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Ann Thorac Surg 2007;83:1245-1250
© 2007 The Society of Thoracic Surgeons
Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
Accepted for publication December 18, 2006.
* Address correspondence to Dr D’Amico, Duke University Medical Center, Box 3496, Duke South Room 3589, Durham, NC 27710 (Email: damic001{at}mc.duke.edu).
Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.
| General thoracic surgery:
The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.
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Abstract |
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Methods: We reviewed the outcomes of 100 consecutive patients with non-small cell lung cancer (NSCLC) who underwent lobectomy and received adjuvant chemotherapy (1999 to 2004). The variables analyzed were time to initiation of chemotherapy, percentage of planned regimen received, number of delayed or reduced chemotherapy doses, toxicity grade, length of hospitalization, chest tube duration, 30-day mortality, and major complications (pneumonia, respiratory failure, atrial fibrillation). The 
2 test and Student t test were used to compare dichotomous and continuous variables, respectively.
Results: Complete resection was performed by thoracotomy in 43 patients and by thoracoscopy in 57 (no conversions). All patients received adjuvant chemotherapy, and 20 (20%) received adjuvant radiation therapy: 13 (30%) of 43 in the thoracotomy group and 7 (12%) of 57 in the thoracoscopy group (p = 0.04). Patients undergoing thoracoscopic lobectomy had significantly fewer delayed (18% versus 58%, p < 0.001) and reduced (26% versus 49%, p = 0.02) chemotherapy doses. A higher percentage of patients undergoing thoracoscopic resection received 75% or more of their planned adjuvant regimen without delayed or reduced doses (61% versus 40%, p = 0.03). There were no significant differences in time to initiation of chemotherapy or toxicity. Patients undergoing a thoracoscopic lobectomy had a shorter median length of hospitalization (4 days versus 5 days, p = 0.02).
Conclusions: Thoracoscopy was associated with an overall higher compliance rate and fewer delayed or reduced doses of chemotherapy in patients receiving adjuvant chemotherapy.
Thoracoscopic lobectomy has been successfully performed worldwide for more than a decade and is currently an accepted oncologic approach for patients with non-small cell lung cancer (NSCLC). Single and multiinstitutional studies have demonstrated that thoracoscopic lobectomy is not only a safe and feasible technique but is also associated with several advantages compared with conventional thoracotomy, including shorter length of hospitalization and chest tube duration, decreased postoperative pain, improved preservation of pulmonary function, reduced inflammatory response as measured by lower postoperative cytokine levels, and fewer overall complications [1–11]. This strategy has been found to be particularly useful for specific subsets of patients such as elderly individuals and those with poor performance status [2, 5, 12, 13].
The results of four prospective randomized trials have demonstrated that adjuvant therapy improves the survival of patients with NSCLC after complete resection [14–17]. Although previous studies of adjuvant therapy for early stage NSCLC failed to demonstrate improved survival after complete resection, a closer analysis of the recent studies may explain this advantage. For example, in Cancer and Leukemia Group B protocol 9633 (CALGB 9633), all four cycles were delivered in 85% of patients, and 55% received all four cycles at full dose [15]. In addition, the chemotherapy was well-tolerated: no toxicity-related deaths occurred, and grade 3 to 4 neutropenia, the most significant toxicity, was observed in only 36% of patients [15]. Thus, it is possible that improved delivery of chemotherapy after complete resection for NSCLC will result in improved outcomes. The purpose of this study was to determine if thoracoscopic lobectomy enables more effective administration of adjuvant chemotherapy compared with lobectomy by thoracotomy.
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Patients and Methods |
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The choice of postoperative therapy was determined by the availability of adjuvant therapy protocols and physician preference. Decisions about dose reduction or dose delay were made by the treating medical oncologist at the time of the scheduled dose using objective criteria (including white blood cell count, absolute neutrophil count, serum creatinine, gastrointestinal symptoms, and neurologic symptoms) and subjective criteria (performance status). Radiation therapy was given sequentially after chemotherapy in selected patients.
Lobectomy was performed by thoracoscopy in 57 patients and by conventional thoracotomy in 43 patients. Patients considered appropriate for the thoracoscopic approach included those with tumors smaller than 6 cm in diameter and without evidence of chest wall or central airway involvement on preoperative imaging.
Overall survival and cancer-free survival data were available on all patients. Median follow-up was 19 months for the thoracoscopy group and 17 months for the thoracotomy group. Baseline and outcome variables collected included demographics, comorbidities, tobacco use, pulmonary function, histology, pathologic stage, conversion rate, complete resection rate, chest tube duration, length of hospitalization, postoperative hemorrhage requiring reoperation, pneumonia, respiratory failure, other major complications, and adjuvant therapy compliance.
The specific outcome variables of interest were time interval to initiation of adjuvant chemotherapy after resection, total percentage of planned regimen received, percentage of patients who received 75% or more of the full regimen without delayed or reduced doses of chemotherapy, number of delayed and reduced chemotherapy doses, and a toxicity grade of 3 or more.
Staging and Surgical Technique
All patients were evaluated with computed tomography (CT) of the chest and upper abdomen. Most were staged with positron emission tomography (PET) and cervical mediastinoscopy before resection. Indications for PET and mediastinoscopy included any of the following: T2 status, suspicion of N1 or N2 disease on CT, or clinical findings that suggested advanced disease.
In this series, all patients underwent lobectomy and mediastinal lymph node dissection; no extended resections were included. Conventional lobectomy was performed without routine sectioning of a rib, and the serratus anterior muscle was spared in all patients. Mediastinal lymph node dissection at thoracotomy and thoracoscopy included the dissection of all hilar lymph nodes and at least three ipsilateral mediastinal lymph node stations.
Thoracoscopic lobectomy was performed as previously described [1, 6, 18, 19]. Briefly, two incisions were used in most patients in this series. The thoracoscope is placed in the seventh or eighth intercostal space in the mid-axillary line, and an anterior utility incision is placed in the fifth intercostal space anteriorly (4 to 5 cm). This provides access for complete hilar and mediastinal dissection. Rib-spreading and retractor use was avoided in all patients. Preoperatively, the established indication for conversion to thoracotomy was an intraoperative finding or the occurrence of an intraoperative event that the surgeon deemed would be managed more effectively with a thoracotomy.
Statistical Analysis
Baseline characteristics and outcomes were compared between the thoracoscopy and thoracotomy groups. Categoric variables were compared using the Pearson 2 test, the Fisher exact test, and R x C contingency tables when appropriate. Continuous variables were compared using the Student t test and Mann-Whitney test when appropriate. Statistical significance was defined as a value of p < 0.05. All statistical analyses were performed using Stata Intercool 8.0 software (StataCorp LP, College Station, TX).
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No significant differences were noted in baseline demographics, including age, sex, tobacco use, medical comorbidities, and preoperative pulmonary function (Table 2). The thorascopic group had a higher percentage of patients who had adenocarcinoma, and the thoracotomy group had a higher percentage of squamous cell carcinomas and other histology types. Also, patients in the thoracotomy group were more likely to have higher stage disease (Table 3).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentDiscussionReferences |
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Historically, randomized trials of adjuvant chemotherapy for completely resected NSCLC failed to demonstrate a consistent benefit. Early trials suffered from poor design, suboptimal compliance, and inactive drug regimens. Four recent studies, however, have demonstrated improved outcomes with adjuvant therapy [14–17], which is now the standard of care for selected patients with completely resected NSCLC [23].
In addition to the improvement in the design of the recent trials, one explanation for the survival benefit in these trials is improved chemotherapy compliance. It has been demonstrated that the ability to administer complete regimens of adjuvant chemotherapy is associated with improved survival outcomes [24, 25], and the recent adjuvant chemotherapy trials reported higher chemotherapy compliance compared with previous studies. For example, in CALGB 9633, all four cycles of adjuvant chemotherapy were delivered in 85% of patients, and 55% of patients received all four cycles at the full dose [15]. In another study, a median number of three cycles was delivered, and 58% of the patients received three or more cycles of cisplatin [16].
If improved compliance with adjuvant chemotherapy is associated with improved outcomes, technical aspects of surgical resection that improve the delivery of chemotherapy may also be associated with improved outcomes. This study analyzed the delivery of adjuvant chemotherapy after 100 lobectomies for NSCLC, comparing 57 patients who underwent thoracoscopic lobectomy with 43 those who underwent lobectomy by conventional thoracotomy. Chemotherapy regimens included platinum in most patients in both groups, and the doublet regimens were similar as well. There was no difference in the time from surgery to the initiation of therapy. Of note, the medical oncologists involved in this study did not routinely evaluate patients for adjuvant therapy until approximately 6 weeks postoperatively, although there may have been patients in both groups who would have been eligible to initiate therapy earlier.
For those who underwent thoracoscopic lobectomy, the procedure resulted in a significant advantage in the number of patients with delayed chemotherapy doses and in the number of patients who received doses that were reduced owing to toxicity-related issues. In addition, 61% of patients who underwent thoracoscopic lobectomy completed at least 75% of the planned regimen compared with only 40% of those who underwent thoracotomy (p = 0.03).
Other factors may explain the difference in chemotherapy delivery in the two groups. Among the thoracotomy lobectomy patients, significantly fewer patients had stage I NSCLC compared with the thoracoscopic lobectomy group (Table 3). When chemotherapy delivery was analyzed according to stage, however, no difference was found in chemotherapy delivery for patients with stage I NSCLC compared with patients with stage II disease or greater.
A greater percentage of patients in the thoracotomy group also received adjuvant radiation therapy, predominately for N1 disease (Table 1). Of note, the adjuvant radiation therapy was given in accordance with National Comprehensive Cancer Network guidelines [23] and was delivered sequentially after chemotherapy rather than concurrently. Currently, on the basis of recent data, adjuvant radiation therapy is not used in these patients [26]. When chemotherapy delivery was analyzed according to the use of adjuvant radiation therapy, no difference was detected (Table 7). It is also possible that this analysis does not account for biases among treating medical oncologists.
The delivery of adjuvant chemotherapy depends on numerous variables, including those that are patient-related, treatment-related, and surgery-related. This study was a retrospective analysis of a series of 100 consecutive patients who underwent lobectomy for NSCLC, followed by adjuvant chemotherapy, which was designed to demonstrate whether the use of thoracoscopic lobectomy was associated with an improvement in chemotherapy delivery.
Because of the relatively small size of the study, the actual contribution of all possible variables cannot be determined; however, it appears that the most powerful variable associated with chemotherapy delivery is the use of thoracoscopic lobectomy. Larger prospective studies would be required to ascertain the effect of pathologic stage and use of radiation therapy. Furthermore, future trials might also take into account the possibility of starting chemotherapy earlier after thoracoscopic lobectomy, which may also improve outcomes [27]. Eventually, the use of adjuvant chemotherapy will be compared with induction therapy for patients with resectable lung cancer. These studies should take into account the improved delivery of postoperative chemotherapy associated with thoracoscopic lobectomy.
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Discussion |
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Lastly, you demonstrated a significantly reduced median chest tube duration and hospital days with your thoracoscopic lobectomy group compared to open thoracotomy in your study. In a recent report by Allen and colleagues of the morbidity and mortality of over 1000 patients as part of the ACOSOG Z-30 trial, the median chest tube duration was 5 days and hospitalization was 6 days, significantly greater than your open thoracotomy group. Do you feel the introduction of thoracoscopic lobectomy in your practice has changed your approach to an open thoracotomy and lobectomy and thus reduced your chest tube duration and hospitalization in your open patients?
DR PETERSEN: Thank you, Dr Howington, for your thoughtful questions. In regard to your first question where you asked if we specifically compared the stage I-only patients to the stage III patients, we did not, and this is largely due to the fact that we had a smaller sample size that did not allow for additional subset analyses. I think more appropriately in a larger prospective study, a logistic regression analysis would be helpful in controlling for confounding factors, not only stage but radiation therapy, performance status, pulmonary function, etcetera. We did, however, dichotomize by stage I versus stage II or higher and did not find an association with the parameters of chemotherapy compliance.
In regard to your question as to what are the indications for radiation therapy and whether it was administered concurrently or consecutively, there were 20 patients out of the 100 patients who received adjuvant radiation therapy, and the main indications were close margins, presence of bulky N1 disease or microscopic N2 disease. The radiation therapy was administered sequentially.
In regard to your third question where you mentioned the ACOSOG trial having a longer chest tube duration and hospitalization for the thoracotomy patients as compared to patients undergoing thoracotomy in our study, I do believe that our practice of performing the majority of lobectomies by thoracoscopy has led us to be more aggressive in discontinuing chest tubes and discharging our thoracotomy patients home earlier.
DR DANIEL L. MILLER (Atlanta, GA): I enjoyed your talk. In your patients that were found to have N2 disease at the time of VATS lobectomy, did you do any type of a flap procedure to protect the bronchial stump from a potential BPF if adjuvant radiotherapy was going to be used postoperatively? The majority of time when we do an open lobectomy and find N2 disease at the time of resection we place a tissue flap over the bronchial stump to prevent a BPF that could develop if postoperative radiation therapy is used. If so what tissue flap was used thoracoscopically?
DR PETERSEN: None of the patients in this study received any additional procedures, including muscle flap coverage of bronchial stumps, beyond an anatomic lobectomy. We do not have extensive experience at Duke performing muscle flap coverage of bronchial stumps via thoracoscopy.
DR ROBERT J. CERFOLIO (Birmingham, AL): A quick comment and perhaps out of order, but I rise to lambaste my good friend and colleague, Dr Dan Miller, to ask him that when he finds N2 disease at a VATS lobectomy, why don’t you stop and give the patient neoadjuvant therapy? Why should the method of the N2 detection change the management of the disease—if you find N2 on a med, don’t you give neoadjuvant therapy—and if so then why is the patient’s cancer treatment different just because of how you discovered N2?
DR MILLER: I haven’t found N2 disease at the time of VATS lobectomy yet. I have only done 225. Tommy has done over 500. Twenty percent of these patients had VATS, so that is the big question.
DR RODNEY LANDRENEAU (Pittsburgh, PA): I think the biggest issue that I see from your data is that you have reduced the hospital stay, potentially reflective of reduced morbidity associated with these approaches, and therefore these patients can have their chemotherapy with less morbidity, or with less problems associated with the recovery from their surgery as impacting their ability to have chemo.
But I think the stage differences is another issue that needs to be determined. That really concerns me about the differences in stage between the groups, and therefore, again, all your conclusions about limitations I think are important ones and I think a big issue here with regard to this analysis. What are your thoughts on that?
DR PETERSEN: We agree with you. We realize that stage, and specifically radiation therapy, are both very important potential confounding factors, as are many other variables that we cannot necessarily control for due to small sample size. However, as mentioned previously, we did perform statistical comparisons between stage I versus stage II or higher in regards to chemotherapy compliance and found no significant association. We also found no significant association between radiation therapy and chemotherapy compliance as well.
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J. P. Shaw, F. R. Dembitzer, J. P. Wisnivesky, V. R. Litle, T. S. Weiser, J. Yun, C. Chin, and S. J. Swanson Video-Assisted Thoracoscopic Lobectomy: State of the Art and Future Directions Ann. Thorac. Surg., February 1, 2008; 85(2): S705 - S709. [Abstract] [Full Text] [PDF]
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T. A. D'Amico Thoracoscopic Segmentectomy: Technical Considerations and Outcomes Ann. Thorac. Surg., February 1, 2008; 85(2): S716 - S718. [Full Text] [PDF]
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T. L. Demmy and C. Nwogu Is Video-Assisted Thoracic Surgery Lobectomy Better? Quality of Life Considerations Ann. Thorac. Surg., February 1, 2008; 85(2): S719 - S728. [Abstract] [Full Text] [PDF]
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