The effects of immunomodulation processes in patients undergoing video-assisted thoracic surgery (VATS) lobectomy are still debated; although, the reduced surgical stress of minimally invasive surgery is evident. The immunological repercussions could also influence the evolution of the disease and the prognosis of patients. The article aims to raise some points of reflection by considering available evidences and reiterating, once again, the prognostic utility of a minimally invasive procedure rather than classical approach. Nagahiro et al. (4) in a trial of 22 NSCLC patients. In fact, serum IL-6 levels appeared significantly increased at POD 0 in the thoracotomy group when compared to the VATS one (21.6 vs. 4.1 pg/mL, P<0.03, respectively). In addition, both surgical and inflammatory stress present high mitogenic and apoptotic stimuli, whose dysregulation may result in a "skip effect" leading to hyperstimulation of cell membranes and the activation of uncontrolled cellular turnover processes. In this regard, Ng et al. (5), about a decade ago, hypothesized a fundamental role of some transcription of growth factors in the prognosis of patients with early stage NSCLC. Furthermore, by comparing VATS versus classical approaches, the Authors found significant differences in postoperative serum levels of insulin-like growth factor binding protein (IGFBP)-3, that, like the insulin growth factor (IGF)-1, promotes cell apoptosis. Moreover, surgical stress seemed to activate the synthesis of matrix metalloproteinase (MMP)-9 with chelating effects on insulin-like growth factors. Regarding IGFBP-3, its levels appeared significantly higher in the VATS group at POD 1; while the levels of MMP-9 were doubled in thoracotomy patients compared to those minimally invasively treated (1,311 vs. 628 ng/mL). Similar conclusions were reported by Zhang et al. (6) in the largest published randomized trial including 122 patients. In particular, in the VATS group, IGFBP-3, VEGF and IL-6 levels at each time point after surgery were dramatically lower than in the thoracotomy brace. It would seem, therefore, that a standard approach represents rather a risk for the persistence of a pro-inflammatory microenvironment with the production of growth factors, cytokines and soluble factors, whose consequences still require further investigation. In the view of a systemic disease, however, inflammation could significantly influence patients' prognosis, as a multiorgan macroenvironments, through systemic manifestations as the onset of cachexia (7), protidemic depletion, increased risk of postoperative complications. In conclusion, the choice of a minimally invasive strategy finds its concrete rational in the preservation of the homeostasis of the organism by minimizing the predictable effects of a standard thoracotomy.
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Conflicts of Interest:The authors have no conflicts of interest to declare. Immune response after video-assisted thoracic surgery in nonsmall cell lung cancer patients. J Vis Surg 201...