Hybrid operating room for advanced non-small cell lung cancer such as T4-NSCLC

Key findings

• The use of the hybrid operating room (HOR) could also be extended to selected cases of advanced non-small cell lung cancer (NSCLC) such as T4-NSCLC that invades the thoracic aorta (T4invAo) that require surgery.

What is known and what is new?

• Thoracic aortic endograft is one of the possible safe surgical options in selected patients with T4invAo NSCLC and is usually performed in two sequential stages.

• The use of an HOR allows for more precise tumor localization and endograft placement and allows for the entire procedure to be performed in a single step.

What is the implication, and what should change now?

• Thoracic surgeons are encouraged to use the HOR in selected cases and to actively collaborate with vascular surgeons in the planning of the endovascular procedure.

The management of non-small cell lung cancer (NSCLC) has recently evolved and is highly dependent on its staging, molecular characteristics, and patient condition. The preoperative stage of NSCLC remains the primary factor in determining treatment and overall prognosis.

Thoracic surgery has made enormous progress in the last decade thanks to minimally invasive procedures, intra-operative imaging, artificial intelligence (AI), and technological evolution, moving towards precision surgery.

In this new scenario, this study evaluates the potential resectability of NSCLC invading the thoracic aorta (T4invAo) and proposes radical surgery in selected patients. The authors proposed approach requires access to a hybrid operating room (HOR) equipped with a C-arm robotic system, an integrated operating table, and the collaboration of vascular surgeons.

Preoperatively, angio-CT images are uploaded to the HOR’s workstation, enabling a chest 3D reconstruction. The key landmarks [left subclavian artery (LSA) and celiac trunk] are manually marked to anticipate where the endovascular prosthesis should land. The tumor mass should be marked, enabling the surgeon to recognize the right landing zone intraoperatively and leave the correct disease-free proximal and distal margin to achieve oncological radicality.

During preoperative planning, it is mandatory to combine endovascular and oncological concepts. This will determine the actual proximal and distal landing zones and identify the correct minimum aortic coverage area for the endoprosthesis.

The use of the HOR should also be extended to selected cases of advanced NSCLC, such as T4invAo, that require surgery, allowing for more precise positioning of the thoracic endoprosthesis and the best technical strategy in a “one-stop” procedure.