Video‐assisted thoracoscopic surgery lobectomy might be a feasible alternative for surgically resectable pathological N2 non‐small cell lung cancer patients

Abstract

Background: The majority of previous studies of the clinical outcome of videoassisted thoracoscopic surgery (VATS) versus open lobectomy for pathological N2 non-small cell lung cancer (pN2 NSCLC) have been single-center experiences with small patient numbers. The aim of this study was therefore to investigate these procedures but in a large cohort of Chinese patients with pathological N2 NSCLC in real-world conditions. Methods: Patients who underwent lobectomy for pN2 NSCLC by either VATS or thoracotomy were retrospectively reviewed from 10 tertiary hospitals between January 2014 and September 2017. Perioperative outcomes and overall survival of the patients were analyzed. Cox regression analysis was performed to identify potential prognostic factors. Propensity-score analysis was performed to reduce cofounding biases and compare the clinical outcomes between both groups. Results: Among 2144 pN2 NSCLC, 1244 patients were managed by VATS and 900 by open procedure. A total of 305 (24.5%) and 344 patients died during VATS and the thoracotomy group during a median follow-up of 16.7 and 15.6 months, respectively. VATS lobectomy patients had better overall survival when compared with those undergoing the open procedure (P < 0.0001). Multivariate COX regression analysis showed VATS lobectomy independently favored overall survival (HR = 0.75, 95% CI: 0.621-0.896, P = 0.0017). Better perioperative outcomes, including less blood loss, shorter drainage time and hospital stay, were also observed in patients undergoing VATS lobectomy (P < 0.05). After propensity-score matching, 169 patients in each group were analyzed, and no survival difference were found between the two groups. Less blood loss was observed in the VATS group, but there was a longer operation time. Conclusions: VATS lobectomy might be a feasible alternative to conventional open surgery for resectable pN2 NSCLC.

Feasibility and oncological outcomes of video‐assisted thoracic surgery versus thoracotomy for pathologic N2 disease in non–small cell lung cancer: A comprehensive systematic review and meta‐analysis

“…For NSCLC patients with mediastinal lymph node metastasis, several factors including inadequate experience during training, 35 narrow visual field with limited range of instrumental movement, 36 and inferior oncological effectiveness (e.g., lymph node assessment) may contribute to the major concerns of VATS for pN2 NSCLC. 21,37 However, Li et al 26 performed a retrospective analysis of 76 patients comparing clinical outcomes for patients with clinical N0, but pathologic N2 NSCLC patients after VATS lobectomy and thoracotomy lobectomy, they F I G U R E 4 Forest plot of (a) 1-year OS, and (b) 3-year OS; PSM, propensity score matched; VATS, video-assisted thoracoscopic surgery; OS, overall survival; CI, confidence interval found that VATS approach could yield similar total number of dissected mediastinal lymph node and the total number of dissected lymph node stations. Zhong et al 10 also found the similar result that VATS approach was effective in lymph node dissection compared with thoracotomy.…”

“…Eight studies reported the results of operation time, blood loss and complication rate. 10,14,[20][21][22][25][26][27] The results showed that VATS for NSCLC patients with pN2 disease yielded significantly less blood loss (WMD, À61.43; 95% CI, [À87.69, À35.18]; p < 0.001) than those receiving thoracotomy (Figure 2(a)). Moreover, VATS surgery could yield comparable operation time (WMD, À8.32; 95% CI, [À23.88, 7.23]; p = 0.29) and post-operation complication rate (RR, 0.95; 95% CI, [0.78, 1.15]; p = 0.59) to thoracotomy (Figure 2(b), (c)).…”

“…Three studies applied PSM analysis to balance the variables that might influence the outcomes between VATS group and thoracotomy group. 14,21,26 Therefore, we further conducted subgroup meta-analysis by only including these studies. Our results indicated that VATS surgery could still yield comparable operation time (Figure 2…”

“…Therefore, it remains controversial whether conversion from VATS to thoracotomy is necessary when intraoperative lymph node (LN) sampling reveals pathologic N2 disease 19 . Moreover, the feasibility and oncological outcomes of VATS versus thoracotomy for pN2 disease in resectable NSCLC is still under debate 10,14,20‐27 . Previous meta‐analysis was performed to determine oncological outcomes and feasibility of VATS for surgical treatment of pathologic N2 NSCLC and found that no significant differences between VATS and thoracotomy, but there were only 3 papers 10,20,23 with relative small sample size included for comparison 19 .…”

“…Previous meta‐analysis was performed to determine oncological outcomes and feasibility of VATS for surgical treatment of pathologic N2 NSCLC and found that no significant differences between VATS and thoracotomy, but there were only 3 papers 10,20,23 with relative small sample size included for comparison 19 . However, after carefully searching and evaluation, we found more relevant evidence to provide sufficient analytical power to compare the efficacy of VATS and thoracotomy in treating pN2 NSCLC 14,21,22,24‐26 . Therefore, we tried to conduct an up‐to‐date comprehensive meta‐analysis comparing the feasibility and oncological outcomes of VATS versus thoracotomy for pathologic N2 NSCLC.…”