A National Analysis of Minimally Invasive Vs Open Segmentectomy for Stage IA Non-Small-Cell Lung Cancer

The Surgical Renaissance: Advancements in Video-Assisted Thoracoscopic Surgery and Robotic-Assisted Thoracic Surgery and Their Impact on Patient Outcomes

Minimally invasive thoracic surgery has advanced the treatment of lung cancer since its introduction in the 1990s. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) offer the advantage of smaller incisions without compromising patient outcomes. These techniques have been shown to be safe and effective in standard pulmonary resections (lobectomy and sub-lobar resection) and in complex pulmonary resections (sleeve resection and pneumonectomy). Furthermore, several studies show these techniques enhance patient outcomes from early recovery to improved quality of life (QoL) and excellent oncologic results. The rise of RATS has yielded further operative benefits compared to thoracoscopic surgery. The wristed instruments, neutralization of tremor, dexterity, and magnification allow for more precise and delicate dissection of tissues and vessels. This review summarizes of the advancements in minimally invasive thoracic surgery and the positive impact on patient outcomes.

Induction chemoimmunotherapy with surgery versus concurrent chemoradiation followed by immunotherapy for stage III-N2 non-small cell lung cancer

OBJECTIVE

Despite the growing relevance of immunotherapy for non-small cell lung cancer (NSCLC), there is limited consensus on the optimal treatment strategy for locally advanced NSCLC. This study evaluated the overall survival of patients with stage III-N2 NSCLC undergoing induction chemoimmunotherapy with surgery (CT/IO+Surgery) and definitive concurrent chemoradiation followed by immunotherapy (cCRT+IO).

METHODS

Patients with cT1-3, N2, M0 NSCLC in the National Cancer Database (2013 to 2019) were included and stratified by treatment regimen: CT/IO+Surgery or cCRT+IO. Overall survival was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching on 10 prognostic variables.

RESULTS

Of the 3382 patients who met the study eligibility criteria, 3289 (97.3%) received cCRT+IO and 93 (2.8%) received CT/IO+Surgery. The 3-year overall survival of the entire cohort was 58.2% (95% CI, 56.2% to 60.1%). Multivariable-adjusted Cox proportional hazards modeling demonstrated better survival after CT/IO+Surgery than after cCRT+IO (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.32 to 0.84; P = .007). In a 3:1 variable ratio propensity score-matched analysis of 223 patients who received cCRT+IO and 76 patients who received CT/IO+Surgery, 3-year overall survival was 63.2% (95% CI, 55.9% to 70.2%) after cCRT+IO and 77.2% (95% CI, 64.6% to 85.7%) after CT/IO+Surgery (P = .029).

CONCLUSIONS

In this national analysis, multimodal treatment including immunotherapy was associated with a 3-year overall survival rate of 58.2% for all patients with stage III-N2 NSCLC and 77.2% for patients who underwent chemoimmunotherapy followed by surgery. These results should be considered hypothesis-generating and demonstrate the importance of developing a randomized trial to evaluate the role of surgery versus chemoradiation for locally advanced NSCLC in the modern immunotherapy era.

Comparing Robotic, Thoracoscopic, and Open Segmentectomy: A National Cancer Database Analysis

INTRODUCTION

Minimally invasive approaches to lung resection have become widely acceptable and more recently, segmentectomy has demonstrated equivalent oncologic outcomes when compared to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, studies comparing outcomes following segmentectomy by different surgical approaches are lacking. Our objective was to investigate the outcomes of patients undergoing robotic, video-assisted thoracoscopic surgery (VATS), or open segmentectomy for NSCLC using the National Cancer Database.

METHODS

NSCLC patients with clinical stage I who underwent segmentectomy from 2010 to 2016 were identified. After propensity-score matching (1:4:1), multivariate logistic regression analyses were performed to determine predictors of 30-d readmissions, 90-d mortality, and overall survival.

RESULTS

22,792 patients met study inclusion. After matching, approaches included robotic (n = 2493; 17%), VATS (n = 9972; 66%), and open (n = 2493; 17%). An open approach was associated with higher 30-d readmissions (7% open versus 5.5% VATS versus 5.6% robot, P = 0.033) and 90-d mortality (4.4% open versus 2.2% VATS versus 2.5% robot, P < 0.001). A robotic approach was associated with improved 5-y survival (50% open versus 58% VATS versus 63% robot, P < 0.001).

CONCLUSIONS

For patients with clinical stage I NSCLC undergoing segmentectomy, compared to the open approach, a VATS approach was associated with lower 30-d readmission and 90-d mortality. A robotic approach was associated with improved 5-y survival compared to open and VATS approaches when matched. Additional studies are necessary to determine if unrecognized covariates contribute to these differences.

[Complications after pulmonary segmentectomy: Impact of the surgical approach]

INTRODUCTION

Pulmonary segmentectomy is becoming increasingly widespread but remains technically challenging. The aim of this study was to evaluate the impact of the surgical approach applied on postoperative complications after pulmonary segmentectomy.

METHODS

All patients having undergone pulmonary segmentectomy by thoracotomy, videothoracoscopy or robot-assisted surgery from 1st January 2018 to 31st December 2021 were included. The primary endpoint was the occurrence of postoperative complications. Secondary endpoints were operative time, length of hospital stay, 30-day readmission rate, 30-day and 90-day mortality.

RESULTS

Two hundred and twenty-three patients were included, 30% (n=67) in the thoracotomy group, 9.4% (n=21) in the videothoracoscopy group and 60.5% (n=135) in the robot-assisted surgery group. There was no difference in the occurrence of postoperative complications according to type of approach (P=0.564), 26.9% of patients (n=60) had at least one postoperative complication. There was no significant difference between the groups in terms of operative time (P=0.385), length of hospital stay (P=0.107), 30 and 90-day mortality (P=0.124 and P=0.249, respectively). Mini-invasive surgery significantly reduced the 30-day readmission rate (P=0.049).

CONCLUSION

The surgical approach applied does not influence the postoperative complications of pulmonary segmentectomy.

Characteristics of High-Volume Lung Segmentectomy Hospitals: A Propensity Score-Matched Analysis

BACKGROUND

Segmental resection continues to gain favor in the treatment of early-stage non-small cell lung cancer, but there is limited data on outcomes as related to facility volume. The purpose of this study is to better define the relationship between segmentectomy outcomes, survival, and facility volume.

METHODS

A retrospective cohort analysis was completed using the National Cancer Database. Patients with stage I disease undergoing segmentectomy 2004 to 2015 were included. Facility volume was determined per year; facilities performing higher than the median number of segmental resections were deemed high-volume and retained that classification for the remainder of the study. Propensity-score matching was used to compare 5-year survival and outcomes.

RESULTS

Six hundred eighty-one centers performing 2481 segmentectomies were included. High-volume centers had higher utilization of minimally invasive approaches and lower conversion rates. There was no difference in readmission or 30-day mortality, but 90-day mortality differed between groups (1.2% vs. 2.6%, P = .03). High-volume centers were more likely to sample lymph nodes (88.5% vs. 80.7%, P < .01), and patients were less likely to have positives margins (1.3% vs. 2.7%, P = .03). Patients were no more likely to be upstaged based on facility volume (4.6% vs. 3.3%, P = .21). Overall, 5-year survival was better for patients treated at high-volume centers in the full cohort (69.5% vs. 66.4%, P = .014) but in propensity score-matched analysis this survival difference became non-significant (68.0% vs. 67.9% (P = .172).

CONCLUSION

Segmentectomy performed at high-volume centers is associated with more frequent use of minimally invasive approach, more frequent negative margins, and improved 90-day survival.

Trends in segmentectomy for the treatment of stage 1A non-small cell lung cancers: Does the robot have an impact?

OBJECTIVES

Lobectomy may unnecessarily resect healthy lung parenchyma in Stage 1A non-small cell lung cancers (NSCLC). Segmentectomies may provide a lung-sparing option. VATS segmentectomies can be technically challenging; robotics may have features that provide advantages in performing segmentectomies. We describe the association of the robot on national trends in segmentectomies.

METHODS

The National Cancer Database (2010-2017) was queried for patients with Stage 1A NSCLC who underwent lobectomies and segmentectomies. The proportion of segmentectomies vs. lobectomies and the proportion of robotic vs. VATS segmentectomies was calculated annually.

RESULTS

The proportion of segmentectomies increased compared to lobectomies for all surgical approaches but remained constant for minimally-invasive approaches. The proportion of robotic segmentectomies increased over the years compared to VATS segmentectomies. Descriptive statistics are reported as numbers and proportions. Trends in the proportions of lobectomies and segmentectomies were compared using Chi-squared test for categorical variables and unpaired t-test for independent means. A p-value of <0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics Software version 24 (IBM Corp, Armonk, NY).

CONCLUSIONS

We demonstrate an increasing trend and proportion of robotic segmentectomies being performed in comparison to VATS segmentectomies. The robotic platform may facilitate the performance of more segmentectomies for early-stage NSCLC.

STATISTICAL ANALYSIS

Adoption of Robotic Core Technology in Minimally Invasive Lung Segmentectomy: Review

A recent randomized trial demonstrated the survival superiority of lung segmentectomy over lobectomy in patients with early stage, small-sized lung cancer. Hence, there is a pressing need for thoracic surgeons to gain familiarity with lung segmentectomy. However, lung segmentectomy, especially via minimally invasive surgery, is a technically challenging thoracic surgical procedure. The robotic surgery platform helps surgeons to improve their operative performance based on its core technological features: improved dexterity, precision, and visualization. Herein, we have discussed the key issues related to robotic lung segmentectomy, explicitly focusing on the technical features of complex segmentectomy under difficult conditions. We have also introduced our preferred surgical strategy for robotic lung segmentectomy with specific maneuvers.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Technical Advances in Segmentectomy for Lung Cancer: A Minimally Invasive Strategy for Deep, Small, and Impalpable Tumors

With the increased detection of early-stage lung cancer and the technical advancement of minimally invasive surgery (MIS) in the field of thoracic surgery, lung segmentectomy using MIS, including video- and robot-assisted thoracic surgery, has been widely adopted. However, lung segmentectomy can be technically challenging for thoracic surgeons due to (1) complex segmental and subsegmental anatomy with frequent anomalies, and (2) difficulty in localizing deep, small, and impalpable tumors, leading to difficulty in obtaining adequate margins. In this review, we summarize the published evidence and discuss key issues related to MIS segmentectomy, focusing on preoperative planning/simulation and intraoperative tumor localization. We also demonstrate two of our techniques: (1) three-dimensional computed tomography (3DCT)-based resection planning using a novel 3DCT processing software, and (2) tumor localization using a novel radiofrequency identification technology.