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Medical thoracoscopy.
Skalski JH, Astoul PJ, Maldonado F
(2014) Semin Respir Crit Care Med 35: 732-43
MeSH Terms: Biopsy, Diagnosis, Differential, Humans, Pleural Diseases, Pleural Effusion, Malignant, Thoracic Surgery, Video-Assisted, Thoracoscopy
Show Abstract · Added July 28, 2015
The burden of pleural diseases continues to rise and affects an increasingly complex and aging patient population. As such, thoracentesis is one of the most common procedures performed by respiratory physicians, as pleural fluid analysis can establish the diagnosis of pleural effusions in approximately 75% of the cases. When a diagnosis is not reached, options include image-guided biopsies, only possible when focal pleural lesions can be identified by computed tomography or ultrasound; closed pleural biopsies, associated with a relatively low diagnostic yield; and surgical pleural biopsies, which typically require general anesthesia and a hospital stay. Medical thoracoscopy addresses some of the limitations of these techniques, allows a comprehensive pleural examination and targeted pleural biopsies, and offers the possibility of treatment of recurrence in the same setting. As such, medical thoracoscopy is ideally positioned as a valuable tool in the diagnosis of unexplained exudative pleural effusions.
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
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7 MeSH Terms
Cost-effectiveness of initial diagnostic strategies for pulmonary nodules presenting to thoracic surgeons.
Deppen SA, Davis WT, Green EA, Rickman O, Aldrich MC, Fletcher S, Putnam JB, Grogan EL
(2014) Ann Thorac Surg 98: 1214-22
MeSH Terms: Biopsy, Fine-Needle, Bronchoscopy, Cost-Benefit Analysis, Decision Support Techniques, Fluorodeoxyglucose F18, Humans, Lung Neoplasms, Male, Middle Aged, Positron-Emission Tomography, Quality-Adjusted Life Years, Solitary Pulmonary Nodule, Surgeons, Thoracic Surgery, Video-Assisted, Tomography, X-Ray Computed
Show Abstract · Added October 28, 2015
BACKGROUND - Patients presenting to thoracic surgeons with pulmonary nodules suggestive of lung cancer have varied diagnostic options including navigation bronchoscopy (NB), computed tomography-guided fine-needle aspiration (CT-FNA), (18)F-fluoro-deoxyglucose positron emission tomography (FDG-PET) and video-assisted thoracoscopic surgery (VATS). We studied the relative cost-effective initial diagnostic strategy for a 1.5- to 2-cm nodule suggestive of cancer.
METHODS - A decision analysis model was developed to assess the costs and outcomes of four initial diagnostic strategies for diagnosis of a 1.5- to 2-cm nodule with either a 50% or 65% pretest probability of cancer. Medicare reimbursement rates were used for costs. Quality-adjusted life years were estimated using patient survival based on pathologic staging and utilities derived from the literature.
RESULTS - When cancer prevalence was 65%, tissue acquisition strategies of NB and CT-FNA had higher quality-adjusted life years compared with either FDG-PET or VATS, and VATS was the most costly strategy. In sensitivity analyses, NB and CT-FNA were more cost-effective than FDG-PET when FDG-PET specificity was less than 72%. When cancer prevalence was 50%, NB, CT-FNA, and FDG-PET had similar cost-effectiveness.
CONCLUSIONS - Both NB and CT-FNA diagnostic strategies are more cost-effective than either VATS biopsy or FDG-PET scan to diagnose lung cancer in moderate- to high-risk nodules and resulted in fewer nontherapeutic operations when FDG-PET specificity was less than 72%. An FDG-PET scan for diagnosis of lung cancer may not be cost-effective in regions of the country where specificity is low.
Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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15 MeSH Terms
Segmentectomy versus wedge resection for non-small cell lung cancer in high-risk operable patients.
Kent M, Landreneau R, Mandrekar S, Hillman S, Nichols F, Jones D, Starnes S, Tan A, Putnam J, Meyers B, Daly B, Fernando HC
(2013) Ann Thorac Surg 96: 1747-54; discussion 1754-5
MeSH Terms: Aged, Aged, 80 and over, Carcinoma, Non-Small-Cell Lung, Female, Humans, Lung Neoplasms, Male, Middle Aged, Pneumonectomy, Prospective Studies, Risk Factors, Thoracic Surgery, Video-Assisted, Thoracotomy
Show Abstract · Added March 7, 2014
BACKGROUND - Patients with early-stage lung cancer and limited pulmonary reserve may not be appropriate candidates for lobectomy. In these situations, sublobar resection (wedge or segmentectomy) is generally performed. Many physicians believe that segmentectomy is superior because it allows for an improved parenchymal margin and nodal sampling.
METHODS - We performed an analysis using operative and pathology reports collected as part of planned data collection for American College of Surgeons Surgical Oncology Group (ACOSG) Z4032. This was a prospective trial in which patients with clinical stage I lung cancer and limited pulmonary function were randomized to sublobar resection with or without brachytherapy. The operative approach (video-assisted thoracic surgery [VATS] vs thoracotomy), extent of resection, and degree of lymph node evaluation were at the discretion of the individual surgeon. The primary aim of this analysis was to compare the parenchymal margin achieved between segmentectomy and wedge resection. Secondary aims included the extent of nodal staging and whether the operative approach (VATS vs open) had an effect on margin status and nodal evaluation.
RESULTS - Among 210 patients, 135 (64%) underwent a VATS approach and 75 (36%) a thoracotomy. A segmentectomy was performed in 57 patients (27%) and a wedge resection in 153 patients (73%). There were no significant differences in the degree of nodal upstaging, stations sampled, or parenchymal margin obtained between VATS and thoracotomy. However, significant differences were observed between patients who underwent a segmentectomy and those who underwent a wedge resection with regard to parenchymal margin (1.5 cm vs 0.8 cm, p = 0.0001), nodal upstaging (9% vs 1%, p = 0.006), and nodal stations sampled (3 vs 1, p < 0.0001) . Notably, 41% of patients treated by wedge resection had no nodes sampled at the time of operation compared with 2% of those who underwent segmentectomy (p < 0.0001).
CONCLUSIONS - In ACOSG Z4032, wedge resection, regardless of the approach, was associated with a smaller parenchymal margin and a lower yield of lymph nodes and rate of nodal upstaging when compared with segmentectomy.
Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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13 MeSH Terms
Solitary cystic mediastinal lymphangioma.
Khobta N, Tomasini P, Trousse D, Maldonado F, Chanez P, Astoul P
(2013) Eur Respir Rev 22: 91-3
MeSH Terms: Adolescent, Diagnostic Errors, Empyema, Pleural, Humans, Lymphangioma, Cystic, Male, Mediastinal Cyst, Mediastinal Neoplasms, Predictive Value of Tests, Thoracic Surgery, Video-Assisted, Tomography, X-Ray Computed, Treatment Outcome
Added February 1, 2016
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1 Members
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12 MeSH Terms
Thirty- and ninety-day outcomes after sublobar resection with and without brachytherapy for non-small cell lung cancer: results from a multicenter phase III study.
Fernando HC, Landreneau RJ, Mandrekar SJ, Hillman SL, Nichols FC, Meyers B, DiPetrillo TA, Heron DE, Jones DR, Daly BD, Starnes SL, Tan A, Putnam JB
(2011) J Thorac Cardiovasc Surg 142: 1143-51
MeSH Terms: Aged, Aged, 80 and over, Brachytherapy, Carcinoma, Non-Small-Cell Lung, Chi-Square Distribution, Female, Humans, Logistic Models, Lung Neoplasms, Male, Middle Aged, Odds Ratio, Patient Selection, Postoperative Complications, Prospective Studies, Pulmonary Surgical Procedures, Radiotherapy, Adjuvant, Risk Assessment, Risk Factors, Thoracic Surgery, Video-Assisted, Time Factors, Treatment Outcome, United States
Show Abstract · Added March 27, 2014
OBJECTIVE - Sublobar resection (SR) is commonly used for patients considered high risk for lobectomy. Nonoperative therapies are increasingly being reported for patients with similar risk because of perceived lower morbidity. We report 30- and 90-day adverse events (AEs) from American College of Surgeons Oncology Group Z4032, a multicenter phase III study for high-risk patients with stage I non-small cell lung cancer.
METHODS - Data from 222 evaluable patients randomized to SR (n = 114) or SR with brachytherapy (n = 108) are reported. AEs were recorded using the Common Terminology Criteria for Adverse Events, Version 3.0, at 30 and 90 days after surgery. Risk factors (age, percent baseline carbon monoxide diffusion in the lung [DLCO%], percent forced expiratory volume in 1 second [FEV1%], upper lobe vs lower lobe resections, performance status, surgery approach, video-assisted thoracic surgery vs open and extent, and wedge vs segmentectomy) were analyzed using a multivariable logistic model for their impact on the incidence of grade 3 or higher (G3+) AEs. Respiratory AEs were also specifically analyzed.
RESULTS - Median age, FEV1%, and DLCO% were similar in the 2 treatment groups. There was no difference in the location of resection (upper vs lower lobe) or the use of segmental or wedge resections. There were no differences between the groups with respect to "respiratory" G3+ AEs (30 days: 14.9% vs 19.4%, P = .35; 0-90 days: 19.3% vs 25%, P = .31) and "any" G3+ AEs (30 days: 25.4% vs 30.6%, P = .37; 0-90 days: 29.8% vs 37%, P = .25). Further analysis combined the 2 groups. Mortality occurred in 3 patients (1.4%) by 30 days and in 6 patients (2.7%) by 90 days. Four of the 6 deaths were thought to be due to surgery. When considered as continuous variables, FEV1% was associated with "any" G3+ AE at days 0 to 30 (P = .03; odds ratio [OR] = 0.98) and days 0 to 90 (P = .05; OR = 0.98), and DLCO% was associated with "respiratory" G3+ AE at days 0 to 30 (P = .03; OR = 0.97) and days 0 to 90 (P = .05; OR = 0.98). Segmental resection was associated with a higher incidence of any G3+ AE compared with wedge resection at days 0 to 30 (40.3% vs 22.7%; OR = 2.56; P < .01) and days 0 to 90 (41.5% vs 29.7%; OR = 1.96; P = .04). The median FEV1% was 50%, and the median DLCO% was 46%. By using these median values as potential cutpoints, only a DLCO% of less than 46% was significantly associated with an increased risk of "respiratory" and "any" G3+ AE for days 0 to 30 and 0 to 90.
CONCLUSIONS - In a multicenter setting, SR with brachytherapy was not associated with increased morbidity compared with SR alone. SR/SR with brachytherapy can be performed safely in high-risk patients with non-small cell lung cancer with low 30- and 90-day mortality and acceptable morbidity. Segmental resection was associated with increased "any" G3+ AE, and DLCO% less than 46% was associated with "any" G3+ AE and "respiratory" G3+ AE at both 30 and 90 days.
Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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23 MeSH Terms
Thoracic operations for pulmonary nodules are frequently not futile in patients with benign disease.
Grogan EL, Weinstein JJ, Deppen SA, Putnam JB, Nesbitt JC, Lambright ES, Walker RC, Dittus RS, Massion PP
(2011) J Thorac Oncol 6: 1720-5
MeSH Terms: Adenocarcinoma, Cohort Studies, Female, Follow-Up Studies, Humans, Lung Neoplasms, Male, Middle Aged, Neoplasm Staging, Pneumonectomy, Prognosis, Prospective Studies, Survival Rate, Thoracic Surgery, Video-Assisted
Show Abstract · Added March 5, 2014
INTRODUCTION - Pulmonary nodules often require operative resection to obtain a diagnosis. However, 10 to 30% of operations result in a benign diagnosis. Our purpose was to determine whether negative thoracic operations are futile by describing the pathological diagnoses; determining new diagnoses and treatment changes initiated based on operative findings; and assessing morbidity, mortality, and cost of the procedure.
METHODS - At our academic medical center, 278 thoracic operations were performed for known or suspected cancer between January 1, 2005, and April 1, 2009. We collected and summarized data pertaining to preoperative patient and nodule characteristics, pathologic diagnosis, postoperative treatment changes resulting from surgical resection, perioperative morbidity and mortality, and hospital charges for patients with benign pathology.
RESULTS - Twenty-three percent (65/278) of patients who underwent surgical resection for a suspicious nodule had benign pathology. We report granulomatous disease in 57%, benign tumors in 15%, fibrosis in 12%, and autoimmune and vascular diseases in 9%. Definitive diagnosis or treatment changes occurred in 85% of cases. Surgical intervention led to a new diagnosis in 69%, treatment course changes in 68% of benign cases, medication changes in 38%, new consultation in 31%, definitive treatment in 9%, and underlying disease management in 34%. There was no intraoperative, in-hospital, or 30-day mortality. Postoperative in-hospital events occurred in seven patients. The mean total cost was $25,515 with a mean cost per day of $7618.
CONCLUSIONS - Patients with a benign diagnosis after surgical resection for a pulmonary nodule received a new diagnosis or had a treatment course change in 85% of the cases.
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4 Members
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14 MeSH Terms
The impact of adjuvant brachytherapy with sublobar resection on pulmonary function and dyspnea in high-risk patients with operable disease: preliminary results from the American College of Surgeons Oncology Group Z4032 trial.
Fernando HC, Landreneau RJ, Mandrekar SJ, Hillman SL, Nichols FC, Meyers B, DiPetrillo TA, Heron D, Jones DR, Daly BD, Starnes SL, Hatter JE, Putnam JB
(2011) J Thorac Cardiovasc Surg 142: 554-62
MeSH Terms: Aged, Aged, 80 and over, Brachytherapy, Carcinoma, Non-Small-Cell Lung, Dyspnea, Female, Forced Expiratory Volume, Humans, Lung Neoplasms, Male, Middle Aged, Prospective Studies, Pulmonary Diffusing Capacity, Radiotherapy, Adjuvant, Thoracic Surgery, Video-Assisted, Thoracotomy, Treatment Outcome
Show Abstract · Added March 27, 2014
BACKGROUND - Z4032 was a randomized study conducted by the American College of Surgeons Oncology Group comparing sublobar resection alone versus sublobar resection with brachytherapy for high-risk operable patients with non-small cell lung cancer (NSCLC). This evaluates early impact of adjuvant brachytherapy on pulmonary function tests, dyspnea, and perioperative (30-day) respiratory complications in this impaired patient population.
METHODS - Eligible patients with stage I NSCLC tumors 3 cm or smaller were randomly allocated to undergo sublobar resection with (SRB group) or without (SR group) brachytherapy. Outcomes measured included the percentage predicted forced expiratory volume in 1 second (FEV1%), percentage predicted carbon monoxide diffusion capacity (DLCO%), and dyspnea score per the University of California San Diego Shortness of Breath Questionnaire. Pulmonary morbidity was assessed per the Common Terminology Criteria for Adverse Events version 3.0. Outcomes were measured at baseline and 3 months. A 10% change in pulmonary function test or 10-point change in dyspnea score was deemed clinically meaningful.
RESULTS - Z4032 permanently closed to patient accrual in January 2010 at 224 patients. At 3-month follow-up, pulmonary function data are currently available for 148 (74 SR and 74 SRB) patients described in this report. There were no differences in baseline characteristics between arms. In the SR arm, 9 patients (12%) reported grade 3 respiratory adverse events, compared with 12 (16%) in the SRB arm (P = .49). There was no significant change in percentage change in DLCO% or dyspnea score from baseline to 3 months within either arm. In the case of FEV1%, percentage change from baseline to 3 months was significant within the SR arm (P = .03), with patients reporting improvement in FEV1% at month 3. Multivariable regression analysis (adjusted for baseline values) showed no significant impact of treatment arm, tumor location (upper vs other lobe), or surgical approach (video-assisted thoracoscopic surgery vs thoracotomy) on 3-month FEV1%, DLCO%, and dyspnea score. There was no significant difference in incidence of clinically meaningful (10% pulmonary function or 10-point dyspnea score change) change between arms. Twenty-two percent of patients with lower-lobe tumors and 9% with upper-lobe tumors demonstrated 10% decline in FEV1% (odds ratio, 2.79; 95 confidence interval, 1.07-7.25; P = .04).
CONCLUSIONS - Adjuvant intraoperative brachytherapy in conjunction with sublobar resection did not significantly worsen pulmonary function or dyspnea at 3 months in a high-risk population with NSCLC, nor was it associated with increased perioperative pulmonary adverse events. Lower-lobe resection was the only factor significantly associated with clinically meaningful decline in FEV1%.
Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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1 Members
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17 MeSH Terms
Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial.
Darling GE, Allen MS, Decker PA, Ballman K, Malthaner RA, Inculet RI, Jones DR, McKenna RJ, Landreneau RJ, Rusch VW, Putnam JB
(2011) J Thorac Cardiovasc Surg 141: 662-70
MeSH Terms: Adult, Aged, Aged, 80 and over, Canada, Carcinoma, Non-Small-Cell Lung, Chi-Square Distribution, Disease-Free Survival, Female, Humans, Kaplan-Meier Estimate, Lung Neoplasms, Lymph Node Excision, Lymphatic Metastasis, Male, Middle Aged, Neoplasm Recurrence, Local, Neoplasm Staging, Pneumonectomy, Prospective Studies, Risk Assessment, Risk Factors, Societies, Medical, Survival Rate, Thoracic Surgery, Video-Assisted, Time Factors, Treatment Outcome, United States, Young Adult
Show Abstract · Added March 27, 2014
OBJECTIVE - To determine whether mediastinal lymph node dissection improves survival compared with mediastinal lymph node sampling in patients undergoing resection for N0 or nonhilar N1, T1, or T2 non-small cell lung cancer.
METHODS - Patients with non-small cell lung cancer underwent sampling of 2R, 4R, 7, and 10R for right-sided tumors and 5, 6, 7, and 10L for left-sided tumors. If all tumors were negative for malignancy, patients were randomized to no further lymph node sampling (mediastinal lymph node sampling) or complete mediastinal lymph node dissection.
RESULTS - Of 1111 patients randomized, 1023 (mediastinal lymph node sampling in 498, mediastinal lymph node dissection in 525) were eligible and evaluable. There were no significant differences between the 2 groups in terms of demographics, Eastern Cooperative Oncology Group status, histology, cancer location, type or extent of resection, and pathologic stage. Occult N2 disease was found in 21 patients in the mediastinal lymph node dissection group. At a median follow-up of 6.5 years, 435 patients (43%) have died: mediastinal lymph node sampling in 217 (44%) and mediastinal lymph node dissection in 218 (42%). The median survival is 8.1 years for mediastinal lymph node sampling and 8.5 years for mediastinal lymph node dissection (P = .25). The 5-year disease-free survival was 69% (95% confidence interval, 64-74) in the mediastinal lymph node sampling group and 68% (95% confidence interval, 64-73) years in the mediastinal lymph node dissection group (P = .92). There was no difference in local (P = .52), regional (P = .10), or distant (P = .76) recurrence between the 2 groups.
CONCLUSIONS - If systematic and thorough presection sampling of the mediastinal and hilar lymph nodes is negative, mediastinal lymph node dissection does not improve survival in patients with early stage non-small cell lung cancer, but these results are not generalizable to patients staged radiographically or those with higher stage tumors.
Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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28 MeSH Terms
Video-assisted thoracic surgery versus open lobectomy for lung cancer: a secondary analysis of data from the American College of Surgeons Oncology Group Z0030 randomized clinical trial.
Scott WJ, Allen MS, Darling G, Meyers B, Decker PA, Putnam JB, McKenna RW, Landrenau RJ, Jones DR, Inculet RI, Malthaner RA
(2010) J Thorac Cardiovasc Surg 139: 976-81; discussion 981-3
MeSH Terms: Aged, Carcinoma, Non-Small-Cell Lung, Female, Humans, Lung Neoplasms, Lymph Node Excision, Male, Middle Aged, Pneumonectomy, Propensity Score, Thoracic Surgery, Video-Assisted, Thoracotomy, Time Factors, Treatment Outcome
Show Abstract · Added March 27, 2014
OBJECTIVE - Video-assisted thoracoscopic lobectomy remains controversial. We compared outcomes from participants in a randomized study comparing lymph node sampling versus dissection for early-stage lung cancer who underwent either video-assisted thoracoscopic or open lobectomy.
METHODS - Data from 964 participants in the American College of Surgeons Oncology Group Z0030 trial were used to construct propensity scores for video-assisted thoracoscopic versus open lobectomy (based on age, gender, histology, performance status, tumor location, and T1 vs T2). Propensity scores were used to estimate the adjusted risks of short-term outcomes of surgery. Patients were classified into 5 equal-sized groups and compared using conditional logistic regression or repeated measures analysis of variance.
RESULTS - A total of 752 patients (66 video-assisted and 686 open procedures) were analyzed on the basis of propensity score stratification. Median operative time was shorter for video-assisted thoracoscopic lobectomy (video-assisted thoracoscopy 117.5 minutes vs open 171.5 minutes; P < .001). Median total number of lymph nodes retrieved (dissection group only) was similar (video-assisted thoracoscopy 15 nodes vs open 19 nodes; P = .147), as were instances of R1/R2 resection (video-assisted thoracoscopy 0% vs open 2.3%; P = .368). Patients undergoing video-assisted thoracoscopic lobectomy had less atelectasis requiring bronchoscopy (0% vs 6.3%, P = .035), fewer chest tubes draining greater than 7 days (1.5% vs 10.8%; P = .029), and shorter median length of stay (5 days vs 7 days; P < .001). Operative mortality was similar (video-assisted thoracoscopy 0% vs open 1.6%, P = 1.0).
CONCLUSION - Patients undergoing video-assisted lobectomy had fewer respiratory complications and shorter length of stay. These data suggest video-assisted thoracoscopic lobectomy is safe in patients with resectable lung cancer. Longer follow-up is needed to determine the oncologic equivalency of video-assisted versus open lobectomy.
Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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14 MeSH Terms
VATS lobectomy is better than open thoracotomy: what is the evidence for short-term outcomes?
Grogan EL, Jones DR
(2008) Thorac Surg Clin 18: 249-58
MeSH Terms: Decision Making, Follow-Up Studies, Humans, Lung Neoplasms, Pneumonectomy, Survival Rate, Thoracic Surgery, Video-Assisted, Thoracotomy, Time Factors, Treatment Outcome, United States
Show Abstract · Added March 5, 2014
VATS lobectomy is an acceptable alternative to open lobectomy for treating early-stage NSCLC. Although no large randomized control trial has compared these procedures, recent large series and case-control studies provide strong evidence that patients undergoing VATS lobectomy have less pain, fewer perioperative complications, shorter chest-tube duration, and decreased length of stay. Increasing evidence supports improved quality of life up to 1 year, less inflammation, and greater safety profile in high-risk patients. More data are needed to better show an improvement in the economic efficacy, ability to more effectively administer adjuvant therapies, and benefit of robotic assistance in VATS lobectomy.
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11 MeSH Terms