přežití. Pokud je ale karcinom plic diagnostikován v časném stadiu, úspěšnost léčby výrazně vzroste. Proto byl v ČR v roce 2021 zahájen preventivní screening, v rámci kterého je u rizikových skupin prováděno vyšetření s využitím LCDT. Stále však probíhá výzkum, který je zaměřen na vývoj neinvazivních metod, jež by doplnily v současnosti používané metody a příp. umožnily preventivní screening širšího spektra lidské populace. S tímto cílem jsme se zaměřili na vyšetření kondenzátu vydechovaného vzduchu. Kondenzát vydechovaného vzduchu je považován za bohatý zdroj biomarkerů vyskytujících se v dýchacím traktu. Mezi zmiňované biomarkery patří proteiny, metabolity kyseliny arachidonové, vazoaktivní peptidové aminy, DNA, RNA, mikroRNA a řada malých molekul. Naším výzkumným cílem je analýza proteinů v kondenzátu vydechovaného vzduchu. Vzorky kondenzátu vydechovaného vzduchu jsou sbírány s využitím přístroje Turbo 14/Turbo DECCS System od zdravých jedinců a pacientů s nemalobuněčným karcinomem plic. Účastníci studie dýchali s volným nosem do přístroje po dobu 10 min. Proteiny v odebraném vzorku byly rozpuštěny, denaturovány, redukovány, štěpeny trypsinem a následně byly přečištěny pomocí StageTip technologie. Připravené vzorky byly měřeny pomocí vysokorozlišovací hmotnostní spektrometrie ve třech technických replikátech. Hmotnostně spektrometrická data byla vyhledána v programu Proteome Discoverer verze 2.5 a dále statisticky zpracována pomocí nástrojů Statistica a Bioconductor R. V rámci studie vyšetření kondenzátu vydechovaného vzduchu bylo napříč všemi vzorky od 226 jedinců identifikováno 4 806 proteinů a z nich bylo 4 179 kvantifikováno alespoň v jednom ze tří technických replikátů. Statistické zpracování dat bylo kombinací univariátní, multivariátní a citlivostní analýzy a výsledkem bylo navržení 72 potenciálních biomarkerů, které mohou odlišit nemalobuněčný karcinom plic od pacientů s chronickou obstrukční plicní nemocí a od zdravých jedinců. Výsledky této studie jsou slibné a budou dále studovány a validovány v zahájené prospektivní klinické studii paralelně s pilotním screeningovým programem. Validační fáze v současné době probíhá s využitím cílené hmotnostně spektrometrické analýzy SureQuant. Plánovaným cílem této studie je vyvinutí kitu nezávislého na hmotnostní spektrometrii pro preventivní screening karcinomu plic.

XXIII/117. Perioperační systémová léčba nemalobuněčného karcinomu plic

Bílek O.

Klinika komplexní onkologické péče LF MU a MOÚ Brno

Východiska: Přibližně 20 % případů nemalobuněčného karcinomu plic (NSCLC) je diagnostikováno v operabilním stadiu. Pacienti, kteří podstoupí chirurgickou resekci, jsou následně v riziku relapsu onemocnění, které se zvyšuje s pokročilostí klinického stadia. Adjuvantní systémová léčba: cílem adjuvantní terapie je léčba mikrometastatického onemocnění a prevence recidivy, zároveň umožňuje dřívější resekci primárního tumoru jako potenciálního zdroje mikrometastáz. Adjuvantní chemoterapie zlepšuje pětileté celkové přežití (OS) cca o 5 %. U pacientů s NSCLC klinického stadia IB–IIIA s prokázanou mutací EGFR (del19 či L858R) je standardně indikována adjuvantní léčba EGFR-TKI III. generace osimertinibem. Studie s atezolizumabem (IMpower 010) a pembrolizumabem (PEARLS/KEYNOTE-091) prokázaly benefit adjuvantní imunoterapie checkpoint inhibitory. Neoadjuvantní systémová léčba: cílem neoadjuvantní léčby je zmenšení velikosti nádoru, zvýšení pravděpodobnosti R0 resekce a léčba časného mikrometastatického onemocnění. Neoadjuvantní chemoterapie zlepšuje 5leté OS cca o 5 %. Předoperační imunoterapie přináší potenciál výrazné a trvající protinádorové odpovědi. K léčebné odpovědi může přispět vyšší fenotypová plasticita nádorových antigenů přítomného tumoru. Dále lze u časných stadií NSCLC očekávat vyšší pravděpodobnost vysoké mutační nálože (TMB). Byla navržena řada studií s checkpoint inhibitory v monoterapii. Následné studie kombinující checkpoint inhibitory s chemoterapií (NADIM, NADIM II a Checkmate 816) prokázaly významný přínos neoadjuvantní chemoimunoterapie s významným zlepšením parametrů kompletní patologické remise (pCR) a větší patologické odpovědi (MPR). Závěr: Perioperační imunoterapie a adjuvantní léčba EGFR-TKI jsou standardní součástí léčebného algoritmu operabilních stadií NSCLC. Stanovení léčebného postupu spadá do kompetence multidisciplinárního týmu. Probíhají další studie hodnotící přínos perioperační imunoterapie a využití dalších cílů terčové léčby.

XXIII/118. Časový interval a vyšetření histologických vzorků

Fabian P.

Oddělení onkologické patologie, MOÚ Brno

Východiska: Tlak na co nejrychlejší dodání výsledků histopatologických vyšetření provází všechny obory medicíny, v pneumoonkologii je pak tento tlak ještě výraznější. Cíl: Popis metodiky histopatologie s důrazem na každodenní praxi a nástin časové osy vyšetření. Popis technických i personálních faktorů limitujících celkový čas odezvy laboratoře. Závěr: Aktuální možnosti léčby navázané na molekulární vyšetření přinášejí do patologie nové výzvy, neboť stanovením histologické klasifikace malignity proces diagnostiky – tak jako dříve – nekončí, ale začíná. Laboratoř patologie musí od prvního kontaktu s biologickým materiálem směřovat k jeho maximálnímu využití v rámci všech dostupných metod. Diskuze s klinickým kolegou nad metodikami odběru a fixace materiálu je nanejvýš žádoucí. Maximální součinnost všech zúčastněných odborností povede k rychlejší, přesnější a komplexnější diagnostice, a tedy i k lepší léčbě.

XXIII/119. Naše zkušenosti se značením subpleurálních plicních ložisek směsí Patentní modře a jodové kontrastní látky pod CT navigovanou kontrolou s následnou videotorakoskopickou (VTS) klínovitou resekcí. Retrospektivní studie. Pohled hrudního chirurga

Chovanec Z.1, Červeňák V.2, Berková A.1, Součková L.3, Penka I.1

1 I. chirurgická klinika LF MU a FN u sv. Anny v Brně, 2 Klinika zobrazovacích metod LF MU a FN u sv. Anny v Brně, 3 Český národní uzel Evropské sítě infrastruktur klinického výzkumu (CZECRIN), Brno

Východiska: Subpleurálně uložená ložiska v plicním parenchymu nejsou perioperačně chirurgem viditelná. Jejich detekce je nejčastěji prováděna pomocí šetrné palpace, která může být v některých případech technicky možná jen za cenu torakotomie. Je obecně známo, že videotorakoskopie (VTS) je pro pacienta šetrnější než torakotomie. K úspěšnému provedení operačního zákroku torakoskopickou metodou je ale nutné subpleurálně uložené ložisko, příp. oblast, ve které je lokalizované, vizualizovat. Cíl: Cílem naší studie bylo v první fázi zhodnotit úspěšnost a proveditelnost značení oblasti plicního parenchymu se subpleurálním ložiskem lokalizovaným ne více než 25 mm od parietální pleury, směsi jodové kontrastní látky a patentní modře aplikované pod CT navigovanou kontrolou intervenčním radiologem v den plánované operace. V druhé fázi byla zhodnocena vizualizace značené oblasti chirurgem perioperačně, úspěšnost provedené VTS extraanatomické resekce, délka operace, pooperační komplikace v podobě bronchopneumonia a pooperačního air leaku, délka hospitalizace a 30denní pooperační mortalita. Výsledky: Do souboru bylo v letech 2017–2023 zařazeno celkem 66 pacientů. Úspěšně byla provedena vizualizace barvené oblasti operatérem s následnou VTS klínovitou resekcí u 55 pacientů. Z první fáze studie byli vyřazeni tři pacienti (2× regrese nálezu v den operace, 1× nevhodná indikace k VTS). Celkem bylo úspěšně označeno 63 pacientů, z toho operatérem byla vizualizována značená oblast v 58 případech (92,06 %). Konverze na torakotomii byla nutná u tří pacientů (4,77 %). Onkologická diagnóza byla potvrzena ve 38 případech (61,3 %). Resekce in sano byla 100 %. Průměrná doba operace byla 55 minut, pooperačně byl air leak u šesti pacientů (9,7 %). Průměrná doba zavedení hrudního drénu byla 2,7 dne vč. operačního dne, průměrná doba hospitalizace byla 4,2 dny. Pooperační pneumonie a komplikace vedoucí k operační revizi nebyly zaznamenány u žádného pacienta. Rovněž nebyla zaznamenána žádná alergická reakce. 30denní mortalita byla 0 %. Závěr: Perioperační vizualizace značeného plicního parenchymu intervenčním radiologem směsí patentní modře a jodové kontrastní látky je dostatečná k provedení radikální VTS extraanatomické resekci s minimálními pooperačními komplikacemi. Nicméně je nutná těsná spolupráce intervenčního radiologa a hrudního chirurga nejenom v době indikace pacientů k danému typu výkonu, ale i v době provádění značení na CT. Otázkou je nahrazení extraanatomické klínovité resekce technicky náročnější resekcí anatomickou v podobě segmentektomie.

XXIII/171. Vliv závažných nežádoucích účinků na účinnost léčby nivolumabem u nemalobuněčného karcinomu plic

Blažek J.1, Hošek P.2, Hrabcová K.3, Bratová M.4, Kultan J.5, Hrnčiarik M.6, Černovská M.7, Zemanová P.8, Krejčí J.9, Svatoň M.10

1 Klinika pneumologie a ftizeologie LF v Plzni UK a FN Plzeň, 2 Biomedicínské centrum, LF v Plzni UK, Plzeň, 3 Institut biostatistiky a analýz, Brno, 4 Klinika nemocí plicních a tuberkulózy LF MU a FN Brno, 5 Klinika plicních nemocí a tuberkulózy LF UP a FN Olomouc, 6 Plicní klinika LF v Hradci Králové UK a FN Hradec Králové, 7 Pneumologická klinika 1. LF UK a FTN Praha, 8 Onkologická klinika 1. LF UK a VFN v Praze, 9 Klinika pneumologie 3. LF UK a FN Bulovka Praha, 10 Klinika pneumologie a ftizeologie LF v Plzni UK a FN Plzeň

Cíl: Cílem práce bylo prozkoumat možný vliv nežádoucích účinků léčby nivolumabem na účinnost léčby u pacientů s nemalobuněčným karcinomem plic (NSCLC). Zaměřili jsme se na závažné nežádoucí příhody, tj. stupně ≥ 3. Hodnotili jsme celkové přežití (OS), přežití bez progrese (PFS) a také objektivní odpověď na léčbu (ORR). Soubor pacientů a metody: Retrospektivně jsme analyzovali soubor pacientů z databáze TULUNG s NSCLC léčených nivolumabem v osmi onkologických centrech. Z tohoto souboru jsme vyhodnotili data pro OS. Pro snížení možného zkreslení jsme dále hodnotili podskupinu pacientů léčených ve FN Plzeň, kde výskyt nežádoucích účinků, PFS a ORR nezávisle kontrolovali dva zkušení lékaři. Statistiky přežití byly vyhodnoceny pomocí Kaplan-Meierovy metody a Coxovy analýzy. Výsledky: Pozorovali jsme signifikantně vyšší OS, PFS a ORR ve skupině pacientů s nežádoucími účinky léčených nivolumabem vs. u pacientů bez nich. Přestože univariační model na celkovém souboru dat pacientů prokázal vyšší OS u pacientů se závažnými nežádoucími účinky, u Coxova multivariačního modelu byl pozorován pouze nevýznamný trend. V podskupině pacientů s hodnocením PFS a ORR jsme pozorovali signifikantní lepší rozdíly u pacientů se závažnými nežádoucími účinky. Závěr: Pacienti se závažnými nežádoucími účinky vykazují tendenci k lepšímu OS, PFS a ORR ve srovnání s pacienty bez/s mírnými nežádoucími účinky při léčbě nivolumabem.

XXIII/211. Cirkulující nádorová DNA koreluje s hladinou LDH, CYFRA 21-1 a CRP u pacientů s pokročilými nemalobuněčnými plicními karcinomy

Svatoň M.1, Burešová M.1, Benešová L.2, Minárik M.3, Hošek P.4, Baxa J.5, Pešek M.1, Fiala O.6, Ptáčková R.2, Hálková T.2

1 Klinika pneumologie a ftizeologie LF v Plzni UK a FN Plzeň, 2 Centrum aplikované genomiky solidních nádorů, Genomac výzkumný ústav s. r. o., Praha, 3 Elphogene, Praha, 4 Biomedicínské centrum, LF v Plzni UK, Plzeň, 5 Klinika zobrazovacích metod LF v Plzni UK a FN Plzeň, 6 Onkologická a radioterapeutická klinika LF v Plzni UK a FN Plzeň

Východiska: ctDNA i některé laboratorní parametry a onkomarkery představují prognostické markery u nemalobuněčného plicního karcinomu (NSCLC). Jejich vztahy však nebyly dosud podrobněji zkoumány. Cílem naší práce proto bylo nalézt potenciální asociaci mezi vybranými nádorovými markery a laboratorními parametry (laktátdehydrogenáza (LDH), neutrofily, hemoglobin, neutrofily, lymfocyty, C-reaktivní protein (CRP), albumin, karcinoembryonální antigen a cytokeratin 19 fragment 21-1 (CYFRA 21-1)) a cirkulující nádorovou DNA (ctDNA). Pacienti a metody: Studie zahrnovala 82 pacientů léčených ve FN Plzeň. Všichni pacienti měli (lokálně) pokročilé adenokarcinomy. ctDNA byla stanovena před zahájením léčby a po 6 týdnech sledování. Laboratorní parametry byly měřeny před každým cyklem terapie a onkomarkery před zahájením terapie jako standardní klinická praxe. Pro statistickou analýzu odpovídajících proměnných byl použit Mann-Whitney U test, Coxův model proporcionálních rizik, Fisherův exaktní test a Kaplan-Meierův odhad přežití s Gehan-Wilcoxonovým testem. Výsledky: Prokázaly statisticky významný vztah mezi hladinami LDH a onkomarkerem CYFRA 21-1 a přítomností, či nepřítomností ctDNA v době diagnózy. Prokázali jsme též významně nižší hladiny CRP u pacientů, u kterých během léčby vymizela ctDNA. Podobný, ale statisticky nevýznamný trend byl pozorován u LDH. Závěr: CYFRA 21-1, LDH a pravděpodobně CRP korelují s hladinami ctDNA u NSCLC. Opakované měření těchto markerů by tak mohlo pomoci při včasné detekci progrese onemocnění stejně jako monitorování ctDNA.

XXIII/338. Imunoterapie u pacientů s karcinomem plic na Masarykově onkologickém ústavu – účinnost, bezpečnost a náklady

Bártová A., Říhová B.

Farmakologický ústav, LF MU Brno

Východiska: Cílem analýzy bylo provést komplexní hodnocení účinnosti a nákladů checkpoint inhibitorů (pembrolizumab, nivolumab, durvalumab, atezolizumab a nivolumab v kombinaci s ipilimumabem) u pacientů s metastatickým nebo lokálně pokročilým karcinomem plic (NSCLC) na základě reálných klinických dat. Součástí analýzy je také přehled výskytu imunitně podmíněných nežádoucích příhod u těchto pacientů. Soubor pacientů a metody: Retrospektivní analýza byla provedena u 129 pacientů s metastatickým nebo lokálně pokročilým NSCLC, kteří absolvovali imunoterapeutickou léčbu na Masarykově onkologickém ústavu mezi lety 2017 až 2022. Do analýzy byli zahrnuti pouze pacienti, jejichž léčba byla vykázána pojišťovně. Sbírány byly jak demografické údaje o pacientech pro charakterizaci souboru pacientů, tak data týkající se toxicity a průběhu léčby checkpoint inhibitory. Jako konečný výstup bylo určeno přežití bez známek progrese (PFS). Data byla analyzována deskriptivními a interferenčními statistickými metodami. Výsledky: Nejčastěji používaným checkpoint inhibitorem byl pembrolizumab (40,31 % pacientů), následovaný byl nivolumabem (34,88 %). U 46,51 % pacientů byly inhibitory nasazeny v 1. linii léčby, zatímco u zbylých 53,49 % pacientů byly použity ve 2., 3. a 4. linii. Nejdelší doba léčby (medián 6,47 měsíce) a zároveň nejvyšší hodnota mediánu PFS (8,25 měsíce) byly zaznamenány u durvalumabu. Následoval pembrolizumab s mediánem doby léčby 4,85 měsíce, mediánem PFS 5,03 měsíce a atezolizumab s mediánem doby léčby 4,16 měsíce, mediánem PFS 4,96 měsíce. Imunitně podmíněná nežádoucí příhoda byla zaznamenána u 38,76 % pacientů (50/129). Průměrné náklady na léčbu jednoho pacienta checkpoint inhibitorem v monoterapii se pohybují okolo 700 000 Kč, přičemž nejnákladnějším inhibitorem je pembrolizumab a následně nivolumab. Závěr: Výsledky této práce přinášejí přehled účinnosti, bezpečnosti a nákladů checkpoint inhibitorů u NSCLC v reálné klinické praxi. Při jejich použití je potřeba brát v úvahu i výskyt imunitně podmíněných nežádoucích příhod, jejichž riziko může ovlivnit rozhodnutí o indikaci.

XXIII/351. Diagnostika a léčba plicního karcinomu pro praktické lékaře v kostce

Jakubíková L.1,2, Turčáni P.2

1 Centrum pneumologie a intervenční bronchologie, MOÚ Brno, 2 Klinika nemocí plicních a tuberkulózy LF MU a FN Brno

Zhoubný nádor plic je v ČR třetím nejčastějším nádorovým onemocněním u mužů i žen. Nejčastěji se vyskytuje po 55. roce života, ale setkat se s ním můžeme i u velmi mladých lidí. I když byla prokázána přímá souvislost mezi kouřením a rakovinou plic (průměrně se uvádí, že rakovinu plic způsobuje kouření 20 cigaret denně po dobu 20 let nebo 40 cigaret denně po dobu 10 let), existuje poměrně značný počet pacientů nekuřáků, u kterých byla rakovina plic diagnostikována. K dalším rizikovým faktorům vzniku karcinomu plic patří pasivní kouření nebo vliv škodlivého životního, případně pracovního prostředí. U karcinomu plic neexistují časné varovné signály, které by umožnily zachytit nemoc v počátečním stadiu. Jakmile se příznaky objeví, jedná se o pokročilé stadium. Zjištěné časné stadium rakoviny plic má největší šanci na dlouholeté přežití, u kuřáků s 20 cigaretami/den po dobu 20 let v rizikovém věku nad 55 let je pak možno využít programu časného záchytu rakoviny plic s pravidelně prováděnými low dose CT vyšetřeními. Moderní léčebné postupy s použitím imunoterapie pro nejpokročilejší stadia plicní rakoviny sice významně prodloužily dobu přežití u nemocných, kteří na léčbu reagují, ale nadále platí, že jen časné stadium onemocnění je možno zásadně ovlivnit chirurgicky s úplným uzdravením. Role praktického lékaře je v diagnostice nepokročilých nádorů plic chirurgicky řešitelných stěžejní s cílem vyhledávání rizikových osob podle vstupních kritérií (věk, kuřáctví v anamnéze, počet vykouřených cigaret) a s motivací k účasti v programu časného záchytu karcinomu plic. Další péči už organizuje a indikuje pneumolog. Na MOÚ probíhá sledování těchto rizikových pacientů na plicní ambulanci s pravidelnými CT vyšetřeními, v případě pozitivního nálezu je předveden na hrudní komisi MOÚ a řešen ve spolupráci s hrudními chirurgy přímo v Ústavu či ve spolupracujícím chirurgickém zařízení s erudovanými hrudními chirurgy. V prezentaci jsou rovněž představeny možnosti endoskopické bronchologické diagnostiky vč. radiálního UZ u perifernějších lézí a lineárního endobronchiálního UZ nutného pro posouzení mediastinálních a hilových LU u pacientů před radikálním chirurgickým zákrokem. Zásady léčebné strategie vč. shrnutí významných pokroků v léčbě a smysluplnosti jejího podávání v komplexních centrech pak doplňují celou prezentaci určenou zejména pro praktické lékaře, aby tak dostali komplexní pohled na možnosti diagnostiky a léčby, které jsou v Centru pneumologie a intervenční bronchologie na MOÚ nabízeny.

XXIII/352. Thorax chapter of youthful surgery project

Ledvina T.

Department of Surgery, Hospital Ivančice, Czech Republic

Theoretical knowledge and practical skills are inextricably linked and form the structural elements of surgical thinking and actions. Extraction of significant data from contemporary overabundance of information and fostering of the integrity of the field are fundamental questions with which medical students and young doctors grapple. And they are not the only ones. The fundamental information of thoracic surgery, which was present at the beginning of this activity, still persists and elicits an outline of leading connections: There is negative pressure in the interpleural space. It is protected by a firm, yet pliable thoracic cage. Negative pressure can be counteracted by a pneumothorax. A pneumothorax can be both the subject and means of treatment. The first action to take in order to restore the pathologically disrupted negative pressure in the pleural cavity – the pneumothorax – is gradient chest drainage with a water seal. In this case, the pneumothorax is the subject of treatment. Disruption of the negative pressure in the pleural cavity by using pneumothorax as means of treatment has a current medical application in thoracic surgery under spontaneous ventilation (spontaneous ventilation thoracic surgery – SVTS). The Czech surgical school aims for a very close concept of physiological surgery, which means maximal utilisation of natural mechanisms for treatment of pathology; thoracic in the given case. Both bronchial and arterial trees have segmental structure. Pulmonary lymphatics have segmental distribution. This is of major importance, in both technically surgical and oncological sense. The pulmonary venous vasculature is profiled intersegmentally. This is important for the support of venous return to the left atrium which results from the mechanics of breathing and also, from the surgical technical point of view, for precise separation of segments on the intersegmental level. Knowledge of the anatomy and mechanics of the thoracic cage is helpful in solving pathological situations with specific procedures – for example the scarcely used but effective posterior upper chest drainage. Knowledge of breathing regulation, shrouded in mystery up to now, is helpful for adequate management of the pain, the importance of which in thoracic traumatology and surgery is crucial. Among other means, medical students acquire practical knowledge and skills thank to the Simulation Center of the Faculty of Medicine of Masaryk University before they enter practice. Therefore, the next logical challenge could be the completion of contemporary teaching methods by adding adequate teaching materials – comprehensive and concise, but an exhaustive overview of surgery. We are trying to do just that.

XXIII/353. Perioperative criteria of quality in thoracic surgery

Peštál A., Chovanec Z., Prudius V., Daňa P., Hanslík T.

First Department of Surgery, Faculty of Medicine, Masaryk University, and St. Anne’s University Hospital Brno, Czech Republic

Monitoring and evaluation of the quality of health care provided should be a routine medical practice. Recently, there has been a strong emphasis on this activity by both the provider and the professional community. Evaluating the quality of healthcare provided can be assessed on the basis of clearly defined criteria or by monitoring compliance with recommended procedures. The Ministry of Health of the Czech Republic together with the Agency for Health Research of the Czech Republic and the Institute of Health Information and Statistics of the Czech Republic, launched a project in 2020 – National portal of clinical guidelines. However, the programme on thoracic surgery has not been proposed yet. Recommendations for the care of patients with NSCLC may be the Clinical Standard for Comprehensive Care of Patients with NSCLC, published by the Czech Pneumological and Phthisiological Society, and updated in 2019. Recommendations issued by the Czech Society of Oncology are in the form of the so-called Blue Book, which is updated about twice a year. Taking into account our membership in the EU, it is possible to follow the recommendations issued by the ESTS. Here, we can use the ERATS recommendations issued in 2018. The recommendations were established on the basis of a consensus of leading specialists in the field of thoracic surgery, intensive care, internists, but also physiotherapists, etc. Clinically relevant criteria can be further based on the three main parameters monitored, which include the occurrence of postoperative sepsis, the need for transfusions and 30-day mortality. More parameters can be proposed, e. g. number of R1 resections, number of rehospitalizations, number of patients with prolonged postoperative air fistula, number of reoperations, assessment of the incidence of major postoperative complications according to the Clavien-Dindo classification, etc. However, in terms of monitoring criteria of major clinical importance, it is sufficient to use only the three abovementioned criteria. In the context of evaluating the long-term effect of cancer treatment, we primarily evaluate DFI, OS and QOL. Another criterion is the total cost of the treatment process for an identical initial diagnosis. This economic criterion should also be taken into account, but should not be a priority criterion for physicians. Correct monitoring of the criteria is only possible on the basis of data collection through the creation of an appropriate database. At present, data are available from Institute of Health Information and Statistics of the Czech Republic.

XXIII/354. Chest ultrasound reduces the roentgenograms after thoracic surgery. Could artificial intelligence play a role there?

Malík M.1, Dzian A.1, Števík M.1, Vetešková Š.2, Hliboký M.3, Magyar J.3, Kolárik M.3, Bundzel M.3, Babič F.3

1 Klinika hrudníkovej chirurgie, Jesseniova lekárska fakulta v Martine Univerzity Komenského v Bratislave a Univerzitná nemocnica Martin, Slovenská republika, 2 Rádiologická klinika, Jesseniova lekárska fakulta v Martine Univerzity Komenského v Bratislave a Univerzitná nemocnica Martin, Slovenská republika, 3 Fakulta elektrotechniky a informatiky, Technická univerzita v Košiciach, Slovenská republika

Background: In various fields of medicine, lung ultrasound proved its superiority over chest X-ray in diagnostics of lung and pleural pathologies. Based on growing evidence, lung ultrasound could reduce the chest X-ray and radiation in postoperative care after non-cardiac thoracic surgery. Subjectivity and investigator dependence of lung ultrasound, investigator education and learning curve are discussed. Despite the simplicity of the basic ultrasound signs the trials from thoracic surgery have shown that complex lung ultrasound protocols and experienced investigator are mandatory to achieve high accuracy and to decrease the numbers of inconclusive results. We assumed, that evaluation of the lung ultrasound videos using artificial intelligence and the visualization of the lung ultrasound signs could solve some of the above-mentioned issues and thus help to implement the lung ultrasound into daily routine in postoperative care after thoracic surgery. Patients and methods: Patients after non-cardiac thoracic surgery will receive lung ultrasound every time the standard chest X-ray will be indicated. Artificial intelligence will be trained to identify the lung ultrasound signs used in the Bedside Lung Ultrasound in Emergency (BLUE) protocol: lung sliding, B-lines, A-lines, lung point, pleural effusion, and lung consolidations. Results: Artificial intelligence was trained to detect the pleural line, the presence or absence of lung sliding, A-lines and B-lines. Automated M-mode classification was used to evaluate the presence or absence of lung sliding. The balanced accuracy, sensitivity and sensitivity were 89, 82 and 92%, respectively. Analytical computer vision methods were used to detect B-lines with an 89% accuracy rate. For A-lines, an 81% accuracy was achieved using a hybrid solution that combined neural networks training in pleura detection and analytical methods. Conclusion: Lung ultrasound can reduce chest X-ray after thoracic surgery. Artificial intelligence could play a role in the objectifying of the lung ultrasound findings, in shortening of the learning curve and in decreasing of the inconclusive results numbers. Our preliminary results confirmed the feasibility of artificial intelligence in detection of the important lung ultrasound signs. Our research will continue with the training of the artificial intelligence in the detection of the rest of the lung ultrasound signs from BLUE protocol and in improvement of the lung sliding, A-lines and B-lines detection.

This research is funded by the Slovak Research and Development Agency, grant number APVV 20-0232.

XXIII/355. Future of surgical oncology in the countries of the Czech Crown

Klein J.*

Department of Surgery, Tomáš Baťa Regional Hospital, Zlín, Czech Republic

Surgical oncology is a highly complex field. The best clinical outcomes can be achieved only by coordinated care of multiple specialties and various healthcare facilities. The role of each involved institution, from primary care physicians to tertiary centers, is unique and irreplaceable. The main aims of the national cancer programs remain across different countries very same – early diagnosis, minimal delays in the investigation process, and a choice of treatment strategy based on a shared decision-making model involving not only experienced clinicians but also patients and their relatives. In the Czech Republic, the key components of surgical oncology care are Complex Oncology Centers (COC). Their strategic selection is paramount. Setting a clear cut-off for caseload requirements is challenging and differs across countries and subspecialties of surgical oncology. During COC accreditation process, other parameters such as morbidity and mortality outcomes, the capacity of the center, experience with the complex management of postoperative complications as well as patients’ factors such as commuting distance and accessibility to continuous psychosocial support should be evaluated. All above have a significant impact on the overall outcome of often frail patients and should be carefully considered. The thoracic surgical oncology care is provided by eight Lung Cancer Surgery Centers, which received the official accreditation approved by the Ministry of Health of the Czech Republic for the period from 30^th June 2023 to 31^st December 2027. The adequate case volume, reflecting also the complexity of the pulmonary resections, is an important aspect. The right selection tools, assessing both hospital caseload and other above-mentioned factors, should be chosen wisely and most importantly with the involvement of other healthcare facilities participating in thoracic cancer care.

* The author belongs to MERATS group 202306: CZ: Thoracic surgeons of Faculty of Medicine Masaryk University at University Hospital Brno, St. Anne’s University Hospital, Masaryk Memorial Cancer Institute, Centre for Cardiovascular and Transplantation Surgery Brno, Surgal Clinic Brno, and Tomas Bata Regional Hospital Zlín. SK: Thoracic surgeons at University Hospital Martin, and Faculty Hospital Banská Bystrica.

XXIII/356. Multilateral trial for enhanced recovery after thoracic surgery (MERATS)

Horváth T.*

Department of Surgery, Faculty of Medicine, Masaryk University, and Faculty Hospital Brno, Czech Republic

Objectives: The suggestion of unified methodology used for the research of results at different circumstances emerged from the shift in the professional accents, in patients routing, and small attention payed to particular details. The base for the multilateral trial is the Guideline published in the European Journal of Cardio-Thoracic Surgery [1]. Study description: All phases of surgical care are explored in 45 items altogether: Preoperative phase has 8, admission 3, perioperative 26, and postoperative 8 components. Feasible options for appropriate decision are offer for every item of the protocol: 1/ yes 0/ no 2/adjusted 3/other. The individual solution in any particular component comes out of knowledge and experience of attending thoracic surgeon. Every decision is recorded into common database. Every subject is coded. That way the anonymity is guaranteed. The database is available for all specialists participated on the trial. Everybody of the team can study any result from their own angle of view. The coworkers from the team are chosen freely according own discretion. Exact dialogue of the progress and tradition is enabled by Implementing regulations of MERATS trial comprise: 1) partners equality by Round Table conception in the process of multifaceted verification of working procedures; 2) joint statement of professional participants onto the trial containing a) the form of data collection, b) independent data processing and interpretation, c) agreement on conditions for publication of individually chosen topic, d) agreement on conditions for publication of aggregate outcomes, e) potential withdrawal from the contract; 3) informed consent between a patient and physician covers information on medical, ethical, legal, and organizational requirements of the trial including guarantee of security electronically coded data, and potential abandonment of the trail. Conclusion: The outcomes will provide authentic data for precise decision making process by conducting survey of general tendencies and genuine feedback of electronically collected records. Progressive medical and organizational solutions can be found.

References: [1] Batchelor TJ, Rasburn NJAbdelnour-Berchtold E et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS^®) Society and the European Society of Thoracic Surgeons (ESTS). European Journal of Cardio-Thoracic Surgery 2019; 55 (1): 91–115.

* The author belongs to MERATS group 202306: CZ: Thoracic surgeons of Faculty of Medicine Masaryk University at Faculty Hospital Brno, Faculty Hospital of St. Anne, Masaryk Memorial Cancer Institute, Centre for Cardiovascular and Transplantation Surgery Brno, Surgal Clinic Brno, and Bata Hospital Zlín, SK: Thoracic surgeons at University Hospital Martin, and Faculty Hospital Banská Bystrica.

XXIII/357. Surgical strategy in the treatment of lower esophagus and cardia

Jedlička V.

Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic

Surgical management of distal esophageal and cardia cancer offers multiple options. The choice of the optimal surgical approach depends on the anatomical location and size of the lesion, the relationship of the tumour to the surrounding structures, and the status of the nodes (PET, EUS). The overall condition of the patient (usually after chemotherapy or chemoradiotherapy) also has a significant influence on the surgical treatment. Siewert classification is only one of the factors influencing the treatment approach, especially in locally advanced cases, where preoperative staging often shows a considerable degree of inaccuracy. Surgical access, extent of resection and lymphadenectomy continue to show considerable variability across the world. This presentation summarizes the controversies and current trends.

XXIII/358. Salvage surgery for advanced lung adenocarcinoma after epidermal growth factor receptor tyrosine kinase inhibitor treatment

Lin M. W.

Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan

Lung cancer is the leading cause of cancer-related death, and more than 60% of cases are found to be stage III or IV at the time of initial diagnosis. Epidermal growth factor receptor (EGFR) mutation is the most common mutation found in patients with lung cancer in Asia, and tyrosine kinase inhibitors (TKIs) are the first-line treatment for those with advanced stages. Several retrospective studies showed the possible survival benefit associated with salvage surgery after TKI treatment in patients with stage III–IV non-small cell lung cancer (NSCLC). In our recent published study, we reported the clinicopathological features of patients with lung adenocarcinoma that underwent TKI therapy followed by salvage surgery before clinical disease progression. Viable tumor cells in the tumor bed were categorized as morphologically treatment sensitive or morphologically treatment resistant. Acquired EGFR exon 20 T790M mutation, high-grade tumor with tumor necrosis, and histologic transformation were present only in regions of the tumor that were morphologically tumor resistant. Tumor heterogeneity raises the possibility of sampling error when patients undergo tumor re-biopsy to analyze the drug-resistant mechanisms. The presence of morphologically treatment resistant tumor regions signaled the emergence of resistant subclones before clinical disease progression. In conclusion, salvage surgery after EGFR TKI treatment in selected advanced-stage lung adenocarcinoma patients before clinical disease progression may contribute to disease control by removing residual viable tumor cells and preventing the progression of TKI-resistant tumor subclones.

XXIII/359. Contemporary spontaneous ventilation thoracic surgery

Lin M. W.

Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan

In thoracoscopic surgery, the traditional approach involves intubated general anesthesia with one-lung ventilation. However, in recent decades, non-intubated thoracoscopic surgery (NITS) has emerged as an alternative method to reduce the negative impacts associated with intubated general anesthesia. Non-intubated procedures have shown to result in fewer adverse events compared to tracheal intubation and general anesthesia, including airway injury related to intubation, lung injury caused by ventilation, extended hospital stays, and postoperative nausea and vomiting. Despite being less invasive, NITS has demonstrated comparable effectiveness to conventional intubated VATS. Numerous comparative studies have reported similar operative times and blood loss volumes between the two approaches. Moreover, non-intubated techniques impose minimal technical challenges on surgeons and contribute to a shorter overall surgical time by eliminating the need for anesthesia induction. During this session, I will share our institute‘s experience with NITS.

XXIII/360. Transcervical thymectomy

Zielinski M.

Department of Thoracic Surgery, Pulmonary Hospital “Odrodzenie”, Zakopane, Poland

Objective: The aim of this article is to describe the technique of minimally invasive extended thymectomy performed through the transcervical video-thoracoscopic (VATS) approach with elevation of the sternum for the thymic tumors with/without myasthenia gravis (MG). The transcervical can be used solely or in combination with a subxiphoid and VATS approaches. Methods: The sole transcervical operation is done through the collar incision in the neck of a length of 4–8 cm. To facilitate an access to the mediastinum a one-tooth hook connected to the Zakopane bar (Aesculap-Chifa, Nowy Tomysl, Poland) is inserted under the sternal notch for elevation of the sternum. Careful anatomical dissection of the structures of the lower neck region is done with preservation from injury of the thyroid gland, the parathyroid glands and both laryngeal recurrent nerves. The thymus gland is resected en-bloc with the surrounding fatty tissue of the lower neck and the anterior superior mediastinum. The blood vessels supplying the thymus are secured and divided – these are inferior thyroid veins and the thymic veins. For better control, a video-thoracoscope (VATS) is inserted to the mediastinum through the cervical incision. The lowers poles of the thymus are separated from the pericardium and the specimen is removed. Usually, the right lower pole is dissected first and the left lower pole is managed during further dissection of the aortopulmonary window is a difficult, but very important part of transcervical thymectomy. In the combined transcervical – subxiphoid – VATS approach, the transcervical incision is supplemented with a subxiphoid approach. Operations are performed under control of a videothoracoscope inserted bilaterally to both pleural cavities. Results: The sole transcervical approach was used in 18 patients (2 for MG with associated thymic tumors and 16 for the tumors/cysts of the anterior mediastinum without MG) in the period 1/1/2009 to 31/12/2017. The morbidity was 5.6%, with no mortality. The mean time of the procedure was 105.4 min (45–150 min). The combined transcervical – subxiphoid – VATS approach was used in 392 patients with nonthymomatous MG and in 8 patients with thymomas associated with MG and in 4 patients for repeated thymectomy (rethymectomy).The mean operative time for the combined transcervical – subxiphoid – VATS approach was 118.5 min. (85–130 min). There was no mortality and less than 5% morbidity. The complete remission rate 53.1% for the transcervical-subxiphoid-VATS maximal thymectomy approach for non-thymomatous MG was reported. Conclusions: The transcervical approach combined with VATS and lifting of the sternum facilitates thymectomy in case of small thymic tumors with/without MG. This technique is more difficult and less extensive than subxiphoid thymectomy. The combination of transcervical approach with a subxiphoid and VATS approaches is highly effective for the treatment of patients with nonthymomatous MG, thymomas associated with MG and for rethymectomies.

XXIII/361. The criteria for completeness of resection surgery in lung cancer

RAMI-PORTA R.

Department of Thoracic Surgery, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, Spain

The residual tumour descriptor (R) indicates whether there is microscopic (R1) or macroscopic (R2) residual cancer after lung cancer resection, no residual tumour (R0) or the presence of residual tumour cannot be assessed (Rx). However, the R0 does not indicate how the cancer resection is performed. To overcome this limitation, individual thoracic surgeons, scientific societies and cooperative groups have proposed their own definitions of complete resection. While these were useful in their respective settings, none was fully accepted or implemented internationally. One of the initial projects of the International Association for the Study of Lung Cancer (IASLC) Staging Project was to propose a definition of complete lung cancer resection that resulted from an international and multidisciplinary consensus. After revising the previous definitions, the IASLC Staging and Prognostic Factors Committee proposed a definition of complete resection in 2005 [1]. The criteria were: negative bronchial, vascular and any peripheral resection margin, confirmed microscopically; systematic nodal dissection or lobe-specific systematic nodal dissection; no extracapsular invasion in lymph nodes removed separately or those in the periphery of the resected specimen; the highest (most cranial) mediastinal lymph node removed must be negative. This definition includes the R0 descriptor, but goes beyond it including a standardized lymphadenectomy. As a counterpart, any of the following conditions would define incomplete resection (R1–R2): tumour invasion of resected margins; extracapsular involvement of the lymph nodes removed separately or in the periphery of the lung specimen; unremoved invaded lymph nodes; or positive pleural or pericardial effusion. Yet, there are resections with no proven residual disease, but that do not fulfil all the criteria of complete resection. These were defined as uncertain resections. They must have negative resection margins, but the intraoperative nodal assessment did not meet the criteria for systematic nodal dissection or lobe-specific systematic nodal dissection; or the highest (most cranial) mediastinal lymph node removed is positive; or there is carcinoma in situ at the bronchial margin; or positive pleural lavage cytology. The prognostic value of the IASLC definitions of completeness of lung resection have been validated in single institutional series, in an international database, in population-based registries, and, specifically, for patients with pN2 [2]. The survival of complete resection is significantly better than that of uncertain resections, and the survival of these is better that that of incomplete resections.

References: [1] Rami-Porta R, Witekind C, Goldstraw P et al. Lung Cancer 2005; 49 (1): 25–33. [2] Rami-Porta R. The evolving concept of complete resection of lung cancer surgery. Cancers 2021; 13 (11): 2583.

XXIII/362. ESTS mission in global lung cancer fighting

Furak J.

University of Szeged, Hungary

ESTS basic statement: “Our mission is to improve quality in all aspects of our specialty: from clinical and surgical management of patients to education, training and credentialing of thoracic surgeons in Europe and worldwide.” Today, we are living in the revolutionary time of the thoracic surgery and lung cancer treatment. According to this statement and the new hot topics like robotic thoracic surgery, perioperative immunotherapy, and sublobar resection, the ESTS has responsibility to help every thoracic surgeon to be familiar in managing the new challenges. For this purpose, many events are organized. During the annual meetings there will be many presentations and discussions about these hot topics of our daily practice. The new trends of the technical background of our practice will be introduced in the technical village of the conference. In the ESTS School project in 2023/24 there are 5 courses (chest wall, VATS lobectomy basic-intermediate, knowledge track, minimal invasive esophagectomy and anastomosis) and 8 webinars (esophagus cancer, TNM9., ECMO in thoracic surgery, lung volume surgery, gender bias in thoracic surgery, lung transplantation, malignant mesothelioma, rare diseases in pediatric thoracic surgery) to give an up dated information about the surgical treatment of the lung cancer. On the ESTS homepage there are many guidelines, videos and surveys to help the members and to show the activity of the ESTS in the global lung cancer fighting. One of the most actual webinar was the lung cancer screening in Europe.

XXIII/363. Spontaneous ventilation thoracic surgery – how we do it

Hudáček K.1, Koláček T.1, Kališ V.1, Horváth T.2

1 Clinic of Anesthesiology, Resuscitation and Intensive Medicine, Faculty of Medicine, Masaryk University, and University Hospital Brno, Czech Republic, 2 Clinic of Surgery, Faculty of Medicine, Masaryk University and University Hospital Brno, Czech Republic

Concerned for severe periprocedural complications and the difficult postoperative recovery of polymorbid patients indicated for thoracic surgery (for various reasons) with one-sided lung ventilation (OLV), a mini-invasive approach (non-intubated thoracic surgery – NITS) not only from the surgeon but also from the anesthesiologist is a frequent choice in recent decades. In this way, complications associated with double lumen tube (DLT) intubation, where there is a risk of tracheal injury and subsequent OLV with a known pathophysiological implications, can be avoided. Also, there is no need for relaxation and imminent postoperative residual muscular blockade, so recovery from anesthesia and subsequent rehabilitation are faster. Contraindications of NITS include obesity, gastroesophageal reflux disease, large pleural adhesions and significant pulmonary movement. Since 2016, when NITS program started in our hospital, more than 30 patients underwent this type of surgery. Of course, the covid-19 pandemic has temporarily interrupted these procedures. From different possibilities, we chose the approach of BIS-controlled general anesthesia (TCI propofol) oxygenation, while maintaining spontaneous ventilation is managed by HFNO (AirVO with Optiflow) and the operation itself under local anesthesia performed by a surgeon. Infiltration port entries by local anesthetic followed by intercostal block of 3^rd to 9^th intercostal space with ypsilateral blockage of the vagal nerve to suppress cough and facilitate lung lobe manipulation. In three of them, intubation of DLT with OLV was necessary due to excessive chest breathing movements after unilateral PNO by surgeon, which could not be influenced by deepening the sedation. Two times, acute intubation with muscle relaxation in the lateral position was required due to massive blood loss and subsequent conversion to open thoracotomy. In two other cases, the surgeon indicated periprocedural conversion to thoracotomy with the necessity to perform pneumonectomy due to massive bleeding (in one case, and a finding not correlating with CT and technically impossible VATS lobectomy in another case). Both patients managed the procedure breathing spontaneously without the need of intubation.

XXIII/364. Anesthetic (r) evolution from the conventional concept to the minimally invasive techniques in thoracic surgery

Szabo Z.

Institute of Surgical Research Minimally Invasive Techniques in Thoracic Surgery

University of Szeged, Hungary

Objective: Thanks to the growing experience with the non-intubated anesthetic and surgical techniques, most pulmonary resections can now be performed by using minimally invasive techniques. Background: The conventional method, i.e., surgery on the intubated, ventilated patient under general anesthesia with one-lung ventilation was considered necessary for the major thoracoscopic lung resections for all patients. An adequate analgesic approach (regional or epidural anesthesia) allows VATS to be performed in anesthetized patients and thus the potential adverse effects related to general anesthesia and mechanical one-lung ventilation can be avoided. Key content and findings: After reviewing the literature, different “schools” were identified with different techniques but with very similar results. Most of the differences were in the anesthetic technique, oxygenation and analgesia, however, the immunological results, and the qualitative parameters (inpatient hospital care days, complication rate, mortality) of the perioperative period showed great similarity, in addition, all three schools identified the same risk factors (hypoxia, hypercapnia, airway safety). Conclusions: Based on the results, non-intubated thoracic surgery appears to be an increasingly widespread, safe procedure, that will be available to a wider range of patients as experience expands and by the implication of the constantly evolving, new processes, featured by an efficiency equal to or greater than that of the gold standard procedures.

XXIII/365. Spontaneous breathing with double lumen tube intubation – worth the trouble?

Fabó C.

University of Szeged, Department of Anesthesiology and Intensive Therapy, Hungary

Background and objective: Maintained spontaneous breathing under surgical procedures has several well-known beneficial effects. Combination of spontaneous breathing and double-lumen tube intubation is a novel and promising anesthetic technique for thoracic surgery. However we have limited knowledge about the safety and the feasibility of this method. Methods: In our anesthetic approach the anesthesia induction and maintenance was performed with fentanyl and propofol target – controlled infusion. The depth of anaesthesia was monitored by following bispectral index, with a target range 40–60. We used mivacurium chloride as a short acting muscle relaxant for providing optimal conditions for double-lumen tube intubation and early surgical steps. Locoregional anesthetic techniques such as local infiltration prior chest opening and deep intercostal nerve blockade were applied. Followed by the vagal nerve blockade to diminish cough reflex. After elimination of muscle relaxant effect, the patients were let to breathe spontaneously without any cough during surgical manipulation. Retrospective data collection and analysis was performed, to assess the safety and identify the potential limiting factors of our technique. Results: In 2021 and 2022, 77 intended uniportal video assisted lobectomies were performed. In 8 cases (10.4%) due to oncologic reasons conversion to thoracotomy was needed. The mean maximal carbon dioxide pressure was 60.2 (37.7–81.7) mmHg and mean lowest oxygen saturation was 94.18 (86–100) %. The mean one-lung, mechanical, and spontaneous one-lung ventilation time was 84.45 (43–140), 19.52 (0–115), and 64.78 (0–130) min, respectively. The mean minimum and maximum breathing frequencies were 11.94 (6–20) and 18.86 (12–30) min, respectively. Conclusion: According to this new anesthetic approach the mechanical one lung ventilation time could be reduced by 78.6%. Spontaneous ventilation with double-lumen tube intubation was safe and feasible for video assisted and for open lobectomies as well. This method combines the beneficial effects of spontaneous ventilation with maximal patient safety.

XXIII/366. Role of anesthesiology in spontaneous ventilation thoracic surgery

CHENG Y. J.

Department of Anesthesiology, National Taiwan University Medical School, Taiwan

In non-intubated thoracic surgery (NITS) or spontaneous ventilation thoracic surgery (SVTS) with spontaneous ventilation, the negative side effects of injuries from endotracheal tubes and mechanical OLV are prevented or reduced, including dysphagia, sore throat, hoarseness, volutrauma, barotrauma, residual muscle weakness, etc. With EEG-controlled TIVA (targeted intravenous anesthesia), amnesia and analgesia could be optimized. However, unlike the traditional ETGA, the anesthetic goals of SVTS are to maintain adequate, smooth spontaneous ventilation. Inhibition from central nervous system to respiratory muscle function should be minimized especially in SVTS with OLV and surgeons’ manipulations. According to the above goals, the anesthetic combinations have to be precisely reconsidered to match the stress along surgical procedures. Locoregional anesthesia, which blocks the sensory input, is the best way to alleviate surgical stimulations. The selection of locoregional anesthesia is goaled to match blockade for the corresponding surgical stimulations. In NTUH, local anesthetic is infiltrated before establishing the first thoracoscopy port. After artificial pneumothorax, breathing is severely affected immediately with gradual collapsing of lungs. Thoracoscopic intercostal nerve blocks (TINBs) could be performed with direct vision of spreading of local anesthetics along within the sheath, then respiration becomes smoother. EEG monitoring and hemodynamic changes along with the sequential VATS operations help the anesthetic team to identify the adequacy effects of locoregional anesthesia and to adjust the systemic anesthetics. With close team communication, locoregional anesthesia could be performed by both surgeons and anesthesiologists. The key consideration is the targeted onset time and its effects. Adequate locoregional anesthesia could spare the requirement of systemic anesthetics which inhibit respiration. In anesthetic perspective, epidural anesthesia could be more controlled than paravertebral blocks with pre-inserted catheters. However, TINBs remain to be the most favorable locoregional anesthesia with adjustable, predictable blocks immediate before operations with less preoperative hypotension. For anatomical resection with manipulations on bronchioles or trachea, vagal nerve blockade is most helpful to relieve the cough reflex induced by surgical traction of airways. However, anesthesiologists could provide a motionless field for surgeons to perform vagal nerve blocks. A short-acting intravenous anesthetic is preferred to avoid prolonged apnea. With close cooperation and monitoring between anesthesia and surgical teams, respirations becomes smooth and stable about 10 minutes after OLV and TINBs. Permissive hypercapnia is allowable with optimal anesthesia and it will back to normal after emergence. Without TIVA or narcotic overdose, the respiratory patterns could be maintained near normal without massive mediastinal movement. Locoregional anesthesia could be repeated with a diluted regimen for postoperative analgesia. The postoperative recovery is enhanced in previous reports. For long-term results on cancer surgeries, SVTS with locoregional anesthesia is also beneficial for less biotrauma in lung parenchyma, optimal systemic inflammatory immune responses, and less postoperative opioids requirement. In conclusion, precise, pre-emptive anesthetic combinations for SVTS indicate the upmost collaboration. The learning of SVTS is from the preoperative patient’s assessment and selection, intraoperative management, and postoperative recoveries. The precise, smooth, gentle SVTS for different teams could be developed with higher performance on each expertise.

XXIII/367. Český program časného záchytu nádorů plic od roku 2022

Špelda S.1, Horváth T.2

1 Klinika komplexní onkologické péče LF MU a MOÚ Brno, 2 Chirurgická klinika LF MU a FN Brno

Bronchogenní karcinom patří mezi nejčastěji se vyskytující nádory s aktuální incidencí cca 60/100 000 osob u mužů a 50/100 000 osob u žen. Většina nádorů je diagnostikována v pokročilém stadiu vylučujícím radikální operaci, která je technicky možná asi u 15–20 % osob s diagnostikovaným bronchogenním karcinomem ve stadiu I–II. Tento nízký podíl resekabilních nádorů se dlouhodobě nemění. Přínos screeningového CT hrudníku u rizikových osob byl prokázán randomizovanými klinickými studiemi – NLST v USA, NELSON v Nizozemí a Belgii. Cílovou populací byli vždy dlouhodobí kuřáci. V americké studii NLST bylo prokázáno 20% snížení mortality u preventivně vyšetřovaných osob. V holandsko-belgické studii NELSON bylo zaznamenáno 24% snížení mortality u preventivně vyšetřovaných osob. V ČR byl pilotní program screeningu bronchogenního karcinomu zahájen 1. 1. 2022. LDCT vyšetření je nabízeno následující populaci: kuřák či exkuřák, alespoň 20 balíčkoroků, věk 55–74 let, ochota k zanechání kouření, ochota zúčastnit se projektu a setrvat v něm po dobu 5 let, ochota podstoupit CT vyšetření (podpis informovaného souhlasu na radiologickém pracovišti). Vylučujícím kritériem je přítomnost závažné komorbidity, která by limitovala životní výhled pacienta v nejbližších 5 letech. V případě negativního nálezu se předpokládá opakované LDCT vyšetření v 1–2letém intervalu. U osob s pozitivním CT nálezem bude další péče realizována v pneumoonkochirurgickém centru. Cílem programu je zlepšení diagnostiky plicních nádorů v časných klinických stadiích I–II z nynějších 15–20 na 70 %.

XXIII/368. Perioperative immunotherapy in non-small cell lung cancer

Bílek O.

Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, and Masaryk Memorial Cancer Institute, Brno, Czech Republic

A small proportion of resected patients with non-small cell lung cancer remain recurrence-free after 5 years. Perioperative chemotherapy has been shown to improve 5-year survival by in this setting. Clinical trials with perioperative immunotherapy have shown highly positive results. Neoadjuvant therapy has the potential to reduce tumor size, increase the probability of complete resection, and treat early micrometastatic disease. Higher phenotypic plasticity of the tumor antigens of the present tumor is associated with the treatment response. Clinical trials with nivolumab (Checkmate 816) or pembrolizumab (KEYNOTE-671) demonstrated a significant benefit of neoadjuvant immunotherapy. The primary goal of adjuvant treatment is the treatment of micrometastatic disease and prevention of recurrence. Data are available from clinical trials with atezolizumab (IMpower010) and pembrolizumab (PEARLS/KEYNOTE-091). Adjuvant treatment studies evaluate disease-free survival (DFS) or event-free survival (EFS). Neoadjuvant clinical trials use parameters pathologic complete response (pCR) and major pathologic response (MPR).