Download Is Video-Assisted Thoracoscopic Lobectomy Inferior to Open

Is Video-Assisted Thoracoscopic Lobectomy Inferior
to Open Lobectomy Oncologically?
Douglas J. Mathisen, MD
General Thoracic Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts
D
uring the last 4 decades, slow but steady progress
has been made in the overall survival of patients
with non-small cell lung cancer (NSCLC). Yet even with
all the improvements in care in chemotherapy, radiotherapy, and surgical techniques, the overall survival is
still less than 20%. No treatment should jeopardize this
slow, but real progress. The goal of treatment of cancer
is—number one—to cure cancer.
For related article, see page 943
Every so often, a disruptive technology comes along to
change the way we treat patients. Video-assisted thoracic
surgery (VATS) is such a technology. It is not a new
treatment, but a new technique to achieve removal of
lung-containing cancer. VATS has become increasingly
common and, in many centers, represents more than 50%
of the procedures performed for non-small cell lung
cancer. In my opinion, it has passed the phase I and phase
II trials widely accepted to evaluate new treatments.
Feasibility has been established, and VATS shows
promise. It has proven to be safe and well tolerated. What
are lacking, however, are adequately powered, randomized prospective studies to evaluate VATS as an equivalent cancer operation to open procedures (phase III).
Many single-institution studies claim VATS lobectomy
is equivalent to open procedures by comparing with
historical controls. There are many reasons to question
that assumption. We recognize the pitfalls of relying on
historical data, which have been shown numerous times
for numerous conditions.
VATS lobectomy is not the same operation as an open
operation, as many claim. Unlike open lobectomy, the
sequence of dealing with the fissure is often last and may
compromise removing nodes in the fissure. There is now
the concept of the “fissure-less” lobectomy to reduce air
leaks and, presumably, reduce clearance of nodes as well.
There are inferential data to support fewer nodes being
removed by VATS [1–4]. There is anecdotal communication that VATS may be less able to remove level 7 nodes.
Now, there is an increasing suggestion that upstaging of
N1 and N2 nodes occurs less often with VATS than with
open lobectomy for clinical stage I lung cancer [4–6], with
the concern being that this may lead to undertreatment
Address correspondence to Dr Mathisen, General Thoracic Surgical Unit,
Massachusetts General Hospital, 55 Fruit St, Blake 1570, Boston, MA
02114-2696; e-mail: [email protected].
Ó 2013 by The Society of Thoracic Surgeons
Published by Elsevier Inc
and worse survival in the most favorable group of nonsmall cell lung cancer patients, those with clinical stage I.
The study by Licht and colleagues [6] makes the
most compelling argument to date. It is an all-inclusive,
prospective, collected national database with nearly 100%
follow-up. N0 to N1 and N0 to N2 upstaging occurred in
open vs VATS in, respectively, 13.1% vs 8.1% (p < 0.001)
and in 11.5% vs 3.8% (p < 0.001).
We can no longer ignore the accumulating evidence of
these recent reports that suggest VATS lobectomy is inferior oncologically to open lobectomy for clinical stage I
lung cancer. It is no longer enough to say VATS has less
pain, fewer complications, shorter length of stay, and
returns patients to normal activities more quickly. It must,
at least, have equivalent survival to open lobectomy. We
must not give back the few hard-won percentage points of
survival that have been gained over the last 4 decades.
Our patients deserve to know the truth. If VATS
lobectomy is equivalent and achieves all that it claims in
lower morbidity and quality of life, it should become the
gold standard. If VATS lobectomy does not achieve equal
or superior survival, the patient should know this to make
informed decisions: many may still choose the less invasive approach, but at least they will be informed.
Randomized prospective clinical trials often shed light on
the merits of new procedures or treatments. Our assumptions and biases are put to rest. New information often
comes to light about exact indications and contraindications.
We must not rely on the limitation of single-institution
studies and historical data. This procedure must be
broadly applicable and not the domain of a few experts for it
to become the new gold standard. Most importantly we can’t
be wrong about its efficacy as a cancer operation.
The time has come for a randomized prospective trial
comparing VATS with open lobectomy for clinical stage I
lung cancer.
References
1. Scott WJ, Allen MS, Darling G, et al. Video-assisted thoracic
surgery versus open lobectomy for lung cancer: a secondary
analysis of data from the American College of Surgeons
Oncology Group Z0030 randomized clinical trial. J Thorac
Cardiovas Surg 2010;139:976–83.
2. Scott WJ, Matteotti RS, Egleston BL, Osenji S, Flaherty JF.
A comparison of perioperative outcomes of video-assisted
thoracic surgical (VATS) lobectomy with open thoracotomy
and lobectomy: Results of an analysis using propensity score
based weighting. Ann Surg Innov Res 2010;4:1.
3. Denlinger CE, Fernandez F, Meyers BF, et al. Lymph node
evaluation in video-assisted thoracoscopic lobectomy
Ann Thorac Surg 2013;96:755–6 0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2013.05.011
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EDITORIAL
MATHISEN
IS VATS INFERIOR ONCOLOGICALLY?
versus lobectomy by thoracotomy. Ann Thorac Surg
2010;89:1730–6.
4. Boffa DJ, Kosinski AS, Paul S, Mitchell JD, Onaitis M. Lymph
node evaluation by open or video-assisted approaches in
11,500 anatomic lung cancer resections. Ann Thorac Surg
2012;94:347–53.
5. Merritt R, Hoang CD, Shrager JB. Open lobectomy for early
stage lung carcinoma achieves a superior lymph node
Ann Thorac Surg
2013;96:755–6
dissection compared to thoracoscopic lobectomy. Abstract
presented at The Society of Thoracic Surgeons 49th Annual
Meeting and Exhibition in Los Angeles, California, Jan 26–29,
2013.
6. Licht PB, Jørgensen OD, Ladegaard L, Jakobsen E.
A national study of nodal upstaging after thoracoscopic
versus open lobectomy for clinical stage I lung cancer. Ann
Thorac Surg 2013;96:943–50.