Is minimally invasive lobectomy as effective as open lobectomy for treatment of operable stage I NSCLC?

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Is minimally invasive lobectomy as effective as open lobectomy for treatment of operable stage I NSCLC?

Introduction

Minimally invasive lobectomy is performed with the intention of achieving the same oncological outcomes as traditional lobectomy by thoracotomy, but with lesser impact in terms of pain, cosmesis, morbidity and post-operative recovery. The definition of minimally invasive lobectomy is somewhat broad, with variations in the size of the utility incision, use of rib-spreading, hilar dissection and node dissection. For the purpose of this guideline, minimally invasive (also known as Video-Assisted Thoracic Surgery, VATS or Thoracoscopic) lobectomy consists of a non-spreading utility incision, three to four instrument ports and dissection of individual hilar structures (viz. bronchus, artery, vein).

There has only been a single small pseudo-randomised controlled trial (randomised by ID number) showing equivalence in long term oncological outcomes with minimally invasive lobectomy[1]. The remaining long term survival evidence comes from systematic reviews of VATS lobectomy based on case-matched and propensity scored series. Relative risks for death within five years are either equivalent, or in the range of 0.45-0.97 with median relative risk in the range of 0.66-0.72 in favour of minimally invasive lobectomy.[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]

Evidence from a further small randomised controlled trial[25] and the above systematic reviews and propensity-scored analyses demonstrate a benefit for minimally invasive lobectomy with respect to overall complications and pulmonary complications. There appears to be a reduced risk of atrial fibrillation with minimally invasive lobectomy, but this evidence is derived only from propensity-scored and retrospective cohort studies.

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Evidence summary and recommendations

Long term survival after minimally invasive lobectomy for operable stage I NSCLC

Evidence summary Level References
Minimally invasive lobectomy is at least as effective as open lobectomy with respect to long term survival.

Last reviewed December 2015

III-1, III-2 [1], [2], [3], [4], [5]
Minimally invasive lobectomy may be superior to open lobectomy with respect to reported post-operative complication rates.

Last reviewed December 2015

II, III-2 [2], [4], [5], [25]
Evidence-based recommendationQuestion mark transparent.png Grade
Minimally invasive lobectomy is at least as effective as open lobectomy with respect to long term survival and reported post-operative complication rates.

Last reviewed December 2015

B


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References

  1. 1.0 1.1 Sugi K, Kaneda Y, Esato K. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg 2000 Jan;24(1):27-30; discussion 30-1 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10594199.
  2. 2.0 2.1 2.2 Cheng D, Downey R, Kernstine K, Stanbridge R,, et al. Video-Assisted Thoracic Surgery in Lung Cancer Resection. A Meta-Analysis and Systematic Review of Controlled Trials. 2(6):261-292. 2017 Nov 20.
  3. 3.0 3.1 Flores RM, Alam N. Video-assisted thoracic surgery lobectomy (VATS), open thoracotomy, and the robot for lung cancer. Ann Thorac Surg 2008 Feb;85(2):S710-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/18222202.
  4. 4.0 4.1 4.2 Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010 Feb;139(2):366-78 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20106398.
  5. 5.0 5.1 5.2 Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol 2009 May 20;27(15):2553-62 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19289625.
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  8. Cao C, Zhu ZH, Yan TD, Wang Q, Jiang G, Liu L, et al. Video-assisted thoracic surgery versus open thoracotomy for non-small-cell lung cancer: a propensity score analysis based on a multi-institutional registry. Eur J Cardiothorac Surg 2013 Nov;44(5):849-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23956268.
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  12. Jeon JH, Kang CH, Kim HS, Seong YW, Park IK, Kim YT, et al. Video-assisted thoracoscopic lobectomy in non-small-cell lung cancer patients with chronic obstructive pulmonary disease is associated with lower pulmonary complications than open lobectomy: a propensity score-matched analysis. Eur J Cardiothorac Surg 2013 Sep 26 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24052605.
  13. Kim SH, Kim HK, Choi YS, Kim K, Kim J, Shim YM. Pleural recurrence and long-term survival after thoracotomy and thoracoscopic lobectomy. Ann Thorac Surg 2013 Nov;96(5):1769-75 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23968762.
  14. Kuritzky AM, Aswad BI, Jones RN, Ng T. Lobectomy by Video-Assisted Thoracic Surgery vs Muscle-Sparing Thoracotomy for Stage I Lung Cancer: A Critical Evaluation of Short- and Long-Term Outcomes. J Am Coll Surg 2015 Jun;220(6):1044-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25868407.
  15. Lee PC, Nasar A, Port JL, Paul S, Stiles B, Chiu YL, et al. Long-term survival after lobectomy for non-small cell lung cancer by video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2013 Sep;96(3):951-60; discussion 960-1 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23866808.
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  17. Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ 2014 Oct 2;349:g5575 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25277994.
  18. Smith CB, Kale M, Mhango G, Neugut AI, Hershman DL, Mandeli JP, et al. Comparative outcomes of elderly stage I lung cancer patients treated with segmentectomy via video-assisted thoracoscopic surgery versus open resection. J Thorac Oncol 2014 Mar;9(3):383-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24495998.
  19. Stephens N, Rice D, Correa A, Hoffstetter W, Mehran R, Roth J, et al. Thoracoscopic lobectomy is associated with improved short-term and equivalent oncological outcomes compared with open lobectomy for clinical Stage I non-small-cell lung cancer: a propensity-matched analysis of 963 cases. Eur J Cardiothorac Surg 2014 Mar 5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24603446.
  20. Su S, Scott WJ, Allen MS, Darling GE, Decker PA, McKenna RJ, et al. Patterns of survival and recurrence after surgical treatment of early stage non-small cell lung carcinoma in the ACOSOG Z0030 (ALLIANCE) trial. J Thorac Cardiovasc Surg 2013 Nov 26 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24290575.
  21. Taioli E, Lee DS, Lesser M, Flores R. Long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis. Eur J Cardiothorac Surg 2013 Feb 14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23413015.
  22. Zhang L, Ren Y, Liu Y. Comparison of the Effects of Lobectomy on Immunologic Function Between Video-Assisted Thoracoscopic Surgery and Traditional Open Surgery for Non-Small-Cell Lung Cancer. Am J Ther 2015 Apr 23 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25909924.
  23. Zhang LB, Wang B, Wang XY, Zhang L. Influence of video-assisted thoracoscopic lobectomy on immunological functions in non-small cell lung cancer patients. Med Oncol 2015 Jul;32(7):639 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26081016.
  24. Zhang Z, Zhang Y, Feng H, Yao Z, Teng J, Wei D, et al. Is video-assisted thoracic surgery lobectomy better than thoracotomy for early-stage non-small-cell lung cancer? A systematic review and meta-analysis. Eur J Cardiothorac Surg 2013 Jan 30 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23371973.
  25. 25.0 25.1 Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy--video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995 May;109(5):997-1001; discussion 1001-2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7739262.

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Appendices

Further resources

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