During minimally invasive pulmonary resection, it is often difficult to localize pulmonary nodules that are small (<2 cm), low-density/subsolid on imaging, or deep to the visceral pleura. The use of near-infrared fluorescence (NIF) imaging for localizing pulmonary nodules using indocyanine green (ICG) contrast is an emerging technology that is increasingly utilized during pulmonary resection. When administered via electromagnetic navigational bronchoscopy (ENB), ICG can accurately localize pulmonary nodules. When injected intravenously (IV), ICG can also help delineate the intersegmental plane. Research is ongoing regarding the utility of ICG for identification of the sentinel lymph node in lung cancer.
Video clip is available online. Feature Editor's Introduction-Welcome to the beginning of a series of new format articles in JTCVS Techniques termed Video Atlas Articles (VAAs). VAAs are peerreviewed descriptions of a surgical procedure crystallized into a series of steps, with each step taught through its own narrated video and corresponding short text. The purpose of the VAA series is to provide continuing surgical education in an enduring format. Quality is maintained by the invitation of expert authors and by the iterative peer-review process involving expert reviewers. Thoracic surgeons are privileged to care for patients with a vast breadth and depth of conditions using an expansive armamentarium of rapidly evolving techniques. Most thoracic surgeons will perform operations they had never before performed in their training, and many will become expert in them. In fact, an entire generation of thoracic surgeons learned robotic thoracic surgery without residency or fellowship training on the robot, and surgeons from this generation are the current leaders in robotic thoracic surgery. This field is fastpaced and rapidly evolving. To provide the highest level of care to our patients, to embrace (and drive) the exciting innovation in our field, and sometimes even to remain relevant in the field of thoracic surgery requires the surgeon's effort in self-learning. There are many modalities for continuing surgical education; however, with regard to technique, there is little substitute for the first-hand experience of observing an expert surgeon operating, for junior and seasoned surgeons alike. The VAA is designed to replicate this experience in a quality-assured, on-hand, and high-impact format. Robotic right upper lobectomy is an index operation of the modern thoracic surgeon, and herein it is professionally illustrated in a VAA.
The past decade has shown considerable promise in immune-checkpoint blockade as a means of augmenting antitumor immunity, placing immunotherapy alongside traditional modalities as a pillar of cancer treatment. Current checkpoint-blockade strategies are centered either on cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) or programmed cell death protein-1 pathway (PD-1/PD-L1) (1).CTLA-4 and PD-1 facilitate T-cell attenuation at different stages of the T-cell response. Immediately following T-cell receptor ligation, CTLA-4 is translocated to the T-cell surface, where it competes for binding to CD80 and CD86, ligands that could otherwise provide positive co-stimulation to the T-cell via CD-28 (2). As a result, CTLA-4 increases the activation threshold of T cells, impeding antitumor immunity by dampening the sensitivity of T-cells to self and tumor antigens (3). The PD-1 pathway, by contrast, is induced later during T cell activation, attenuating TCR signaling following binding by PD-L1. Cancer cells expressing PD-L1 are thereby able to evade immune detection, while tumor-infiltrating immune cells can themselves express PD-L1 in response to cytokines such as . PD-L1 expression throughout the inflammatory tumor microenvironment can therefore lead to PD-1-mediated T-cell exhaustion (2).Whereas anti-CTLA-4 monoclonal antibody therapy has earned FDA-approval for treating advanced melanoma, CTLA-4 blockade has shown minimal activity in the treatment of non-small cell lung cancer (NSCLC). Meanwhile, agents targeting the PD-1/PD-L1 axis have shown considerable efficacy in treating advanced NSCLC (4). Currently, there is significant interest in determining the therapeutic potential of combined CTLA-4 and PD-1 blockade. In CheckMate 227, a randomized, open-label, phase 3 trial by Hellman et al. first-line treatment of stage IV or recurrent NSCLC with nivolumab (anti-PD-1) plus ipilimumab (anti-CTLA-4) resulted in a longer duration of overall survival than did chemotherapy (5).
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