Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy

BACKGROUND

Minimally invasive lung lobectomy and segmentectomy by video-assisted thoracic surgery (VATS) are assumed to result in better quality of life and less postoperative pain compared with standard open approaches. To date, few prospective studies have compared the two approaches. We performed a prospective cohort study to compare quality of life and pain scores during the first 12 months after VATS or open anatomic resection.

METHODS

Patients were prospectively enrolled from May 2009 to April 2012. Patients with clinical stage I lung cancer who were scheduled to undergo anatomic lung resection were eligible. The Brief Pain Index and Medical Outcomes Study 36-Item Short Form Health Survey were conducted perioperatively and at four assessments during the first 12 months after the operation. Intent-to-treat analyses using mixed-effects models were used to longitudinally assess the effect of treatment on quality of life components (physical component summary and mental component summary) and pain.

RESULTS

In total, 74 patients underwent thoracotomy, and 132 underwent VATS (including 19 patients who were converted to thoracotomy); 40 and 80 patients, respectively, completed the 12-month surveys. Baseline characteristics were similar between the two groups. Physical component summary and Brief Pain Index scores were similar between the two groups throughout the 12 months of follow-up. The mental component summary score, however, was consistently worse in the VATS group.

CONCLUSIONS

Patient-reported physical component summary and pain scores after VATS and thoracotomy were similar during the first 12 months after surgical resection.

Contraindications of video-assisted thoracoscopic surgical lobectomy and determinants of conversion to open

Since the introduction of anatomic lung resection by video-assisted thoracoscopic surgery (VATS) was introduced 20 years ago, VATS has experienced major advances in both equipment and technique, introducing a technical challenge in the surgical treatment of both benign and malignant lung disease. The demonstrated safety, decreased morbidity, and equivalent efficacy of this minimally invasive technique has led to the acceptance of VATS as a standard surgical modality for early-stage lung cancer and increasing application to more advanced disease. However, only a minority of lobectomies are performed using the VATS technique, likely owing to concern for intraoperative complications. Optimal operative planning, including obtaining baseline pulmonary function tests with diffusion measurements, positron emission tomography and/or computed tomography scans, bronchoscopy, and endobronchial ultrasound or mediastinoscopy, can be used to anticipate and potentially prevent the occurrence of complications. With increasing focus on operative planning, as well as comfort and experience with the VATS technique, the indications for which this technique is used has grown. As such, the absolute contraindications have narrowed to inability to tolerate single lung ventilation, inability to achieve complete resection with lobectomy, T3 or T4 tumors, and N2 or N3 disease. However, as VATS lobectomy has been applied to more advanced stage disease, the rate of conversion to open thoracotomy has increased, particularly early in the surgeon's learning curve. Causes of conversion are generally classified into four categories: intraoperative complications, technical problems, anatomical problems, and oncological conditions. Though it is difficult to anticipate which patients may require conversion, it appears that these patients do not suffer from increased morbidity or mortality as a result of conversion to open thoracotomy. Therefore, with a focus on a safe and complete resection, conversion should be regarded as a means of completing resections in a traditional manner rather than as a surgical failure.

Benefits of video-assisted thoracoscopic surgery in the treatment of non-small-cell lung cancer

SUMMARY Anatomic lung resection remains the gold standard in the treatment of lung cancer. The traditional approach has been an open thoracotomy with anatomic lobectomy. The approach to the operation has continued to evolve, transitioning from large thoracotomy incisions to smaller muscle sparing incisions to video-assisted thoracic surgery. This article reviews the studies and evidence in support of the potential benefits afforded by the video-assisted thoracic surgery approach in the treatment of lung cancer.

Mediastinal lymph node dissection in early-stage non-small cell lung cancer: totally thoracoscopic vs thoracotomy

OBJECTIVES

Although major pulmonary resections for early-stage non-small cell lung cancer (NSCLC) are more and more frequently performed through thoracoscopy, the adequacy of lymphadenectomy achieved via this approach is still questioned. The aim of this study was to evaluate the results of lymph node dissection (LND) during totally thoracoscopic (TT) major pulmonary resections.

METHODS

Clinical and pathological data of consecutive patients who underwent lobectomy or segmentectomy for clinical-N0 NSCLC between 1 January 2007 and 31 December 2009 were reviewed. The main evaluation criterion was the number of mediastinal lymph nodes (LNs) and mediastinal stations dissected through a TT approach when compared with the classical posterolateral thoracotomy (PLT) approach.

RESULTS

A total of 296 major pulmonary resections (278 lobectomies and 18 anatomic segmentectomies) for clinical stages I-II NSCLC were performed, 96 via a TT approach and 200 through PLT. Patients' clinical characteristics were similar in both groups. The overall-i.e mediastinal and lobar-number of dissected mediastinal LNs and of dissected mediastinal stations were similar in both groups (TT: mean ± SD = 17.7 ± 8.2; PLT: 18.2 ± 9.3(P < 0.937) and 3.2 ± 0.9 vs 3.4 ± 0.9, respectively). The overall numbers of stations (TT: mean ± SD 5.1 ± 1.1; PLT: 4.5 ± 1.2) and LNs (TT: 22.6 ± 9.4, PLT: 25.4 ± 10.8) were slightly but significantly different between the two groups (P < 0.001 and P = 0.033, respectively); there was no difference in terms of post-operative complications, although patients from the TT group had significantly fewer days with the chest tube (mean ± SD = 4.0 ± 1.8 vs 5.7 ± 3.9, P < 0.001) and shorter length of stay (7.0 ± 2.5 days vs 10.3 ± 7.4, P < 0.001).

CONCLUSIONS

For patients undergoing thoracoscopic lobectomy or segmentectomy for clinical early-stage NSCLC, the quality of mediastinal LND is equivalent to that performed by thoracotomy.

Lymph node evaluation in video-assisted thoracoscopic lobectomy versus lobectomy by thoracotomy

BACKGROUND

With the emergence of video-assisted thoracic surgery (VATS) lobectomy, concern remains regarding the adequacy of nodal assessment versus thoracotomy.

METHODS

All clinical stage I non-small cell lung cancer patients treated with VATS or open lobectomy were retrospectively evaluated. Total nodes, N2 nodes, and nodes at each station were evaluated for associations with surgery type and location of involved lobe.

RESULTS

There were 79 VATS and 464 open lobectomy or segmental resections for stage I tumors. Overall, fewer lymph nodes were sampled with VATS compared with thoracotomy (7.4 +/- 0.6 vs 8.9 +/- 0.2, respectively; p = 0.029), and fewer N2 nodes were sampled with VATS versus thoracotomy as well (2.5 +/- 3.0 vs 3.7 +/- 3.3, p = 0.004). There were no differences in N1 node sampling between the two groups (5.2 +/- 3.6 vs 4.9 +/- 4.2, p = 0.592). Furthermore, there were more station 7 nodes with thoracotomy versus VATS (1.2 +/- 0.1 vs 0.6 +/- 0.1, p = 0.002). Among right-sided lesions, there was no difference in 4R nodes between groups (1.4 +/- 0.4 vs 1.6 +/- 0.2, p = 0.7) although there was a trend toward more level 7 nodes with thoracotomy (1.0 +/- 0.2 vs 1.4 +/- 0.2, p < 0.08). Among left-sided resections there were more station 7 nodes with thoracotomy versus VATS (1.0 +/- 0.1 vs 0.4 +/- 0.1, p < 0.001) and more station 5/6 nodes (1.1 +/- 0.1 vs 0.5 +/- 0.1, p < 0.04). For upper lobe resections, the total nodes (8.9 +/- 0.3 vs 7.4 +/- 0.7, p = 0.05) and station 7 nodes (1.0 +/- 0.1 vs 0.6 +/- 0.1, p < 0.01) were higher with thoracotomy than VATS. There was no difference in 2-year survival between groups (81% vs 83%, p = 0.4).

CONCLUSIONS

Our early experience with VATS has been associated with fewer lymph nodes sampled compared with open lobectomy although there was no survival difference. Analysis of these differences has directed us toward a more focused lymph node sampling with VATS lobectomy.

VATS lobectomy is better than open thoracotomy: what is the evidence for short-term outcomes?

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.

Variation in the Approach to VATS Lobectomy: Effect on the Evaluation of Surgical Morbidity Following VATS Lobectomy for the Treatment of Stage I Non–Small Cell Lung Cancer

Recent advances in imaging, chemical pathology, and target therapy have made it necessary to redefine the role of surgery in the therapeutic algorithm in the management of lung cancer. Although video-assisted thoracic surgery lobectomy with hilar and mediastinal lymph node dissection was proposed over a decade ago to treat early lung cancer, this technique is currently not widely practiced, despite many documented advantages. This article examines the role of video-assisted thoracic surgery lobectomy in the treatment of early lung cancer and, in particular, variations in the approach and published results.

Systematic node dissection by VATS is not inferior to that through an open thoracotomy: A comparative clinicopathologic retrospective study

BACKGROUND

Major pulmonary resection with systematic node dissection (SND) for early lung cancer by video-assisted thoracic surgery (VATS) is performed in many institutes, but the feasibility of SND for early lung cancer by VATS remains controversial. The aim of this study was to elucidate the feasibility and safety of SND by VATS.

METHODS

Three hundred fifty patients with clinical stage I lung cancer who underwent pulmonary major resection with SND between 1998 and 2003 were enrolled in this study. Of these patients, 191 (VATS group) underwent pulmonary resection with SND by VATS; 159 patients (open thoracotomy [OT] group) did so through anterolateral thoracotomy. The clinical and pathologic data, including the number of dissected nodes in each nodal station, of the 2 groups were compared to evaluate the feasibility of SND by VATS.

RESULTS

Pathologic data showed that, in the VATS group, more patients had adenocarcinoma (P = .0078) and fewer patients had advanced factors than the OT group. The greatest tumor diameter was 24.5 mm and 29.6 mm in the VATS group and OT group, respectively (P < .0001). The total number of mediastinal nodes dissected in right upper lobectomy plus right middle lobectomy (RUL+RML), right lower lobectomy (RLL), left upper lobectomy (LUL), and lower left lobectomy (LLL) also did not differ between the 2 groups. The total number of mediastinal nodes dissected in RUL+RML, RLL, LUL, and LLL was 19.7 in the VATS group versus 22.0 in the OT group (P = .122), 23.4 versus 21.0 (P = .241), 14.8 versus 17.5 (P = .123), and 18.8 versus 15.8 (P = .202), respectively. The number of dissected nodes in each nodal station in RUL+RML, RLL, LUL, and LLL was similar between the 2 groups. Operative mortality, morbidity, or recurrence did not differ between the 2 groups.

CONCLUSIONS

With regard to the number of dissected nodes, SND by VATS was not inferior to that of OT. SND by VATS is technically feasible and safe, and seems acceptable for clinical stage I lung cancer.

[Video-assisted lobectomy through the auscultatory triangle for the surgical treatment of bronchopulmonary carcinoma. Preliminary experience]

OBJECTIVE

To describe a technique for video-assisted lobectomy through the auscultatory triangle (VALAT) and to assess early and medium-term outcome of the procedure in patients with non-small cell bronchopulmonary carcinoma in stage I.

PATIENTS AND METHOD

Between April 1999 and May 2002 we performed 25 VALAT procedures (24 lobectomies and 1 bilobectomy) in 25 patients with a mean age of 63.6 years (range 39-80).

RESULTS

No deaths occurred during or after surgery. Conversion to conventional thoracotomy was necessary in two cases. One patient was re-operated to resolve hemothorax and one developed a bronchopleural fistula that was treated by pleural drainage. The mean hospital stay was 6.3 days. Twenty-three patients have been disease-free throughout a mean follow-up period of 11.5 months (range 1-36). The two-year actuarial survival rate (Kaplan-Meier) was 93% 7%.

CONCLUSIONS

VALAT is a safe procedure that nevertheless requires specific training. The rate of complications was low in our patient series and mortality was nil. The outcome for patients with stage I bronchogenic carcinoma over a two-year follow-up period has been comparable to results obtained with conventional thoracotomy.

Prognostic significance of high-resolution CT findings in small peripheral adenocarcinoma of the lung: a retrospective study on 64 patients

OBJECTIVE

We studied the prognostic importance of high-resolution CT (HRCT) findings in lung adenocarcinomas.

PATIENTS AND METHODS

HRCT findings (lesion size, percentage of ground-glass opacity (GGO) areas of lesion, and presence or absence of lobulation, coarse spiculation, air space, pleural tag, and multiplicity of lesion), clinical data (age and surgical method), and pathologic findings (tumor subtypes and presence or absence of nodal metastasis) in 64 consecutive patients with 64 peripheral adenocarcinomas of 20 mm or less (mean, 13 mm), including 36 women and 28 men with a mean age of 64 years were analyzed and correlated with survival of the patients using Kaplan-Meier method and stepwise Cox proportional hazards modeling. Follow-up periods of the patients ranged from 6 to 45 months (mean, 22 months). Tumors were classified into six subtypes (types A-F) according to tumor growth patterns defined by Noguchi et al.

RESULTS

Six (9%) of the 64 patients died of lung cancer. In univariate analyses, a significant difference was noted for lesion size (P=0.043), the percentage of GGO areas (P=0.005), and tumor subtypes (P=0.006). Lesion size of <15 mm (n=35), a lesion with GGO areas of >57% (n=36), and type A (n=16) or type B adenocarcinomas (n=16) indicated a significantly better survival. In multivariate analyses using these three parameters as independent variables, the percentage of GGO areas was the only significant independent factor for survival (P=0.044, relative risk=0.95).

CONCLUSION

GGO areas measured on HRCT may have an independent prognostic significance of small adenocarcinomas of the lung.

Discrimination of subtypes of small adenocarcinoma in the lung with thin-section CT

We studied the usefulness of thin-section CT in discriminating two categories of adenocarcinoma in the lung. Thin-section CT findings, such as, lesion size, ground-glass opacity (GGO) areas of lesion and presence or absence of lobulation, coarse spiculation, air bronchogram, small air space, or pleural tag of lesion in 62 consecutive patients with 62 adenocarcinomas (35 type A or B tumors (Noguchi's classification) and 27 type C tumors) of < or =20 mm, including 36 women and 26 men with a mean age of 64 years were analyzed. We performed stepwise logistic modeling using all the CT findings as independent variables to estimate the significant factors for discriminating type C from type A or B tumor. Lesion size in type C tumors was significantly (P<0.001) greater than that in type A or B tumors. GGO areas in type C tumors were significantly (P<0.001) smaller than that in type A or B tumors. The prevalence of coarse spiculation, air bronchogram, and pleural tag in type C tumors was significantly greater (P=0.001, 0.010, and <0.001, respectively) than that in type A or B tumors. Logistic modeling revealed that the GGO area was the only significant factor for discriminating two categories (P<0.001). Using the percentage of GGO areas for predicting type C tumor, 40% or less showed the highest accuracy of 85% with 70% sensitivity and 97% specificity. GGO areas of 30% or less had no false-positive diagnosis (100% specificity) with 81% accuracy but its sensitivity was low (56%). Thin-section CT was useful in discriminating two categories of adenocarcinoma in the lung.

Video-assisted thoracoscopic surgery for diagnosis, staging, and management of lung cancer with suspected mediastinal lymphadenopathy

The aim of this report was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) in staging, diagnosis, and treatment of lung cancer. Fifty-two patients were scheduled for mediastinal lymph node VATS biopsy at the Oncologic Thoracic Surgery Department of the National Cancer Institute in Milan. Fifty patients underwent lymph nodal thoracoscopic biopsy (96%), whereas for the other 2 patients, histologic diagnosis was done by pleural metastatic nodule thoracoscopic biopsy (4%). We performed 17 lymph nodal biopsies in level 5 (33%), 14 in level 6 (27%), 12 in level 7 (23%), and 7 in level 8 (13%). No postoperative complications were observed, and 19 subjects (36%) underwent open lung resection. The histologic diagnosis was adenocarcinoma in 25 cases (48%), epidermoid carcinoma in 14 (27%), microcytoma in 9 (17%), and giant-cell lung carcinoma in 4 (8%); 10 patients were at stage I (19%), 9 at stage II (17%), 31 at stage III (60%), and 2 at stage IV (4%). The use of VATS allowed diagnosis of the suspected involved mediastinal lymph nodes in lung cancer patients and obviated the need for painful thoracotomy, enabling accurate staging and thus selection of the optimal treatment.

Video-assisted thoracic surgery major pulmonary resections. Present experience

OBJECTIVE

The purpose of this report is to review our experience of video-assisted thoracic surgery (VATS) major pulmonary resections.

METHODS

From January 1993 to December 1999 we proposed VATS, for major pulmonary resections, with these indications: benign lesions and solitary metastases not removable by wedge resection and stage I non-small cell lung cancer (NSCLC). The maximum size of the lesion had to be less than 4 cm.

RESULTS

There were 125 patients, 87 men and 38 women with a mean age of 62. We successfully performed VATS procedure in 112 cases (one hamartoma, one tubercoloma, 12 typical carcinoids, 11 metastases and 87 lung cancers), while in another 13 (10.4%) a conversion to open surgery was required. There were 108 lobectomies, three bilobectomies and one pneumonectomy. Out of the first three cases of NSCLC, in all patients mediastinal node sampling or lymphadenectomy was performed. We recorded 13 (11.6%) postoperative complications, one of which required re-operation (bleeding). In the 99 patients without complications, the mean postoperative stay was 5.8 days. In a mean follow-up period of 36 months with patients having lung cancer we achieved a 3-year survival rate of 85+/-9 and 90+/-8% when only the patients in Stage I were considered.

CONCLUSIONS

We believe that VATS, in performing pulmonary lobectomy, is a safe and effective approach and it seems to give the same long-term results as open surgery. Now the main problems concern the indications that should be strictly respected and the conversion to thoracotomy which should be undertaken without hesitation when the anatomic or pathologic conditions are not favourable.

Changes in right ventricular performance in elderly patients who underwent lobectomy using video-assisted thoracic surgery for primary lung cancer

OBJECTIVE

Even though lobectomy using video-assisted thoracic surgery for primary lung cancer has been reported to be beneficial in terms of the perioperative outcome, changes in the right ventricular performance have not yet been reported. The aim of this study was to determine whether lobectomy by video-assisted thoracic surgery is also advantageous with respect to the right ventricular performance in elderly patients who are 70 years old or older.

SUBJECTS AND METHODS

Thirteen patients (mean age: 76 years) who underwent lobectomy using video-assisted thoracic surgery (Video-assisted Thoracic Surgery Group), and 10 patients (mean age: 76 years) who underwent lobectomy using a standard thoracotomy as a historical control group (Standard Thoracotomy Group) were studied. The hemodynamics and right ventricular ejection fraction were evaluated preoperatively, and at 6, 12, 24, and at 48 hours postoperatively.

RESULTS

Postoperative values were expressed as a percentage of the preoperative values. The systemic vascular resistance index decreased to a greater extent in the Video-assisted Thoracic Surgery Group than in the Standard Thoracotomy Group. The pulmonary arteriolar resistance index at 24 hours postoperation tended to be higher in the Standard Thoracotomy Group than in the Video-assisted Thoracic Surgery Group. The stroke index, cardiac index, and right ventricular ejection fraction at 24 hours postoperation were each significantly higher in the Video-assisted Thoracic Surgery Group than in the Standard Thoracotomy Group.

CONCLUSION

Lobectomy using video-assisted thoracic surgery for elderly patients offers not only beneficial effects in the right ventricular afterload but also acceleration in the expected compensatory hyperdynamics during the acute postoperative phase.

Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy

BACKGROUND

Data regarding pulmonary function and prognosis after video-assisted thoracic surgery lobectomy are limited.

METHODS

From September 1992 to April 2000, 204 video-assisted thoracic surgery lobectomies were performed, and their preoperative and postoperative pulmonary function test results and prognoses were evaluated.

RESULTS

The postoperative to preoperative ratio of pulmonary function tests (vital capacity and forced expiratory volume in 1 s) were better in video-assisted thoracic surgery lobectomy than in open thoracotomy (p < 0.0001). Furthermore, the 5-year survival rate of pathologic stage I lung cancers after video-assisted thoracic surgery was 97.0%, whereas that after open thoracotomy was 78.5% (p = 0.0173; Mantel-Cox).

CONCLUSIONS

Pulmonary function and prognosis were far better after video-assisted thoracic surgery lobectomy than after open thoracotomy.

Lymphocyte responses following open and minimally invasive thoracic surgery

BACKGROUND

Immunosuppression associated with surgery may predispose to increased tumour growth or recurrence. Lymphocytes are central components of the immune network, signalling specific and non-specific responses in tumour immunosurveillance. This study was therefore designed to compare the effects of minimally invasive and conventional approaches to major thoracic surgery on lymphocyte populations and oxidative activity.

PATIENTS AND METHODS

The effects of conventional and minimally invasive video-assisted thoracic surgery (VATS) on the numbers and types of circulating lymphocytes and on lymphocyte oxidation were compared in a prospective randomized study of 41 patients undergoing lobectomy for peripheral bronchogenic carcinoma. Blood taken pre-operatively and on days 2 and 7 post-operatively was analysed for T (CD4, CD8), B (CD19) and natural killer (NK) (CD56, CD16) cell counts and for lymphocyte oxidative activity. Leucocyte numbers were compared with pre-surgical values and oxidative rate with healthy donor controls.

RESULTS

Lymphocyte counts fell after surgery; VATS was associated with less effect on circulating T (CD4) cells at 2 days and on NK lymphocytes at 7 days post-surgery. Lymphocyte oxidation was less suppressed in the VATS group 2 days after surgery. In general, post-surgical changes in key cells of cellular immunity were smaller in the VATS group, and recovery to normal levels was more rapid.

CONCLUSION

The degree of invasiveness of thoracic surgery may influence the extent of immunosuppression in patients undergoing pulmonary lobectomy for pulmonary neoplasm.

Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience

Between September 1992 and October 1997, we performed 128 video-assisted thoracic surgery (VATS) lobectomies. The indications for surgery were 103 cases of lung cancer, 11 cases of bronchiectasis, 8 cases of granuloma, 4 cases of benign lesions, and 2 cases of metastatic tumors. Of the 103 cases of lung cancer, 62 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, and the 4-year survival rate of final stage I lung cancer was 94.4%. VATS lobectomy is far less invasive than open thoracotomy, and survival rates after VATS lobectomy with extended lymph node dissection are comparable with those after open thoracotomy. Thus, VATS lobectomy with extended lymph node dissection should be considered as a standard surgical alternative to open thoracotomy for stage I lung cancer.