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Interact CardioVasc Thorac Surg 2007;6:110-116. doi:10.1510/icvts.2006.148080 © 2007 European Association of Cardio-Thoracic Surgery
Does video-assisted thoracoscopic lobectomy produce equal cancer clearance compared to open lobectomy for non-small cell carcinoma of the lung?
a Department of Thoracic Surgery, Hairmyres Hospital, East Kilbride, Scotland Received 6 November 2006; accepted 7 November 2006
*Corresponding author. Department of Thoracic Surgery, Hairmyres Hospital, Eaglesham Road, East Kilbride, G75 8RG, UK.
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether a VATS lobectomy produces an equivalent cancer clearance compared to an open technique. Using the reported search 409 papers were identified. Twenty-one papers represented the best evidence on the subject from which 15 are fully tabulated. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. We conclude that 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 <3–5 cm in size and five-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.
Key Words: Video-assisted thoracoscopic surgery; Lobectomy; Non-small cell carcinoma of the lung
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
You are referred a fit 66-year-old man with a 2-cm 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 to be 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.
In patients with [non-small cell carcinoma suitable for lobectomy] does [VATS lobectomy compared to open lobectomy] provide equal [cancer clearance]
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 Table 1.
Kirby et al. [2] published the first RCT in this area. Fifty-five patients were randomized to VATS or muscle sparing thoracotomy. There were no differences in length of day (around seven days) operating time (mean 2.5 h) and only two patients died after mean 13-month 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 [3]. Robert McKenna Jnr presented the Sinai Medical centre series of 1,100 VATS lobectomies in 2006 [4]. They report a mean 4.7-day inpatient stay with 20% being discharged in <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 four-year survival of 70% for Stage Ia was reported. Walker et al. [5] presented a cohort of 159 VATS lobectomies, showing a 78% five-year survival for Stage I cancer (51% for stage II). There was an 11% conversion rate and a mean hospital stay of six 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. [6] published a series of 110 VATS resections of stage I tumours, compared to open controls. The five-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. [7] reported 112 VATS resections who achieved an 85% three-year survival, with a mean six-day hospital stay. Interestingly, seven resection samples were too macerated on extraction to accurately determine their ‘T’ status. Ohtsuka et al. [8] reported a 79% three-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 of 21 lymph nodes removed per patient. Iwasaki et al. [9] reported a 77% five-year survival for stage I patients with tumours under 3 cm having a VATS resection. Roviaro et al. [10] reported a five-year survival of 64% for stage I cancer patients with a tumour <3-cm having a VATS resection. Kaseda et al. [11] 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. [12] compared 81 VATS resections to 79 open procedures. Operating time and blood loss were the same, as was five-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 [13–16]. There has been some concern that a VATS procedure can cause seeding of the tumour to the chest wall. Buhr presented two cases [17], 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 [18]. He reported 21 cases that included five 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. [19] measured blood carcinoembryonic antigen (CEA) mRNA in patients undergoing VATS resections. Sixteen 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 [20] Repeated cohort studies have shown five-year survival rates similar in the VATS groups to that achieved from open thoracotomy. The majority of resections are in stage I tumours <3–5 cm in size and five-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.
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Abstract
1. Introduction