Thoracotomy versus VATS: short term outcomes from a large randomized controlled trial

In the February 2018 issue of Annals of Thoracic Surgery, the results of the “Thoracoscopic Surgery Versus Thoracotomy For Lung Cancer: Short Term Outcomes Of A Randomized Trial” by Hao Long et al. were published (1). The aim of this non-inferiority, phase 3, multicenter randomized controlled trial both for short-term and oncologic outcome, was “to confirm that VATS lobectomy is non-inferior to open surgery for the treatment of early-stage NSCLC”. The results of this study merit the attention of thoracic surgeons for several reasons.

First of all, the results of this study, which recruited 508 patients between 2008 and 2014 from five leading thoracic referral centers in China, reported a statistically significant difference between the VATS and open groups in terms of intraoperative bleeding and duration of operation. None of the other considered parameters reached statistical significance: type of pulmonary resection, completeness of resection, modality of lymphadenectomy, duration of chest drainage, total volume of chest drainage, length of hospitalization, postoperative complications. The analysis of these operation-related variables and morbidity within 28 days was executed both including and excluding eight VATS procedures (3.72%) intraoperatively converted to open surgery, without any substantial change of the results. The primary end points for the trial were 5-year overall and disease-free survival, whereas the short-term secondary end points on perioperative outcomes were: death (28 days), morbidity (28 days), operation time, intraoperative blood loss, duration and volume of chest drainage, length of stay, completeness of operation and yield of lymph nodes. This study focused on perioperative outcomes, since long-term efficacy will be addressed in future articles by the authors. The study enrolled patients aged from 18 to 75 years with clinical stage I–II NSCLCs surgically treated with radical lobectomy and mediastinal lymph node dissection. The number of ports for the VATS approach was not defined, but they were generally three or four; whereas patients in the control group underwent a muscle-sparing rib-spreading axillary thoracotomy.

In the present study, no differences were found between the two groups in terms of the observed incidence of macroscopic incomplete resections, surgical margins and mediastinal lymph node dissections. The authors also reported similar pathological upstaging, with incidental stage III disease for the two studied groups. Perioperative variables were also analyzed: mean operative time was statistically lower in the VATS lobectomy than in the thoracotomy group (P=0.009), intraoperative blood loss was significantly reduced with VATS rather than with thoracotomy (P=0.001). No statistically significant differences were recorded in terms of duration of chest tube drainage, postoperative complications and length of hospital stay.

However, we have to take into account that neither PET-CT nor invasive diagnostic procedures were carried on mediastinal lymph nodes and this could have led to bias in the patients selection, disease staging and therein in the final affirmations of the paper (2,3). Nonetheless, the study results suggest, as had past studies, that VATS lobectomy is superior, or at least non-inferior, to open lobectomy for the treatment of early stages NSCLC, both for postoperative and oncological outcomes (4-6). In light of this, in 2013, the American College of Chest Physicians suggested that a minimally invasive approach should be preferred to the open one for anatomic pulmonary resection in clinical stage I NSCLC (7). This recommendation for the most part, was based on retrospective observational study results (4,8-11) and only three RCTs (12-14).

After this recommendation, in 2016, Bendixen et al. reported on a RCT study with the aim of “investigating postoperative pain and the quality of life” (15). Their results stated that “VATS is associated with less postoperative pain and better quality of life than anterolateral thoracotomy for the first year after surgery”; suggesting that VATS should again be the preferred surgical approach for lobectomy in stage I NSCLC. Moreover, the authors reported shorter duration of epidural analgesia, less perioperative blood loss and shorter length of stay, for the VATS group, compared to the thoracotomy group.

This first ever large RCT, published in 2018, is important, in that it further supports the 2013 decision of the American College of Chest Physicians to recommend a minimally invasive approach over open thoracotomy for anatomic pulmonary resection in clinical stage I NSCLC. Additionally, it allows surgeons to have a more confident guide in this setting. Moreover, the long-term follow-up data on these patients regarding postoperative pain, acute inflammatory reaction, respiratory function and quality of life is due by the end of 2019 and it is expected that these results will further bolster the use of VATS. Consequently, the mini-invasive approach would be further adopted worldwide therein necessitating changes in the education of health care professionals and the organization of hospital management. In fact, as seen in the past with a greater use of VATS, the costs associated with treating clinical stage I NSCLC would most likely decline in tandem with the expected higher detection rates for early lung cancer in the near future (16).

In conclusion, this RCT, comparing VATS and open lobectomy, provides further evidence that VATS lobectomy seems to be a safe and reliable procedure for the treatment of clinically early stage NSCLC.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Section Editor Dr. Federico Raveglia (Department of Thoracic Surgery, ASST-Santi Paolo e Carlo, University of Milan Medical School, Milan, Italy).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/vats.2018.05.02). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Long H, Tan Q, Luo Q, et al. Thoracoscopic Surgery Versus Thoracotomy for Lung Cancer: Short-Term Outcomes of a Randomized Trial. Ann Thorac Surg 2018;105:386-92. [Crossref] [PubMed]
2. Licht PB, Jørgensen OD, Ladegaard L, et al. A national study of nodal upstaging after thoracoscopic versus open lobectomy for clinical stage I lung cancer. Ann Thorac Surg 2013;96:943-9; discussion 949-50. [Crossref] [PubMed]
3. Palade E, Passlick B, Osei-Agyemang T, et al. Palade Video-assisted vs open mediastinal lymphadenectomy for Stage I non-small-cell lung cancer: results of a prospective randomized trial. Eur J Cardiothorac Surg 2013;44:244-9; discussion 249. [Crossref] [PubMed]
4. Yan TD, Black D, Bannon PG, et al. 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;27:2553-62. [Crossref] [PubMed]
5. Li Z, Liu H, Li L. Video-assisted thoracoscopic surgery versus open lobectomy for stage I lung cancer: A meta-analysis of long-term outcomes. Exp Ther Med 2012;3:886-92. [Crossref] [PubMed]
6. Zhang Z, Zhang Y, Feng H, 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;44:407-14. [Crossref] [PubMed]
7. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e278S-313S.
8. Cheng D, Downey RJ, Kernstine K, et al. Video-assisted thoracic surgery in lung cancer resection: a meta-analysis and systematic review of controlled trials. Innovations (Phila) 2007;2:261-92. [Crossref] [PubMed]
9. Detterbeck F. Thoracoscopic versus open lobectomy debate: the pro argument. Thorac Surg Sci 2009;6:Doc04. [PubMed]
10. West D, Rashid S, Dunning J. Does video-assisted thoracoscopic lobectomy produce equal cancer clearance compared to open lobectomy for non-small cell carcinoma of the lung? Interact Cardiovasc Thorac Surg 2007;6:110-6. [Crossref] [PubMed]
11. Whitson BA, Groth SS, Duval SJ, e al. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg 2008;86:2008-16; discussion 2016-8.
12. Craig SR, Leaver HA, Yap PL, et al. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg 2001;20:455-63. [Crossref] [PubMed]
13. Kirby TJ, Mack MJ, Landreneau RJ, et al. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995;109:997-1001; discussion 1001-2. [Crossref] [PubMed]
14. 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;24:27-30; discussion 30-1. [Crossref] [PubMed]
15. Bendixen M, Jørgensen OD, Kronborg C, et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016;17:836-44. [Crossref] [PubMed]
16. Vannucci F, Gonzalez-Rivas D. Is VATS lobectomy standard of care for operable non-small cell lung cancer? Lung Cancer 2016;100:114-9. [Crossref] [PubMed]