Lobectomy for Non-Small Cell Lung Cancer by Video-Assisted Thoracic Surgery: Effects of Cumulative Institutional Experience on Adequacy of Lymphadenectomy.

Because video-assisted thoracic surgery (VATS) lobectomies are increasingly being performed by thoracic surgeons, the adequacy of lymph node clearance by VATS compared with thoracotomy has been questioned, raising the possibility that patients are being understaged. One factor that may be overlooked in published studies is the learning curve of the surgeons and surgical volume in the adoption of VATS lobectomy. This study examined the effect of cumulative institutional VATS lobectomy experience on the adequacy of lymphadenectomy. We retrospectively reviewed a prospective database to identify 500 consecutive patients who underwent VATS lobectomy for non-small cell lung cancer (NSCLC) at our institution between 2002 and 2012. For comparative purposes, the cohort was divided into halves, with an early group (first 250 cases) vs a late group (next 250 cases). Clinical and pathologic factors were analyzed. A propensity-matching analysis controlling for age, gender, pathologic stage, and percentage of forced expiratory volume in 1 second was done to compare survival and adequacy of lymphadenectomy. Patients operated on in the late group were significantly older (72 vs 69 years, p = 0.001) and had worse pulmonary functions (median forced expiratory volume in 1 second 83% vs 91%, p < 0.001; median diffusion capacity of the lung for carbon monoxide, 76% vs 85%, p < 0.001). Clinical and pathologic tumor sizes were significantly larger in the late group compared with the early group, with a median of 2.0 vs 1.8 cm (p = 0.002) for clinical T size and median of 2.1 vs 2.0 cm (p = 0.003) for pathologic T size. Patients in the late group had significantly more advanced clinical and pathologic stage distribution. The total number of lymph nodes and the number of nodal stations removed were significantly greater in the late group (p = 0.012) than in the early group (p < 0.001), and same results were obtained after propensity matching. No difference was seen in disease-free survival between the propensity-matched early vs late groups at 3 years (82% vs 85%, p = 0.187). For patients with NSCLC resected by VATS lobectomy, cumulative institutional experience significantly and positively affects the adequacy of lymphadenectomy. This may be related to the initial surgeon's learning curve with VATS lobectomy. As the experience with VATS lobectomy becomes more mature, the procedure is increasingly being performed on older patients, often with more compromised pulmonary function and more advanced stage disease. Despite the expanded inclusion of older and sicker patients for VATS lobectomy, no compromise was seen in their disease-free survival.

Lee PC ，Kamel M ，Nasar A ，Ghaly G ，Port JL ，Paul S ，Stiles BM ，Andrews WG ，Altorki NK ... -  《-》

Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy.

Video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) is increasingly popular. However, the oncologic soundness of VATS for patients with NSCLC as measured by long-term survival has not been proven. The objective here is to determine the overall survival (OS) and disease-free survival (DFS) in two well-matched groups of patients with NSCLC resected by VATS or thoracotomy. We conducted a retrospective review of a prospective database to identify patients who had a lobectomy for NSCLC. A propensity score-matched analysis was done with variables of age, sex, smoking history, Charlson comorbidity index, forced expiratory volume in 1 second, lung diffusing capacity for carbon monoxide, histology, and clinical T and N status. Medical records were reviewed and survival was analyzed. After matching, there were 208 patients in each group. Patient and tumor characteristics were similar. The VATS group had a shorter length of stay. More nodes (14.3 versus 11.3; p=0.001) and more nodal stations (3.8 versus 3.1; p<0.001) were removed by thoracotomy. No differences were seen in OS and DFS. Median follow-up was 36 months. More than 90% of patients had clinical stage I disease, with 3- and 5-year OS of 87.4% and 76.5%, respectively, for VATS, and 81.6% and 77.5%, respectively, for thoracotomy (p=0.672). Both the incidence and distribution of recurrence were similar. Multivariate Cox regression analyses of OS and DFS confirmed the noninferiority of VATS. For patients with clinical stage I NSCLC, VATS lobectomy offered similar OS and DFS compared with thoracotomy. Thoracotomy offers a more thorough lymph node evaluation, and may be appropriate for patients with more advanced clinical disease.

Lee PC ，Nasar A ，Port JL ，Paul S ，Stiles B ，Chiu YL ，Andrews WG ，Altorki NK ... -  《-》

A national study of nodal upstaging after thoracoscopic versus open lobectomy for clinical stage I lung cancer.

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) occurs when unsuspected lymph node metastases are found during the final evaluation of surgical specimens. Recent data from The Society of Thoracic Surgery (STS) database demonstrated significantly lower nodal upstaging after thoracoscopic (VATS) lobectomy than after thoracotomy. STS data, however, may be biased from voluntary reporting, and survival was not investigated. We used a complete national registry to compare nodal upstaging and survival after lobectomy by VATS or thoracotomy. The Danish Lung Cancer Registry was used to identify patients who underwent lobectomy for clinical stage I NSCLC from 2007 to 2011. Patient demographics, comorbidity, preoperative staging, surgical approach, number of lymph nodes harvested, final pathology, and survival were evaluated. Nodal upstaging was identified by comparing cT N M with pT N M. Lobectomy for clinical stage I NSCLC was performed in 1,513 patients: 717 (47%) by VATS and 796 (53%) by thoracotomy. Nodal upstaging occurred in 281 patients (18.6%) and was significantly higher after thoracotomy for N1 upstaging (13.1% vs 8.1%; p<0.001) and N2 upstaging (11.5% vs 3.8%; p<0.001). Overall unadjusted survival was significantly higher after VATS, but after adjusting for differences in sex, age, comorbidity, and pT N M by Cox regression analysis, we found no difference between VATS and thoracotomy (hazard ratio, 0.98; 95% confidence interval, 0.80 to 1.22, p=0.88). National data confirm that nodal upstaging was lower after VATS than after open lobectomy for clinical stage I NSCLC. Multivariate survival analysis, however, showed no difference in survival, indicating that differences in nodal upstaging result from patient selection for reasons not captured in our registry.

Licht PB ，Jørgensen OD ，Ladegaard L ，Jakobsen E ... -  《-》

Lymph node evaluation achieved by open lobectomy compared with thoracoscopic lobectomy for N0 lung cancer.

Controversy remains regarding the adequacy of the lymph node evaluation achieved by video-assisted thoracic surgery (VATS) lobectomy for lung cancer. This study compared the completeness of the lymph node dissection or sampling for patients undergoing lobectomy by open thoracotomy vs VATS for clinical N0 lung cancer. This study was a retrospective review of 129 patients who underwent lobectomy for clinical N0 lung carcinoma from December 2008 to January 2012. Lobectomy was an open procedure in 69 patients (53.5%) and by VATS in 60 (46.5%). The VATS and open groups were well matched for age (p = 0.50) and forced expiratory volume in 1 second percentage predicted (p = 0.16). The mean pathologic tumor sizes were not significantly different (2.9 ± 0.26 vs 3.4 ± 0.25 cm, respectively; p = 0. 14). The mean number of nodes dissected in the open group was significantly higher (14.7 ± 1.3 vs. 9.9 ± 0.8 nodes; p = 0.003). In the open lobectomy group, 24.6% of the patients were upstaged to pathologic N1 or N2 compared with 10% in the VATS group (p = 0.05). The Kaplan-Meier 3-year survival was similar between the groups. In our hands, significantly more lymph nodes were dissected, and a higher percentage of patients were upstaged to N1/N2, during open lobectomy compared with VATS lobectomy in patients with clinical stage N0 lung cancer. Although this did not translate into improved survival at 3 years, concern is raised about the adequacy of lymph node dissection during VATS lobectomy.

Merritt RE ，Hoang CD ，Shrager JB 《-》

Video-assisted thoracic surgery lobectomy versus lobectomy by thoracotomy for lung cancer: pilot study.

Papiashvilli M ，Sasson L ，Azzam S ，Hayat H ，Schreiber L ，Ezri T ，Priel IE ... -  《-》