Lymph node evaluation by open or video-assisted approaches in 11,500 anatomic lung cancer resections

Early-stage non-small cell lung cancer: surgery, stereotactic radiosurgery, and individualized adjuvant therapy

Despite cures in early stage (IA-IIB) non-small cell lung cancer (NSCLC), the 5-year survival rate is only 36%-73%. Surgical resection via lobectomy is the treatment of choice in early-stage NSCLC, with the goal being complete anatomic resection of the tumor and mediastinal lymph node evaluation. Newer technologies, including the minimally invasive thoracoscopic approach and the many techniques available to stage the mediastinum, have introduced advantages over traditional approaches in achieving this goal. The advent of stereotactic ablative radiotherapy (SABR) has changed how we treat those patients who cannot undergo surgery secondary to comorbidities or patient preference. SABR allows for precise radiation delivery in a short course and at high doses. Adjuvant cisplatin-based chemotherapy is the standard of care for completely resected high-risk stage IB and stage II NSCLC based on a ~5% improvement in 5-year overall survival. The concept of customized adjuvant chemotherapy is emerging, and we will explore the potential value of targeting tumor mutations with available drugs (ie, epidermal growth factor receptor [EGFR] mutations with erlotinib), a strategy that for the moment should be restricted to clinical trials.

Towards optimal pathologic staging of resectable non-small cell lung cancer

Pathologic nodal staging is the most accurate means of determining prognosis of patients with resectable non-small cell lung cancer (NSCLC), but confusion prevails about the optimal pre-operative and surgical lymph node examination procedures for candidates of curative-intent resection. The landmark American College of Surgeons Oncology Group Z0030 trial revealed no difference in the survival of patients with clinical T1 or T2, N0 or N1 (hilar node-negative), M0 NSCLC who either had a fastidious, pre-defined systematic hilar and mediastinal lymph node sampling procedure, or who received a complete mediastinal lymph node dissection. We place the results of this major trial into a contemporary clinical practice context, and discuss problems associated with apparent misunderstanding of the lessons from this trial, especially in light of evidence of prevailing sub-optimal nodal examination practices. We also discuss evolving knowledge about the origin of the quality gap in pathologic nodal staging and the emerging literature on corrective interventions.

Teaching video-assisted thoracic surgery (VATS) lobectomy

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations

BACKGROUND

While video-assisted thoracic surgery (VATS) lobectomies are being increasingly accepted, VATS segmentectomies are still considered as technically challenging. With the renewed interest for sublobar resection in the management of early stage lung carcinomas, the thoracoscopic approach may have a major role in a near future. We report our technique and results.

PATIENTS AND METHODS

Totally thoracoscopic anatomic segmentectomiy, i.e., using only endoscopic instrumentation and video-display without utility incision, was attempted on 117 patients (51 males and 66 females), aged 18 to 81 years (mean: 62 years). The indication was a clinical N0 non-small cell lung carcinoma in 69 cases, a solitary metastasis in 17 cases and a benign lesion in 31 cases. The following segmentectomies were performed: right apicosuperior [26] right superior [10], right basilar [18], lingula sparing left upper lobectomy [15], left apicosuperior [11], lingula [7], left superior [14], left basilar [13] and subsegmental resection [3]. Segmentectomy was associated with a radical lymphadenectomy in 69 cases.

RESULTS

There were 5 conversions to thoracotomy. The mean operative time was 181±52 minutes, the mean intraoperative blood loss was 77±81 cc. There were 12 postoperative complications (11.7%). The median postoperative stay was 5.5±2.2 days. Out of the 69 patients operated on for a cN0 lung carcinoma, 6 were finally upstaged.

CONCLUSIONS

Totally thoracoscopic anatomic pulmonary segmentectomies are feasible and have a low complication rate.

Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.

METHODS

The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.

RESULTS

Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.

Predictive factors for complications of anatomical pulmonary segmentectomies

OBJECTIVES

The role of anatomical pulmonary segmentectomy is increasing, but there are few data about its complication rate. We have analysed the postoperative morbidity, mortality and risk factors in a consecutive series of 228 segmentectomies performed in our department.

METHODS

Between January 2007 and December 2011, 221 patients underwent 228 segmentectomies. There were 99 women (45%) and 122 men (55%). The mean age was 61 years (range 18-86 years). The mean forced expiratory volume in 1 s (FEV1) was 87%, and 30 patients had an FEV1 of ≤60%. Fifty-seven patients had a previous history of pulmonary resection. Indications for segmentectomy were: primary lung cancer (111 cases), metastases (71 cases), benign non-infectious (25 cases) and benign infectious diseases (21 cases). The approach was a posterolateral thoracotomy (Group PLT) in 146 patients (64%) and a thoracoscopy (Group TS) in 82 (36%). The two groups were homogenous in terms of age, gender, indications of surgery and type of segmentectomy.

RESULTS

The mortality rate at 3 months was 1.3% (3 patients). The overall complication rate was 34%. Ten patients were reoperated for the following reasons: haemothorax (4 cases), ischaemia of the remaining segment (3 cases), active bleeding (1 case), prolonged air leak (1 case) and dehiscence of thoracotomy (1 case). The average duration of drainage was 5 days (range 1-34 days) and the average length of stay was 9 days (range 3-126 days). On univariate analysis, FEV1, male gender and thoracotomy were statistically significant risk factors for complications. On multivariate analysis, the same three predictive factors of complications independently of age were found statistically significant: preoperative FEV1 < 60% [odds ratio (OR) = 5.9, 95% CI (2.5-13.7), P < 0.001] male gender [OR = 2.04, 95% CI (1.2-3.6), P < 0.013] and thoracotomy [OR = 2.14, 95% CI (1.33-3.46), P = 0.001].

CONCLUSIONS

Pulmonary anatomical segmentectomies have an acceptable morbidity rate. Postoperative complications are more likely to develop in male gender patients, with FEV1 ≤ 60% and operated by open surgery.

Robotic lobectomy for non-small cell lung cancer

Over the last 5 years, there has been a tremendous increase in the interest in and use of robotics in thoracic surgery. The focus of this review is on the use of robotics for pulmonary lobectomy, which is being approached with 3 or 4 arm techniques. Early experiences suggest that the learning curve is approximately 20 cases for most surgeons but could be shortened with previous advanced thoracoscopic skills. Robotic lobectomy is feasible and safe in limited reports from experienced centers. Operative and clinical outcomes favor robotic lobectomy over open and appear to be similar to VATS. Limited data on oncologic effectiveness and survival suggest that robotics is similar to VATS. Widespread adoption and integration into practice will require future research efforts to prove oncologic and survival benefits in concert with cost effectiveness evaluation.

Minimally invasive pulmonary surgery for lung cancer, up to date

Recently, the minimally invasive surgical approach is an important issue in the pulmonary surgery. In this review, we present the current fashion of video-assisted thoracic surgery (VATS) and new approach including robotic lobectomy. There is no clear definition or standard for this surgical procedure regarding VATS lobectomy. Therefore, no randomized controlled trial of VATS and conventional lobectomy can be set up. Although the definition of VATS lobectomy is not straightforward, VATS lobectomy showed the technical feasibility of conventional lobectomy in mortality and postoperative complication as well as lymph node dissection. VATS procedure for advanced lung cancer is unclear whether such observations can be developed into a standardized approach. There are no reports to evaluate the advantages of robotic lobectomy in terms of treatment outcomes for lung cancer compared with VATS lobectomy. However, we believe that robotic lobectomy has clear potential to improve the quality of minimally invasive surgery.

Recent advances in video-assisted thoracoscopic surgery for lung cancer

As a result of increased use of CT in both screening and daily practice, the number of early lung cancers has increased enormously. Surgeons pursue both curativity and reduced invasiveness in treating patients with early stage lung cancer; therefore, minimally invasive operations, such as video-assisted thoracoscopic surgery (VATS) lobectomy are now being routinely performed. Most previous reports have shown that there is no difference in mortality and local recurrence between open surgery and VATS in stage I patients. However, surgeons' improved technical experience and patients' demands could soon make VATS lobectomy the operative method of choice for early stage lung cancer. Moreover, the indications for VATS are expanding to encompass complex procedures such as segmentectomy or sleeve resection. Training and dissemination of the technique and the monitoring of outcomes are necessary.