Video-assisted thoracoscopic lobectomy after neoadjuvant chemotherapy for non-small cell lung cancer: a multicenter propensity-matched study

Background

The role of video-assisted thoracoscopic surgery for the treatment of non-small-cell lung cancer after neoadjuvant chemotherapy remains controversial. The aim of this study is to demonstrate the reliability of video-assisted lobectomy compared to the open approach by evaluating perioperative and long-term outcomes.

Methods

In this retrospective, multicentric study from January 2010 to December 2018, we included all patients with non-small-cell lung cancer who underwent lobectomy through the video-assisted or open approach after neoadjuvant chemotherapy. The perioperative outcomes, including data concerning the feasibility of the surgical procedure, the occurrence of any medical and surgical complications and long-term oncological evidence, were collected and compared between the two groups. To minimize selection bias, propensity score matching was performed.

Results

A total of 286 patients were enrolled: 193 underwent thoracotomy lobectomy, and 93 underwent VATS lobectomy. The statistical analysis showed that surgical time (P < 0.001), drainage time (P < 0.001), days of hospitalization (P < 0.001) and VAS at discharge (P = 0.042) were lower in the VATS group. The overall survival and disease-free survival were equivalent for the two techniques on long-term follow-up.

Conclusions

VATS lobectomy represents a valid therapeutic option in patients affected by non-small-cell lung cancer after neoadjuvant chemotherapy. The VATS approach in our experience seems to be superior in terms of the perioperative outcomes, while maintaining oncological efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08431-z.

Oncological advantage of nonintubated thoracic surgery: Better compliance of adjuvant treatment after lung lobectomy

BACKGROUND

Video-assisted thoracoscopic (VATS) surgery contributes to improved survival, adjuvant chemotherapy delivery and less postoperative complications. Nonintubated thoracic surgery (NITS) VATS procedures improves immunological responses in lung cancer patients; however, there is no data regarding adjuvant chemotherapy delivery effectiveness following NITS lobectomies. In this study, we aimed to compare protocol compliance and toxic complications during adjuvant chemotherapy after intubated and nonintubated VATS lobectomies in non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed the medical records of 66, stage IB-IIIB NSCLC patients who underwent intubated or nonintubated VATS lobectomy and received adjuvant chemotherapy.

RESULTS

A total of 38 patients (17 males, mean age 64 years) underwent conventional VATS and 28 (7 males; mean age 63 years) uniportal VATS NITS. Both groups had comparable demographic data, preoperative pulmonary function, and Eastern Cooperative Oncology Group (ECOG) status. Among the intubated and nonintubated patients, 82% and 75% were diagnosed with adenocarcinoma, respectively. The incidence of adenocarcinoma and squamous cell carcinoma cases were similar in both groups; however, the pathological staging showed significant differences, as 5 (18%) nonintubated patients had stage IB lung cancer, compared with the intubated group (P = 0.01). Further distribution of stages was similar between the groups. We observed significant differences in chest tube duration and operation time in the nonintubated group (P < 0.01). Among nonintubated patients, 92% completed the planned chemotherapy protocol, compared to 71% of the intubated group (P = 0.035). Grade 1/2 toxicity occurred significantly more often in the intubated group (16% vs. 0%, P = 0.03) and there was a lower incidence of grade 4 neutropenia in the nonintubated group (0% vs. 16%, P = 0.03).

CONCLUSIONS

Our results showed that the nonintubated procedure resulted in improved adjuvant chemotherapy compliance and lower toxicity rates after lobectomy.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Oncological advantage of the non-intubated thoracic surgery: better compliance with therapy protocol. What this study adds NITS lobectomies contribute to better administration of adjuvant chemotherapy with the planned cycle number and dosage.

Late-onset bronchopleural fistula after lobectomy and adjuvant chemotherapy for lung cancer: A case report and review of the literature

RATIONALE

Late-onset bronchopleural fistula (BPF) induced by chemotherapy after lobectomy for lung cancer is rarely reported, lacking reliable preventive approaches. A timely identification and individualized treatment is essential for prognosis.

PATIENT CONCERNS

A 52-year-old female patient complained of fever, productive cough, and fatigue 1 week after adjuvant chemotherapy following right lower lobectomy and systemic mediastinal lymph node dissection. Chest computed tomography (CT) indicated pneumothorax and thick-walled empyema cavity within her right-sided thorax.

DIAGNOSES

The patient was diagnosed as late-onset BPF based on clinical manifestation and chest radiography.

INTERVENTIONS

In addition to antibiotics, a chest tube was reinserted under CT guidance, and vacuum suction was utilized for continuous drainage. Next cycle of adjuvant chemotherapy was terminated.

OUTCOMES

The empyema cavity was gradually closed in 1 month after conservative treatment, and the patient survived with good condition up to now.

LESSONS

Late-onset BPF should be kept in mind when the patient suffered from productive cough and chills during postoperative chemotherapy. And a prompt conservative management might be effective.

Association of Delayed Adjuvant Chemotherapy With Survival After Lung Cancer Surgery

IMPORTANCE

Adjuvant chemotherapy offers a survival benefit to a number of staging scenarios in non-small-cell lung cancer. Variable recovery from lung cancer surgery may delay a patient's ability to tolerate adjuvant chemotherapy, yet the urgency of chemotherapy initiation is unclear.

OBJECTIVE

To assess differences in survival according to the time interval between non-small-cell lung cancer resection and the initiation of postoperative chemotherapy to determine the association between adjuvant treatment timing and efficacy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational study examined treatment-naive patients with completely resected non-small-cell lung cancer who received postoperative multiagent chemotherapy between 18 and 127 days after resection between January 2004 and December 2012. The study population was limited to patients with lymph node metastases, tumors 4 cm or larger, or local extension. Patients were identified from the National Cancer Database, a hospital-based tumor registry that captures more than 70% of incident lung cancer cases in the United States. The association between time to initiation of adjuvant chemotherapy and survival was evaluated using Cox models with restricted cubic splines.

EXPOSURES

Adjuvant chemotherapy administered at different time points after surgery.

MAIN OUTCOMES AND MEASURES

Effectiveness of adjuvant chemotherapy according to time to initiation after surgery.

RESULTS

A total of 12 473 patients (median [interquartile range] age, 64 [57-70] years) were identified: 3073 patients (25%) with stage I disease; 5981 patients (48%), stage II; and 3419 patients (27%), stage III. A Cox model with restricted cubic splines identified the lowest mortality risk when chemotherapy was started 50 days postoperatively (95% CI, 39-56 days). Initiation of chemotherapy after this interval (57-127 days; ie, the later cohort) did not increase mortality (hazard ratio [HR], 1.037; 95% CI, 0.972-1.105; P = .27). Furthermore, in a Cox model of 3976 propensity-matched pairs, patients who received chemotherapy during the later interval had a lower mortality risk than those treated with surgery only (HR, 0.664; 95% CI, 0.623-0.707; P < .001).

CONCLUSIONS AND RELEVANCE

In the National Cancer Database, adjuvant chemotherapy remained efficacious when started 7 to 18 weeks after non-small-cell lung cancer resection. Patients who recover slowly from non-small-cell lung cancer surgery may still benefit from delayed adjuvant chemotherapy started up to 4 months after surgery.

Risk factors for short-term outcomes after thoracoscopic lobectomy for lung cancer

Few studies have analysed postoperative risk factors in patients undergoing thoracoscopic lobectomy, including assessments of preoperative physical function. The objectives of this study were to identify predictors of postoperative deterioration of performance status and cardiopulmonary complications in cases of thoracoscopic lobectomy.

Between June 2005 and October 2012, we retrospectively reviewed 188 consecutive subjects who underwent thoracoscopic lobectomy for preoperative stage I nonsmall cell lung cancer. The demographic and clinical parameters, including physical function, were analysed using a multivariate logistic regression to clarify the determinants.

The percent predicted diffusing capacity of the lung for carbon monoxide, quadriceps muscle strength and pathologic stage were independent risk factors for deterioration of performance status after surgery in the multivariate analyses. Chronic obstructive pulmonary disease, 6-min walking distance and pathologic stage were also independent risk factors for postoperative cardiopulmonary complications.

Our data suggest that, in addition to a greater pathologic stage, lower diffusing capacity and comorbid chronic obstructive pulmonary disease, poor physical function was associated with worse short-term outcomes after thoracoscopic lobectomy. An evaluation of preoperative quadriceps muscle strength and 6-min walk test is easily performed and may therefore be a useful predictor in cases of thoracoscopic lobectomy.

Uniportal VATS: the first German experience

BACKGROUND

The acceptance of uniportal video-assisted thoracic surgery (VATS) for minor and major thoracic procedures is growing in Europe. This study presents the first experience with uniportal VATS in Germany.

METHODS

In a retrospective study of prospectively collected data, 56 uniportal VATS were analyzed between 06/2012 and 06/2014. The technique was used for diagnostic aims, pleurectomies, wedge resections, segmentectomies and major resections. All procedures were performed without rib spreading. Patients' demographic data, preoperative and postoperative management as well as results were analyzed.

RESULTS

A total of 42 patients (75%) were males. The mean age was 59.2±15 years. The uniportal VATS procedures included one or multiple wedge resections in 30 cases (53.6%), major resections in 9 cases (16.1%), anatomical segment resections in 6 cases (10.7%) and other indications in 11 cases (19.6%). The median operation time was 252, 114, 88 and 73 minutes for major resections, anatomical segment resections, wedge resections and other indications, respectively. There were three conversions in two cases of major resections and in one anatomical segmentectomy. The mean chest tube duration was 3.4±2.1 days. The mean hospital stay was 8.3±5.3 days for the whole group.

CONCLUSIONS

Uniportal VATS is a feasible and safe technique for various indications in thoracic surgery. The perioperative results are promising. It can be performed by thoracic surgeons experienced in the postero-lateral thoracotomy approach.