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OBJECTIVES To investigate the impact of lung window (LW) and mediastinal window (MW) settings on the clinical T classifications and prognostic prediction of patients with subsolid nodules. METHODS Seven hundred and nineteen surgically resected subsolid nodules were reviewed, grouping into pure ground-glass nodules (n = 179) or part-solid nodules (n = 540) using LW. Interobserver agreement on nodule classifications was assessed via kappa-value, and predictive performance of the solid portion measurement in LW and MW for pathological invasiveness and malignancy were compared using receiver-operating characteristic analysis. Cox regression was used to identify prognostic factors. Prognostic significance of T classifications based on LW (c[l]T) and MW (c[m]T) was evaluated by Kaplan–Meier method after propensity score matching. The performance of c(m)T for discrimination survival was estimated via the concordance index (C-index), net reclassification improvement and integrated-discrimination improvement. RESULTS By adopting MW, 124 part-solid nodules were reclassified as pure ground-glass nodules, and interobserver agreement improved to 0.917 (95% confidence interval 0.888–0.946). The solid portion size under MW more strongly predicted pathological invasiveness (P = 0.030), but did not better predict pathological malignancy. For remaining 416 part-solid nodules, c(l)T and c(m)T were both independent risk factors. c(m)T led to T classifications shifts in 321 nodules (14 upstaged and 307 downstaged) with no significant prognostic difference existing between the shifted c(m)T and matching c(l)T group after propensity score matching. The corrected C-index was improved to 0.695 (0.620–1.000) when adopting c(m)T with no significant difference in net reclassification improvement (P = 0.098) and integrated-discrimination improvement (P = 0.13) analysis. CONCLUSIONS As there is no significant benefit provided by MW in evaluating clinical T classification and prognosis, the current usage of LW is appropriate for assessing subsolid nodules.

OBJECTIVES The goal of this study was to compare the feasibility and safety of uniportal thoracoscopic segmentectomy (UTS) with that of multiportal thoracoscopic segmentectomy (MTS). METHODS From January 2014 to December 2015, a total of 1056 patients who underwent thoracoscopic segmentectomy were identified, including 375 and 681 who had simple and complex segmentectomies, respectively. A propensity matched analysis was applied to compare perioperative indicators. Survival outcomes, which included disease-free survival and overall survival, were assessed by Kaplan–Meier estimates and Cox hazards regression analysis. RESULTS Propensity matching generated 454 paired patients for the UTS and MTS cohorts; the perioperative results were comparable. Survival analysis indicated that the surgical approach (UTS versus MTS) was not an independent risk factor in either disease-free survival (P = 0.247) or overall survival (P = 0.870) of patients with invasive adenocarcinoma. A shorter operative time was observed in patients who had a UTS (P CONCLUSIONS Although minor differences could be found in the simple and complex segmentectomy groups, respectively, these results were clinically irrelevant. Our study supports UTS as a feasible and safe surgical technique.

OBJECTIVES This study aimed to investigate the efficacy of bronchial sleeve lobectomy with pulmonary arterioplasty by uniportal video-assisted thoracoscopic surgery (UniVATS) in centrally located non-small-cell lung cancer. METHODS One hundred and two thoracotomy and 31 UniVATS cases were included in this retrospective, single-centre study. Baseline characteristics, perioperative performance and survival outcomes were compared between the 2 groups. RESULTS Compared with the thoracotomy group, the UniVATS group was associated with lower postoperative blood transfusion rate (P = 0.043), decreased postoperative hospital stays (P = 0.008), shorter drainage duration (P = 0.003) and less drainage volume during the first postoperative 24 h (P = 0.005). Besides, the 3-year overall survival and recurrence-free survival were comparable between the 2 groups (log-rank, P = 0.81 and P = 0.78, respectively). In addition, squamous cell carcinoma was proved to be the independent favourable predictor for overall survival [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.24–0.80; P = 0.008], and advanced pathological stage was found to be independently associated with worse overall survival (IIIB stage: HR 3.21, 95% CI 1.13–9.12; P = 0.028) and recurrence-free survival (IIIB stage: HR 3.54, 95% CI 1.32–9.51; P = 0.012). CONCLUSIONS With appropriate patient selection, UniVATS sleeve lobectomy with pulmonary arterioplasty is feasible and safe for centrally located lung cancer in the hands of thoracic surgeons with extensive thoracoscopy experience.

OBJECTIVES The aim of the study was to investigate the relationship between ground-glass opacity (GGO) and tumour spread through air space (STAS), as well as their joint influence on the prognosis of stage I lung adenocarcinoma. METHODS A total of 620 consecutive patients with surgically resected lung adenocarcinoma between January 2011 and December 2012 were reviewed retrospectively. The relevance of STAS and GGO was analysed by logistic regression, and their prognostic significance was investigated via the Kaplan–Meier method and Cox regression models. Furthermore, to determine the magnitude of the prognostic impact of GGO and STAS, we respectively performed survival analysis in subgroups according to the presence of STAS and GGO. RESULTS Of all 620 cases, 26.7% were positive for STAS, and 32.9% had a GGO component. STAS was present in 10.8% of part-solid lesions and 34.9% of pure solid nodules (P CONCLUSIONS STAS is associated with a GGO component, and each factor was a significant predictor for the prognosis of stage I lung adenocarcinoma. Moreover, the favourable prognostic impact of a GGO component was greater than the adverse prognostic influence of STAS, indicating that GGO is a more reliable prognostic predictor in stage I lung adenocarcinoma.

OBJECTIVES As evidence has proven that sublobar resection is oncologically contraindicated by tumour spread through air spaces (STAS), its preoperative recognition is vital in customizing surgical strategies. We aimed to assess the value of radiomics in predicting STAS in stage I lung adenocarcinoma. METHODS We retrospectively reviewed the patients with stage I lung adenocarcinoma, who accepted curative resection in our institution between January 2011 and December 2013. Using ‘PyRadiomics’ package, 88 radiomics features were extracted from computed tomography (CT) images and a prediction model was consequently constructed using Naïve Bayes machine-learning approach. The accuracy of the model was assessed through receiver operating curve analysis, and the performance of the model was validated both internally and externally. RESULTS A total of 233 patients were included as the training cohort with 69 (29.6%) patients being STAS (+). Patients with STAS had worse recurrence-free survival and overall survival (P CONCLUSIONS CT-based radiomics is valuable in preoperatively predicting STAS in stage I lung adenocarcinoma, which may aid surgeons in determining the optimal surgical approach.

Objectives We aimed to assess the predictive value of different T descriptors, including the whole tumour size (Dwhole) and solid component size (Dsolid), in patients with clinical Stage IA adenocarcinoma who underwent sublobar resection. Methods According to computed tomography images in the lung window, T descriptors, Dwhole and Dsolid, were applied. To evaluate the predictive value of these 2 different descriptors in predicting tumour recurrence and pathological malignant behaviours, Cox hazard regression and a receiver-operating characteristic curve analysis, respectively, were used. Results In total, 247 patients were included. Of these patients, 109 and 138 had ground glass and solid nodules, respectively. When the T descriptor was changed from Dwhole to Dsolid, 37 tumours (15%) were downgraded to T1a status from T1b/T1c status. Multivariable Cox analysis showed that Dsolid was an independent risk factor of worse recurrence-free survival [hazard ratio (HR) 2.36, 95% confidence interval (CI) 1.24-4.47; P = 0.009], while Dwhole was not (HR 1.51, 95% CI 0.79-2.89; P = 0.215). In the receiver-operating characteristic analysis, the areas under the curves for Dwhole and Dsolid used to identify pathological malignant behaviours were 0.598 and 0.739, respectively. Conclusions The T descriptor, which is represented by Dsolid, rather than Dwhole, is a better predictor of tumour recurrence after sublobar resection in clinical Stage IA lung adenocarcinoma. Furthermore, our results provide some clues indicating that sublobar resection should be performed cautiously in patients with lung adenocarcinoma manifesting as ground glass nodule with Dsolid >2 cm.

Objectives The objective of this study is to build a novel prognostic nomogram in non-small-cell lung cancer (NSCLC) incorporating pre-treatment peripheral blood markers beyond known pathoclinical predictors. Methods We analysed 7158 patients with NSCLC diagnosed between 1 January 1997 and 31 December 2012 from a single institution with a uniform medical record and routine follow-up information. Besides common clinicopathological factors, we investigated the prognostic value of the neutrophil to lymphocyte ratio, monocytes and haemoglobin level in peripheral blood before treatment. Patients were randomly assigned to training (4772 patients, 66.7%) or validation cohorts (2386 patients, 33.3%). Cox proportional hazards models determined the effects of multiple factors on overall survival (OS). A nomogram was developed to predict median survival and 1-, 3-, 5- and 10-year OS for NSCLC. The performance of the nomogram was assessed by a concordance index and calibration curve. Results In the training cohort, the multivariate Cox model identified the neutrophil to lymphocyte ratio, monocytes and haemoglobin level before treatment as significant prognostic factors for OS independent of patient age, gender, smoking history of intensity and cessation, performance status, disease stage, tumour cell type and differentiation grade and therapies. All the significant prognostic variables were incorporated into a nomogram. In the validation cohort, the nomogram showed notable accuracy in predicting OS, with a concordance index of 0.81, and was well calibrated for predictions of OS. Conclusions The proposed nomogram incorporating peripheral blood markers and known prognostic factors could accurately predict individualized survival probability of patients with NSCLC. It could be used in treatment planning and stratification in clinical trials.

OBJECTIVES Although there is growing interest in single-port video-assisted thoracic surgery for a number of thoracic operations, there is still not enough known about its use for mediastinal pathologies. The present study was aimed at assessing the safety and efficacy of single-port video-assisted thoracic surgery in comparison with the multi-port variants in terms of short-term perioperative outcomes. METHODS From July 2013 to December 2015, 285 consecutive non-myasthenic adult patients undergoing single- or multi-port video-assisted thoracic surgery for mediastinal diseases including thymoma were retrospectively reviewed. Patients were stratified depending on whether the pathology was thymoma. A propensity score matching pertaining to the approach used was performed within each stratified category. Perioperative outcomes were compared between matched cohorts. RESULTS During the study period, 141 (49.5%) patients were treated with single-port thoracoscopic surgery. Preoperative variables were comparable between both pairs of cohorts after matching. No morbidity or mortality occurred, except 1 case of empyema in a 2-port case. Single-port technique exhibited shorter operation time (thymoma: 78.8 vs 120.0 min, P = 0.011; non-thymoma: 78.4 vs 107.9 min, P

OBJECTIVES Subxiphoid uniportal video-assisted thoracoscopic surgery (SUVATS) is a technically difficult and challenging operation that can help decrease pain around the incision after traditional intercostal uniportal video-assisted thoracoscopic surgery (IUVATS), and can also treat bilateral lesions through the same incision. We aimed to compare perioperative outcomes and pain scores after SUVATS and IUVATS in patients receiving synchronous treatment of bilateral lung lesions. METHODS Patients who received SUVATS and IUVATS bilateral lung resections from September 2014 to February 2018 were analysed. Ultimately a total of 381 cases were analysed after using one-to-one propensity score matching to match baseline characteristics between the 2 groups. RESULTS The 381 patients included 56 with SUVATS and 325 with IUVATS. After matching, 54 SUVATS and 54 IUVATS cases were analysed. The 2 groups had similar preoperative factors and did not differ with respect to duration of chest tube placement, length of stay in hospital and incidence of postoperative complications. SUVATS was associated with a significantly longer operative time (212.3 vs 154.6 min, P CONCLUSIONS Compared with IUVATS, despite the longer operative time and greater blood loss, SUVATS for bilateral lung lesions is a safe surgical procedure associated with significantly less postoperative pain and a similar incidence of postoperative complications in selected patients.

Objectives Single-port video-assisted thoracic surgery (VATS) technique has been used for thoracic diseases. There was no report about single-port VATS in large series. Outcomes following single-port VATS were analysed to determine its efficacy and safety. Methods From June 2012 to June 2014, 1063 single-port VATSs were performed by four surgeons. Patient demographics, perioperative parameters, histopathology and outcomes were analysed. Results There were 1063 patients (524 men and 539 women). The median age was 56.1 ± 8.7 years (range, 15-86 years). Lobectomy was performed in 569 patients, segmentectomy in 162, wedge resection in 264, pleural biopsy in 7, drainage of effusion in 20, pleural tumour resection in 5, mediastinal tumour resection in 54, mediastinal tumour biopsy in 2, bilobectomy in 7, sleeve lobectomy in 3 and pneumonectomy in 2. Synchronous bilateral single-port VATS was performed in 27 cases, whereas metachronous bilateral single-port VATS was performed in 5 cases. Pathological diagnoses included primary lung cancer in 635 cases, metastatic lung cancer in 19, mediastinal tumour in 56, pleural disease in 32 and benign pulmonary conditions in 353. Fifteen intraoperative vascular injuries were identified in 15 patients. The total conversion rate was 4.6%. The average operation time was 135 ± 31 min (range, 30-230 min), and the average blood loss was 117 ± 47 ml (range, 50-2000 ml). The median intensive care unit stay was 1 day (0-4 days). The postoperative hospital stay was 6.2 ± 2.6 days on average. There was no operative death, and operative complications occurred in 59 patients (5.6%). The 1-year overall survival and 1-year disease-free survival for the primary lung cancer group were 98 and 96%, respectively. Conclusions Our findings indicate that single-port VATS for thoracic diseases is safe and feasible.