Ann Thorac Surg 2010;89:359. doi:10.1016/j.athoracsur.2009.11.039
© 2010 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
William Burfeind, Jr, MD
Thoracic Surgery, St. Luke's Health Network, 701 Ostrum St, Ste 201, Bethlehem, PA 18015
(Email: burfeiw{at}slhn.org).
Thoracoscopic lobectomy continues to slowly increase in popularity, although in recent years only 30% of the lobectomies entered in the Society of Thoracic Surgeons' database were labeled as being performed using thoracoscopy. However, experienced thoracoscopic surgeons typically perform 80% or more of their lobectomies thoracoscopically, reserving thoracotomy for extremely large tumors or resections that demand bronchial or arterial reconstruction. The reasons for this disparity are multiple and likely include: (1) lack of training for practicing surgeons, (2) a relatively steep learning curve for thoracoscopic lobectomy, and (3) questions regarding long-term effectiveness. Hopefully the wealth of current literature addressing the safety profile of thoracoscopic lobectomy would lead surgeons to preferentially choose this approach. Data from large propensity-matched series, case-matched series, and a meta-analysis all document a reduction in morbidity from lobectomy when a thoracoscopic approach is adopted, with no difference in 30-day mortality rates.
Long-term effectiveness of thoracoscopic lobectomy in comparison with lobectomy by thoracotomy remains incompletely defined at this time. Because it is unlikely that a large multicenter, randomized clinical trial will ever be undertaken, studies such as this one by Kazumichi and colleagues are important additions to the literature [1]. Kazumichi and colleagues have presented a relatively large series of thoracoscopic major pulmonary resections (87% lobectomies) that have all been followed-up for at least 5 years. These authors report data that are most robust for stage I patients, as the number of higher stage patients is small [1]. They report overall and disease-free survival, and their stage-specific overall survival is as good or better than those in the 7th Edition of the American Joint Committee on Cancer (AJCC) Tumor, Node, and Metastasis (TNM) classification [1]. Kazumichi and colleagues have documented survival rates that were equivalent, both during the early years of the study (highly selected patients) as well as the latter years (relatively unselected patients). These survival results are remarkably similar to other large, single institution series, such as those from Cedars Sinai and Duke.
When performed, according to accepted standards (including individual hilar vessel and bronchial ligation, complete hilar nodal dissection, appropriate management of mediastinal lymph nodes, and extraction of the specimen in a protective bag) thoracoscopic lobectomy is oncologically the same as open lobectomy, but just using smaller incisions and no rib spreading. In addition, patients who undergo thoracoscopic lobectomy are more likely to tolerate adjuvant chemotherapy. It is quite possible that long-term survival is improved by a thoracoscopic approach. Therefore, the answer to Kazumichi and colleagues' [1] question: "Can [video-assisted thoracoscopic surgery] VATS become a standard approach," is an emphatic yes. Not only can it become a standard approach, but it should be the standard approach to the resection of early stage lung cancer.
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- Yamamoto K, Ohsumi A, Kojima F, et al. Long-term survival after video-assisted thoracic surgery lobectomy for primary lung cancer Ann Thorac Surg 2010;89:353-359.[Abstract/Free Full Text]
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Long-Term Survival After Video-Assisted Thoracic Surgery Lobectomy for Primary Lung Cancer
- Kazumichi Yamamoto, Akihiro Ohsumi, Fumitsugu Kojima, Naoko Imanishi, Katsunari Matsuoka, Mitsuhiro Ueda, and Yoshihiro Miyamoto
Ann. Thorac. Surg. 2010 89: 353-359.
[Abstract]
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