Feasibility and long-term efficacy of video-assisted thoracic surgery for unexpected pathologic N2 disease in non-small cell lung cancer

Minimally invasive surgery vs. open thoracotomy for non-small-cell lung cancer with N2 disease: a systematic review and meta-analysis

Background

This meta-analysis aimed to investigate the effectiveness and safety of minimally invasive surgery [MIS, including robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS)] and open thoracotomy (OT) for non-small cell lung cancer (NSCLC) patients with N2 disease.

Methods

We searched online databases and studies from the creation of the database to August 2022, comparing the MIS group to the OT group for NSCLC with N2 disease. Study endpoints included intraoperative outcomes [e.g., conversion, estimated blood loss (EBL), surgery time (ST), total lymph nodes (TLN), and R0 resection], postoperative outcomes [e.g., length of stay (LOS) and complication], and survival outcomes [e.g., 30-day mortality, overall survival (OS), and disease-free survival (DFS)]. We estimated outcomes using random effects meta-analysis to account for studies with high heterogeneity (I² > 50 or p < 0.05). Otherwise, we used a fixed-effect model. We calculated odds ratios (ORs) for binary outcomes and standard mean differences (SMDs) for continuous outcomes. Treatment effects on OS and DFS were described by hazard ratio (HR).

Results

This systematic review and meta-analysis of 15 studies on MIS vs. OT for NSCLC with N2 disease included 8,374 patients. Compared to OT, patients that underwent MIS had less estimated blood loss (EBL) (SMD = - 64.82, p < 0.01), shorter length of stay (LOS) (SMD = -0.15, p < 0.01), higher R0 resection rate (OR = 1.22, p = 0.049), lower 30-day mortality (OR = 0.67, p = 0.03), and longer overall survival (OS) (HR = 0.61, P < 0.01). The results showed no statistically significant differences in surgical time (ST), total lymph nodes (TLN), complications, and disease-free survival (DFS) between the two groups.

Conclusion

Current data suggest that minimally invasive surgery may provide satisfying outcomes, a higher R0 resection rate, and better short-term and long-term survival than open thoracotomy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022355712.

Feasibility and oncological outcomes of video-assisted thoracic surgery versus thoracotomy for pathologic N2 disease in non-small cell lung cancer: A comprehensive systematic review and meta-analysis

This meta-analysis aimed to evaluate the feasibility and oncological outcomes between video-assisted thoracic surgery (VATS) and thoracotomy for non-small cell lung cancer (NSCLC) patients with pathologic N2 (pN2) disease. Data for analysis included short-term outcomes and long-term outcomes. We calculated the weighted mean differences (WMDs) for continuous data and the results of overall survival (OS) and disease free survival (DFS) were pooled using the hazard ratios (HRs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the Q-test and I² -test. Sensitivity analysis was performed to further examine the stability of pooled HRs and WMDs. In the pooled analyses of 10 eligible studies, results showed that VATS for NSCLC patients with pN2 disease yielded significantly less blood loss (WMD = -61.43; 95% confidence intervals [CI], [-87.69, -35.18]; p < 0.001), less post-operation hospital stay (WMD, -1.62; 95% CI, [-2.96, -0.28]; p = 0.02), and comparable operation time (WMD,  -8.32; 95% CI, [-23.88, 7.23]; p = 0.29), post-operation complication rate (risk ratio [RR], 0.95; 95% CI, [0.78, 1.15]; p = 0.59), chest tube duration to thoracotomy (WMD, -0.64; 95% CI, [-1.45, 0.17]; p = 0.12), extent of lymph node dissection (WMD, -1.46; 95% CI, [-3.87, 0.95]; p = 0.23) and 1-year OS (HR, 1.30; 95% CI, [0.96, 1.76]; p = 0.09) than thoracotomy. However, VATS may improve 3-year OS (HR, 1.26; 95% CI, [1.12, 1.42]; p = 0.0002) and yield comparable 1-year DFS (HR, 1.14; 95% CI, [0.89, 1.46]; p = 0.32) and 3-year DFS (HR, 1.03; 95% CI, [0.88, 1.22]; p = 0.70) for NSCLC patients with pN2 disease than thoracotomy. VATS could yield less surgical trauma and improve post-operative recovery than thoracotomy. Moreover, VATS may improve the oncological outcomes of those patients.

Prognostic Value of Tumor Size in Resected Stage IIIA-N2 Non-Small-Cell Lung Cancer

The eighth edition of the American Joint Committee on Cancer (AJCC) staging system for lung cancer was introduced in 2017 and included major revisions, especially of stage III. For the subgroup stage IIIA-N2 non-small-cell lung cancer (NSCLC), surgical resection remains controversial due to heterogeneous disease entity. The aim of this study was to evaluate the clinicopathologic features and prognostic factors of patients with completely resected stage IIIA-N2 NSCLC. We retrospectively evaluated 77 consecutive patients with pathologic stage IIIA-N2 NSCLC (AJCC eighth edition) who underwent surgical resection with curative intent in China Medical University Hospital between 2006 and 2014. Survival analysis was conducted, using the Kaplan–Meier method. Prognostic factors predicting overall survival (OS) and disease-free survival (DFS) were analyzed, using log-rank tests and multivariate Cox proportional hazards models. Of the 77 patients with pathologic stage IIIA-N2 NSCLC examined, 35 (45.5%) were diagnosed before surgery and 42 (54.5%) were diagnosed unexpectedly during surgery. The mean age of patients was 59 years, and the mean length of follow-up was 38.1 months. The overall one-, three-, and five-year OS rates were 91.9%, 61.3%, and 33.5%, respectively. Multivariate analysis showed that tumor size <3 cm (hazards ratio (HR): 0.373, p = 0.003) and video-assisted thoracoscopic surgery (VATS) approach (HR: 0.383, p = 0.014) were significant predictors for improved OS. For patients with surgically treated, pathologic stage IIIA-N2 NSCLC, tumor size <3 cm and the VATS approach seemed to be associated with better prognosis.

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.

Surgical management of advanced non-small cell lung cancer

More than 75% of the cases of non-small cell lung cancer (NSCLC) are diagnosed in advanced stages (IIIA-IV). Although in these patients the role of surgery is unclear, complete tumor resection can be achieved in selected cases, with good long-term survival. In this review, current indications for surgery in advanced NSCLC are discussed. In stage IIIA (N2), surgery after induction chemotherapy seems to be the best option. The indication of induction chemotherapy plus radiotherapy is debatable due to potential postoperative complications but recently reported experiences have not shown a higher postoperative risk in patients after chemo and radiotherapy induction even if pneumonectomy is performed. In cases of unexpected N2 found during thoracotomy, lobectomy plus systematic nodal dissection is recommended mostly for patients with single station disease. In stage IIIB, surgery is only the choice for resectable T4N0-1 cases and should not be indicated in cases of N2 disease. Favorable outcomes are reported after extended resections to the spine and mediastinal structures. Thorough and individualized discussion of each stage IIIB case is encouraged in the context of a multidisciplinary team. For stage IV oligometastatic cases, surgery can still be included when planning multimodality treatment. Brain and adrenal gland are the two most common sites of oligometastases considered for local ablative therapy.