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Eur J Cardiothorac Surg 2003;23:397-402
© 2003 Elsevier Science NL

Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma

^a Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh, Scotland EH3 9YW, UK
^b Department of Anaesthesia, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh, Scotland EH3 9YW, UK

Received 6 November 2002; accepted 3 December 2002.

^* Corresponding author. Tel.: +44-131-536-4185; fax: +44-131-229-0659
e-mail: wsw{at}holyrood.ed.ac.uk

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objectives: Despite advantages regarding pain and muscle function, video-assisted thoracic surgery (VATS) lobectomy is infrequently performed and is particularly controversial in bronchogenic carcinoma. We have, therefore, reviewed our experience with VATS lobectomy for non-small cell lung cancer (NSCLC) in an attempt to define the long-term results of VATS lobectomy in this setting. Methods: Patients were selected for surgery on the basis of clinical Stage I or II disease with routine use of thoracic/upper abdominal CT scanning and cervical mediastinoscopy. VATS resection was performed using the endoscopic hilar dissection technique. All related hilar nodes were cleared and supportative sampling of mediastinal stations beyond the reach of mediastinoscopy was undertaken. Perioperative data were collected prospectively and oncologic outcomes were assessed by 6 monthly census. Results: One hundred and fifty eight patients (mean age 66 years) underwent 159 VATS lobectomies for NSCLC between May 1992 and December 2001. One patient underwent staged bilateral resections. Twenty further procedures were uneventfully converted to open thoracotomy (rate=11.2%). The median operation time was 130 min and median operative blood loss was 60 ml. The median postoperative stay was 6 days. One patient (0.6%) died following VATS resection from acute respiratory distress syndrome (ARDS). Two VATS resection patients died following discharge but within 30 days of surgery. Combined, inpatient and 30-day outpatient mortality was, therefore, 1.8%. The stage distribution for resected lesions was: Stage I, 117; II, 33 and III, 8. Mean follow-up was 38 months (range: 1–107). Tumour recurred in 36 patients presenting as local recurrence in the hilum or mediastinum in nine (25%), metastatic disease in 23 (63.9%) and unknown pattern in four (11.1%). Kaplan–Meier calculated probabilities of freedom from cancer related or associated death at 60 months were Stage I, 77.9%; II, 51.4% and III, 28.6%. Conclusion: VATS lobectomy is a safe procedure which is associated with a low probability for conversion to open thoracotomy. The patterns of cancer recurrence do not suggest inadequate local clearance while the long-term survival data for Stage I NSLC cases is encouraging. We believe that this technique should become the operation of choice for early stage NSCLC.

Key Words: Bronchogenic carcinoma • Video-assisted thoracic surgery • Pulmonary lobectomy • Survival

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Major pulmonary resection using video-assisted thoracic surgery (VATS) techniques was first described some 10 years ago [1–4]. In the early years following the evolution of this approach, several limited series were published detailing excellent short-term results [5–9]. While some groups have continued to pursue VATS lobectomy [10–14], it is clear that interest has spread slowly if at all. Uptake of this procedure in the UK, for example, amounts to approximately 2–3% of all lobectomies performed annually [15] and has been static at this level for several years. This situation is likely to reflect concern regarding the long-term oncological validity of VATS resection for cancer. We have, therefore, reviewed our extended experience with VATS lobectomy for non-small cell bronchogenic carcinoma (NSCLC) using the endoscopic hilar dissection technique in order to determine the perioperative risk, pattern of local recurrence and long-term survival associated with this procedure.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
2.1. Selection
Patients were selected for VATS lobectomy according to a protocol established at the outset of our endoscopic surgery program. This was intended to target clinical Stage I or II bronchogenic carcinoma cases in suitable operative candidates. Non-invasive staging was undertaken using thoracic and upper abdominal CT in order to exclude multiple pulmonary lesions and hepatic or adrenal metastases. Supplementary hepatic ultrasound, bone scintigraphic and brain CT scans were ordered where clinically indicated. All patients underwent routine cervical mediastinoscopy with systematic investigation and biopsy of Station 7 and ipselateral Stations 2 and 4. Controlateral mediastinal stations were biopsied where nodes were identified. Negative mediastinoscopy was a prerequisite for VATS resection. A size criterion of 5 cm was used as the upper limit for VATS resection on the basis that lesions greater than this could not be extracted between the anterior ribs without the use of a mechanical retractor.

Fitness criteria were similar to those used for open resection but, as our confidence in the reduced trauma of a VATS procedure developed, we accepted less fit patients including those with a preoperative ratio of actual vs. predicted FEV1 of 30–35%. Patients with obvious complete obliteration of the pleural cavity on preoperative chest films were excluded.

2.2. Operative technique
Details of the surgical techniques used in this series have been presented elsewhere [16]. In brief, we utilised an endoscopic hilar dissection methodology that was intended to provide an endoscopic analogue to a conventional open dissection lobectomy. The videothoracoscope was introduced through a posterior port approximately 1 cm below and posterior to the tip of the scapula. This provides an excellent view of the thoracic cavity and major fissure that is similar to the aspect presented to the surgeon at a conventional thoracotomy. Thus, the anatomical relationships learned at open surgery are immediately apparent. A 5 cm incision was then created in the lateral submammary area as a utility port for the passage of large instruments and staplers and, ultimately, for extraction of the specimen. If conversion to an open thoracotomy was required, this was effected by linking the posterior videothoracoscope port and the submammary incision. Two inferior ports were created for additional instrument access, which were then utilised at the end of the procedure for apical and basal pleural drains.

The first operative step was to undertake a VATS inspection of the pleural cavity in order to exclude unexpected causes of irresectability and to confirm that the lesion was not more advanced than anticipated. We did not regard moderate adhesions or absent fissures as a contraindication to VATS resection. Having confirmed operability, the pulmonary artery was identified at the base of the major fissure and the sheath of the artery entered. In general, the hilar structures were divided according to the most convenient manner determined at surgery, usually with division of the arteries prior to the vein in order to avoid congestion of the lobe. All hilar level nodes were cleared and the lower mediastinal node stations [8 and 9], together with left stations 5 and 6, were removed in order to supplement the preoperative staging. Finally the upper mediastinal node stations were re-inspected in case obviously suspect nodes had been missed. The resected lobe was placed inside a polythene bag within the chest and then extracted intact via the anterior utility port. All patients were specifically consented for a VATS lobectomy procedure.

2.3. Data acquisition and follow-up
Pre-, peri- and postoperative patient details were entered prospectively into a computer database. A survival and disease status census is carried out every 6 months. This was achieved by clinical assessment, direct enquiry to the patient's general practitioner and review of any inpatient admissions that had occurred during each 6-month interval. If cancer had recurred, we attempted to determine whether the recurrence was locoregional or metastatic. Causes of death were also sought from the general practitioner or relevant hospital unit. By law, a copy of the death certificate of all patients registered in Scotland as having cancer must be lodged with the Scottish National Cancer Registry. In instances where the cause of death details could not otherwise be ascertained, we, therefore, obtained the certificated cause of death from this Registry.

2.4. Data analysis
Patients scheduled to undergo VATS lobectomy from the inception of the endoscopic surgery program in May 1992 until end of December 2001 were selected for analysis. Routine summary statistics were obtained and Kaplan–Meier survival curves were generated using a standard desk top computer package (Statview 5, SAS Institute Inc, USA). Survival calculations were based on freedom from death due to or in the presence of NSCLC. Death from non-cancer related causes, when recurrent disease was not known to be present, were ignored.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
During the period under study, 179 VATS lobectomies for NSCLC were scheduled in 178 patients. Of these, 20 procedures were converted to conventional open thoracotomy for a variety of reasons, predominantly, extent of disease or minor intraoperative bleeding (Table 1), yielding a conversion rate of 11.2%. The majority of these conversions occurred during the early phase of our experience with only four conversions in the past 4 years. There were no inpatient deaths. All converted cases experienced an uneventful postoperative recovery.

Kaplan–Meier calculated probabilities of freedom from cancer related or associated death are shown in Fig. 1 . This analysis generated a probability of survival to 60 months for Stage I cases of 77.9% (95% confidence limits (CL): 68.6–87.2%), Stage II was 51.4% (95% CL: 28–75%) and III was 28.6%, although the numbers in this category were too small for CL estimation.

View larger version (11K): [in this window] [in a new window]   Fig. 1. Survival by stage following VATS lobectomy for NSCLC calculated as freedom from cancer related or associated death. Event times shown as circles (Stages I), squares (Stage II) and triangles (Stages III).

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

This study confirms previous findings regarding the safety of VATS lobectomy [7–14,17]. It is evident that this procedure can be accomplished for early stage lung cancer in most patients – approximately 90% on the basis of our data – and with minimal in hospital mortality and morbidity. Even for those in whom a VATS approach does not ultimately prove possible, there is much to be gained by the preliminary VATS inspection. By this, strategy experience is gained in VATS assessment and it is possible to detect unforeseen causes of inoperability or to demonstrate that a greater level of resection is required than the patient can tolerate. In our experience, routine application of preoperative VATS assessment has reduced our open and shut thoracotomy rate to 1.6% overall in lung cancer cases. A similar beneficial reduction was reported by Roviaro who reduced his exploratory thoracotomy rate to 2.6% [23]. The use of videothoracoscopic assessment to identify a non-resectable situation allows the patient to recover quickly and to proceed in far better condition and more rapidly to alternative treatment by radio or chemotherapy than would be the case following a fruitless thoracotomy. The oncological validity of VATS lobectomy will be principally judged by two outcome measures: the rate of local recurrence within the hilum or mediastinum which might imply inadequate local clearance and long-term survival as compared with open lobectomy.

Our data would suggest a local recurrence rate of approximately 25–30%. Local recurrence is, unfortunately, rarely commented on by VATS authors. Sugi [24], in a limited study of 100 patients with Stage Ia disease randomised to open or VATS resection, observed a composite rate of six locoregional recurrences out of 15 patients with recurrent disease i.e. 40%. Sugi and others [7,14] have commented on equivalence in lymph node harvest. These data, although, limited, are consistent with the patterns of recurrence generally observed in the literature for open resection. Wound implantation appears to be a negligible risk. McKenna and coworkers [13] observed one case in a multi-institution series of 298 NSCLC cases and we are not aware of any other such reports with VATS lobectomy. It must be observed, also, that whereas this outcome would appear to be exceptionally uncommon in VATS resection cases, we have no data at all regarding the probability of this complication for open surgical resection series.

Survival data following VATS lobectomy have been presented by various authors albeit usually with limited follow-up [10,11,14–17]. These reports describe excellent results but at relatively short follow-up intervals. McKenna [13] in his large multi-institutional series recorded a 70%, 4-year Kaplan–Meier survival for Stage I cases and Sugi [24] reported a remarkable 90% absolute 5-year survival for his Stage Ia cases. Our present experience is derived from reasonably extended follow-up and allows relatively firm 95% CL (±9.7%) around the observed 5-year survival for Stage I of 78%. It is of interest that this figure is consistent with our earlier data [17]. In general, our findings support the view that although survival following VATS lobectomy is largely stage-dependent, it may be particularly good for early stage disease. We believe that this is likely to reflect the reduced trauma and lung handling inherent in VATS lobectomy performed using the endoscopic hilar dissection technique. It could be argued that this series may contain an element of selection bias, but we would suggest that there are few Stage I lesions, which are not suitable for lobectomy. The only Stage I NSCLC cases which would be excluded by our selection criteria are central Stage I lesions. These are extremely uncommon in our experience and would anyway require pneumonectomy or sleeve resection rather than a lobectomy. Ultimately, only a randomised prospective study comparing open and VATS lobectomy will resolve the question of comparative survival and a multi-institution study of this type is planned to commence in 2003.

The currently available evidence suggests that VATS lobectomy for clinical Stage I and II NSCLC is a technically safe procedure which is associated with long-term survival and recurrence outcomes that are at least equivalent to those provided by open thoracotomy. We, therefore, conclude that VATS lobectomy should be the treatment of choice for early stage lung cancer.

	Footnotes

 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr O. Kshivets (Siauliai, Lithuania): What is the ratio between central and peripheral lung cancer?

Dr Walker: The strategy is aimed at patients with peripheral lung cancer. That is a valid observation.

Dr I. Poliakov (Krasnodar, Russia): I wanted to ask you one question. How many surgeries do you perform per year now, 2 years ago, 5 years ago, and 10 years ago? It means how intensively do you apply this technique, VATS lobectomy, compared with open surgery?

Dr Walker: It probably accounts for about 30% of our lobectomies in our unit. My previous senior colleague has retired, so I now have access to more cases, and that helps.

Prof A. Yim (Hong Kong, China): My question to you is, have you compared VATS with open surgery (perhaps in a historical group) on survival and recurrence?

Dr Walker: The short answer to that is no, and I'm not sure whether it would be helpful in our case, because we took the decision to go to fairly extensive preoperative staging at the time of the VATS program. Prior to that our use of mediastinoscopy had been occasional rather than systematic, so I'm not sure they would be comparable groups.

Dr T. Szoke (Szeged, Hungary): I have two questions. First, at open lobectomies do you perform lymphadenectomy or extended sampling or sampling? Second, did you have any control group from patients operated by open thoracotomy?

Dr Walker: I missed the second point.

Dr Szoke: Did you have any control group from the patients who were operated via thoracotomy?

Dr Walker: We didn't have any control group. We are in the process of trying to organize a multi-institutional randomized study, and that has now received ethical approval. I hope we'll start in the spring of next year. As regards lymphadenectomy, the open cases are dealt with in exactly the same manner. We have not made any difference in our approach.

Dr D. Wood (Seattle, Washington): I question your conclusion. Your data certainly show that you are able to accomplish VATS lobectomy in a safe fashion. I am not sure that that makes it the procedure of choice. You did not show us any evidence that it was superior to an open lobectomy. I urge caution in interpreting the results based upon selection bias. You have two potential types of selection bias. One is a cohort selection bias. As Mark Ferguson just showed in his paper, there was a difference in the outcomes in a historical cohort and a more modern cohort in terms of accuracy of staging and more sophisticated operative and postoperative care. That will favor better outcomes in the more recent patient series. There is also the patient selection bias of selecting patients with more central tumors for open lobectomy and patients with more favorable peripheral stage I cancers for VATS lobectomy. That will also skew your results to favor VATS. I am very happy to hear that you are organizing a prospective randomized trial, both to verify your results, as well as to emphasize what the benefits are of VATS lobectomy.

Dr Walker: I take those points entirely. I think our position is not to say that VATS lobectomy is better than an open lobectomy from an oncological perspective, merely that, as far as we can judge, it doesn't disadvantage the patient, and given the other benefits, we would therefore wish to promote this form of surgery.

Dr R. Stanbridge (London, England): Can I just ask a quick question here about the training for doing VATS lobectomy. For two or three years now I have been doing lobectomies through minithoracotomy holes with a camera to visualise but mostly by direct vision, and I have converted recently to doing them entirely closed VATS, but it is quite a step to go from seeing something to doing it entirely on the camera around major vessels, and I wondered whether you feel that the training program should go through a mini hole first - by direct vision, or whether you should just go straight on to it. How do you feel you should train people?

Dr Walker: I have two registrars in the room, both of whom have been doing some of these cases. I think it's just something that one is as well to go straight to. I have to say my own knowledge of pulmonary anatomy improved enormously with the VATS program, because I don't think I ever really looked at the anatomy of the lung in quite the same way at the time of an open operation. But I agree that there is a learning curve and it takes a while to climb up it.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion Appendix A. Conference... References

 

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