Efficacy of Mediastinal Lymph Node Dissection During Lobectomy for Lung Cancer by Thoracoscopy and Thoracotomy

Optimizing surgical precision: a comparative study of three-port vs. four-port robotic-assisted lobectomy for NSCLC

BACKGROUND

In recent years, robot-assisted thoracoscopic surgery has seen major advances. The feasibility and safety of this new surgical procedure have been widely recognized. However, only a few studies have investigated the short-term postoperative outcomes of lobectomy in early-stage non-small cell lung cancer (NSCLC) patients using different numbers of ports in Da Vinci robot-assisted surgery. This study aimed to evaluate the clinical value of robot-assisted lobectomy by comparing the perioperative data of NSCLC patients who underwent three-port and four-port surgical methods.

METHODS

The data of 121 consecutive patients who were admitted to our hospital for NSCLC and underwent Da Vinci robot-assisted thoracic surgery (RATS) for radical resection from January 2020 to October 2021 were retrospectively collected and analyzed. The cases that did not meet the inclusion criteria were removed, and the patients were divided into the three-port group (76 cases) and the four-port group (45 cases). The general clinical data, perioperative data, and postoperative pain were individually compared to determine the different clinical effectiveness of the two approaches.

RESULTS

All 121 patients in the 2 groups successfully underwent lobectomy and systemic lymph node dissection. No significant difference in age, sex, tumor location, tumor size, history of chronic disease, pathological type, pathological tumor-node-metastasis (pTNM) staging, postoperative complications, and number or stations of total lymph nodes dissected was observed between the two groups (P > 0.05). The operation time [(117.32 ± 36.55) min vs. (136.83 ± 40.63) min], the console time [(90 ± 19.35) min vs. (103 ± 15.65) min], the intraoperative blood loss [(94.34 ± 32.16) mL vs. (102.73 ± 33.67) mL], the chest tube drainage time [(2.43 ± 0.65) d vs. (2.79 ± 1.42) d], and the postoperative hospitalization time [(4.55 ± 1.43) d vs. (5.14 ± 1.66) d] were lower in the three-port group compared to the four-port group but showed no statistically significant difference (P > 0.05). However, the three-port group demonstrated significantly superior visual analogue scale pain scores compared to the four-port group at 24, 48, and 72 h postoperatively (all p < 0.001).

CONCLUSIONS

Compared to four-port RATS, the three-port robotic-assisted lobectomy is safe, practicable and effective. Operative incision optimization leads to less postoperative pain and appears to be more acceptable for patients with NSCLC.

Lymph node dissection in lung cancer surgery: a comparison between robot-assisted vs. video-assisted thoracoscopic approach

BACKGROUND

TNM staging is the most important prognosticator for non-small cell lung cancer (NSCLC) patients. Staging has significant implications for the treatment modality for these patients. Lymph node dissection in robot-assisted thoracoscopic (RATS) surgery remains an area of ongoing evaluation. In this study, we aim to compare lymph node dissection in RATS and VATS approach for lung resection in NSCLC patients.

METHODS

We retrospectively compiled a database of 717 patients from July 31, 2015-July 7, 2022, who underwent either a wedge resection, segmentectomy or lobectomy. We analysed the database according to lymph node dissection. The database was divided into RATS (n = 375) and VATS (n = 342) procedures.

RESULTS

The mean number of lymph nodes harvested overall with RATS was 6.1 ± 1.5 nodes; with VATS approach, it was 5.53 ± 1.8 nodes. The mean number of N1 stations harvested was 2.66 ± 0.8 with RATS, 2.36 ± 0.9 with VATS. RATS approach showed statistically higher lymph node dissection rates compared to VATS (p = 0.002). Out of the 375 RATS procedures, 26 (6.4%) patients undergoing a RATS procedure were upstaged from N0/N1 staging to N2. N0/N1-N2 upstaging was reported in 28 of 342 (8.2%) patients undergoing a VATS procedure. The majority of upstaging was seen in N0-N2 disease: 19 of 375 (5%) for RATS and 23 of 342 (6.7%) for VATS.

CONCLUSIONS

We conclude that in RATS procedures, there is a higher rate of lymph node dissection compared to VATS procedures. Upstaging was mostly seen in N0-N2 disease, this was observed at a higher rate with VATS procedures.

Results of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer in a mixed practice medium-volume hospital: a propensity-matched study

OBJECTIVES

The aim of this study was to compare the short- and long-term results of video-assisted thoracoscopic surgery (VATS) and thoracotomy for non-small-cell lung cancer in a medium-volume centre, where cardiothoracic surgeons perform both cardiac and general thoracic surgery. The primary outcome of interest was 5-year overall survival and disease-specific survival. Secondary outcomes were short-term postoperative complications, length of hospital stay and lymph node yield.

METHODS

This was a retrospective cohort study including 670 lung cancer patients undergoing VATS (n = 207) or open surgery (n = 463) with a curative intent in Oulu University Hospital between the years 2000-2020. Propensity score matching was implemented with surgical technique as the dependent and age, sex, Charlson comorbidity index, pulmonary function, pathological stage, histological type and the year of the operation as covariates resulting in 127 pairs.

RESULTS

In the propensity-matched cohort, 5-year overall survival was 64.3% after VATS and 63.2% after thoracotomy (P = 0.969). Five-year disease-specific survival was 71.6% vs 76.2% (P = 0.559). There were no differences in overall (34.6% vs 44.9%, p = 0.096) or major postoperative complications (8.7% vs 14.2%, P = 0.167) between the study groups. The average length of hospital stay was shorter (5.8 vs 6.6 days, P = 0.012) and the median lymph node yield was lower (4.0 vs 7.0, P < 0.001) in the VATS group compared to the thoracotomy group.

CONCLUSIONS

According to this study, the long-term results of lung cancer surgery in a mixed practice are comparable between VATS and open surgery.

The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Staging and multidisciplinary management of patients with early-stage non-small cell lung cancer

Novel targeted therapy and immunotherapy drugs have recently been approved for use in patients with surgically resectable lung cancer. Accurate staging, early molecular testing, and knowledge of recent trials are critical to optimize oncologic outcomes in these patients.

A Comparison of Total Thoracoscopic and Robotic Surgery for Lung Cancer Lymphadenectomy

BACKGROUND

Robotic-assisted thoracic surgery (RATS) is used increasingly frequently in major lung resection for early stage non-small-cell lung cancer (NSCLC) but has not yet been fully evaluated. The aim of this study was to compare the surgical outcomes of lymph node dissection (LND) performed via RATS with those from totally thoracoscopic (TT) four-port videothoracoscopy.

METHODS

Clinical and pathological data were collected retrospectively from patients with clinical stage N0 NSCLC who underwent pulmonary resection in the form of lobectomy or segmental resection between June 2010 and November 2022. The assessment criteria were number of mediastinal lymph nodes and number of mediastinal stations dissected via the RATS approach compared with the four-port TT approach.

RESULTS

A total of 246 pulmonary resections with LND for clinical stages I-II NSCLC were performed: 85 via TT and 161 via RATS. The clinical characteristics of the patients were similar in both groups. The number of mediastinal nodes dissected and mediastinal stations dissected was significantly higher in the RATS group (TT: mean ± SD, 10.72 ± 3.7; RATS, 14.74 ± 6.3 [p < 0.001]), except in the inferior mediastinal stations. There was no difference in terms of postoperative complications.

CONCLUSIONS

In patients with early stage NSCLC undergoing major lung resection, the quality of hilomediastinal LND performed using RATS was superior to that performed using TT.

Subcarinal lymph node dissection facilitated by applying suture passer in uniportal video-assisted thoracoscopic surgery

With the advancement of surgical skills and instrumentation, uniportal video-assisted thoracoscopic surgery (UniVATS) has become a popular option for the treatment of early stage lung cancer surgery. However, performing subcarinal lymph node dissection remains technically challenging under UniVATS view. We introduce a novel technique that utilized a suture passer to improve the exposure of the subcarinal area and simplify lymph node dissection, which has the potential for widespread adoption in clinical practice. There were 13 lung cancer patients who underwent UniVATS lobectomy with mediastinal lymphadenectomy in our institution from July to August 2022. Clinical data of the patients were documented and reviewed. The study population consisted of nine females and four males, with an average age of 57.5 ± 9.1 years. UniVATS lobectomy with mediastinal lymphadectomy was successfully performed in all patients without conversion to open surgery. The mean operation time was 90.7 ± 36.0 min (53-178 min), intraoperative blood loss was 73.1 ± 43.8 mL (50-200 mL), and postoperative hospital stay was 2.9 ± 0.3 days (2-3 days). No complications related to lymph node dissection, such as chylothorax, occurred. Our novel method of using a suture passer could simplify the procedure of subcarinal lymph node dissection during UniVATS in initial clinical practice. Further comparative studies are warranted in the future.

Comparison of the Outcomes between Systematic Lymph Node Dissection and Lobe-Specific Lymph Node Dissection for Stage I Non-small Cell Lung Cancer

BACKGROUND

This study compares the surgical and long-term outcomes, including disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS), between lobe-specific lymph node dissection (L-SND) and systematic lymph node dissection (SND) among patients with stage I non-small cell lung cancer (NSCLC).

METHODS

In this retrospective study, 107 patients diagnosed with clinical stage I NSCLC undergoing video-assisted thoracic surgery lobectomy (exclusion of the right middle lobe) from January 2011 to December 2018 were enrolled. The patients were assigned to the L-SND (n = 28) and SND (n = 79) groups according to the procedure performed on them. Demographics, perioperative data, and surgical and long-term oncological outcomes were collected and compared between the L-SND and SND groups.

RESULTS

The mean follow-duration was 60.6 months. The demographic data and surgical outcomes and long-term oncological outcomes were not significantly different between the two groups. The 5-year OS of the L-SND and SND groups was 82% and 84%, respectively. The 5-year DFS of the L-SND and SND groups was 70% and 65%, respectively. The 5-year CSS of the L-SND and SND groups was 80% and 86%, respectively. All the surgical and long-term outcomes were not statistically different between the two groups.

CONCLUSION

L-SND showed comparable surgical and oncologic outcomes with SND for clinical stage I NSCLC. L-SND could be a treatment choice for stage I NSCLC.

VATS versus Open Lobectomy following Induction Therapy for Stage III NSCLC: A Propensity Score-Matched Analysis

Objectives: This study aims to evaluate the perioperative and oncologic outcomes of thoracoscopic lobectomy for advanced stage III NSCLC. Methods: We retrospectively reviewed 205 consecutive patients who underwent VATS or open lobectomy for clinical stage III lung cancer between January 2013 and December 2020. The perioperative and oncologic outcomes of the two approaches were compared. Long-term survival was assessed using the Kaplan−Meier estimator. Propensity score-matched (PSM) comparisons were used to obtain a well-balanced cohort of patients undergoing VATS and open lobectomy. Results: VATS lobectomy was performed in 77 (37.6%) patients and open lobectomy in 128 (62.4%) patients. Twelve patients (15.6%) converted from VATS to the open approach. PSM resulted in 64 cases in each group, which were well matched according to twelve potential prognostic factors, including tumor size, histology, and pTNM stage. Between the VATS and the open group, there were no significant differences in unmatched and matched analyses, respectively, of the overall postoperative complications (p = 0.138 vs. p = 0.109), chest tube duration (p = 0.311 vs. p = 0.106), or 30-day mortality (p = 1 vs. p = 1). However, VATS was associated with shorter hospital stays (p < 0.0001). The five-year overall survival (OS) and five-year Recurrence-free survival (RFS) were comparable between the VATS and the open groups. There was no significant difference in the recurrence pattern between the two groups in both the unmatched and matched analyses. Conclusion: For the advanced stage III NSCLC, VATS lobectomy achieved equivalent postoperative and oncologic outcomes when compared with open lobectomy without increasing the risk of procedure-related locoregional recurrence.

Number of lymph nodes dissected and upstaging rate of the N factor in robot-assisted thoracic surgery versus video-assisted thoracic surgery for patients with cN0 primary lung cancer

PURPOSE

The accuracy of lymph node (LN) dissection in robotic surgery for lung cancer remains controversial. We compared the accuracy of LN dissection in robot-assisted thoracic surgery (RATS) vs. video-assisted thoracic surgery (VATS).

METHODS

The subjects of this retrospective analysis were 226 patients with cN0 primary lung cancer who underwent robot-assisted or video-assisted thoracic lobectomy with LN dissection, in our department, between April, 2016 and February, 2021. We compared the numbers of all LNs and mediastinal LNs dissected, the time required for LN dissection, complications, and upstaging rates of the N factor between the groups. Furthermore, we performed an inverse probability of treatment weighting-adjusted analysis to reduce potential bias between the groups.

RESULTS

The number of dissected LNs was higher in the RATS group in both the unweighted and weighted analyses. The time required for lymph node dissection was also longer in RATS. There was no significant difference in complications or in the upstaging rate of the N factor between the groups.

CONCLUSION

More LNs were dissected with RATS. Thus, the usefulness of robot-assisted surgery for LN dissection needs to be investigated further.

Thoracoscopic Versus Open Lobectomy After Induction Therapy for Nonsmall Cell Lung Cancer: New Study Results and Meta-analysis

INTRODUCTION

The use of video-assisted thoracoscopic surgery (VATS) lobectomy has become a mainstay of modern thoracic surgery practice and the technique of choice for resection of early-stage lung cancers. However, the benefits of VATS following induction therapy are yet to be clarified. This study aims to assess whether VATS lobectomy achieves similar perioperative and oncologic outcomes compared to thoracotomy for nonsmall cell lung cancer after induction therapy.

METHODS

We retrospectively reviewed the outcomes of 72 patients who underwent lung lobectomy after induction therapy in our institution from January 2017 to January 2020. Subsequently, we carried out a comprehensive literature search and pooled our results with available data from previously published studies to perform a meta-analysis.

RESULTS

VATS was associated with reduced intraoperative blood loss (P = 0.05) and less perioperative complications (P = 0.04) in our local institution. The meta-analysis comprised nine studies. A total of 943 patients underwent VATS and 2827 patients underwent open lobectomy. VATS was associated with significant shorter surgery duration (P < 0.0001), shorter chest-tube drainage duration (P < 0.0001), and shorter hospital stays (P < 0.0001). Furthermore, there was significantly less perioperative complications (P = 0.006) and less intraoperative blood loss (P = 0.036) in the VATS group. However, there were no significant differences in 3-y overall survival and 3-y disease-free survival rates.

CONCLUSIONS

In some selected patients undergoing induction therapy, VATS lobectomy could achieve equivalent perioperative outcomes to thoracotomy but evidence is lacking on oncologic outcomes. Further trials with a focus on oncologic outcomes and longer follow-up are required.

A Comparative Analysis of Video-Assisted Thoracoscopic Surgery and Thoracotomy in Non-Small-Cell Lung Cancer in Terms of Their Oncological Efficacy in Resection: A Systematic Review

Video-assisted thoracoscopic surgery (VATS) is considered the standard procedure for surgical resection in non-small-cell lung cancer (NSCLC). However, there is still lingering speculation on its adequacy of lymph node (LN) dissection or sampling and the long-term survival benefits when compared to open thoracotomy. Given the above, we conducted a systematic review comparing VATS and thoracotomy in terms of their oncological effectiveness in resection. We explored major research literature databases and search engines such as MEDLINE, PubMed, PubMed Central, Google Scholar, and ResearchGate to find pertinent articles. After the meticulous screening, quality check, and applying relevant filters according to our eligibility criteria, we identified 16 studies relevant to our research question, out of which one was a randomized controlled trial, one meta-analysis, and 14 were observational studies. The study comprised 44,673 patients with NSCLC, out of whom 15,093 patients were operated by VATS and the remaining 29,580 patients by thoracotomy. The results indicate that VATS is equivalent to thoracotomy in total LNs (N1 + N2) and LN stations dissected. However, a thoracotomy may achieve slightly better mediastinal lymph node dissection (N2) in terms of assessing a greater number of mediastinal lymph nodes and nodal stations. This may be attributed to a better visual field during mediastinal nodal clearance by an open approach. Also, nodal upstaging was consistently more common with an open approach. In terms of long-term outcomes, both overall survival and disease-free survival rates were similar between the two groups, with VATS offering a slightly better survival benefit. Irrespective of the increased rates of nodal upstaging by an open approach, we conclude that VATS should be considered a highly efficient alternative to thoracotomy in both early and locally advanced NSCLC.

RAVAL trial: Protocol of an international, multi-centered, blinded, randomized controlled trial comparing robotic-assisted versus video-assisted lobectomy for early-stage lung cancer

Background

Retrospective data demonstrates that robotic-assisted thoracoscopic surgery provides many benefits, such as decreased postoperative pain, lower mortality, shorter length of stay, shorter chest tube duration, and reductions in the incidence of common postoperative pulmonary complications, when compared to video-assisted thoracoscopic surgery. Despite the potential benefits of robotic surgery, there are two major barriers against its widespread adoption in thoracic surgery: lack of high-quality prospective data, and the perceived higher cost of it. Therefore, in the face of these barriers, a prospective randomized controlled trial comparing robotic- to video-assisted thoracoscopic surgery is needed. The RAVAL trial is a two-phase, international, multi-centered, blinded, parallel, randomized controlled trial that is comparing robotic- to video-assisted lobectomy for early-stage non-small cell lung cancer that has been enrolling patients since 2016.

Methods

The RAVAL trial will be conducted in two phases: Phase A will enroll 186 early-stage non-small cell lung cancer patients who are candidates for minimally invasive pulmonary lobectomy; while Phase B will continue to recruit until 592 patients are enrolled. After consent, participants will be randomized in a 1:1 ratio to either robotic- or video-assisted lobectomy, and blinded to the type of surgery they are allocated to. Health-related quality of life questionnaires will be administered at baseline, postoperative day 1, weeks 3, 7, 12, months 6, 12, 18, 24, and years 3, 4, 5. The primary objective of the RAVAL trial is to determine the difference in patient-reported health-related quality of life outcomes between the robotic- and video-assisted lobectomy groups at 12 weeks. Secondary objectives include determining the differences in cost-effectiveness, and in the 5-year survival data between the two arms. The results of the primary objective will be reported once Phase A has completed accrual and the 12-month follow-ups are completed. The results of the secondary objectives will be reported once Phase B has completed accrual and the 5-year follow-ups are completed.

Discussion

If successfully completed, the RAVAL Trial will have studied patient-reported outcomes, cost-effectiveness, and survival of robotic- versus video-assisted lobectomy in a prospective, randomized, blinded fashion in an international setting.

Trial registration

ClinicalTrials.gov, NCT02617186. Registered 22-September-2015. https://clinicaltrials.gov/ct2/show/NCT02617186

Video-assisted thoracoscopic lobectomy versus open lobectomy in the treatment of large lung cancer: propensity-score matched analysis

Background

There are several concerns on thoracoscopic surgery for large tumors because of the increased risk of tumor cell spillage. This study aimed to compare perioperative outcomes and oncological validity between video-assisted thoracoscopic surgery (VATS) and open lobectomy for non-small cell lung cancer (NSCLC) with tumor size > 5 cm.

Methods

We retrospectively reviewed 355 patients who underwent lobectomy with clinical N0 NSCLC with solid tumor component diameter > 5 cm between January 2009 and December 2016. Patients with tumor invading adjacent structures were excluded. The patients were divided into the VATS group (n = 132) and thoracotomy group (n = 223). Propensity score matching (1:1) was applied.

Results

After propensity score matching, 204 patients were matched, and clinical characteristics of the two groups were well balanced. The VATS group was associated with a shorter length of hospital stay (6 days vs. 7 days; P < 0.001) than the thoracotomy group. There were no significant differences in the 5-year overall survival (71.5% in VATS vs. 64.4% in thoracotomy, P = 0.390) and 5-year recurrence-free survival (60.1% in VATS vs. 51.5% in thoracotomy, P = 0.210) between the two groups. The cumulative incidence of ipsilateral pleural recurrence was not significantly different between the two groups (12.0% in VATS vs. 7.9% in thoracotomy; P = 0.582).

Conclusions

In clinical N0 NSCLC larger than 5 cm, VATS lobectomy resulted in shorter hospital stay and similar survival outcome compared to open lobectomy. Based on these results, VATS lobectomy is a valuable option in this subset of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01749-8.

Thoracoscopic Surgery Shows Non-Inferiority to Open Surgery for Clinical N0-N2 and Pathologic N2 Non-Small Cell Lung Cancer

Objectives

Controversy has remained over the primary surgical management for stage IIIA-N2 non–small cell lung cancer. Minimal or non-bulky N2 disease defined as single-station nodal involvement may still be a candidate of radical surgery. The aim of this study was thus to assess the outcome of thoracoscopic surgery in clinical N0-N2 and pathologic N2 disease.

Methods

Seventy-nine cases of pathologic N2 diseases without induction therapy (clinical N0, 27; N1, 13; N2, 39) were operated on between September 2003 and December 2010 in our institute. Forty-seven patients underwent thoracoscopic surgery (group T) and 32 patients underwent standard thoracotomy (group S). Perioperative and oncologic outcomes were compared between the 2 groups.

Results

There were no significant differences between the 2 groups regarding dissected number of lymph nodes, operative time, morbidity, and mortality. However, blood loss in group T was less than in group S (Mean: T, 229 versus S, 534 mL, respectively; P = 0.0004). Although disease-free survival in group T did not differ from that in group S, overall survival in group T was better than in group S after propensity score matching to adjust confounding factors including tumor size and T factor (P = 0.03). Multivariate analysis showed that multinodal stations was significantly worse prognostic factor [hazard ratio (HR) = 4.79; 95% confidence interval (CI) = (1.6–14.3); P = 0.005) in disease-free and overall survivals [HR = 8.21; 95% CI = (1.9–35.4); P = 0.005]. Thoracoscopic surgery was favorable prognostic factor in overall survivals [HR = 0.13; 95% CI = (0.03–0.6); P = 0.009].

Conclusions

Our study demonstrated that thoracoscopic surgery for non-bulky N2 disease was feasible and not inferior to standard thoracotomy in terms of oncologic outcome.

Video-Assisted Thoracic Surgery Lobectomy

Video-assisted thoracoscopic surgery (VATS) has been established as the surgical approach of choice for lobectomy in patients with early-stage non-small cell lung cancer (NSCLC). Patients with clinical stage I NSCLC with no lymph node metastasis are considered candidates for VATS lobectomy. To rule out the presence of metastasis to lymph nodes or distant organs, patients should undergo meticulous clinical staging. Assessing patients' functional status is required to ensure that there are no medical contraindications, such as impaired pulmonary function or cardiac comorbidities. Although various combinations of the number, size, and location of ports are available, finding the best method of port placement for each surgeon is fundamental to maximize the efficiency of the surgical procedure. When conducting VATS lobectomy, it is always necessary to comply with the following oncological principles: (1) the vessels and bronchus of the target lobe should be individually divided, (2) systematic lymph node dissection is mandatory, and (3) touching the lymph node itself and rupturing the capsule of the lymph node should be minimized. Most surgeons conduct the procedure in the following sequence: (1) dissection along the hilar structure, (2) fissure division, (3) perivascular and peribronchial dissection, (4) individual division of the vessels and bronchus, (5) specimen retrieval, and (6) mediastinal lymph node dissection. Surgeons should obtain experience in enhancing the exposure of the dissection target and facilitating dissection. This review article provides the basic principles of the surgical techniques and practical maneuvers for performing VATS lobectomy easily, safely, and efficiently.

Nodal Upstaging Evaluation After Robotic-Assisted Lobectomy for Early-Stage Non-small Cell Lung Cancer Compared to Video-Assisted Thoracic Surgery and Thoracotomy: A Retrospective Single Center Analysis

Introduction: The standard surgical procedures for patients with early-stage NSCLC is lobectomy-associated radical lymphadenectomy performed by using the thoracotomy approach. In the last few years, minimally invasive techniques have increasingly strengthened their role in lung cancer treatment, especially in the early stage of the disease. Although the lobectomy technique has been accepted, controversy still surrounds lymph node dissection. In our study, we analyze the rate of upstaging early non-small cell lung cancer patients who underwent radical surgical treatment using the robotic and the VATS techniques compared to the standard thoracotomy approach.

Methods and Materials: We retrospectively reviewed patients who underwent a lobectomy and radical lymphadenectomy at our Institute between 2010 and 2019. We selected 505 patients who met the inclusion criteria of the study: 237 patients underwent robotic surgery, 158 patients had thoracotomy, and 110 patients were treated with VATS. We analyzed the demographic features between the groups as well as the nodal upstaging rate after pathological examination, the number of dissected lymph nodes and the ratio of dissected lymph nodes to metastatic lymph nodes of the three groups.

Results: The patients of the three groups were homogenous with respect to age, sex, and histology. The postoperative major morbidity rate was significantly higher in the thoracotomy group, and hospital stay was significantly longer. The percentage of the mediastinal nodal upstaging rate and the number of dissected lymph nodes was significantly higher in the robotic group compared with the VATS group. The ratio of dissected lymph nodes to metastatic lymph nodes was significantly lower compared with the VATS group and the thoracotomy group.

Discussion: The prognostic impact of the R(un) status is still highly debated. A surgical approach that allows better results in terms of resection has still not been defined. Our results show that robotic surgery is a safe and feasible approach especially regarding the accuracy of mediastinal lymphadenectomy. These findings can lead to defining a more precise pathological stage of the disease and, if necessary, to more accurate postoperative treatment.

Quality assessment of robot assisted thoracic surgical resection of non-small cell lung cancer: nodal upstaging and mediastinal recurrence

Background

Robot assisted thoracic surgery (RATS) is the minimally invasive surgical technique of choice for treatment of patients with non-small cell lung cancer (NSCLC), at the Isala Hospital. The aim of this study is to compare clinical and pathological staging results and mediastinal recurrence after RATS for anatomical resections of lung cancer as surrogate markers for quality of mediastinal lymph node dissection (MLND).

Methods

This single institute retrospective study was conducted in patients who underwent RATS for NSCLC. Excluded were patients with a history of concurrent malignant disease, with other previous neoplasms, with small cell lung cancer (SCLC) and patients in whom the robotic technique was converted to thoracotomy, prior to lymph node dissection. Data were obtained from the hospital database. The difference between clinical and pathological staging was expressed as upstaging and downstaging. Computed Tomography scanning was used for follow-up, and diagnosis of mediastinal recurrence.

Results

From November 2011 to May 2016, 227 patients underwent RATS at Isala Hospital Zwolle, the Netherlands. Of those, 130 (mean age, 69.5±9.3 years) met the eligibility criteria. Preoperative mediastinal lymph node staging was done by endoscopic ultrasound/endobronchial ultrasound, by positron emission tomography (PET) or mediastinoscopy. In 14 patients (10.8%) unforeseen N2 disease was found, 6 patients (4.6%) were upstaged from cN0 to pN2 and 8 patients (6.2%) were upstaged from cN1 to pN2. Mediastinal recurrence was detected in 7 patients (5.4%) during a median follow-up of 54 months (range, 1.5-102 months).

Conclusions

In patients with NSCLC, who underwent anatomical resection by means of RATS, an unforeseen N2 disease rate of 10.8% was demonstrated and a mediastinal recurrence rate of 5.4%. It is concluded that robotic surgery provides an accurate lymph node dissection.

Completeness of lymph node dissection in patients undergoing minimally invasive- or open surgery for non-small cell lung cancer: A nationwide study

OBJECTIVE

In patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary- and mediastinal lymph node dissection (LND) as part of the operation is mandatory. The aim of this study is to assess the completeness of LND in patients undergoing an intended curative resection for NSCLC in the Netherlands and to compare performance between open surgery and minimally invasive surgery (MIS).

MATERIALS AND METHODS

The intraoperative LND was evaluated in 7460 patients who had undergone a lobectomy for clinically staged N0-1 NSCLC (2013-2018). The LND was considered complete, when three mediastinal (N2) lymph node stations, including station 7, were sampled or dissected, in addition to the lymph nodes from station 10 and 11. A comparison was made between open surgery and MIS.

RESULTS

Of 5154 patients, who had MIS, a sufficient intrapulmonary LND was performed in 47.9% and a sufficient mediastinal LND in 58.6%. A complete LND was performed in 31.6%. For 2306 patients who had an open resection, these numbers were 45.0%, 59.0%, and 30.6%, respectively. The overall between-hospital variation in a complete LND ranged between 0 and 72.5%.

CONCLUSION

In the Netherlands, a complete LND of both intrapulmonary- and mediastinal lymph nodes is performed only in a minority of patients with clinically staged N0-1 NSCLC, with substantial between-hospital variation. No differences were seen between open surgery and MIS. Because of poor performance, completeness of lymph node dissection will be recorded as a mandatory performance indicator in our national audit, to improve the quality of resection.

Video-assisted thoracoscopic surgery lobectomy might be a feasible alternative for surgically resectable pathological N2 non-small cell lung cancer patients

Background

The majority of previous studies of the clinical outcome of video‐assisted thoracoscopic surgery (VATS) versus open lobectomy for pathological N2 non‐small cell lung cancer (pN2 NSCLC) have been single‐center experiences with small patient numbers. The aim of this study was therefore to investigate these procedures but in a large cohort of Chinese patients with pathological N2 NSCLC in real‐world conditions.

Methods

Patients who underwent lobectomy for pN2 NSCLC by either VATS or thoracotomy were retrospectively reviewed from 10 tertiary hospitals between January 2014 and September 2017. Perioperative outcomes and overall survival of the patients were analyzed. Cox regression analysis was performed to identify potential prognostic factors. Propensity‐score analysis was performed to reduce cofounding biases and compare the clinical outcomes between both groups.

Results

Among 2144 pN2 NSCLC, 1244 patients were managed by VATS and 900 by open procedure. A total of 305 (24.5%) and 344 patients died during VATS and the thoracotomy group during a median follow‐up of 16.7 and 15.6 months, respectively. VATS lobectomy patients had better overall survival when compared with those undergoing the open procedure (P < 0.0001). Multivariate COX regression analysis showed VATS lobectomy independently favored overall survival (HR = 0.75, 95% CI: 0.621–0.896, P = 0.0017). Better perioperative outcomes, including less blood loss, shorter drainage time and hospital stay, were also observed in patients undergoing VATS lobectomy (P < 0.05). After propensity‐score matching, 169 patients in each group were analyzed, and no survival difference were found between the two groups. Less blood loss was observed in the VATS group, but there was a longer operation time.

Conclusions

VATS lobectomy might be a feasible alternative to conventional open surgery for resectable pN2 NSCLC.

Key points

Significant findings of the study: VATS lobectomy has comparative OS in pN2 NSCLC versus open procedure in resectable patients.

What this study adds: VATS lobectomy might be feasible for pN2 NSCLC.

Long-term survival of thoracoscopic surgery compared with open surgery for clinical N0 adenocarcinoma

Background

Early stage non-small cell lung cancer (NSCLC) is good candidate for video-assisted thoracoscopic surgery (VATS). Long-term outcome compared between VATS and open surgery remains unclear. The aim of this study was to assess the long-term outcome of VATS in early stage adenocarcinoma.

Methods

A retrospective study was performed in 546 patients which were operated between January 2006 and December 2010 in our institute and of those, 240 (220 lobectomies, and 20 segmentectomies) were clinical N0 adenocarcinoma. One hundred and thirty-five patients underwent VATS and 105 patients for open surgery. Long-term oncological outcomes were compared in both groups.

Results

There were significant differences in age, gender, Blinkman index, clinical T factor and tumor size between two groups. VATS group showed statistically longer operation time (P=0.01), less blood loss (P=0.005), shorter length of stay (P=0.001), and less dissected number of lymph nodes (P<0.001) compared with open surgery. Disease-free survival in VATS was significantly better than open surgery (5- and 10-year survival; VATS, 91.4%, 79.0%; open, 85.1%, 73.6%; respectively, P=0.04). Overall survival in VATS was not different from open (P=0.58). Propensity matched disease-free and overall survival was not significantly different between two groups. Multivariate Cox regression analysis showed that age [P=0.04, 95% confidence interval (CI): (1.02–6.81)] in overall and T factor [P=0.01, 95% CI: (1.41–17.3)] in disease-free survival was prognostic significant after propensity matching.

Conclusions

Our study demonstrated that long-term outcome in VATS for early stage adenocarcinoma was equivalent to open surgery. VATS may be a treatment of choice for promising long-term prognosis.

Long-term results of robotic anatomical segmentectomy for early-stage non-small-cell lung cancer

OBJECTIVES

Anatomical segmentectomy is advocated for curative resection in select patients. We investigated the long-term results of robotic anatomical segmentectomy with mediastinal nodal dissection in patients with early-stage lung cancer.

METHODS

We retrospectively reviewed patients who underwent robotic anatomical segmentectomy for early-stage non-small-cell lung cancer (NSCLC). The follow-up data were obtained to determine survival and statistically significant risk factors in both univariable and multivariable models.

RESULTS

Seventy-one patients had clinical stage I NSCLC (36 men, 35 women, mean age 70 ± 12 years). All patients underwent R0 resection. The mean operating time was 134 min. Ten of 71 (14%) patients were upstaged. Eight of 71 (11%) patients were upstaged due to the size of tumour in the pathological specimen, and 2 of 71 (3%) patients were upstaged due to microscopic N2 nodal metastasis. Median hospitalization was 4 days (2-31 days). Complication rate was 29%. There were no complications attributable to the surgical robot. No patient died within 90 days. Mean follow-up was 54 months (range 2 months to 9 years). The overall 5-year survival was 43%, whereas lung cancer-specific 5-year survival was 55%. The 5-year lung cancer-specific survival for pathological stage I disease was 73%. Local or mediastinal recurrence occurred in 4 of 71(5%) patients. Pathological upstaging or recurrence resulted in 0% 5-year survival. The univariable and multivariable analyses showed that advanced age and pathological upstaging were statistically significant risk factors for lung cancer-specific death.

CONCLUSIONS

Robotic anatomical segmentectomy with mediastinal nodal dissection is a safe and feasible procedure. Accurate preoperative clinical staging is of critical importance for long-term survival.

Uniportal video-assisted thoracic surgery for the treatment of lung cancer: a consensus report from Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS) and Chinese Association of Thoracic Surgeons (CATS)

Uniportal video-assisted thoracoscopic surgery (UniVATS) has been widely adopted in China, where several ultra-high volume thoracic surgical and training centers are located. The objective of this consensus from Chinese experts was to summarize the current application and give reference for the future development of UniVATS in the treatment of lung cancer. A panel of 41 experts from 21 Chinese hospitals was invited to join this project. The Delphi method was used in this consensus consisting of two rounds of voting. The questionnaire was based on the current clinical evidence. Forty (97.6%) experts completed the 2 rounds of questionnaires. The experts’ experience was relatively similar. We defined the UniVATS as monitor-dependent surgery, no use of rib-spreading and single incision less than 4 cm. Tumor with stage of T1–T3 and N0–N2 is considered amenable to UniVATS. Other consensus was reached on several points outlining the safety and feasibility, surgical skills, learning curve, short-term and long-term outcomes for lung cancer, and current application of subxiphoid and nonintubated UniVATS approach. This consensus statement represents a collective agreement among Chinese experts to suggest that UniVATS is an effective alternative to multi-portal approach, although high-level evidence is expected in the future. Some agreements can be referred in the training of young surgeons.

Minimizing residual occult nodal metastasis in NSCLC: recent advances, current status and controversies

Introduction: Nodal involvement in lung cancer is a significant determinant of prognosis and treatment management. New evidence exists regarding the management of occult lymph node metastasis and residual disease in the fields of imaging, mediastinal staging, and operative management.Areas covered: This review summarizes the latest body of knowledge on the identification and management of occult lymph node metastasis in NSCLC. We focus on tumor-specific characteristics; imaging modalities; invasive mediastinal staging; and operative management including, technique, degree of resection, and lymph node examination.Expert opinion: Newly identified risk-factors associated with nodal metastasis including tumor histology, location, radiologic features, and metabolic activity are not included in professional societal guidelines due to the heterogeneity of their reporting and uncertainty on how to adopt them into practice. Imaging as a sole diagnostic method is limited. We recommend confirmation with invasive mediastinal staging. EBUS-FNA is the best initial method, but adoption has not been uniform. The diagnostic algorithm is less certain for re-staging of mediastinal nodes after neoadjuvant therapy. Mediastinal node sampling during lobectomy remains the gold-standard, but evidence supports the use of minimally invasive techniques. More study is warranted regarding sublobar resection. No consensus exists regarding lymph node examination, but new evidence supports reexamination of current quality metrics.

Predictors of nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC): results from the Italian VATS Group Registry

PURPOSE

Accurate staging of early non-small cell lung cancer is fundamental for selecting the best treatment. The aim of this study was to identify risk factors for nodal upstaging after video-assisted thoracoscopic lobectomy for clinical T1-3N0 tumors.

METHODS

From 2014 to 2017, 3276 thoracoscopic lobectomies were recorded in the prospective database "Italian VATS Group". Linear and multiple logistic regression models were adapted to identify independent predictors of nodal upstaging and factors associated with progression in postoperative N status.

RESULTS

Nodal upstaging was found in 417 cases (12.7%), including 206 cases (6.2%) of N1-positive nodes, 81 cases of N2 nodes (2.4%), and 130 cases (4%) of involvement of both N1 + N2 nodes. A total of 241 (7.3%) patients had single-station nodal involvement, whereas 176 (5.3%) had multiple-station involvement. In the final regression model, the tumor grade, histology, pathologic T status, and > 12 resected nodes were independent predictors of nodal upstaging.

CONCLUSIONS

The number of resected lymph nodes seems to predict nodal upstaging better than the type of intraoperative lymph node management. Other preoperative risk factors correspond to those for which the current guidelines of the European Society of Thoracic Surgery recommend more extensive preoperative mediastinal staging.

Pathological lymph node involvement is not a predictor of adverse outcomes in patients undergoing thoracoscopic lobectomy for lung cancer†

OBJECTIVES

As the practice of video-assisted thoracoscopic surgery (VATS) lobectomy gains widespread acceptance, the complexity of procedures attempted increases and the stage of tumour that may be safely approached remains controversial. We examined the impact of nodal involvement with respect to perioperative outcomes after VATS lobectomy.

METHODS

All patients listed for VATS lobectomy for non-small-cell lung cancer at our institution from 2012 to 2016 were analysed. Bronchoplastic or chest wall resections and tumours over 7 cm were considered a contraindication to a thoracoscopic approach.

RESULTS

Of the 489 patients identified, 97 (19.8%) patients had pathological nodal involvement. The overall conversion rate was 6.1%, reoperation rate was 5.3% and readmission rate was 5.9%. Median hospital stay was 5 days, 30-day mortality was 0.6% and 90-day mortality was 1.6%. No significant difference was identified between the nodal-negative or -positive groups in terms of preoperative demographics, hospital stay, postoperative complications, conversion rate, reoperation rate or readmission rate. Univariate logistic regression identified gender, Thoracoscore, dyspnoea score, performance status, chronic obstructive pulmonary disease, previous stroke, preoperative lung function and non-adenocarcinoma as predictors of postoperative complications. A multivariate model including nodal status identified Thoracoscore (odds ratio 1.57, 95% confidence interval 1.16-2.18; P < 0.001) and preoperative transfer factor (odds ratio 0.97, 95% confidence interval 0.96-0.98; P < 0.001) as the only predictors of complications.

CONCLUSIONS

In non-small-cell lung cancer patients with pathological hilar or mediastinal lymph node involvement, VATS lobectomy can be safely performed, as there does not appear to be an adverse effect on the incidence of perioperative complications, length of stay or readmissions.

Propensity-score adjusted comparison of pathologic nodal upstaging by robotic, video-assisted thoracoscopic, and open lobectomy for non-small cell lung cancer

OBJECTIVE

To assess the effectiveness of intraoperative lymph node (LN) staging by comparing upstaging between robotic-assisted surgery, video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach for lobectomy for non-small cell lung cancer.

METHODS

We retrospectively analyzed 1053 patients with clinical stage N0/N1 non-small cell lung cancer who underwent lobectomy at 2 centers between 2011 and 2018. Propensity score adjustment by inverse probability of treatment weighting was used to balance baseline characteristics. The primary end point was LN upstaging.

RESULTS

A total of 911 patients (254 robotic, 296 VATS, and 261 open) were included in the inverse probability of treatment weighting adjusted analysis. The overall rate of LN upstaging was highest with open lobectomy (21.8%), followed by robotic (16.2%), and VATS (12.3%) (P = .03). Mediastinal N2 upstaging was observed in similar frequencies (open 6.9% vs robotic 6.3% vs VATS 4.4%; P = .6). No differences were seen for total LN counts, but were observed in the number of stations sampled (mean, open 4.0 vs robotic 3.8 vs VATS 3.6; P = .001). On multivariate analysis, LN upstaging was lower for VATS compared with open (odds ratio, 0.50; 95% confidence interval, 0.29-0.85), but not different between robotic and open (odds ratio, 0.72; 95% confidence interval, 0.44-1.18). No significant differences were seen in mediastinal N2 upstaging between groups.

CONCLUSIONS

Pathologic LN upstaging following lobectomy for clinically N0/N1 NSCLC remains high. Compared with a traditional thoracotomy approach, robotic lobectomy was associated with similar and VATS with lower overall nodal upstaging. A thorough evaluation of hilar and mediastinal LNs remains critical to ensure accurate staging by detection of occult LN metastases.

Safety of lymphadenectomy during video-assisted thoracic surgery lobectomy: analysis from a national database

OBJECTIVES

The Italian VATS Group database was accessed to evaluate whether preoperative and intraoperative factors may affect the safety of lymphadenectomy (LA) during video-assisted thoracic surgery lobectomy.

METHODS

All video-assisted thoracic surgery lobectomy procedures performed between 1 January 2014 and 30 March 2017 for non-small-cell lung cancer with cN0 or cN1 disease were identified in the database. LA safety was evaluated based on intraoperative (operative time, bleeding and conversion rate) and postoperative (30-day morbidity and mortality, chest drain duration and length of stay) outcomes and was correlated with the number of resected lymph nodes and the rates of nodal upstaging. Continuous variables were presented as mean ± standard deviation and compared using the unpaired t-test; the χ2 test was used for categorical variables. Univariable analysis was performed on selected variables. Significant variables (P < 0.30) were entered into a Cox multivariable logistic regression model, using the overall and specific occurrence of complications as dependent variables. The Spearman's rank correlation coefficient was applied as needed.

RESULTS

A total of 3181 cases (2077 men, 65.3%; mean age of 69 years) met the enrolment criteria. Final pathology was consistent with adenocarcinoma (n = 2262, 67.5%), squamous cell (n = 520, 15.5%), typical (n = 184, 5.5%) and atypical carcinoid (n = 48, 1.4%) and other (n = 335, 10%). The mean number of resected lymph nodes was 13.42 ± 8.24; nodal upstaging occurred in 308 of 3181 (9.68%) cases. Six hundred and fifty-five complications were recorded in 404 (12.7%) patients; in this series, no mortality was observed. Univariable and multivariable analyses did not show any association between the extension of LA and intraoperative or postoperative outcomes. The number of resected lymph nodes and nodal upstagings showed a minimal correlation with intraoperative outcomes and a moderate correlation with postoperative air leak (ρ = 0.35 and ρ = 0.48, respectively), arrhythmia (ρ = 0.29 and ρ = 0.35, respectively), chest drain duration (ρ = 0.35 and ρ = 0.51, respectively) and length of stay (ρ = 0.35).

CONCLUSIONS

Based on the VATS Group data, video-assisted thoracic surgery LA proved to be safe and displayed good outcomes even when performed with an extended approach.

Optimal Approach to Lobectomy for Non-Small Cell Lung Cancer: Systemic Review and Meta-Analysis

Objective

Video-assisted thoracic surgery (VATS) lobectomy was introduced over 25 years ago. More recently, the technique has been modified from a multiport video-assisted thoracic surgery (mVATS) to uniportal (uVATS) and robotic (rVATS), with proponents for each approach. Additionally most lobectomies are still performed using an open approach. We sought to provide evidence-based recommendations to help define the optimal surgical approach to lobectomy for early stage non-small cell lung cancer.

Methods

Systematic review and meta-analysis of articles searched without limits from January 2000 to January 2018 comparing open, mVATS, uVATS, and rVATS using sources Medline, Embase, and Cochrane Library were considered for inclusion. Articles were individually scrutinized by ISMICS consensus conference members, and evidence-based statements were created and consensus processes were used to determine the ensuing recommendations. The ACC/AHA Clinical Practice Guideline Recommendation Classification system was used to assess the overall quality of evidence and the strength of recommendations.

Results and recommendations

One hundred and forty-five studies met the predefined inclusion criteria and were included in the meta-analysis. Comparisons were analyzed between VATS and open, and between different VATS approaches looking at oncological outcomes (survival, recurrence, lymph node evaluation), safety (adverse events), function (pain, quality of life, pulmonary function), and cost-effectiveness. Fifteen statements addressing these areas achieved consensus. The highest level of evidence suggested that mVATS is preferable to open lobectomy with lower adverse events (36% versus 42%; 88,460 patients) and less pain (IIa recommendation). Our meta-analysis suggested that overall survival was better (IIb) with mVATS compared with open (71.5% versus 66.7% 5-years; 16,200 patients). Different VATS approaches were similar for most outcomes, although uVATS may be associated with less pain and analgesic requirements (IIb).

Conclusions

This meta-analysis supports the role of VATS lobectomy for non-small cell lung cancer. Apart from potentially less pain and analgesic requirement with uVATS, different minimally invasive surgical approaches appear to have similar outcomes.

Is video-assisted thoracoscopy a sufficient approach for mediastinal lymph node dissection to treat lung cancer after neoadjuvant therapy?

Background

The role of video‐assisted thoracoscopic surgery (VATS) in mediastinal lymph node dissection (MLND) for non‐small cell lung cancer (NSCLC) following neoadjuvant therapy remains controversial. The aim of this study was to demonstrate the sufficiency of VATS by evaluating perioperative and long‐term outcomes.

Methods

Patients with locally advanced NSCLC and treated with radical surgery after neoadjuvant therapy were identified in our database. The thoroughness of MLND was compared by approach. Multivariable logistic regression analysis was used to evaluate predictors of sufficient MLND. Propensity score matching was performed. Kaplan–Meier and Cox proportional hazard analyses were used to assess long‐term survival.

Results

Of the 127 enrolled patients, 56 underwent attempted VATS and 71 underwent thoracotomy. Multivariable logistic regression analysis revealed that approach was not a predictor of sufficient MLND (odds ratio 0.81, 95% confidence interval [CI] 0.364–1.803; P = 0.606). After matching, 28 pairs of patients were selected from the two groups. There was no significant difference between the numbers of dissected lymph nodes (15 vs. 20; P = 0.191) and nodal stations (7 vs. 7; P = 0.315). Recurrence‐free (log‐rank P = 0.613) and overall survival (log‐rank P = 0.379) was similar in both groups. Multivariable Cox proportional hazards model analysis indicated that VATS was not an independent predictor of recurrence‐free (hazard ratio 0.955, 95% CI 0.415–2.198; P = 0.913) or overall survival (hazard ratio 0.841, 95% CI 0.338–2.093; P = 0.709).

Conclusion

Compared to thoracotomy, VATS is a sufficient approach for MLND to treat locally advanced NSCLC following neoadjuvant therapy without compromising long‐term survival.

Updates on Minimally Invasive Surgery in Non-Small Cell Lung Cancer

OPINION STATEMENT

Video-assisted thoracic surgery (VATS) has become widely used since the 1990s and has become a standard treatment approach mainly for early-stage non-small cell lung cancer. The few randomized controlled trials providing evidence of the effectiveness of VATS lobectomy at present are supported by a large number of propensity-matched studies, several high-quality meta-analyses, and outcome studies. These studies provide comprehensive data demonstrating the lower morbidity, shorter chest tube duration, and shorter hospital stay of VATS than thoracotomy during the postoperative course. Moreover, VATS shows equivalent oncological outcome as thoracotomy and therefore should be performed for lobectomy as much as possible. Importantly, VATS has recently been applied to advanced cases and previously contraindicated complex procedures such as bronchoplasty and chest wall resection. Attention has also been paid to reduced port surgery performed by frontier surgeons. Thus, the indications of VATS have seen a significant expansion. This major development logically negates any hesitation to change to the VATS technique as any doubt will likely constrain its wider applications. Preparation of scientific learning environments is necessary and should be actively pursued to adopt new skills instead of debating between the choice of "VATS or open."

Nodal upstaging evaluation in NSCLC patients treated by robotic lobectomy

BACKGROUND

Open pulmonary resection is considered the gold standard treatment of early-stage non-small cell lung cancer (NSCLC). However, in the last decades, the use of minimal-invasive techniques has given promising results. Survival in lung cancer, after surgery, depends on the number of pathological nodes (pN), thus lymph nodal upstaging can be considered a surrogate for surgical quality of the procedure. Several studies have demonstrated a lower rate of upstaging in video-assisted thoracic surgery than in open surgery, suggesting an approach-related difference in lymphadenectomy. Features of robotic technique could consent a lymph nodal dissection similar to open surgery. The aim of the study is to compare nodal upstaging between thoracotomy and robotic approaches to evaluate the oncologic radicality.

METHODS

Between January 2013 and December 2016, 212 consecutive cN0 NSCLC patients underwent lobectomy and lymphadenectomy (N1 + N2 stations) by either thoracotomy (Open Group) or robotic surgery (Robotic Group).

RESULTS

Lobectomy and lymphadenectomy were performed in 106 cN0-cN1 NSCLC patients by robotic surgery and in 106 cN0-cN1 NSCLC patients by open surgery. A mean of 14.42 ± 6.99 lymph nodes was removed in the Robotic Group (RG) and a mean of 14.32 ± 7.34 nodes in the Open Group (OG). Nodal upstaging was observed in 22 (20.75%) RG patients and in 19 OG (17.92%) patients.

CONCLUSIONS

Robotic lobectomy for clinical N0-N1 NSCLC appears to be equivalent to thoracotomy in terms of efficacy of lymph node dissection and nodal upstaging. Given that the nodal upstaging is a surrogate of quality of surgery, we can consider robotic lobectomy an appropriate procedure which ensures similar result to the open approach.

Lymph node upstaging for non-small cell lung cancer after uniportal video-assisted thoracoscopy

Background

Radical lymph node dissection (LND) plays a major role in the treatment of non-small cell lung cancer (NSCLC). This study presents the analysis of the results after uniportal video-assisted thoracoscopy (VATS) lymphadenectomy during anatomical lung resections for NSCLC, focusing on pathological nodal upstaging. Any possible risk factor affecting nodal upstaging was also investigated.

Methods

The prospectively collected clinical data of 136 patients undergone uniportal VATS anatomical lung resections, from June 2012 to September 2017, were reviewed. In particular, all details inherent the clinical and pathological node stage and any possible risk factor affecting nodal upstaging were analyzed.

Results

The patient population consisted of 90 males and 46 females; their mean age was 67.42±10.64 years. The mean number of lymph nodes retrieved during uniportal VATS lymphadenectomy was 20.14±10.73 (7.27±5.90 and 12.60±7.96 in N1 and N2 stations, respectively). The incidence of nodal upstaging was 13.3% (18 cases). In particular there was a N0-1 upstaging in 10 cases (7.4%), a N1-2 upstaging in 3 (2.2%) and a N0-2 in 4 (3%). The ROC analysis showed that the resection of 18 lymph nodes was the best predictor of a general upstaging with an AUC-ROC of 0.595, while the resection of 7 hilar lymph nodes was the best predictor of N1 upstaging (AUC-ROC: 0.554) and 11 mediastinal nodes was the best predictor of N2 upstaging (AUC-ROC: 0.671). The number of positive lymph nodes of stations 5-6 (OR: 2.035, 95% CI: 1.082-3.826, P=0.027) and stations 2-3-4 (OR: 6.198, 95% CI: 1.580-24.321, P=0.009) were confirmed to be the only independent risk factors for N2 upstaging by multivariate analysis.

Conclusions

According to our experience, uniportal VATS allows a safe and effective radical lymphadenectomy, with a satisfactory pathological nodal upstaging, comparable to other minimally invasive techniques.

Non-intercostal access for video-assisted thoracic surgery-analysis of technical advantages and disadvantages

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted method for the treatment of early-stage non-small-cell lung cancer (NSCLC). The standard VATS approach is an intercostal one which is often followed by postoperative pain due to injury of the intercostal nerve. The non-intercostal techniques of VATS include the subxiphoid, transcervical, transdiaphragmatic and transoral procedures.

Methods

The technical difficulty of operative management of the anatomical structures during VATS anatomical resection are compared for the intercostal, subxiphoid and transcervical approaches.

Results

Some operative steps have different range of difficulty, which are analyzed in detail.

Conclusions

The clearest advantages of the non-intercostal approaches include less postoperative pain and superradial bilateral mediastinal lymphadenectomy in case of the transcervical approach. However, the non-intercostal approaches are more technically demanding procedures, which therapeutic role has to be clarified in the future.

Oncologic Equivalence of Minimally Invasive Lobectomy: The Scientific and Practical Arguments

BACKGROUND

Despite the slow adoption of minimally invasive lobectomy (MIL), it is now a preferred approach for early lung cancer. Nevertheless, ongoing concerns about MIL oncologic effectiveness has led to calls for prospective, randomized trials.

METHODS

Retrospective analysis of on-line databases, collected readings, and other scholarly experiences of the experienced authors were used to construct this review. All available reports that contained long-term survival comparisons for open versus MIL were tabulated.

RESULTS

The preponderance of limited randomized and numerous large propensity-matched database analyses indicate equivalent or improved long-term MIL survival for early-stage disease. MIL lymph node dissection quality has been challenged; however, this was attributed to MIL avoidance of central tumors in early reports. Although technical inadequacies for MIL should be amplified for advanced cancer resections, early reports show no such concern. In fact, for special populations such as older, frail patients, evidence is much stronger that MIL confers a survival advantage.

CONCLUSIONS

MIL is an oncologically equivalent operation with substantially less morbidity, especially in frail populations. It is reasonable to suggest that MIL should be the technique of choice, even a quality indicator, for lobectomy.

Surgical treatment for early stage non-small cell lung cancer

Surgery is the standard of care for early stage non-small cell lung cancer. There is significant debate about the type of operation most effective for lung cancer. Minimally invasive techniques like video-assisted (VATS) and robot-assisted thoracoscopic surgery (RATS) have been shown to reduce postoperative complications and shorten hospitalization. However, there remains skepticism about their oncologic effectiveness when compared to an open approach, though recent literature suggests no differences in upstaging or survival between VATS and thoracotomy. The extent of resection for early lung cancer also remains a matter of debate. Lobectomy remains the preferred operation and is associated with better survival and lower locoregional recurrence, but there is increased interest in the role of sublobar resections. Sublobar resections have similar mortality to lobar resections in small ground glass-predominant tumors. We examine the literature surrounding these controversies in this review.

Outcomes of Pulmonary Resection and Mediastinal Node Dissection by Video-Assisted Thoracoscopic Surgery Following Neoadjuvant Chemoradiation Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer

Background

We evaluated the feasibility and outcomes of pulmonary resection and mediastinal node dissection (MND) by video-assisted thoracoscopic surgery (VATS) following neoadjuvant therapy for stage IIIA N2 non-small cell lung cancer (NSCLC).

Methods

From November 2009 to December 2013, a total of 35 consecutive patients with pathologically or radiologically confirmed stage IIIA N2 lung cancer underwent pulmonary resection and MND, performed by a single surgeon, following neoadjuvant chemoradiation. Preoperative patient characteristics, surgical outcomes, postoperative drainage, postoperative complications, and mortality were retrospectively analyzed.

Results

VATS was completed in 17 patients. Thoracotomy was performed in 18 patients, with 13 planned thoracotomies and 5 conversions from the VATS approach. The median age was 62.7±7.9 years in the VATS group and 60±8.7 years in the thoracotomy group. The patients in the VATS group tended to have a lower diffusing capacity for carbon monoxide (p=0.077). There were no differences between the 2 groups in the method of diagnosing the N stage, tumor response and size after induction, tumor location, or histologic type. Complete resection was achieved in all patients. More total and mediastinal nodes were dissected in the VATS group than in the thoracotomy group (p<0.05). The median chest tube duration was 5.3 days (range, 1 to 33 days) for the VATS group and 7.2 days (range, 2 to 28 days) for the thoracotomy group. The median follow-up duration was 36.3 months. The 5-year survival rates were 76% in the VATS group and 57.8% in the thoracotomy group (p=0.39). The 5-year disease-free survival rates were 40.3% and 38.9% in the VATS and thoracotomy groups, respectively (p=0.8).

Conclusion

The VATS approach following neoadjuvant treatment was safe and feasible in selected patients for the treatment of stage IIIA N2 NSCLC, with no compromise of oncologic efficacy.

Predictors of unexpected nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC) submitted to thoracoscopic lobectomy

Background

In the last decades, the use of video-assisted thoracoscopic surgery (VATS) lobectomy for the treatment of early stage non-small cell lung cancer is continuously growing. This is mainly due to the development of more advanced surgical devices, to the rising incidence of peripheral lung tumors and is also favored by the increased reliability of preoperative staging techniques. Despite this progress, postoperative unexpected nodal upstaging is still a relevant issue. Aim of this study is to identify possible predictors of unexpected nodal upstaging in patients affected by cT1-3N0 NSCLC submitted to VATS lobectomy.

Methods

A total of 231 cases of cT1-3N0 patients submitted to thoracoscopic lobectomy at our centre between June 2012 and October 2016 were retrospectively reviewed. All data regarding clinical staging by means of computed tomography (CT) and positron-emission tomography (PET)/CT were collected and reviewed. The subsequent pathological staging has been analyzed, with special regards to the possible type of nodal involvement, and the number of pathological nodal stations.

Results

Most of the patients included in this study were in a clinical stage cT1aN0, cT1bN0 (stage IA) and cT2aN0 (stage IB), 86 (37.2%) patients, 73 (31.6%) patients and 62 (26.8%) patients, respectively. Postoperative histopathological analysis showed that the most frequent tumor histotype was adenocarcinoma (192 patients, 83.1%). Thirty-eight (16.5%) patients had a nodal upstaging; among these, 17 (7.4%) patients had N2 disease (8 patients with isolated mediastinal nodal involvement, 9 patients with N1 + N2 disease) and 21 (9.1%) patients had an isolated hilar nodal involvement (N1). At bivariate analysis, the clinical T (cT)-parameter (P=0.023), the histotype (P=0.029) and the pathological T (pT)-parameter (P=0.003) were identified as statistically significant predictors of nodal upstaging. Concerning the type of nodal upstaging, the pT was found to be statistically significant (P=0.042). At bivariate analysis for the number of involved nodal stations, a statistical significance was highlighted for the parameters cT (P=0.030) and pT (P=0.027). With linear logistic regression, histology as well as pT reached statistical significance (P=0.0275 and P=0.0382, respectively). No correlation was found between nodal upstaging and the intensity of FDG uptake in the primary lung tumor or with the timing between PET and surgery.

Conclusions

There is a strong correlation between the clinical staging of the parameter T evaluated with CT and the possible unexpected nodal upstaging. The same correlation with nodal upstaging is found for pT. At equal clinical stage, in patients affected by adenocarcinoma of the lung the relative risk of having a postoperative unexpected nodal upstaging is almost 7 times higher than in patients with squamous cell carcinoma.

Lymphadenectomy during thoracoscopy: techniques and efficacy

Nowadays several studies have shown that, in the management of patients with early-stage lung cancer, video-assisted thoracoscopic surgery (VATS) lobectomy compared to open surgery is associated with many clinical short-term benefits, such as less post-operative pain and shorter hospital stay. Despite the advantages described earlier, some authors have expressed concern about the effectiveness of the procedure arguing that the lymph node harvest performed during VATS lobectomy is inferior to that performed through thoracotomy access. Experience from a multicentre database, with a more balanced number of VATS versus open patients, actually has shown that there is no difference in the efficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. In expert hands the technique of VATS lymphadenectomy is the same as that performed by thoracotomy: instrumentation and tricks can change but not the oncologic principles. We believe that is necessary to follow a learning curve not only for VATS lobectomy but also for thoracoscopic lymph node dissection. However even experienced VATS surgeons should keep in mind that the metastatic lymphadenopathy with extracapsular lymph node spread requires great caution during dissection and that a preoperative plan for conversion to thoracotomy can be useful in this case.

Nodal upstaging: effects of instrumentation and three-dimensional view in clinical stage I lung cancer

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) is defined as the presence of unsuspected pathologic hilar (pN1) or mediastinal (pN2) disease detected during the final histopathologic evaluation of surgical specimens. The prevalence of pathologic nodal upstaging is used as a quality measure for the definition of the completeness of the nodal dissection. Risk factors for nodal upstaging may be patient-related (history of tuberculosis, rheumatoid arthritis, and diabetes mellitus), or tumor-related (central tumor, higher T stage, higher SUVmax value, or adenocarcinoma). Actually, the theorical superiority of a minimally invasive resections is the lymph node dissection. Studies may suggest that, expert video-assisted thoracoscopic surgery (VATS) surgeon could do similar lymph node dissection as it is done in open. Robotic surgeons may replicate the results of lymph node dissection in the open techniques. The possible reason for this is the instrumental superiority provided by the higher technology.

Uniportal right upper video-assisted thoracoscopic surgery lobectomy: safe and feasible

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy is now well established and performed all around the world. We are going to share the surgical technique for uniportal VATS right upper lobectomy based on our experience. A 62-year-old patient underwent Uniportal VATS right upper lobectomy for a primary non-small cell lung cancer (NSCLC). Our patient had no perioperative complications and was then discharged to his home on postoperative day 4. The patient's pain was managed with a paravertebral catheter during the first 48 hours and then with oral analgesics. Pathology report: well-differentiated adenocarcinoma; the size of the tumour was 1 cm × 0.8 cm × 1 cm; all margins were negative for residual tumour. The patient did not require adjuvant radiation or chemotherapy. Uniportal VATS lobectomy is a safe and effective procedure providing a favourable clinical outcome in the patient.

Nodal management and upstaging of disease: initial results from the Italian VATS Lobectomy Registry

BACKGROUND

VATS lobectomy is an established option for the treatment of early-stage NSCLC. Complete lymph node dissection (CD), systematic sampling (SS) or resecting a specific number of lymph nodes (LNs) and stations are possible intra-operative LN management strategies.

METHODS

All VATS lobectomies from the "Italian VATS Group" prospective database were retrospectively reviewed. The type of surgical approach (CD or SS), number of LN resected (RN), the positive/resected LN ratio (LNR) and the number and types of positive LN stations were recorded. The rates of nodal upstaging were assessed based on different LN management strategies.

RESULTS

CD was the most frequent approach (72.3%). Nodal upstaging rates were 6.03% (N0-to-N1), 5.45% (N0-to-N2), and 0.58% (N1-to-N2). There was no difference in N1 or N2 upstaging rates between CD and SS. The number of resected nodes was correlated with both N1 (OR =1.02; CI, 1.01-1.04; P=0.03) and N2 (OR =1.02; CI, 1.01-1.05; P=0.001) upstaging. Resecting 12 nodes had the best ability to predict upstaging (6 N1 LN or 7 N2 LN). The finding of two positive LN stations best predicted N2 upstaging [area under the curve (AUC) of receiver operating characteristic (ROC) =0.98].

CONCLUSIONS

Nodal upstaging (and, indirectly, the effectiveness of intra-operative nodal management) cannot be predicted based on the surgical technique (CD or SS). A quantitative assessment of intra-operative LN management may be a more appropriate and measurable approach to justify the extension of LN resection during VATS lobectomy.