Optimal Approach to Lobectomy for Non-Small Cell Lung Cancer: Systemic Review and Meta-Analysis

Objective

Video-assisted thoracic surgery (VATS) lobectomy was introduced over 25 years ago. More recently, the technique has been modified from a multiport video-assisted thoracic surgery (mVATS) to uniportal (uVATS) and robotic (rVATS), with proponents for each approach. Additionally most lobectomies are still performed using an open approach. We sought to provide evidence-based recommendations to help define the optimal surgical approach to lobectomy for early stage non-small cell lung cancer.

Methods

Systematic review and meta-analysis of articles searched without limits from January 2000 to January 2018 comparing open, mVATS, uVATS, and rVATS using sources Medline, Embase, and Cochrane Library were considered for inclusion. Articles were individually scrutinized by ISMICS consensus conference members, and evidence-based statements were created and consensus processes were used to determine the ensuing recommendations. The ACC/AHA Clinical Practice Guideline Recommendation Classification system was used to assess the overall quality of evidence and the strength of recommendations.

Results and recommendations

One hundred and forty-five studies met the predefined inclusion criteria and were included in the meta-analysis. Comparisons were analyzed between VATS and open, and between different VATS approaches looking at oncological outcomes (survival, recurrence, lymph node evaluation), safety (adverse events), function (pain, quality of life, pulmonary function), and cost-effectiveness. Fifteen statements addressing these areas achieved consensus. The highest level of evidence suggested that mVATS is preferable to open lobectomy with lower adverse events (36% versus 42%; 88,460 patients) and less pain (IIa recommendation). Our meta-analysis suggested that overall survival was better (IIb) with mVATS compared with open (71.5% versus 66.7% 5-years; 16,200 patients). Different VATS approaches were similar for most outcomes, although uVATS may be associated with less pain and analgesic requirements (IIb).

Conclusions

This meta-analysis supports the role of VATS lobectomy for non-small cell lung cancer. Apart from potentially less pain and analgesic requirement with uVATS, different minimally invasive surgical approaches appear to have similar outcomes.

Thoracotomy is better than thoracoscopic lobectomy in the lymph node dissection of lung cancer: a systematic review and meta-analysis

Background

The aim of this study was to investigate which surgical method is better in lymph node (LN) dissection of lung cancer.

Methods

A comprehensive search of PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus, and Google Scholar was performed to identify studies comparing thoracoscopic lobectomy (video-assisted thoracic surgery (VATS) group) and thoracotomy (open group) in LN dissection.

Results

Twenty-nine articles met the inclusion criteria and involved 2763 patients in the VATS group and 3484 patients in the open group. The meta-analysis showed that fewer total LNs (95% confidence interval [CI] −1.52 to −0.73, p < 0.0001) and N2 LNs (95% CI −1.25 to −0.10, p = 0.02) were dissected in the VATS group. A similar number of total LN stations, N2 LN stations, and N1 LNs were harvested in both groups. Only one study reported that fewer N1 LN stations were dissected in the VATS group (1.4 ± 0.5 vs. 1.6 ± 0.6, p = 0.04).

Conclusions

Open lobectomy could achieve better LN dissection efficacy than thoracoscopic lobectomy in the treatment of lung cancer, especially in the N2 LNs dissection. These findings require validation by high-quality, large-scale randomized controlled trials.

Management of the pulmonary artery during video-assisted thoracoscopic left upper lobectomy

BACKGROUND

Complete video-assisted thoracoscopic surgery (c-VATS) for left upper lobectomy is difficult due to the branching pattern of the left pulmonary artery.

OBJECTIVE

Our purpose was to report outcomes of a modified technique of c-VATS left upper lobectomy.

METHODS

We retrospectively compared the outcomes of 83 patients with stage I/II non-small-cell lung cancer (NSCLC) who received left upper lobectomy between 2008 and 2011; 32 underwent conventional c-VATS and 50 received modified c-VATS. In the modified procedure, the order in which hilum of lung was treated was from the lingular segmental artery to the superior pulmonary vein to the bronchus, and then finally the pulmonary artery.

RESULTS

The mean patient age was 63.6 ± 8.4 years, and no differences were observed in age, gender, and largest tumor diameter between the two groups. No conversion occurred in either group. The surgical time for modified c-VATS was significantly shorter than that for conventional c-VATS (210 vs. 270 min, p < 0.001). Drainage time after surgery and length of hospitalization for the modified c-VATS group were significantly less than those for the conventional group (drainage 3 vs. 4 days, respectively, p = 0.041; length of hospitalization 7 versus 12 days, respectively; p < 0.001). Surgical margins were clear in all cases. Four (8.0 %) complications occurred in the modified procedure group compared with ten (31.3 %) in the conventional group (p = 0.015).

CONCLUSION

This new technique offers shorter surgical and postoperative drainage time, shorter hospital stays, and fewer complications than conventional c-VATS upper left lobectomy.

[A study on quality of life after thoracoscopic assistant lobectomy for lung cancer]

BACKGROUND

Conventional radical surgeries for lung cancer incur a large amount of trauma, thoracoscopic surgeries can reduce trauma, and hopefully improve patients' postoperative quality of life (QOL). The aim of this study is to evaluate the impact of thoracoscopic radical surgeries on quality of life of patients with non-small cell lung cancer (NSCLC).

METHODS

Use Quality of Life-Core 30 Questionnaire (QLQ-C30) which was exploited by European Organization for Research and Treatment (EORTC) and Quality of Life-Lung Cancer 13 Questionnaire (QLQ-LC13) which is the supplementary questionnaire according to the lung cancer patients to evaluate QOL of 60 NSCLC patients in thoracoscopic surgery group and conventional surgery group from 3 days before operation to 24 weeks after operation.

RESULTS

A total of 215 questionnaires were collected from 60 patients; 25 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits. QOL declined markedly in all patients at 3 days postoperatively; preoperative and 3-day postoperative global QOL scores in the conventional surgery and thoracoscopic surgery group were 87.8 ± 10.3 vs 38.3 ± 13.1 (P<0.001) and 82.7 ± 9.6 vs 56.3 ± 14.8 (P<0.001), respectively. Thereafter, QOL recovered gradually in all patients. Patients who underwent open surgery showed the most pronounced decline in QOL; global scores were lower in this group than in the thoracoscopic surgery group (P=0.012,9) at 3 days postoperatively and was not restored to the preoperative level at 24 weeks postoperatively (P=0.012,4). QOL declined less in patients undergoing thoracoscopic surgery, and most indices had recovered to preoperative levels at 24 weeks postoperatively.

CONCLUSIONS

With the advantages of small trauma, faster recovery and higher postoperative QOL, thoracoscopic surgery is a preferable lung cancer surgery.