Video-assisted versus open thoracotomy lobectomy: comparison on lymphadenectomy and survival in early stage of lung cancer

Results of video-assisted thoracoscopic surgery versus thoracotomy for lung cancer in a mixed practice medium-volume hospital: a propensity-matched study

OBJECTIVES

The aim of this study was to compare the short- and long-term results of video-assisted thoracoscopic surgery (VATS) and thoracotomy for non-small-cell lung cancer in a medium-volume centre, where cardiothoracic surgeons perform both cardiac and general thoracic surgery. The primary outcome of interest was 5-year overall survival and disease-specific survival. Secondary outcomes were short-term postoperative complications, length of hospital stay and lymph node yield.

METHODS

This was a retrospective cohort study including 670 lung cancer patients undergoing VATS (n = 207) or open surgery (n = 463) with a curative intent in Oulu University Hospital between the years 2000-2020. Propensity score matching was implemented with surgical technique as the dependent and age, sex, Charlson comorbidity index, pulmonary function, pathological stage, histological type and the year of the operation as covariates resulting in 127 pairs.

RESULTS

In the propensity-matched cohort, 5-year overall survival was 64.3% after VATS and 63.2% after thoracotomy (P = 0.969). Five-year disease-specific survival was 71.6% vs 76.2% (P = 0.559). There were no differences in overall (34.6% vs 44.9%, p = 0.096) or major postoperative complications (8.7% vs 14.2%, P = 0.167) between the study groups. The average length of hospital stay was shorter (5.8 vs 6.6 days, P = 0.012) and the median lymph node yield was lower (4.0 vs 7.0, P < 0.001) in the VATS group compared to the thoracotomy group.

CONCLUSIONS

According to this study, the long-term results of lung cancer surgery in a mixed practice are comparable between VATS and open surgery.

Modern therapies of nonsmall cell lung cancer

Lung cancer (LC), particularly nonsmall cell lung cancer (NSCLC), is one of the most prevalent types of neoplasia worldwide, regardless of gender, with the highest mortality rates in oncology. Over the years, treatment for NSCLC has evolved from conventional surgery, chemotherapy, and radiotherapy to more tailored and minimally invasive approaches. The use of personalised therapies has increased the expected efficacy of treatment while simultaneously reducing the frequency of severe adverse effects (AEs). In this review, we discuss established modern approaches, including immunotherapy and targeted therapy, as well as experimental molecular methods like clustered regularly interspaced short palindromic repeat (CRISPR) and nanoparticles. These emerging methods offer promising outcomes and shorten the recovery time for various patients. Recent advances in the diagnostic field, including imaging and genetic profiling, have enabled the implementation of these methods. The versatility of these modern therapies allows for multiple treatment options, such as single-agent use, combination with existing conventional treatments, or incorporation into new regimens. As a result, patients can survive even in the advanced stages of NSCLC, leading to increased survival indicators such as overall survival (OS) and progression-free survival (PFS).

Predictors of Long-Term Survival of Thoracoscopic Lobectomy for Stage IA Non-Small Cell Lung Cancer: A Large Retrospective Cohort Study

The standard of care for patients with early-stage non-small cell lung cancer (NSCLC) is anatomical lung resection with lymphadenectomy. This multicenter, retrospective, cohort study aimed to identify predictors of 5-year survival in patients after thoracoscopic lobectomy for stage IA NSCLC. The study included 1249 patients who underwent thoracoscopic lobectomy for stage IA NSCLC between 17 April 2007, and December 28, 2016. The 5-year survival rate equaled 77.7%. In the multivariate analysis, higher age (OR, 1.025, 95% CI: 1.002 to 1.048; p = 0.032), male sex (OR, 1.410, 95% CI: 1.109 to 1.793; p = 0.005), chronic obstructive pulmonary disease (OR, 1.346, 95% CI: 1.005 to 1.803; p = 0.046), prolonged postoperative air leak (OR, 2.060, 95% CI: 1.424 to 2.980; p < 0.001) and higher pathological stage (OR, 1.271, 95% CI: 1.048 to 1.541; p = 0.015) were related to the increased risk of death within 5 years after surgery. Lobe-specific mediastinal lymph node dissection (OR, 0.725, 95% CI: 0.548 to 0.959; p = 0.024) was related to the decreased risk of death within 5 years after surgery. These findings provide valuable insights for clinical practice and may contribute to improving the quality of treatment of early-stage NSCLC.

The absence of lymph nodes removed (pNx status) impacts survival in patients with lung cancer treated surgically

OBJECTIVES

We aimed to study the clinical significance of the lack of lymph node assessment (pNx status) and its impact on survival in non-small-cell lung cancer patients.

METHODS

We retrospectively analysed the Polish Lung Cancer Study Group database. pNx status was defined as 0 lymph nodes removed. We included 17,192 patients.

RESULTS

A total of 1080 patients (6%) had pNx status. pNx patients were more likely to be younger, be female, have a different pT distribution, have squamous cell carcinoma, undergo open thoracotomy, be operated on in non-academic hospitals, and have a lower rate of some comorbidities. pNx was more likely to be cN0 than pN1 and pN2 but less likely than pN0 (p < 0.001). pNx patients were less likely to undergo preoperative invasive mediastinal diagnostics than pN1 and pN2 patients but more likely than pN0 patients (p < 0.001). Overall, the five-year overall survival rates were 64%, 45%, 32% and 50% for pN0, pN1, pN2 and pNx, respectively. In pairwise comparisons, all pN descriptors differed significantly from each other (all p < 0.0001 but pNx vs. pN1 p = 0.016). The placement of the pNx survival curve and survival rate depended on histopathology, surgical approach and pT status. In multivariable analysis, pNx was an independent prognostic risk factor (HR = 1.37, 95%CI: 1.23-1.51, p < 0.01).

CONCLUSION

The resection of lymph nodes in lung cancer remains a crucial step in the surgical treatment of this disease. The survival of pNx patients is similar to that of pN1 patients. pNx survival curve placement depends on the other variables which could be useful in clinical decisions.

Lobectomías pulmonares en Colombia: una caracterización demográfica y clínico-patológica

Introducción. La lobectomía pulmonar es uno de los procedimientos más frecuentes en la cirugía torácica en Colombia y a nivel mundial. El objetivo de este estudio fue proporcionar información sobre el comportamiento clínico de los individuos sometidos a este tipo de cirugías. Métodos. Estudio observacional retrospectivo en un Hospital Universitario de Cali, Colombia, que incluyó todos los pacientes sometidos a lobectomía pulmonar, por causas benignas o malignas, entre los años 2010 y 2020. La información se extrajo del registro institucional de cirugía de tórax, obteniendo datos demográficos, clínicos y patológicos. Resultados. Se evaluaron los registros clínicos de 207 individuos. El 55,5 % eran mujeres, la edad promedio fue 58 años y el 41 % tuvieron antecedente de tabaquismo. En el 51,6 % de los casos se diagnosticaron neoplasias, de las cuales el 47,8 % eran primarias de pulmón, siendo el adenocarcinoma el subtipo más común. Las enfermedades benignas no tumorales representaron el 48,3 % de los casos y la causa más frecuente fueron las infecciones, dentro de las que se incluyeron 17 casos de tuberculosis pulmonar. La técnica más frecuente fue la cirugía toracoscópica video asistida (82,6 %). Presentaron un porcentaje de reintervención del 5,8 %, 10,6 % de complicaciones severas y una mortalidad hospitalaria del 4,3 %. Conclusión. La población evaluada muestra una carga alta de comorbilidades y riesgo operatorio elevado; de forma consecuente, al compararla con otras series internacionales, se encontró un porcentaje mayor de complicaciones perioperatorias y mortalidad.

Would the width of a metal rib spreader affect postoperative pain in patients who undergo video-assisted mini-thoracotomy (VAMT)?

Background

Hitherto, no study has evaluated postoperative pain in patients with non-small cell lung cancer (NSCLC) treated with video-assisted mini-thoracotomy (VAMT). In this study, we aimed to assess postoperative pain related to the width of the metal rib spreader in patients who underwent lobectomy using VAMT.

Methods

We retrospectively analysed the data of 94 consecutive patients with NSCLC who underwent lobectomy using VAMT at our institution between March 2019 and May 2022. We divided the patients into groups according to the width ratio of the rib spreader to that of a single intercostal space. Patients with width ratios ≤ 2.5 times were assigned to group A, and those with width ratios > 2.5 times were assigned to group B. Pre-, intra-, and postoperative data were collected and reviewed.

Results

We successfully performed VAMT in 94 patients with NSCLC. Forty-five patients were in group A, and 49 were in group B. There were no intraoperative mortalities, although one patient, due to respiratory failure, experienced 30-day mortality. There were no significant differences between the two groups in terms of the blood loss volume, operative time, drainage time, postoperative complications, length of hospital stay, or number of lymph node stations explored and retrieved. The drainage volumes (Day 1–Day 3) were higher in group B than in group A (P < 0.05). The postoperative visual analogue scale (VAS) pain scores were significantly lower in Group A than in Group B at 12, 24, and 48 h (P < 0.05), although there was no significant difference in the VAS scores between the two groups at 72 h and 1 week postoperatively (P > 0.05).

Conclusion

The smaller the width of the metal rib spreader used in surgery, the less pain experienced by the patient and the faster the recovery. Multicentre, randomised, controlled trials should be conducted in the future.

Perioperative Outcomes of Video-Assisted Thoracoscopic Surgery Versus Open Thoracotomy After Neoadjuvant Chemoimmunotherapy in Resectable NSCLC

Background

Neoadjuvant chemoimmunotherapy becomes more widespread in the treatment of NSCLC, but few studies have reported the details of surgical techniques and perioperative challenges following neoadjuvant chemoimmunotherapy until now. The primary aim of our study was to address the feasibility and safety of pulmonary resection after neoadjuvant chemoimmunotherapy via different surgical approaches, video-assisted thoracoscopic surgery (VATS) and open thoracotomy.

Methods

Patients with an initial diagnosis of clinical stage IB-IIIB(T3-4N2) NSCLC, who received neoadjuvant chemoimmunotherapy and surgery between January 2019 and August 2021 were included. Patients were retrospectively divided into two groups (VATS, and thoracotomy), and differences in perioperative, oncological, and survival outcomes were compared.

Results

In total, there were 131 NSCLC patients included. Surgery was delayed beyond 42 days in 21 patients (16.0%), and radical resection (R0) was achieved in 125 cases (95.4%). Lobectomy was the principal method of pulmonary resection (102 cases, 77.9%) and pneumonectomy was performed in 11 cases (8.4%). Postoperative complications within 30 days occurred in 28 patients (21.4%), and no 90-day mortality was recorded. There were 53 patients (38.5%) treated with VATS, and 78 (59.5%) with open thoracotomy. VATS could achieve similar definitive resection rates, postoperative recovery courses, comparable morbidities, and equivalent RFS rates(p>0.05), with the advantages of reduced operative time (160.1 ± 40.4 vs 177.7 ± 57.7 min, p=0.042), less intraoperative blood loss (149.8 ± 57.9 vs 321.2 ± 72.3 ml, p=0.021), and fewer intensive care unit(ICU) stays after surgery (3.8% vs 20.5%, p=0.006) compared with open thoracotomy. However, the mean number of total lymph nodes resected was lower in the VATS group (19.5 ± 7.9 vs 23.0 ± 8.1, p=0.013). More patients in the thoracotomy group received bronchial sleeve resection/bronchoplasty (53.8% vs 32.1%, p=0.014) and vascular sleeve resection/angioplasty (23.1% vs 3.8%, p=0.003). After propensity score matching (PSM) analysis, VATS still had the advantage of fewer ICU stays after surgery (2.3% vs. 20.5%, p=0.007).

Conclusions

Our results have confirmed that pulmonary resection following neoadjuvant PD-1 inhibitors plus chemotherapy is safe and feasible. VATS could achieve similar safety, definitive surgical resection, postoperative recovery, and equivalent oncological efficacy as open thoracotomy, with the advantage of fewer ICU stays after surgery.

Lung Cancer Treatment: From Tradition to Innovation

Lung cancer (LC) is the second most commonly diagnosed cancer and the primary cause of cancer death worldwide in 2020. LC treatment is associated with huge costs for patients and society; consequently, there is an increasing interest in the prevention, early detection with screening, and development of new treatments. Its surgical management accounts for at least 90% of the activity of thoracic surgery departments. Surgery is the treatment of choice for early-stage non-small cell LC. In this article, we discuss the state of the art of thoracic surgery for surgical management of LC. We start by describing the milestones of LC treatment, which are lobectomy and an adequate lymphadenectomy, and then we focus on the traditional and innovative minimally invasive surgical approaches available: video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). A brief overview of the innovation and future perspective in thoracic surgery will close this mini-review.

[Experience of Thoracotomy and Robot-assisted Bronchial Sleeve Resection after Neoadjuvant Chemoimmunotherapy for Local Advanced Central Lung Cancer]

BACKGROUND

Immunoneoadjuvant therapy opens a new prospect for local advanced lung cancer. The aim of our study was to explore the safety and feasibility of robotic-assisted bronchial sleeve resection in patients with locally advanced non-small cell lung cancer (NSCLC) after neoadjuvant chemoimmunotherapy.

METHODS

Data of 13 patients with locally advanced NSCLC that underwent bronchial sleeve resection after neoadjuvant chemoimmunotherapy during August 2020 and February 2021 were retrospectively included. According to the surgical methods, patients were divided into thoracotomy bronchial sleeve resection (TBSR) group and robot-assisted bronchial sleeve resection (RABSR) group. Oncology, intraoperative, and postoperative data in the two groups were compared.

RESULTS

The two groups of patients operated smoothly, the postoperative pathology confirmed that all the tumor lesions achieved R0 resection, and RABSR group no patient was transferred to thoracotomy during surgery. Partial remission (PR) rate and major pathological remissions (MPR) rate of patients in the TBSR group were 71.43% and 42.86%, respectively. Complete pathological response (pCR) was 28.57%. They were 66.67%, 50.00% and 33.33% in RABSR group, respectively. There were no significant differences in operative duration, number of lymph nodes dissected, intraoperative blood loss, postoperative drainage time and postoperative hospital stay between the two groups, but the bronchial anastomosis time of RABSR group was relatively short. Both groups of patients had a good prognosis. Successfully discharged from the hospital and post-operative 90-d mortality rate was 0.

CONCLUSIONS

In patients with locally advanced central NSCLC after neoadjuvant chemoimmunotherapy can achieve the tumor reduction, tumor stage decline and increase the R0 resection rate, bronchial sleeve resection is safe and feasible. Under the premise of following the two principles of surgical safety and realizing the tumor R0 resection, robot-assisted bronchial sleeve resection can be preferred.

Acupuncture against chronic postsurgical pain in non-small cell lung cancer patients: A protocol of randomized controlled trial

INTRODUCTION

Video-assisted thoracoscopic lobectomy is the prior recommended treatment for non-small cell lung cancer (NSCLC), with the advantages of small trauma, less postoperative pain, and quick recovery. However, a large number of patients may suffer chronic postsurgical pain (CPSP), which makes the patients unwilling to practice pulmonary exercises, and it would directly affect patient's cough, sputum expectoration, and mobility. Opioids could greatly improve the quality of postoperative analgesia and the quality of life after surgery, but it is accompanied with obvious side effects. A number of clinical studies have proved that acupuncture could improve postoperative pain and reduce opioid use. In this study, we try to conduct a randomized controlled study to evaluate the efficacy and safety of plum-blossom needle acupuncture combined with Tramadol in improving CPSP after lobectomy in NSCLC patients.

METHODS

Patients will be randomly divided into treatment group (acupuncture plus Tramadol) and control group (sham acupuncture plus Tramadol) with a random number table in 1:1 ratio. The patients, outcome assessor, and statistician will be blinded. The outcomes are changes of numerical rating scale, Karnofsky performance score, brief pain inventory, blood routine, liver and kidney function. The data will be analyzed by SPSS 22.0.

CONCLUSIONS

The results will help to evaluate the efficacy and safety of plum-blossom needle acupuncture in improving CPSP after lobectomy in NSCLC patients.

500 Consecutive Robotic Lobectomies for Non-Small Cell Lung Cancer: Perioperative and Oncologic Outcomes

OBJECTIVE

Clinical adoption of robotic lobectomy for management of lung cancer is rapidly increasing across the world. Several studies have evaluated the technique with regards to perioperative and cost outcomes, with evidence beginning to grow regarding long-term oncologic outcomes. We report perioperative and oncologic outcomes in our single institution experience with 500 consecutive robotic lobectomies, including a significant portion for locally advanced disease.

METHODS

This study is a retrospective review of the first 500 robotic lobectomies performed at our institution from 2010 to 2018. Segmentectomy, pneumonectomy, and lobectomy for other conditions were excluded. Descriptive statistics and Kaplan-Meier survival analysis are presented.

RESULTS

Pathologic stage distribution was IA in 194 (39%), IB in 54 (11%), IIA in 41 (8%), IIB in 109 (22%), IIIA in 83 (17%), IIIB in 11 (2%), and IV in 8 (2%). Elective conversion occurred in 26 cases (5.2%) and emergent conversion occurred in 3 cases (0.6%). Mean length of stay was 3.7 days (1 to 40). The most common complications encountered were atrial fibrillation in 71 (14.2%) and prolonged air leak in 49 (9.8%). Thirty-day mortality occurred in 3 patients (0.6%). Nodal upstaging was 16.6%. Stage specific overall survival outcomes included an 84% survival for stage IA patients, 73% for IB, 68% for IIA, 63% for IIB, and 49% for IIIA disease.

CONCLUSIONS

Robotic lobectomy for lung cancer is a feasible technique for treatment of non-small cell lung cancer with low perioperative morbidity and mortality. Furthermore, excellent oncologic outcomes can be achieved with this approach.