Video-assisted thoracoscopic surgery for the treatment of lung cancer
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.
MEDIASTINAL LYMPHADENECTOMY
Meticulous clinical staging of lung cancer directs clinical decision-making and has prognostic value. Imaging with computed tomography (CT) and fluorodeoxyglucose (FDG) positron emission tomography (PET) is neither sensitive nor specific for nodal metastases. The increasing popularity of less invasive staging and operative approaches for lung cancer imparts the risk of obtaining inadequate mediastinal information and the potential for undertreatment or overtreatment. At a minimum, systematic lymph node sampling is an essential component of any surgical approach (minimally invasive or open). Lymph node sampling should not be compromised by VATS, although more expertise is required for a complete VATS lymphadenectomy.
In patients with early-stage lung cancer, thorough lymphadenectomy may confer an important survival benefit even if sampled lymph nodes are found to be negative.8 Resection of occult (undetected) disease is one potential explanation for this survival benefit.
CASE STUDY: LYMPHADENECTOMY VIA MINIMALLY INVASIVE TECHNIQUE
A 45-year-old man with a 15 pack-year history of tobacco use presented with chest pain. He quit smoking 3 years previously. Although his chest pain resolved, a lesion in the right chest was incidentally found on chest radiograph.
The patient underwent spirometry and had normal values. A follow-up CT revealed a 2.1-cm spiculated right upper lobe nodule. There was no significant nodule uptake of FDG (standardized uptake value: 1.5 to 1.8) on PET. Percutaneous fine-needle aspiration biopsy demonstrated atypical cells of unclear significance. Navigational bronchoscopy-directed biopsy also revealed atypical cells but was nondiagnostic. The concern was that because the size of the mass was 2.1 cm, surveillance was not a viable option.
Ultimately, because of the biopsy ambiguity, large nodule size, and excellent patient performance status, VATS resection was offered. As a prelude, the mediastinum was staged with mediastinoscopy. The entire central (N2) compartment was surveyed with this technique and all samples were found to be free of cancer.
A VATS lobectomy was then performed. One utility incision (4 cm) was made and two to three ports (1 cm each) were placed within the thorax. No rib-spreading was utilized. An anatomic lobectomy with division of major vascular structures and the bronchus was performed similarly to an open procedure. When fully mobilized, the specimen (the right upper lobe in this case) was placed in a protective bag and delivered through the utility incision. Regional lymph nodes were also harvested for pathologic examination.
This patient was found to have a T1aN0M0 NSCLC and had an uneventful 3-day hospital course. Based on this final pathology and on institutional data, his projected survival was approximately 85%, 10% to 15% higher than national averages.8
SUMMARY
VATS lung resection is slowly becoming the standard of care for patients with stage I lung cancer. Advantages to the VATS approach compared with open lobectomy are less morbidity and shorter hospitalization. The perioperative stress response is attenuated with VATS, which suggests a potential superior oncologic outcome, although this remains to be proved. A complete mediastinal lymphadenectomy, regardless of the approach, may confer a survival advantage in early-stage lung cancer.
