Efficacy of mediastinal lymph node dissection during thoracoscopic lobectomy

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.

Thoracotomy is better than thoracoscopic lobectomy in the lymph node dissection of lung cancer: a systematic review and meta-analysis

Background

The aim of this study was to investigate which surgical method is better in lymph node (LN) dissection of lung cancer.

Methods

A comprehensive search of PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus, and Google Scholar was performed to identify studies comparing thoracoscopic lobectomy (video-assisted thoracic surgery (VATS) group) and thoracotomy (open group) in LN dissection.

Results

Twenty-nine articles met the inclusion criteria and involved 2763 patients in the VATS group and 3484 patients in the open group. The meta-analysis showed that fewer total LNs (95% confidence interval [CI] −1.52 to −0.73, p < 0.0001) and N2 LNs (95% CI −1.25 to −0.10, p = 0.02) were dissected in the VATS group. A similar number of total LN stations, N2 LN stations, and N1 LNs were harvested in both groups. Only one study reported that fewer N1 LN stations were dissected in the VATS group (1.4 ± 0.5 vs. 1.6 ± 0.6, p = 0.04).

Conclusions

Open lobectomy could achieve better LN dissection efficacy than thoracoscopic lobectomy in the treatment of lung cancer, especially in the N2 LNs dissection. These findings require validation by high-quality, large-scale randomized controlled trials.

Long-Term Outcomes of Lobectomy for Non-Small Cell Lung Cancer After Definitive Radiation Treatment

BACKGROUND

Salvage surgical resection for non-small cell lung cancer (NSCLC) patients initially treated with definitive chemotherapy and radiotherapy can be performed safely, but the long-term benefits are not well characterized.

METHODS

Perioperative complications and long-term survival of all patients with NSCLC who received curative-intent definitive radiotherapy, with or without chemotherapy, followed by lobectomy from 1995 to 2012 were evaluated.

RESULTS

During the study period, 31 patients met the inclusion criteria. Clinical stage distribution was stage I in 2 (6%), stage II in 5 (16%), stage IIIA in 15 (48%), stage IIIB in 5 (16%), stage IV in 3 (10%), and unknown in 1 (3%). The reasons surgical resection was initially not considered were: patients deemed medically inoperable (5 [16%]); extent of disease was considered unresectable (21 [68%]); small cell lung cancer misdiagnosis (1 [3%]), and unknown (4 [13%]). Definitive therapy was irradiation alone in 2 (6%), concurrent chemoradiotherapy in 28 (90%), and sequential chemoradiotherapy in 1 (3%). The median radiation dose was 60 Gy. Patients were subsequently referred for resection because of obvious local relapse, medical tolerance of surgical intervention, or posttherapy imaging suggesting residual disease. The median time from radiation to lobectomy was 17.7 weeks. There were no perioperative deaths, and morbidity occurred in 15 patients (48%). None of the 3 patients with residual pathologic nodal disease survived longer than 37 months, but the 5-year survival of pN0 patients was 36%. Patients who underwent lobectomy for obvious relapse (n = 3) also did poorly, with a median overall survival of 9 months.

CONCLUSIONS

Lobectomy after definitive radiotherapy can be done safely and is associated with reasonable long-term survival, particularly when patients do not have residual nodal disease.

Non-grasping en bloc mediastinal lymph node dissection for video-assisted thoracoscopic lung cancer surgery

Background

This study aims to introduce an optimized method named “non-grasping en bloc mediastinal lymph node dissection (MLND)” through video-assisted thoracoscopic surgery (VATS).

Methods

Between February 2009 and July 2013, 402 patients with clinical stage I non-small cell lung cancer (NSCLC) underwent “non-grasping en bloc MLND” conducted by one surgical team. Target lymph nodes (LNs) were exposed following non-grasping strategy with simple combination of a metal endoscopic suction and an electrocoagulation hook or an ultrasound scalpel. In addition, dissection was performed following a stylized three-dimensional process according to the anatomic features of each station. Clinical and pathological data were prospectively collected and retrospectively reviewed.

Results

The postoperative morbidity and mortality were 17.4% (70/402) and 0.5% (2/402), respectively. The total number of LNs (N1 + N2) was 16.0 ± 5.9 (range of 5–52), while the number of N2 LNs was 9.5 ± 4.0 (range of 3–23). The incidences of postoperative upstaging from N0 to N1 and N2 disease were 7.7% and 12.2%, respectively.

Conclusions

Non-grasping en bloc MLND enables en bloc dissection of mediastinal LNs with comparable morbidity and oncological efficacy while saving troubles of excessive interference of instruments and potential damage to the target LN.

Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database

OBJECTIVE

To compare long term survival after minimally invasive lobectomy and thoracotomy lobectomy.

DESIGN

Propensity matched analysis.

SETTING

Surveillance, Epidemiology and End Results (SEER)-Medicare database.

PARTICIPANTS

All patients with lung cancer from 2007 to 2009 undergoing lobectomy.

MAIN OUTCOME MEASURE

Influence of less invasive thoracoscopic surgery on overall survival, disease-free survival, and cancer specific survival.

RESULTS

From 2007 to 2009, 6008 patients undergoing lobectomy were identified (n=4715 (78%) thoracotomy). The median age of the entire cohort was 74 (interquartile range 70-78) years. The median length of follow-up for entire group was 40 months. In a matched analysis of 1195 patients in each treatment category, no statistical differences in three year overall survival, disease-free survival, or cancer specific survival were found between the groups (overall survival: 70.6% v 68.1%, P=0.55; disease-free survival: 86.2% v 85.4%, P=0.46; cancer specific survival: 92% v 89.5%, P=0.05).

CONCLUSION

This propensity matched analysis showed that patients undergoing thoracoscopic lobectomy had similar overall, cancer specific, and disease-free survival compared with patients undergoing thoracotomy lobectomy. Thoracoscopic techniques do not seem to compromise these measures of outcome after lobectomy.

The feasibility of a Two-incision video-assisted thoracoscopic lobectomy

Background

This study is to evaluate the feasibility and safety of video-assisted thoracoscopic (VATS) lobectomy with two incisions.

Methods

A total of 73 patients (male 47, female 26; mean age 61.2 ± 12.00 years old) who underwent major pulmonary resection, through VATS, using two incisions were included in this study. The thoracoscopy port was placed at the 7th or the 8th intercostal space in the mid-axillary line, and the working port, 3~5 cm long, at the 5th intercostal space, on the operator’s side.

Results

The preoperative diagnosis was benign lung disease in 8 patients (11.0%) and malignant lung disease in 65 (89.0%). Two patients (3.1%) needed a third port during surgery due to severe pleural adhesion, and conversion to thoracotomy was needed in 5 (6.8%), due to bleeding at pulmonary arterial branch (n = 3), anthracofibrotic lymph nodes around pulmonary artery (n = 1), and severe pleural adhesion (n = 1). The mean duration of the operation in the 66 patients, completed by a two-incision VATS lobectomy, was 163.4 ± 30.40 minutes. In 56 cases, which were completed by a two-incision VATS lobectomy for primary lung cancer, a total number of dissected lymph nodes per patient were 20.2 ± 11.2. The chest tube was removed on postoperative day 5.4 ± 2.8, and there was no occurrence of major perioperative morbidity and mortality.

Conclusions

Two-incision VATS lobectomy is applicable in the selected cases, and may obtain similar results with the conventional VATS lobectomy, through a certain period of learning curve.