Does video-assisted thoracoscopic lobectomy produce equal cancer clearance compared to open lobectomy for non-small cell carcinoma of the lung?

February 6, 2007

May 10, 2007

Douglas West, Sameena Rashid, Specialist Registrars in Cardiothoracic Surgery (Department of Thoracic Surgery, Hairmyres Hospital, East Kilbride and Department of Cardiothoracic Surgery, James Cook University Hospital)

Joel Dunning, Department of Thoracic Surgery, Hairmyres Hospital, East Kilbride and Department of Cardiothoracic Surgery, James Cook University Hospital

In patients with [non-small cell carcinoma suitable for lobectomy] does [VATS lobectomy compared to open lobectomy] provide equal [cancer clearance]

You are referred a fit 66-year old man with a 2cm lesion in the periphery of his right lower lobe on CT scanning. Bronchoscopy was normal, and a CT guided biopsy has confirmed non-small cell lung cancer. His lung function is satisfactory for lobectomy. You have just been on a Video-assisted Thoracoscopic (VATs) Lobectomy course and he seems an ideal candidate for this procedure. The patient seems quite keen but then asks you if it cures his cancer just as effectively as the usual way. You reassure him, but resolve to check this in the literature.

Medline 1966-Oct 2006 using the OVID interface.

[Lobectomy.mp OR Lobectomies.mp] AND [exp Thoracic Surgery, Video-Assisted/ OR VATS.mp OR videoendoscopic.mp OR video-assisted.mp ]

The search strategy found 409 abstracts from which 21 were deemed to represent the best evidence on the subject. Due to space constraints 15 were fully tabulated. These are summarized in the table.

Kirby et al published the first RCT in this area. 55-patients were randomized to VATs or muscle sparing thoracotomy. There were no differences in length of day(around 7 days) operating time(mean 2½ hrs) and only 2-patients died after mean 13-months follow up. This study demonstrated operative equivalence with the open technique but was too small to make any conclusions regarding operative cancer clearance. The only other RCT in this area looked at acute phase response in 41 patients who either underwent VATS or open thoracotomy. There was a decrease in these markers although because there was no follow up data for these patients we did not tabulate this paper[Craig].

Robert McKenna Jnr presented the Sinai Medical centre series of 1,100 VATs lobectomies in 2006. They report a mean 4.7-day inpatient stay with 20% being discharged in less than 2-days. The perioperative mortality was 0.8% and the conversion rate was 2.5%. However no longer term survival was presented other than a 298 patient subset in a previous paper where a 4-year survival of 70% for Stage Ia was reported.
Walker et al presented a cohort of 159 VATs lobectomies, showing a 78% 5-year survival for Stage I cancer (51% for stage II). There was an 11% conversion rate and a mean hospital stay of 6 days. Mention in this paper was given to having obtained ethical approval to perform a multi-centre randomised trial in this area.
Thomas et al published a series of 110 VATS resections of stage I tumours, compared to open controls. The 5-year survival was 63% which was the same as the open group. Of note they used a mini-thoracotomy with a rib spreader in all cases.
Solaini et al reported 112 VATS resections who achieved an 85% 3-year survival, with a mean 6 day hospital stay. Interestingly 7 resection samples were too macerated on extraction to accurately determine their 'T' status.
Ohtsuka et al reported a 79% 3-year survival in 106 patients who had a VATS lung cancer resection. Interestingly all patients also had systematic lymph node dissection by VATS with an average 21 lymph nodes removed per patient.
Iwasaki et al reported a 77% 5-year survival for stage I patients with tumours under 3cms having a VATS resection. Roviaro et al reported a 5-year survival of 64% for stage I cancer patients with a tumour <3m having a VATS resection.
Kaseda et al reported their experience with 204 VATS resections. Post-operative lung spirometry was superior to open controls and in a subgroup of 50-patients followed up for a median 30 months, survival was 97% for the VATS patients compared to 79% for open controls.
Shirashai et al compared 81 VATs resections to 79 open procedures. Operating time and blood loss were the same, as was 5-year survival with 89% in VATS patients and 78% in the open group.
Other cohorts have also been reported with similar results which were not tabulated due to our own table space restraints[Gharagozloo, Okada, Lewis, Shigemura].

There has been some concern that a VATS procedure can cause seeding of the tumour to the chest wall. Buhr presented 2 cases, although only one of them sounded like true seeding. Downey published the results of a survey of 55 VATS surgeons who were asked if they had seen any cases of incision seeding. He reported 21 cases that included 5 patients with mesothelioma and 11 cases of NSCLC, and 17 cases directly recurring in the incision line. However there is no denominator to these findings and the incidence of recurrence in open incision lines is unknown.
Yamashita et al measured blood carcinoembryonic antigen (CEA) mRNA in patients undergoing VATS resections. 16 of 18 patients had positive blood levels intraoperatively compared to a previous study in open lobectomy patients where only 18 of 35 patients were positive intraoperatively. They hypothesised that the lack of manual handling of the lung meant that firm lung retraction and tumour manipulation by instruments may cause an increased level of tumour disruption. Another study measured immunosuppresion levels during VATS or open surgery. Ng et al found a significantly reduced level of immunosuppression in the VATS group.

Repeated cohort studies have shown 5-year survival rates similar in the VATS groups to that achieved from Open thoracotomy. The majority of resections are in Stage I tumours less than 3-5cm in size and 5 year survival rates of 70% or better have consistently been reported. It is reasonable to assume that this cancer cure is similar to open resection although it must be remembered that significant selection bias occurs in all these non randomized studies. A few case reports have raised concerns about port site recurrence and seeding with VATS but the incidence of incision recurrence in open procedures is also unknown. Finally there is little data to support improved hospital stay, reduced costs or improved patient experience with VATS, and thus while equivalence has been well shown with the open technique , further randomized studies are required to demonstrate superiority.

1. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW.. Lobectomy--video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial.
2. Craig SR, Leaver HA, Yap PL, Pugh GC, Walker WS.. Acute phase responses following minimal access and conventional thoracic surgery.
3. McKenna RJ, Jr., Houck W, Fuller CB.. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases.
4. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G.. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma.
5. Thomas P, Doddoli C, Yena S, Thirion X, Sebag F, Fuentes P, Giudicelli R.. VATS is an adequate oncological operation for stage I non-small cell lung cancer.
6. Solaini L, Prusciano F, Bagioni P, Di FF, Basilio PD.. Video-assisted thoracic surgery major pulmonary resections. Present experience.
7. Ohtsuka T, Nomori H, Horio H, Naruke T, Suemasu K.. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer?
8. Iwasaki A, Shirakusa T, Shiraishi T, Yamamoto S.. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer.
9. Roviaro G, Varoli F, Vergani C, Nucca O, Maciocco M, Grignani F.. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer.
10. Kaseda S, Aoki T, Hangai N, Shimizu K.. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy.[see comment].
11. Shiraishi T, Shirakusa T, Hiratsuka M, Yamamoto S, Iwasaki A.. Video-assisted thoracoscopic surgery lobectomy for c-T1N0M0 primary lung cancer: its impact on locoregional control.
12. Gharagozloo F, Tempesta B, Margolis M, Alexander EP .. Video-assisted thoracic surgery lobectomy for stage I lung cancer.[see comment].
13. Okada M, Sakamoto T, Yuki T, Mimura T, Miyoshi K, Tsubota N.. Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery.
14. Lewis RJ, Caccavale RJ, Bocage JP, Widmann MD.. Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy: a more patient-friendly oncologic resection.
15. Shigemura N, Akashi A, Funaki S, Nakagiri T, Inoue M, Sawabata N, Shiono H, Minami M, Takeuchi Y, Okumura M, Sawa Y.. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study.[see comment].
16. Buhr J, Hurtgen M, Kelm C, Schwemmle K.. Tumour dissemination after thoracoscopic resection for lung cancer.
17. Downey RJ, McCormack P, LoCicero III J.. Dissemination of malignant tumours after video-assisted thoracic surgery. A report of twenty-one cases.
18. Yamashita JI, Kurusu Y, Fujino N, Saisyoji T, Ogawa M.. Detection of circulating tumor cells in patients with non-small cell lung cancer undergoing lobectomy by video-assisted thoracic surgery: a potential hazard for intraoperative hematogenous tumor cell
19. Ng CS, Lee TW, Wan S, Wan IY, Sihoe AD, Arifi AA, Yim AP.. Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer.
20. Sugi K, Kaneda Y, Esato K.. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer.
21. McKenna RJ, Jr., Wolf RK, Brenner M, Fischel RJ, Wurnig P.. Is lobectomy by video-assisted thoracic surgery an adequate cancer operation?