VATS LOBECTOMY FOR EARLY NSCLC

Video-assisted thoracoscopic (VATS) lobectomy is associated with shorter hospital stay and non-inferior long-term survival in patients with stage 1 non-small-cell lung cancer (NSCLC), compared with open lobectomy, according to findings from the National Cancer Data Base.

"The results are not surprising, supporting previous findings from smaller single- and multi-institution studies using a larger, national database,” Dr. Thomas A. D'Amico from Duke University Medical Center, in Durham, North Carolina, told Reuters Health by email.

VATS improves short-term outcomes, compared with open lobectomy, but this approach has not been uniformly accepted by thoracic surgeons, and its oncologic efficacy has been called into question.

Dr. D'Amico's team evaluated long-term survival and other outcomes after more than 7,000 lobectomies, including 5,566 open lobectomies and 1,548 VATS lobectomies, in patients with clinical T1-2, N0, M0 NSCLC.

During a median follow-up of 52.0 months, estimated five-year survival was 62.5% for the open group and 66.0% for the VATS group (P=0.34), the researchers report in Annals of Surgery, online August 9.

In a propensity-score-matched analysis of 1,464 patient pairs, the open-surgery and VATS groups did not differ significantly in 30-day mortality, 30-day readmission, nodal upstaging rate, or five-year overall survival. The VATS group had a significantly shorter length of hospital stay (by 1 day).

The overall costs of thoracoscopic lobectomy are also lower than open lobectomy (and much lower than robotic lobectomy),” Dr. D’Amico said.

Results were similar in subgroup analyses of patients with no comorbidities and of patients who had 11 or more lymph nodes evaluated.

“The interesting element is that despite all of this evidence regarding advantages, the use of thoracoscopic strategies for early-stage lung cancer remains low, approximately 50% in the U.S. and lower in Europe,” Dr. D’Amico said. “Other studies highlight this practice variation by looking at hospital-to-hospital variation (5% to 90%) and geographic variation.”

“The real limitation is that most patients are not exposed to surgeons with the expertise needed,” he said. “Referring physicians should be aware of the advantages of minimally invasive (thoracoscopic) lobectomy and direct patients to appropriate surgeons and centers.”

Dr. Peter B. Licht, a cardiothoracic surgeon at Odense University Hospital in Denmark, told Reuters Health by email, "VATS is safe in centers with VATS experience/skills, and short-term benefits of VATS (pain, quality of life) are not compromised by long-term survival.”

There has been a lot of debate whether VATS as an approach for early-stage NSCLC lobectomy was ontologically inadequate,” he said. “In the absence of randomized trials with survival as primary endpoint, this study is as good as it gets, and it adds important new information to all the skeptics of VATS.”

Dr. Licht, who was not involved in the study, added, “This study still suffers from selection bias, because we really do not know why the individual surgeon decided to do VATS or open surgery, but I note that VATS was done more in academic centers, and there is a potential problem with external validity: it appears that VATS is safe in the hands of surgeons who do VATS, but we don´t know the outcome if these patients had (had) open surgery by surgeons who have VATS skills and particularly the opposite, if patients had been operated with VATS by surgeons who do not have VATS skills.”

Dr. Zeynep Bilgi, a thoracic surgeon at Kars Harakani State Hospital, in Kars, Turkey, said the “VATS learning curve is not that steep and is actually doable if there are sufficient case numbers. There is a tendency for better results than open surgery if VATS gains more traction and more case numbers.”

“Patient preference is becoming a real driver of change,” said Dr. Bilgi, who also was not involved in the new work. “In Turkey, there is a single-payer system, so nearly all physicians are ‘in network.’ Patients will seek minimally invasive surgery even if it means traveling long distances.

“So, unless the patient has some features making VATS unsafe (tumor with a close margin, maybe needing a sleeve resection, big tumor making intraoperative handling difficult, chest wall invasion, etc.), we will do VATS,” Dr. Bilgi told Reuters Health by email.

SOURCE: http://bit.ly/2g4a7FV

Ann Surg 2017.