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Video-assisted thoracoscopic surgery for the treatment of lung cancer

May 1, 2012|Cleveland Clinic Journal of Medicine
Sudish Murthy, MD, PhD
Author and Disclosure Information

Sudish Murthy, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH

Correspondence: Sudish Murthy, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, J4-1, Cleveland, OH 44195; MURTHYS1@ccf.org

Dr. Murthy reported that he has received royalties from Hood Laboratories.

This article was developed from an audio transcript of Dr. Murthy’s presentation at the “Advances in Lung Cancer Evaluation and Management” symposium held in Cleveland, Ohio, on April 30, 2011. The transcript was formatted and edited by Cleveland Clinic Journal of Medicine staff for clarity and conciseness and was then reviewed, revised, and approved by Dr. Murthy.

ABSTRACTA growing proportion of lung resections is being performed by video-assisted thoracoscopic surgery (VATS). VATS lobectomy is indicated for clinical stage I suspected lung cancer with pulmonary function sufficient to tolerate resection. Retrospective and matched analyses suggest less morbidity with fewer postoperative complications with VATS compared with open lobectomy. Five-year survival for VATS lobectomy in stage I non–small lung cancer patients approaches 80%. A potential oncologic benefit of VATS lobectomy (over thoracotomy) has been proposed through attenuation of postoperative cytokine release. Regardless of whether VATS or an open approach is utilized, thorough lymphadenectomy is important and may confer an additional survival benefit.

Video-assisted thoracoscopic surgery (VATS) is emerging as a therapeutic option for a variety of thoracic applications. When applied to the patient with lung cancer, the therapeutic benefit of VATS lobectomy appears to be confined to node-negative, relatively small tumors. Operable patients with larger tumors are currently best served by thoracotomy and mediastinal lymph node dissection. As an alternative to thoracotomy for stage I lung cancer, VATS lobectomy is associated with less postoperative pain, less surgical morbidity, fewer complications, and shorter hospitalization.1–4

LIMITED SPECIALIZED INSTRUMENTATION REQUIRED

Technologic innovation in minimally invasive surgery applied to the lung has lagged behind that of radiation oncology and interventional cardiology. VATS lobectomy requires relatively limited specialized instrumentation beyond standard minimally invasive surgical instruments commonly used for a variety of nonthoracic operations.

Video-assisted thoracoscopic surgery takes advantage of the reproducible anatomy of the lungs. However, knowledge of the vascular and bronchial anatomy is essential to avoid compromise of critical structures during VATS lobectomy.

The indication for VATS lobectomy at Cleveland Clinic is suspected clinical stage I lung cancer with pulmonary function sufficient to tolerate resection. A peripheral cancer or nodule of 3 cm or less is preferable for minimally invasive thoracic surgery.

Until 2007, the definition of a VATS lobectomy lacked uniformity. A standardized definition of VATS was provided by the Cancer and Leukemia Group B, which conducted a prospective multiinstitutional feasibility study of VATS lobectomy. It defined a true VATS lobectomy as one with individual identification and ligation of lobar vessels and bronchus, with accompanying hilar and mediastinal lymph node sampling or dissection, and performed without rib spreading.5

VATS OUTCOMES: FEWER COMPLICATIONS, SHORTER LENGTH OF STAY

The proportion of lung resections by VATS has increased steadily in the United States over the past decade, reaching 29% in 2007.1 The obvious question is whether thoracoscopic lobectomy holds an advantage over thoracotomy in terms of morbidity. Park documented significantly less postoperative atrial fibrillation, blood transfusion, renal failure, and other complications when VATS lobectomy was compared with thoracotomy (Table).4

In a propensity-matched analysis, Paul et al1 found an overall lower rate of complications with VATS compared with open lobectomy (26.2% vs 34.7%; P < .0001), including a lower incidence of arrhythmia (7.3% vs 11.5%; P = .0004), a lower frequency of blood transfusion (2.4% vs 4.7%; P = .0028), a reduced need for reintubation (1.4% vs 3.1%; P = .0046), and a shorter length of stay (4.0 vs 6.0 days; P < .0001) and chest tube duration (3.0 vs 4.0 days; P < .0001). At Cleveland Clinic, length of hospital stay has been shortened by about 1 day in patients undergoing VATS compared with open lobectomy.

The advantage of thoracoscopic lobectomy compared with thoracotomy may be limited to reduction in associated morbidity alone. Five-year survival was 78% in a series of 411 patients with clinical stage I non–small cell lung cancer (NSCLC) who underwent VATS lobectomy and the more technically difficult VATS segmentectomy.6 This rate of survival is equivalent to or better than any other reported series of patients with stage I NSCLC.

A potential oncologic benefit to the VATS approach through preservation of host immunity has also been suggested. Release of inflammatory mediators such as interleukin (IL)-6, IL-8, and IL-10 has been observed following thoracotomy and a subsequent immunosuppressive effect proposed. Liberation of these inflammatory cytokines appears attenuated by the VATS approach. Cellular proliferation and stimulation of tumor growth may be consequences of postoperative cytokine release, and limiting liberation of these products may have a direct beneficial tumor effect.7

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