Page 102 - Read Online

Page 6 of 10 Dolan et al. Mini-invasive Surg 2020;4:40 I http://dx.doi.org/10.20517/2574-1225.2020.17

difference between the two groups. They proceeded to apply multivariable logistic regression and did not
find side or surgical technique to be significant predictors for sufficient lymph node dissection; upper
[37]
or middle lobe location did note a 3.843 hazard ratio for sufficient lymph node dissection (P = 0.002) .
[34]
Park et al. also demonstrated no difference with their MIS comparison to open, and, although
nonsignificant, it trended towards a higher median for lymph node stations sampled in the combined MIS
[36]
group (RATS and VATS) than the open cohort, 5 (3-7) vs. 4 (1-9) (P = 0.081) . When Gonfiotti et al.
[34]
compared their locally advanced NSCLC VATS resections to their early stage NSCLC VATS resection, they
had more total lymph nodes sampled (15.69 ± 10.47 vs. 13.48 ± 8.18, P < 0.001), more N1 stations sampled
[36]
(7.55 ± 6.96 vs. 6.38 ± 4.30, P < 0.001), and more N2 stations sampled (8.27 ± 6.62 vs. 7.02 ± 5.58, P < 0.001) .
All this evidence indicates that VATS is at least equivalent to open in terms of lymph node sampling for
locally advanced NSCLC.

An additional benefit of VATS as the primary surgical modality is that it can serve as a restaging method
before definitive resection. CALGB 39803 was a prospective phase II trial designed to evaluate the
possibility of restaging Stage III NSCLC patients, 7th edition TNM staging, after they had undergone
neoadjuvant therapy for N2 disease burden. The study was multi-center and ran from 1998 to 2003. The
protocol mandated histologically confirmed N2 NSCLC disease and a two-cycle course of platinum-based
chemotherapy and/or 40 Gy or more of radiotherapy. Patients then underwent a VATS restaging procedure
focusing on signs of pleural carcinomatosis, malignant effusion, or any positive mediastinal node with at
least three sampled. Of 68 patients who were evaluated, 20 had no nodal tissue present due to neoadjuvant
therapy, 7 had negative nodes, 16 had persistent N2 disease, and 4 had progression to carcinomatosis. This
gave a feasibility rate of 69% (95%CI: 57%-80%) for VATS as a restaging modality . While this study was
[38]
done, as noted by the authors, before the more regular use of EBUS, this demonstrates that VATS can be
used as a restaging modality prior to committing to an open thoracotomy.

Long-term outcomes
[39]
Yang et al. published, in 2016, Duke University’s retrospective review of 111 cases of Stage IIIA pN2
NSCLC, 7th edition IASCLC staging, who had received induction chemotherapy with or without radiation
and then proceeded on to lobectomy. Cases were from 1996 to 2012 with a distinct trend towards increased
VATS in later years. They found patients who had undergone VATS had significantly better 5-year overall
survival than open surgery, 56.6% vs. 31.4% (P = 0.007). No significant difference was noted in recurrence
[40]
[39]
free survival between VATS and open groups, 27.3% vs. 22.3% (P = 0.17) . Yang et al. followed up on
this by focusing on VATS vs. thoracotomy after preoperative chemotherapy for any stage NSCLC, including
203 thoracotomy and 69 VATS patients from 1996 to 2012. On univariate analysis, they found significantly
better 3-year overall survival for VATS patients vs. open, 61% vs. 43% (P = 0.010), but no difference with
multivariable analysis despite a trend towards significance, HR 0.56 (0.32-1.01) (P = 0.053). Recurrence
free survival was no different on univariate or multivariable analysis, 36% vs. 27% (P = 0.12) and HR 0.68
(0.42-1.09) (P = 0.11). They proceeded with propensity matching on preoperative variables and found
no difference on multivariable analysis between VATS and open for overall survival or for recurrence
[40]
free survival, HR 0.88 (0.39-1.97) (P = 0.76) and HR 0.91 (0.46-1.83) (P = 0.80) . Matsuoka et al.
[41]
from Japan published their institution’s experience with 132 patients who had undergone induction
therapy before VATS or open and followed them out to 5 years. For the 97 patients they defined as locally
advanced Stage II/III, the 5-year overall survival was not statistically different in the VATS vs. open groups,
[34]
[41]
but precise values were not reported (P = 0.227) . Lastly, Park et al. demonstrated similar findings in
their RATS and VATS vs. open study with 3-year overall and recurrence free survival being no different,
48.3% vs. 56.6% (P = 0.84) and 49.0% vs. 42.1% (P = 0.19), respectively . Taken together, all these studies
[34]
demonstrate that even in long-term outcomes VATS or RATS is as good as or better than thoracotomy.