Propensity-matched comparison of video-assisted thoracoscopic with thoracotomy lobectomy for locally advanced non-small cell lung cancer.

We evaluated whether video-assisted thoracoscopic lobectomy for locally advanced non-small cell lung cancer could be performed safely and with acceptable long-term outcomes by our improved technique and compared with standard thoracotomy lobectomy in a well-balanced population. Patients with clinical stage II and III A non-small cell lung cancers who received lobectomy were reviewed. Video-assisted thoracoscopic lobectomies were all performed with Wang's technique by the surgeons who had overcome the learning curve and achieved proficiency. By using propensity-matched analysis, perioperative outcomes and long-term survival were compared. Matching based on propensity scores produced 120 patients in each group. Conversion rate to thoracotomy was 11.7%. After thoracoscopic lobectomy, hospital length of stay was shorter compared with thoracotomy (9.2 vs 12 days; P = .014) despite similar rates of postoperative complications (30/125 [25%] vs 34/125 [28.3%]; P = .56). Disease-free survival (49.1% vs 42.2%; P = .40) and overall survival (55.0% vs 57.1%; P = .73) at 5 years were similar between groups. Although advanced pathologic stage (hazard ratio [HR], 2.018; 95% confidence interval [CI], 1.330-3.062) and no postoperative chemotherapy (HR, 1.880; 95% CI, 1.236-2.858) were independently associated with increased hazard of death in multivariable Cox regression at each time point in follow-up, thoracoscopic lobectomy was not (HR, 1.075; 95% CI, 0.714-1.620; P = .73). With continued experience and optimized technique, video-assisted thoracoscopic lobectomy can be performed in the majority of cases without compromising perioperative outcomes and oncologic efficacy.

Chen K ，Wang X ，Yang F ，Li J ，Jiang G ，Liu J ，Wang J ... -  《-》

Comparison of video-assisted thoracoscopic surgery with thoracotomy in bronchial sleeve lobectomy for centrally located non-small cell lung cancer.

The aim of this study was to investigate the adequacy of bronchial sleeve lobectomy by video-assisted thoracoscopic surgery in perioperative outcomes and its oncological efficacy by comparing with thoracotomy in a balanced population. A total of 363 patients who received bronchial sleeve lobectomy for non-small cell lung cancer from January 2013 to December 2017 were included and placed in the thoracotomy (n = 251) and video-assisted thoracoscopic surgery (n = 112) groups. Statistical analyses were performed to compare patients' demographics, perioperative outcomes, and survival between the 2 groups. A total of 116 thoracotomy cases were matched with 72 video-assisted thoracoscopic surgery cases by propensity score. Compared with thoracotomy, patients in the video-assisted thoracoscopic surgery group after matching had less intraoperative blood loss (P < .01) and length of postoperative hospital stay (P < .01), duration of chest tube drainage (P < .01), and intensive care unit stay (P = .03) despite comparable operative time, complication rate, and 30- to 90-day mortality rate. The overall survival and recurrence-free survival were similar in patients who received sleeve lobectomy by thoracotomy and video-assisted thoracoscopic surgery (log-rank, P = .24 and .20, respectively) at 3 years. Although advanced TNM stage was independently associated with worse overall survival and recurrence-free survival in multivariable analysis, older age was only predictive for worse overall survival (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02). Body mass index was also found be a predictive factor (overall survival: hazard ratio, 0.93; 95% confidence interval, 0.86-0.99, P = .03; recurrence-free survival: hazard ratio, 0.93; 95% confidence interval, 0.87-0.99, P = .02). With appropriate patient selection and continued experience, video-assisted thoracoscopic surgery appears to be safe in the short-term perioperative period and does not appear to comprise oncologic outcomes in performing sleeve lobectomy.

Xie D ，Deng J ，Gonzalez-Rivas D ，Zhu Y ，Jiang L ，Jiang G ，Chen C ... -  《-》

Long-term outcomes of video-assisted thoracoscopic surgery lobectomy vs. thoracotomy lobectomy for stage IA non-small cell lung cancer.

Oda R ，Okuda K ，Osaga S ，Watanabe T ，Sakane T ，Tatematsu T ，Yokota K ，Haneda H ，Nakanishi R ... -  《-》

Long-term survival following open versus thoracoscopic lobectomy after preoperative chemotherapy for non-small cell lung cancer.

Video-assisted thoracoscopic (VATS) lobectomy is increasingly accepted for the management of early-stage non-small cell lung cancer (NSCLC), but its role for locally advanced cancers has not been as well characterized. We compared outcomes of patients who received induction therapy followed by lobectomy, via VATS or thoracotomy. Perioperative complications and long-term survival of all patients with NSCLC who received induction chemotherapy (ICT) (with or without induction radiation therapy) followed by lobectomy from 1996-2012 were assessed using Kaplan-Meier and Cox proportional hazard analysis. Propensity score-matched comparisons were used to assess the potential impact of selection bias. From 1996 to 2012, 272 patients met inclusion criteria and underwent lobectomy after ICT: 69 (25%) by VATS and 203 (75%) by thoracotomy. An 'intent-to-treat' analysis was performed. Compared with thoracotomy patients, VATS patients had a higher clinical stage, were older, had greater body mass index, and were more likely to have coronary disease and chronic obstructive pulmonary disease. Induction radiation was used more commonly in thoracotomy patients [VATS 28% (n = 19) vs open 72% (n = 146), P < 0.001]. Thirty-day mortality was similar between the VATS [3% (n = 2)] and open [4% (n = 8)] groups (P = 0.69). Seven (10%) of the VATS cases were converted to thoracotomy due to difficulty in dissection from fibrotic tissue and adhesions (n = 5) or bleeding (n = 2); none of these conversions led to perioperative deaths. In univariate analysis, VATS patients had improved 3-year survival compared with thoracotomy (61% vs 43%, P = 0.010). In multivariable analysis, the VATS approach showed a trend towards improved survival, but this did not reach statistical significance (hazard ratio, 0.56; 95% confidence interval, 0.32-1.01; P = 0.053). Moreover, a propensity score-matched analysis balancing patient characteristics demonstrated that the VATS approach had similar survival to an open approach (P = 0.56). VATS lobectomy in patients treated with induction therapy for locally advanced NSCLC is feasible and effective and does not appear to compromise oncologic outcomes.

Yang CF ，Meyerhoff RR ，Mayne NR ，Singhapricha T ，Toomey CB ，Speicher PJ ，Hartwig MG ，Tong BC ，Onaitis MW ，Harpole DH Jr ，D'Amico TA ，Berry MF ... -  《-》

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 ... -  《-》