An increase in the stage of non–small cell lung cancer (NSCLC) due to cancer-positive lymph node discovery was more common following open chest surgery for lung lobe removal of early-stage lung cancer compared to the closed-chest procedure known as video-assisted thoracic surgery (VATS).
The standard and often most effective treatment for early-stage lung cancer is surgical removal of the tumor and a portion of the lung, with open thoracotomy the traditional method of choice. Thoracotomies do pose some risk, especially in patients with other health problems. VATS is a less invasive approach that has fewer complications, less pain, improved lung function, shorter recovery periods, and lower acute care costs. However, incomplete lymph node staging by VATS could compromise survival by leaving residual cancer and altering optimal postsurgical treatment because of inaccurate understaging.
The National Cancer Data Base was examined for NSCLC patients who underwent lobectomy between 2010 and 2011 for tumors < 7 cm and no apparent lymph node involvement prior to surgery. Statistical analyses were performed to compare nodal upstaging in VATS vs open thoracotomies and to determine if there were differences depending on surgical center.
The results published by Medbery et al in the Journal of Thoracic Oncology1 show a total of 16,983 lobectomies were performed, 29.1% using VATS. Of all 4,935 VATS, 4.9% were performed at community centers, 50% at comprehensive community cancer programs, and 45.1% at academic or research centers. Upstaging because of the discovery of cancer in lymph nodes during surgery was more frequent in the open vs closed group (12.8% vs 10.3%; P < .001), even though a greater number of lymph nodes (≥9 LNs, 43.7% vs 38.8%; P < .001) were sampled using VATS. The open approach resulted in longer length of hospital stay (mean, 7.4 vs 6.1 days, P < .001), and a higher 30-day mortality rate (2.1% vs 1.3%; P < .001), whereas VATS was more likely to lead to an unplanned 30-day readmission (6.9% vs 5.9%; P = .014).
The authors suggest that, “nodal upstaging appears to be affected by facility type, which may represent a surrogate for expertise in minimally invasive surgical procedures.” The authors note, “Standardized quality assurance of lymph node staging during VATS lobectomy is needed to achieve the goal of eliminating differences in staging, and there needs to be an analysis of differences in long-term survival rates between VATS and open thoracotomy for lobectomy to ensure that minimally invasive approaches provide tumor control equivalent to that provided by open approaches.” ■
1. Medbery R, et al: J Thorac Oncol. January 11, 2016 (early release online).