VATS is an adequate oncological operation for stage I non-small cell lung cancer

Dynamics of coagulation factor XIII activity after video-assisted thoracoscopic lobectomy for non-small cell lung cancer

Background

The present study was performed to investigate the perioperative dynamics of coagulation factor XIII (FXIII) in patients with non-small cell lung cancer undergoing video-assisted thoracoscopic surgery (VATS) lobectomy compared with open lobectomy.

Methods

Perioperative coagulation factors including FXIII were analyzed in 30 patients who underwent VATS lobectomy and 10 patients who underwent open lobectomy at Teikyo University Hospital from December 2017 to April 2019.

Results

Patients in the VATS lobectomy group showed higher FXIII activity on postoperative day (POD) 5 than patients in the open lobectomy group (P=0.028). The FXIII activity was significantly lower on POD3, POD5, and POD7 than that in the preoperative period and on POD1, even in patients who had undergone VATS lobectomy (P<0.001). No factors were found to affect the maintenance of FXIII in the VATS lobectomy group.

Conclusion

The postoperative decrease of FXIII activity differed between patients who underwent VATS lobectomy and those who underwent open lobectomy. Based on the characteristics of FXIII, the FXIII activity may be a good marker of the invasiveness of VATS lobectomy versus open lobectomy.

Continuous 389 cases of Da Vinci robot-assisted thoracoscopic lobectomy in treatment of non-small cell lung cancer: experience in Shanghai Chest Hospital

Background

To analyze the perioperative indexes of 389 patients with non-small cell lung cancer in single center after robot-assisted thoracoscopic (RATS) lobectomy, and to summarize the surgical key points in robotic lobectomy.

Methods

The clinical data of 389 stage I non-small cell lung cancer patients who underwent RATS lobectomy from May 2013 to December 2016 were retrospectively analyzed. Among them, there were 261 females (67.1%) and 128 males (32.9%); aged from 20-76 years old, with a mean age of 55.01 years; with ASA I in 106 cases, ASA II in 267 cases and ASA III in 16 cases; with BMI from 16.87-34.05, averaged at 23.09±2.79. The largest tumor in preoperative chest CT measurement was 0.3-3.0 cm, ranging from 1.29±0.59 cm; with stage Ia in 153 cases, stage Ib in 148 cases, stage Ic in 32 cases, stage IIb in 26 cases and stage IIIa in 30 cases; including 380 adenocarcinomas and 9 squamous carcinomas.

Results

The operating time was 46-300 min, averaged at 91.51±30.80 min; with a blood loss of 0-100 mL in 371 cases (95.80%), 101-400 mL in 12 cases (3.60%) and >400 mL in 2 cases (0.60%); there were 4 (1.2%) conversions to thoracotomy, in which 2 patients had massive hemorrhage and 2 patients had extensive dense adhesion; there was no mortality during operation and perioperatively. The drainage on the first day after operation was 0-960 mL, averaged at 231.39±141.87 mL; the postoperative chest tube was placed for 2-12 d, averaged at 3.96±1.52 d; the postoperative hospital stay was 2-12 d, averaged at 4.96±1.51 d, with postoperative hospital stay >7 d in 12 cases (3.60%). The postoperative air leakage was the main reason (35 cases, 9%) for prolonged hospital stay, and there was no re-admitted case within 30 days. All the patients underwent systemic lymph node dissection. The total cost of hospitalization was 60,389.66-134,401.65 CNY, averaged at 93,809.23±13,371.26 CNY.

Conclusions

The application of Da Vinci robot surgery system in resectable non-small cell lung cancer is safe and effective, and could make up for the deficiencies of traditional thoracoscopic surgery. The number and level of robot surgery in our center have reached international advanced level, but the relatively expensive cost has become a major limitation in limiting its widespread use. With continuous improvements in robotic technology, its scope of application will be wider, which will inevitably bring new insights in lung surgical technology.

The long-term survival of robotic lobectomy for non-small cell lung cancer: A multi-institutional study

OBJECTIVE

Our objective is to report the world's largest series with the longest follow-up of robotic lobectomy for non-small cell lung cancer (NSCLC).

METHODS

This was a multi-institutional retrospective review of a consecutive series of patients from 4 institutions' prospective robotic databases.

RESULTS

There were 1339 patients (men 55%, median age 68 years). The median operative time was 136 minutes, median number of lymph nodes was 13 (5 N2 stations and 1 N1), median blood loss was 50 cc, and 4 (0.005%) patients received intraoperative transfusions. Conversions occurred in 116 patients (9%) and for bleeding in 24 (2%). Median length of stay was 3 days. Major morbidity occurred in 8%. The 30-day and 90-day operative mortality was 0.2% and 0.5%, respectively. Follow-up was complete in 99% of patients with a median follow-up of 30 months (range 1-154 months). The 5-year stage-specific survival was: 83% for the 672 patients with stage IA NSCLC, 77% for the 281 patients with stage IB, 68% for the 118 patients with stage IIA, 70% for 99 patients with IIB, 62% for 143 patients with stage IIIA (122 had N2 disease, 73%), and 31% for 8 patients with stage IIIB (none had N3 disease). The cumulative incidence of metastatic NSCLC was 15% (128 patients, 95% confidence interval, 13%-18%). The cumulative incidence of local recurrence in the ipsilateral operated chest was 3% only (26 patients, 95% confidence interval, 2%-5%).

CONCLUSIONS

The oncologic results of robotic lobectomy for NSCLC are promising, especially for patients with pathologic N2 disease. However, further follow-up and studies are needed.

Video-assisted thoracoscopic surgery and thoracotomy during lobectomy for clinical stage I non-small-cell lung cancer have equivalent oncological outcomes: A single-center experience of 212 consecutive resections

The aim of the present study was to compare the oncological outcomes following lobectomy using either video-assisted thoracoscopic surgery (VATS) or thoracotomy in clinical stage I non-small cell lung cancer (NSCLC) patients. Short- and long-term data from 212 consecutive patients who underwent lobectomy for clinical stage I NSCLC via VATS or thoracotomy between February 2003 and July 2013 were retrospectively reviewed. The primary endpoints were mediastinal lymph node staging, disease-free survival time and overall survival time. A total of 212 lobectomies for clinical stage I NSCLC were performed, 123 by VATS and 89 by thoracotomy. Patients’ demographic data, pathological stage and residual tumor were similar in the two groups. Reduced blood loss, less post-operative analgesia required and earlier hospital discharge were recorded for the VATS group, as compared with the thoracotomy group. The overall morbidity was similar in the two groups. However, the rate of major complications was higher following thoracotomy than following VATS. No 30-day mortality occurred subsequent to either thoracotomy or VATS lobectomy. The overall survival and disease-free survival times were comparable between the two groups. In the univariate analysis, the treatment approach was not associated with the overall five-year survival or the disease-free survival times. Multivariate Cox regression analysis of survival times revealed that significant predictors of shorter survival times were advanced pathological T3 stage, pathological N1 or N2 disease and poor cancer differentiation. In conclusion, it is reasonable to conclude from the present study that VATS lobectomy performed by specialist thoracic surgeons is safe and may achieve similar long-term survival times to the open surgery approach. However, further prospective randomized multi-center trials are warranted prior to incorporating VATS into clinical routine.

A prospective trial comparing pain and quality of life measures after anatomic lung resection using thoracoscopy or thoracotomy

BACKGROUND

Minimally invasive lung lobectomy and segmentectomy by video-assisted thoracic surgery (VATS) are assumed to result in better quality of life and less postoperative pain compared with standard open approaches. To date, few prospective studies have compared the two approaches. We performed a prospective cohort study to compare quality of life and pain scores during the first 12 months after VATS or open anatomic resection.

METHODS

Patients were prospectively enrolled from May 2009 to April 2012. Patients with clinical stage I lung cancer who were scheduled to undergo anatomic lung resection were eligible. The Brief Pain Index and Medical Outcomes Study 36-Item Short Form Health Survey were conducted perioperatively and at four assessments during the first 12 months after the operation. Intent-to-treat analyses using mixed-effects models were used to longitudinally assess the effect of treatment on quality of life components (physical component summary and mental component summary) and pain.

RESULTS

In total, 74 patients underwent thoracotomy, and 132 underwent VATS (including 19 patients who were converted to thoracotomy); 40 and 80 patients, respectively, completed the 12-month surveys. Baseline characteristics were similar between the two groups. Physical component summary and Brief Pain Index scores were similar between the two groups throughout the 12 months of follow-up. The mental component summary score, however, was consistently worse in the VATS group.

CONCLUSIONS

Patient-reported physical component summary and pain scores after VATS and thoracotomy were similar during the first 12 months after surgical resection.

Long-term survival outcomes of video-assisted thoracic surgery for patients with non-small cell lung cancer

BACKGROUND

Video-assisted thoracic surgery (VATS) has been shown to be a safe alternative to conventional thoracotomy for patients with non-small cell lung cancer (NSCLC). However, popularization of this relatively novel technique has been slow, partly due to concerns about its long-term outcomes. The present study aimed to evaluate the long-term survival outcomes of patients with NSCLC after VATS, and to determine the significant prognostic factors on overall survival.

METHODS

Consecutive patients diagnosed with NSCLC referred to one institution for VATS were identified from a central database. Patients were treated by either complete-VATS or assisted-VATS, as described in previous studies. A number of baseline patient characteristics, clinicopathologic data and treatment-related factors were analyzed as potential prognostic factors on overall survival.

RESULTS

Between January 2000 and December 2007, 1,139 patients with NSCLC who underwent VATS and fulfilled a set of predetermined inclusion criteria were included for analysis. The median age of the entire group was 60 years, with 791 male patients (69%). The median 5-year overall survival for Stage I, II, III and IV disease according to the recently updated TNM classification system were 72.2%, 47.5%, 29.8% and 28.6%, respectively. Female gender, TNM stage, pT status, and type of resection were found to be significant prognostic factors on multivariate analysis.

CONCLUSIONS

VATS offers a viable alternative to conventional open thoracotomy for selected patients with clinically resectable NSCLC.

Initial experience of robot-assisted thoracoscopic surgery in China

Background

The objective of this study was to evaluate the safety and feasibility of robot-assisted thoracoscopic surgery (RATS).

Methods

From May 2009 to May 2013, 48 patients with intrathoracic lesions underwent RATS with the da Vinci® Surgical System was reported (11 lobectomies, 37 mediastinal tumour resections).

Results

RATS was successfully and safely completed in all 48 patients. Conversion of the operation to open surgery was not needed in any patient. The average operation time was 85.9 min, average blood loss 33 ml, and average hospital stay 3.9 days. No patient required blood transfusion. The only recognized adverse event was the development of a bronchopleural fistula in one patient.

Conclusions

RATS appears feasible and safe in thoracic surgery. More investigation will be needed in order to determine its possible long-term benefits and cost effectiveness. Copyright © 2014 John Wiley & Sons, Ltd.

Video-assisted thoracic surgery in lung cancer resection: a meta-analysis and systematic review of controlled trials

OBJECTIVES

: This meta-analysis sought to determine whether video-assisted thoracic surgery (VATS) improves clinical and resource outcomes compared with thoracotomy (OPEN) in adults undergoing lobectomy for nonsmall cell lung cancer.

METHODS

: A comprehensive search was undertaken to identify all randomized (RCT) and nonrandomized (non-RCT) controlled trials comparing VATS with OPEN thoracotomy available up to April 2007. The primary outcome was survival. Secondary outcomes included any other reported clinical outcome and resource utilization. Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences (SMD), and their 95% confidence intervals (95% CI) were analyzed as appropriate.

RESULTS

: Baseline prognosis was more favorable for VATS (more females, smaller tumor size, less advanced stage, histology associated with peripheral location and with more indolent disease) than for OPEN in non-RCTs, but not RCT. Postoperative complications were significantly reduced in the VATS group compared with OPEN surgery when both RCT and non-RCT were considered in aggregate (OR 0.48, 95% CI 0.32-0.70). Although overall blood loss was significantly reduced with VATS compared with OPEN (-80 mL, 95% CI -110 to -50 mL), the incidence of excessive blood loss (generally defined as >500 mL) and incidence of re-exploration for bleeding was not significantly reduced. Pain measured via visual analog scales (10-point VAS) was significantly reduced by <1 point on day 1, by >2 points at 1 week, and by <1 point at week 2 to 4. Similarly, analgesia requirements were significantly reduced in the VATS group. Postoperative vital capacity was significantly improved (WMD 20, 95% CI 15-25), and at 1 year was significantly greater for VATS versus OPEN surgery (WMD 7, 95% CI 2-12). The incidence of patients reporting limited activity at 3 months was reduced (OR 0.04, 95% CI 0.00-0.82), and time to full activity was significantly reduced in the VATS versus OPEN surgery (WMD -1.5, 95% CI -2.1 to -0.9). Overall patient-reported physical function scores did not differ between groups at 3 years follow-up. Hospital length of stay was significantly reduced by 2.6 days despite increased 16 minutes of operating time for VATS versus OPEN. The incidence of cancer recurrence (local or distal) was not significantly different, but chemotherapy delays were significantly reduced for VATS versus OPEN (OR 0.15, 95% CI 0.06-0.38). The need for chemotherapy reduction was also decreased (OR 0.37, 95% CI 0.16-0.87), and the number of patients who did not receive at least 75% of their planned chemotherapy without delays were reduced (OR 0.41, 95% CI 0.18-0.93). The risk of death was not significantly reduced when RCTs were considered alone; however, when non-RCTs (n = 18) were included, the risk of death at 1 to 5 years was significantly reduced (OR 0.72, 95% CI 0.55-0.94; P = 0.02) for VATS versus OPEN. Stage-specific survival to 5 years was not significantly different between groups.

CONCLUSIONS

: This meta-analysis suggests that there may be some short term, and possibly even long-term, advantages to performing lung resections with VATS techniques rather than through conventional thoracotomy. Overall, VATS for lobectomy may reduce acute and chronic pain, perioperative morbidity, and improve delivery of adjuvant therapies, without a decrease in stage specific long-term survival. However, the results are largely dependent on non-RCTs, and future adequately powered randomized trials with long-term follow-up are encouraged.

Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis

Video-assisted thoracic surgery (VATS) lobectomy is an appealing alternative to open lobectomy via thoracotomy for non-small-cell lung cancer. However, there is no clear consensus in regard to the superior approach for long-term outcomes. The data are limited to small series, which precludes further clarification. Meta-analysis of these studies was performed in order to obtain a more objective determination of the oncological feasibility of VATS lobectomy. A systematic review of the PubMed and Embase databases was performed. Twenty observational studies reporting long-term outcomes were included, involving 2106 VATS and 2661 thoracotomy patients. There was an advantage in long-term mortality for patients who underwent VATS vs patients who underwent thoracotomy (meta difference in survival: 5%; 95% CI: 3-6%) with large heterogeneity among studies (Q = 42.6; P-value: 0.001; I(2) = 55.7%). There was no evidence of publication bias. Compared with open lobectomy, VATS lobectomy appears to have improved long-term outcomes.

Surgical outcomes of lung cancer measuring less than 1 cm in diameter

OBJECTIVES

The increased use of computed tomography has led to an increasing proportion of lung cancers that are identified when still less than 1 cm in diameter. However, there is no defined treatment strategy for such cases. The aim of this study was to investigate the surgical outcomes of small lung cancers.

METHODS

A total of 143 patients were retrospectively evaluated, who had undergone a complete surgical resection for lung cancer less than 1 cm in diameter between January 1995 and December 2011.

RESULTS

The 143 study subjects included 62 male and 81 female patients. The mean age was 64.0 years (43-82 years). The mean tumour size was 0.8 cm (0.3-1.0 cm). Seventy-seven patients (53.8%) underwent lobectomy. Thirty-two patients (22.4%) underwent segmentectomy and 34 patients (23.8%) underwent wedge resection. The 3-, 5- and 10-year survival rates were 95.7, 92.2 and 85.7%, respectively, after resection for sub-centimetre lung cancer. There were no significant differences between sub-lobar resection and lobectomy. However, two patients (1.4%) had recurrent cancer and seven (4.9%) had lymph node metastasis.

CONCLUSIONS

The selection of the surgical procedure is important and a long-term follow-up is mandatory, because lung cancer of only 1 cm or less can be associated with lymph node metastasis and distant metastatic recurrence.

The surgical management of stage I and stage II lung cancer

There have been recent advances in the treatment of non-small cell lung cancer (NSCLC). Surgical resection remains the cornerstone in the treatment of patients with stages I and II NSCLC. Anatomic lobectomy combined with hilar and mediastinal lymphadenectomy constitutes the oncologic basis of surgical resection. The surgical data favor video-assisted thoracic surgery (VATS) lobectomy over open lobectomy and have established VATS lobectomy as a gold standard in the surgical resection of early-stage NSCLC. However, the role of sublobar pulmonary resection, either anatomic segmentectomy or nonanatomic wedge resection, in patients with subcentimeter nodules may become important.

Video-assisted surgery for lung cancer. State of the art and personal experience

This paper reviews the role of videothoracoscopy in lung cancer, highlighting its utility in definitive staging, diagnosis, and treatment. We show exploratory videothoracoscopy to be the perfect technique for last-minute staging, looking for tumor invasion, especially parietal T3 and vascular T4 (due to videopericardioscopy), management of solitary pulmonary nodules, and the possibility of radical treatment with video-assisted thoracoscopic lobectomy. We perform an overview of the literature and analyze our experience of 1,381 patients with lung cancer. In 1,277 of them, the final decision on resectability was made by exploratory videothoracoscopy, including 91 by videopericardioscopy (only 30 were considered non-resectable on videopericardioscopy). Solitary pulmonary nodules were diagnosed in 382 cases (190 were cancer), and we performed 260 major lung resections by video-assisted thoracoscopic surgery (22 pneumonectomies, 238 lobectomies/bilobectomies).

The VATS lobectomist: analysis of costs and alterations in the traditional surgical working pattern in the modern surgical unit

It is beyond the scope of this article to review the advantages of VATS lobectomy, but the data in support of this technique are increasing progressively. There is excellent evidence to support the oncologic equivalence and safety profile as compared with open thoracotomy, and data that demonstrate the reduced pain associated with VATS resection. Also, reduction in immune disturbance provides a tantalizing glimpse of one additional potential modality of benefit for less traumatic surgery. Unfortunately, in the economic world, equivalence, preferably with less cost, is the test applied. Whatever the societal benefit of improved quality of life following surgery, this has no cost benefit attached. From the foregoing discussion one can conclude that VATS lobectomy is no more costly than open resection and does generate additional hospital beds. The authors remain uncertain as to the preferred form of VATS lobectomy but it seems that the reduced trauma of the endoscopic procedure is associated with more benefit in terms of shorter hospitalization albeit at the cost of some increase in operating time. VATS techniques and lobectomy sit comfortably within the structure of any thoracic unit requiring little adjustment to established process. It is likely that ultimately 30% or thereabouts of major pulmonary resection will be undertaken using this technique and that VATS interventions will aid patient assessment regardless of stage or ultimate intended therapy. Competency and responsible use remain paramount considerations.

Can stereotactic fractionated radiation therapy become the standard of care for early stage non-small cell lung carcinoma

Management of early stages non-small cell lung carcinoma has traditionally been surgery with radiation selected for medically inoperable patients. Recent emergence of stereotactic body radiation therapy allows for delivery of high radiation dose to the tumor while sparing normal lungs. This reviews compares loco-regional control, survival and complications rates between these two treatment modalities. Literature search identifies studies with stereotactic body radiation therapy and surgery for early stages non-small cell lung cancer. Effectiveness and toxicity of these two modalities was assessed. Stereotactic body radiation therapy is associated with minimal morbidity and provides comparable local control and survival in patients with multiple co-morbidities factors. Stereotactic body radiation therapy may become standard of care for operable early stages non-small cell lung cancer.

The emerging role of minimally invasive surgical techniques for the treatment of lung malignancy in the elderly

As a consequence of the general aging of the population, improved diagnostic techniques, and preoperative interventions to enhance the efficacy of surgical therapy, increasing numbers of elderly patients are presenting for pulmonary resection. Clear association between advanced age and the perioperative morbidity and mortality associated with lung cancer surgery has generated considerable interest in applying minimally invasive operative techniques in the geriatric population under the belief that this approach will improve outcome. This review examines the available data regarding video-assisted thoracoscopic lobectomy and concludes that this technique for the surgical treatment of early-stage lung cancer may parallel conventional thoracotomy in terms of oncologic efficacy while decreasing perioperative morbidity in the elderly.

Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications

BACKGROUND

The purpose of this study was to determine if the utilization of video-assisted thoracic surgery (VATS) for lobectomy for clinical stage I non-small cell lung cancer in elderly patients results in decreased complications compared with lobectomy by thoracotomy (THOR).

METHODS

A retrospective, matched case-control study was performed evaluating the perioperative outcomes after lobectomy by VATS versus THOR performed in elderly patients (age > or = 70 years) at a single institution. All complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov/reporting/ctc.html).

RESULTS

Between May 1, 2002 and December 31, 2005 333 patients (245 THOR, 88 VATS) 70 years old or greater underwent lobectomy for clinical stage I non-small cell lung cancer. After matching based on age, gender, presence of comorbid conditions, and preoperative clinical stage, there were 82 patients in each group. Patients had similar preoperative characteristics. A VATS approach resulted in a significantly lower rate of complications compared with THOR (28% vs 45%, p = 0.04) and a shorter median length of stay (5 days, range 2 to 20 vs 6 days, range 2 to 27, p < 0.001). No patients undergoing VATS lobectomy had higher than grade 2 complications, whereas 7% of complications in the THOR group were grade 3 or higher. There were no perioperative deaths in the VATS patients compared with an in-hospital mortality rate of 3.6% (3 of 82) for THOR patients.

CONCLUSIONS

A VATS approach to lobectomy for clinical stage I non-small cell lung cancer in the elderly was associated with fewer and overall reduced severity of complications as well as a shorter hospital stay compared with thoracotomy.

Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy

OBJECTIVE

The objective was to define the incidence of atrial fibrillation after video-assisted thoracic surgery lobectomy and determine whether video-assisted thoracic surgery reduces atrial fibrillation rate compared with thoracotomy.

METHODS

With the use of a single-institution database of patients who underwent lobectomy for clinical stage I non-small cell lung cancer, 389 patients were identified who were in sinus rhythm preoperatively and received no prophylactic antiarrhythmics. Patients undergoing video-assisted thoracic surgery were age and gender matched with those undergoing thoracotomy.

RESULTS

After matching, 122 patients undergoing video-assisted thoracic surgery and 122 patients undergoing thoracotomy were eligible for analysis. Patients undergoing video-assisted thoracic surgery had a higher preoperative diffusion capacity (92% +/- 28% vs 80% +/- 18% predicted, P = .001) and a lower rate of induction chemotherapy (5/122, 4% vs 11/122, 11%, P = .05) than patients undergoing thoracotomy. Atrial fibrillation occurred in 12% of patients (15/122) undergoing video-assisted thoracic surgery and 16% of patients (20/122) undergoing thoracotomy (P = .36). Overall, complications were lower in the video-assisted thoracic surgery group (17.2% vs 27.9%, P = .046). Patients with atrial fibrillation were older in both video-assisted thoracic surgery (73 +/- 7 years vs 66 +/- 9 years, P = .002) and thoracotomy groups (72 +/- 7 years vs 66 +/- 10 years, P = .005). Length of stay for patients with atrial fibrillation was greater in both video-assisted thoracic surgery (6.0 +/- 1.5 days vs 4.7 +/- 2.5 days, P = .01) and thoracotomy groups (9.2 +/- 4.3 days vs 6.8 +/- 3.6 days, P = .03).

CONCLUSIONS

Regardless of surgical approach, atrial fibrillation after lobectomy occurred with equal frequency. This supports the theory that autonomic denervation and stress-mediated neurohumoral mechanisms are responsible for the pathogenesis of postoperative atrial fibrillation. Prophylaxis regimens against atrial fibrillation should be the same for either operative approach.

Pulmonary resection in the elderly

PURPOSE OF REVIEW

With increasing longevity, altered demographics of the lung cancer population, and preoperative interventions to enhance the efficacy of surgical therapy, increasing numbers of elderly people will present for anesthesia and pulmonary resection.

RECENT FINDINGS

The geriatric population often exhibits wide disparity between chronologic and physiologic senescence which is underscored by data indicating that outcome following lung resection for cancer is influenced more by tumor stage, preoperative functional status and comorbidities than age alone. Nonetheless, the normal process of cardiopulmonary aging can limit the physiological reserve necessary to compensate for perioperative stress even in otherwise healthy elderly patients. Data indicate a relatively favorable risk-benefit relationship for lung resection in the elderly given the poor prognosis for patients undergoing palliative care or chemotherapy or radiation alone. Emerging experience now suggests that minimally invasive surgical techniques for the treatment of lung cancer may parallel conventional thoracotomy in terms of oncologic efficacy while decreasing perioperative morbidity in the elderly.

SUMMARY

The combination of an aging population, recent advances in neoadjuvant therapies, data supporting the oncologic efficacy of resection, and minimally invasive surgical techniques strongly suggests that more elderly patients will be candidates for surgical management of their lung cancer, thus presenting anesthesiologists with unique challenges.

Outcome following lung resections for pT1 non-small cell lung cancer

AIMS

To analyse the outcome of patients with pT1 NSCLC treated at our institution by antero-lateral thoracotomy, anatomical lung resections and mediastinal lymph node dissection between 1980 and 2001.

METHODS

Follow-up data were obtained retrospectively from 1980 to 1990 and prospectively after 1990. Survival was analysed using the Kaplan-Meier method.

RESULTS

Histopathological examinations revealed mediastinal lymph node infiltration in 27.6% (pN1 17.8% and pN2 9.8%). pN2 was classified in 14.1% of adenocarcinomas compared to 6.2% of squamous cell carcinomas. Median overall survival of patients with pT1 carcinomas was 89+16 months (median+standard error). Histopathological N-classification indicates differential prognostic and therapeutic implications in pT1 adeno- and squamous cell carcinomas.

CONCLUSIONS

Complete lymph node dissection is required for all patients with T1 NSCLC treated by either open surgery or VATS resection. Histopathological N-classification indicates differential prognostic and therapeutic implications in pT1 adeno- and squamous cell carcinomas.

Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results

OBJECTIVES

There is little experience with telerobotic assistance for video-assisted thoracic surgical lobectomy. We developed a technique for robotic assistance during video-assisted thoracic surgical lobectomy and report our initial results.

METHODS

Video-assisted thoracic surgical lobectomy with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, Calif) was attempted in 34 patients (median age, 69.0 years; age range, 12-85 years). Robotic instruments were used for individual dissection of the hilar structures through 2 thoracoscopic ports and a 4-cm utility incision without rib spreading. Data on patient characteristics and perioperative results were collected prospectively.

RESULTS

Robot-assisted video-assisted thoracic surgical lobectomy was accomplished in 30 patients (19 female and 11 male patients). Every type of lobectomy was performed. Four (4/34 [12%]) patients required conversion to thoracotomy. The majority of patients had non-small cell lung cancer (32/34 [94%]), and 1 patient each had a typical carcinoid tumor and an extranodal B-cell lymphoma. Every patient underwent an R0 resection. The median number of lymph node stations dissected with robotic assistance was 4 (range, 2-7). Operative mortality was 0%, with no in-hospital or perioperative deaths. Nine (26%) patients experienced National Cancer Institute Common Toxicity Criteria for Adverse Events version 3.0 grade 2 or 3 complications. The median chest tube duration was 3.0 days (range, 2-12 days), and the median length of stay was 4.5 days (range, 2-14 days). The median operative time was 218 minutes (range, 155-350 minutes).

CONCLUSIONS

Robot assistance for video-assisted thoracic surgical lobectomy is feasible and safe. The utility and advantages of robotic assistance for video-assisted thoracic surgical lobectomy require further refinement and study of the technique.

Intraoperative 125I Vicryl mesh brachytherapy after sublobar resection for high-risk stage I nonsmall cell lung cancer

PURPOSE

To assess the feasibility and outcomes of (125)I Vicryl mesh brachytherapy after sublobar resection in stage I non small cell lung cancer (NSCLC) patients with poor pulmonary function.

METHODS AND MATERIALS

Between January 1997 and July 2004, patients with poor cardiopulmonary reserve who had stage IA and IB (T1-2 N0 M0) NSCLC and a forced expiratory volume in 1s (FEV(1)) of > micro=0.6L were considered for limited surgical resection either by an open or video-assisted thoracoscopic procedure and for a subsequent (125)I Vicryl mesh brachytherapy implant. Mediastinal and hilar lymph node staging was performed routinely in all patients. After clear margins were obtained grossly and on frozen section, a single-plane (125)I implant was designed to encompass a plane consisting of the staple line and a 2-cm margin of surrounding visceral pleura. The implant was introduced through the surgical incision and sutured to the visceral pleura. A prescribed dose of 100-120 y was delivered to a volume within 0.5 cm rom the plane of the implant. Follow-up orthogonal films or CTs were obtained for dosimetric analysis. Kaplan-Meier analyses were used to estimate the local control, locoregional control, and overall survival rates.

RESULTS

Of the 110 patients, 65 had stage IA and 45 had stage IB NSCLC. The mean preoperative FEV(1) was 47% of the predicted volume. With a median follow-up of 11 months (range 1-68 months), there were four recurrences within the radiation volume. The estimated 5-year local (in-field) control, locoregional control, and overall survival rates were 90%, 61%, and 18%, respectively.

CONCLUSION

Vicryl mesh brachytherapy after sublobar resection for high-risk stage I NSCLC patients is a feasible procedure, which results in an excellent local (in-field) control rate.

Bronchial margins in lung cancer resection specimens: utility of frozen section and gross evaluation

Pathology reports for all lobectomy and pneumonectomy specimens at UNC Hospitals between 1991 and 2000 (n=405) were reviewed for correlation between frozen section and final bronchial margin, gross distance between tumor and margin and tumor type. Frozen section was performed in 268 cases (66%). A total of 243 were true negatives (90.6 %), 16 (6.0%) were true positives, four (1.5%) were false positives and five (1.9%) were false negatives. The site of tumor in true-positive cases was mucosal (11), submucosal (three), lymphatics (one), peribronchial (one). The site of tumor in false-negative cases was submucosal (two), lymphatics (one), peribronchial (two). In 137 cases, no bronchial frozen section was performed; there was one case (0.7%) with positive margin. There was no correlation between final margin positivity and distance between gross tumor and margin. Tumor distance to margin in positive margin cases varied from grossly involved to 3 cm away. There were 72 cases in which wedge resection was performed before lobectomy in which no gross tumor remained in the lobectomy, and in all cases final bronchial margins were negative. In all, 373 of cases (92%) were nonsmall carcinomas. Of these, 10 (2.7%) had positive margins. Tumors other than nonsmall cell carcinoma accounted for a disproportionate number of positive margins. In all, 3/6 of adenoid cystic/mucoepidermoid carcinoma, 1/7 small cell carcinoma and 1/1 lymphoma cases had positive margins. In conclusion, frozen section evaluation of bronchial margins is helpful in central lung tumors. Mucosal tumor is preferentially identified in frozen section. Gross evaluation of margins is problematic, as intramucosal carcinoma or tumor in lymphatics may not be detected, but 3 cm was a 'safe' distance for gross tumor from margin. In lobectomies following wedge resection in which no gross tumor remained, all had negative margins. Salivary gland-type tumors have a high incidence of positive margins, and frozen section is particularly indicated in these tumors.

Surgical aspects in the treatment of lung cancer

PURPOSE OF REVIEW

The treatment of lung cancer has been most successful when surgery is involved. This review is a succinct overview of lung cancer treatment from the thoracic surgeon's perspective over the past 2 years.

RECENT FINDINGS

Starting with the evidence-based guidelines developed by the American College of Chest Physicians, the main themes in the literature are a multimodality approach and the miniaturization of surgical approaches. Palliative procedures, staging, and extension of surgery to patients previously thought inoperable are other subjects covered.

SUMMARY

We are standing on the verge of having a definitive answer to the 20-year-old question whether adjuvant or neoadjuvant chemotherapy benefits patients with early-stage non-small cell lung cancer. Sufficient data will be available shortly to determine whether minimally invasive surgical approaches yield similar long-term outcomes as traditional approaches.

Is Major Pulmonary Resection by Video-Assisted Thoracic Surgery an Adequate Procedure in Clinical Stage I Lung Cancer?

OBJECTIVE

Although several studies have shown that video-assisted thoracic surgery (VATS) for major pulmonary resection is less invasive than open thoracotomy, VATS for lung cancer has been performed in only a limited number of institutions. We aimed to review our experience of VATS for major pulmonary resections, and to determine its safety and adequacy in stage I lung cancer.

METHODS

Between August 1999 and March 2003, we performed major pulmonary resection by VATS in 106 patients with lung cancer and preoperatively determined clinical stage I disease. We evaluated the number of procedures converted to open thoracotomy and the reasons for conversion, the intraoperative blood loss, interval between surgery and chest tube removal, length of postoperative hospital stay, postoperative complications, mortality rate, prognoses, and patterns of recurrence.

RESULTS

We successfully performed VATS in 95 patients, whereas in another 11 patients (10%) conversion to open thoracotomy was required. The operative procedures were lobectomy in 86 patients, segmentectomy in 8 patients, and bilobectomy in 1 patient. In 95 patients who underwent VATS, postoperative complications developed in 9 patients (9%), and 1 patient (1%) died from pneumonia. In the 86 patients without complications, the mean postoperative hospital stay was 7.6 days (range, 4 to 15 days). In a mean follow-up period of 25 months (range, 6 to 48 months) in patients with non-small cell lung cancer (NSCLC), including the one perioperative death, the 3-year survival rate was 93% in 82 patients with clinical stage I disease, and 97% in 68 patients with pathologic stage I disease. The 3-year disease-free survival rate was 79% in patients with clinical stage I disease, and 89% in patients with pathologic stage I disease. Local recurrence was observed in six patients (6%): recurrence in mediastinal lymph nodes in five patients, and in the bronchial stump in one patient.

CONCLUSIONS

Major pulmonary resection by VATS is acceptable in view of its low perioperative mortality and morbidity, and is an adequate procedure for the achievement of local control and good prognosis in patients with clinical stage I NSCLC.

[Video-assisted lobectomy through the auscultatory triangle for the surgical treatment of bronchopulmonary carcinoma. Preliminary experience]

OBJECTIVE

To describe a technique for video-assisted lobectomy through the auscultatory triangle (VALAT) and to assess early and medium-term outcome of the procedure in patients with non-small cell bronchopulmonary carcinoma in stage I.

PATIENTS AND METHOD

Between April 1999 and May 2002 we performed 25 VALAT procedures (24 lobectomies and 1 bilobectomy) in 25 patients with a mean age of 63.6 years (range 39-80).

RESULTS

No deaths occurred during or after surgery. Conversion to conventional thoracotomy was necessary in two cases. One patient was re-operated to resolve hemothorax and one developed a bronchopleural fistula that was treated by pleural drainage. The mean hospital stay was 6.3 days. Twenty-three patients have been disease-free throughout a mean follow-up period of 11.5 months (range 1-36). The two-year actuarial survival rate (Kaplan-Meier) was 93% 7%.

CONCLUSIONS

VALAT is a safe procedure that nevertheless requires specific training. The rate of complications was low in our patient series and mortality was nil. The outcome for patients with stage I bronchogenic carcinoma over a two-year follow-up period has been comparable to results obtained with conventional thoracotomy.