There have been recent advances in the treatment of non–small cell lung cancer (NSCLC). Surgical resection remains the cornerstone in the treatment of patients with stages I and II NSCLC. Anatomic lobectomy combined with hilar and mediastinal lymphadenectomy constitutes the oncologic basis of surgical resection. The surgical data favor video-assisted thoracic surgery (VATS) lobectomy over open lobectomy and have established VATS lobectomy as a gold standard in the surgical resection of early-stage NSCLC. However, the role of sublobar pulmonary resection, either anatomic segmentectomy or nonanatomic wedge resection, in patients with subcentimeter nodules may become important.
In 2010, there were 225,000 new cases of lung cancer, of which approximately 25% to 30% were early stage (American Joint Committee on Cancer stages I and II) and potentially curable with surgical resection. Stages I and II lung cancer include many different subsets, ranging from very small tumors (T1aN0) (<2 cm), to more advanced cancers (ie, T4N0) (multiple nodules within the same lobe). Yet despite there being many subsets within these 2 stages ( Table 1 ), they are defined by the fact that a complete resection can always be achieved by an anatomic resection, either lobectomy or pneumonectomy. In the case of T3 tumors that invade adjacent structures (chest wall, pericardium, or diaphragm) complete resection can be achieved with en bloc resection. Therefore, surgical resection, to include the tumor with complete intraoperative hilar and mediastinal nodal staging, is the preferred treatment of patients with early-stage lung cancer. Although chemotherapy and radiation have roles in treating patients with lung cancer, there has never been a randomized trial comparing these modalities with surgery for early-stage lung cancer. Based on the expected 5-year survival after resection of 60% to 80% for stage I non–small cell lung cancer (NSCLC), and 40% to 60% for stage II NSCLC, complete surgical resection of early-stage lung cancer affords patients the best chance for long-term survival.
| T | N0 | N1 | |
|---|---|---|---|
| Sixth Edition TNM | Seventh Edition TNM | Stage | Stage |
| T1 (≤3 cm) | T1a (≤2 cm) | IA | IIA |
| T1b (>2–3 cm) | IA | IIA | |
T2 (>3 cm)
| T2a (>3–5 cm) | IB | IIA (IIB) |
| T2b (>5–7 cm) | IIA (IB) | IIB (IIB) | |
| T3 (>7 cm) | IIB (IB) | IIIA | |
T3 Invasion
| T3 | IIB | IIIA |
T4
| T3 | IIB (IIIB) | IIIA (IIIB) |
When large central tumors invade vascular structures or the proximal bronchus either directly or through nodal extension (N1), and complete resection cannot be achieved by a lobectomy, then a bilobectomy or pneumonectomy is necessary. There is no benefit to the patient when an incomplete resection is performed. In keeping with the basic tenet of achieving a complete resection, and preserving lung function, occasionally in patients with central tumors, a sleeve resection of the bronchus, the pulmonary artery, and rarely both structures, can be performed to avoid performing a pneumonectomy. (See article by Rendina elsewhere in this issue.)
The quest to preserve pulmonary function after surgical resection raises the question of performing lesser resections than lobectomy, especially in patients with very small peripheral tumors (ie, clinical stage T1aN0 tumors and particularly with noninvasive or microinvasive carcinoma [formerly defined as bronchioloalveolar carcinoma (BAC)]). In patients with compromised lung function, sublobar resection, either wedge resections or segmental resections, are well-established acceptable treatment alternatives to nonsurgical therapy, and are routinely performed in higher-risk surgical patients. There is mounting evidence to support consideration of sublobar resections in certain subsets of patients with small (<2 cm) NSCLC tumors.
Although the incidence of stage II NSCLC is less frequent than the other stages, metastases to regional lymph nodes greatly influence both treatment and survival in NCSLC. Nodal involvement with direct extension into hilar structures affects the extent of resection, thereby requiring a larger resection than lobectomy, with greater inherent surgical morbidity and mortality. Yano and colleagues reported that hilar nodal involvement affected 5-year survival greater than presence of lobar nodes (64.5% vs 39.7%). Over the past decade, the roles of both adjuvant and neoadjuvant therapies have been defined. Several randomized studies have independently identified patients with stages I and II lung cancer who will likely benefit from adjuvant chemotherapy.
Preoperative imaging and staging, as discussed in the staging article, is paramount in selecting patients with locally advanced tumors who should receive neoadjuvant therapy.
Lobectomy
After the report by Graham and colleagues of a successful pneumonectomy for lung cancer in 1932, pneumonectomy became the standard of care in the surgical management of patients with bronchogenic carcinoma. Over the next several decades reports of lesser resections, namely lobectomy, for patients with peripheral tumors were reported, using surgical techniques incorporating individual lobar vascular and bronchial division. After the report by Churchill and colleagues in 1950 of long-term survival in patients with early-stage lung cancer after lobectomy, lobectomy began to replace pneumonectomy as the preferred surgical treatment of small peripheral lung tumors. This report coincided with the increasing incidence of bronchogenic cancers in North America and Western Europe from tobacco exposure, subsequently resulting in widespread acceptance and performance of anatomic lobectomy for lung cancer. The oncologic principle involves removal of the primary tumor within the lobe, and thereby the lymphatic drainage associated with the tumor. Intraoperative staging, which is critical in the surgical management of lung cancer, includes removal of lymph nodes based on their anatomic location as outlined by the American Thoracic Society (ATS) guidelines.
The major surgical developments in the management of patients with operable lung cancers between 1960 and 1990 included improving postthoracotomy pain management, developing surgical selection criteria based on exercise tolerance and pulmonary function testing, and the evolution of surgical staplers. These devices combined with better postoperative pain management allowed surgeons to perform pulmonary resections through smaller incisions, even in patients with chronic obstructive pulmonary disease (COPD) and elderly patients, who frequently have multiple medical comorbidities.
The most recently published data on morbidity and mortality associated with open lobectomy come from the Society of Thoracic Surgeons (STS) database of 5957 patients, thereby establishing the current guidelines with which to compare all treatments for lung cancer. Morbidity after open lobectomy was 32% and the 30-day mortality was 2%.
Video-assisted thoracic surgery lobectomy
Video-assisted thoracic surgery (VATS) lobectomy represents the further evolution in the surgical management of early-stage lung cancer. Initial reports of VATS lobectomy from the early 1990s were highly criticized because it was believed that both oncologic principles and patient safety might be compromised during lung resections without a thoracotomy. In the first single-institution randomized trial of VATS lobectomy, Kirby and colleagues randomized 61 patients to either VATS lobectomy (n = 31) or muscle-sparing thoracotomy (n = 30). The complication rate was lower in the VATS group (6% vs 16%), indicating that VATS lobectomy could be performed safely. Sugi and colleagues randomized 100 patients with clinical stage I lung cancer to either VATS lobectomy or a standard thoracotomy and lobectomy. There was no significant difference in 5-year survival between VATS lobectomy and open lobectomy (90% vs 85%), indicating that VATS lobectomy did not compromise oncologic principles.
McKenna and colleagues reported the largest single-institution study of VATS lobectomy. In their series of 1100 patients with various stages of lung cancer, mortality was 0.8%, and morbidity 15.3%, with a conversion rate to open thoracotomy of 2.5%. As a result of this and other large series, there has been a gradual acceptance within the surgical community of VATS lobectomy, for patients with early-stage NSCLC. CALGB 39,802, a prospective multi-institution study of the feasibility of total video-assisted resection reported that VATS lobectomy is safe and associated with low morbidity. Comparative studies between VATS lobectomy and open lobectomy are primarily single-institution retrospective reviews ( Table 2 ). VATS lobectomy compares favorably in regards to surgical morbidity, mortality, and the incidence of serious complications. As surgeons became more experienced with performance of VATS lobectomy and recognized its benefits compared with open lobectomy, establishing a large intergroup randomized trial to compare the 2 operations became difficult because of difficulty in enrolling patients. A multi-institution registry designed to collect data prospectively comparing open and VATS lobectomy (CALGB 140,501) failed to proceed as well. The review by Whitson and colleagues of publications between 1992 and 2007 yielded 39 articles comparing open with VATS lobectomy. Although the reduction in surgical morbidity was not statistically significant, the reductions in both length of stay (absolute reduction 5 days) and duration of chest tube drainage (absolute difference 1.5 days) were both statistically significant. VATS lobectomy can be performed safely and does not increase the surgical risk of anatomic lobectomy. However, the most important outcome when comparing cancer treatments is survival. Although there are no large randomized trials comparing the 2 operations, the published data indicate that long-term survival and locoregional recurrence are not compromised by VATS lobectomy ( Table 3 ). In the meta-analysis by Yan and colleagues, 21 comparative studies were reviewed. VATS lobectomy had no significant impact on locoregional recurrence. There was a statistically significant decrease in systemic recurrence and improved 5-year survival with VATS lobectomy compared with open lobectomy. Data suggest that the improved 5-year survival in early-stage NSCLC may result from modulation of the inflammatory and cellular immune responses after VATS lobectomy, similar to that seen in other minimally invasive surgical procedures. In a randomized controlled trial by Craig and colleagues, VATS lobectomy was associated with decreased acute phase inflammatory response. More data are necessary before any conclusions regarding the relationship between immune response and survival after VATS lobectomy can be made.
| Study | Conversion Rate (%) | n | Blood Loss | Complication Rate (%) | Chest Tube (d) | Length of Stay (d) | Mortality (%) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| VATS | Open | VATS | Open | VATS | Open | VATS | Open | VATS | Open | VATS | Open | ||
| Kirby et al, 1995 prospective | 10 | 25 | 30 | <250 | <250 | 24 | 53 | 6.5 | 4.6 | 7.1 | 8.3 | 0 | 0 |
| Petersen et al, 2007 retrospective | 5 | 43 | 57 | NR | NR | 9 | 11 | 3.1 | 4.7 | 4.2 | 4.3 | 0 | 0 |
| Whitson et al, 2007 retrospective | 15.7 | 59 | 88 | 251 | 255 | NR | NR | 5.0 | 6.1 | 6.4 | 7.7 | 0 | 0 |
| Villamizar et al, 2009 retrospective | 4.6 | 284 | 284 | NR | NR | 31 | 51 | 3 | 4 | 4 | 5 | 3 | 5 |
| Flores et al, 2009 retrospective | 17.5 | 398 | 343 | NR | NR | 23 | 33 | NR | NR | 5 | 7 | 0.3 | 0.3 |
| Whitson et al, 2008 Systematic review | NR | 3114 | 3256 | 251 | 255 | 16.4 | 32 | 5 | 6.1 | 6.4 | 7.7 | NR | NR |
| Yan et al, 2009 Systematic review | 8.1 | 1391 | 1250 | 146 | 235 | NR | NR | 4.6 | 5.3 | 12 | 12.2 | 0.4 | 0.7 |
| Scott et al, 2010 retrospective | 6.7 | 74 | 62 | NR | NR | 34 | 39 | 3 | 5 | 4 | 7 | 1.6 | 1.4 |
| Author, Year | Clinical Stage | Technique | n | Results 5-Year Survival (%) |
|---|---|---|---|---|
| Sugi et al, 2000 | I | VATS Open | 48 52 | 90 85 |
| Walker et al, 2003 | I and II | VATS | 159 | Stage I = 78 Stage II = 51 |
| Thomas et al, 2002 | I | VATS Open | 110 404 | 62.9 62.8 |
| Rovario et al, 2004 | I | VATS | 257 | 63.6 |
| Shiraishi et al, 2006 | I | VATS Open | 81 79 | 89 77 |
| Flores et al, 2009 | I | VATS Open | 398 343 | 79 75 |
VATS lobectomy results in decreased postoperative pain and earlier ambulation, which is likely responsible for the reduction in pulmonary complications. There is decreased pulmonary morbidity with improved pulmonary function and performance status with VATS, allowing anatomic resections to be offered to patients who would otherwise be considered high risk for thoracotomy and lobectomy such as elderly patients, patients with poor performance status, or those with reduced pulmonary function. Many octogenarians diagnosed with clinical stage I lung cancer are denied anatomic lobectomy despite its oncologic advantages over nonanatomic resections, or other alternative strategies such as stereotactic radiation, merely because of their age, and the presumed morbidity and mortality associated with a thoracotomy. The data on VATS lobectomy in elderly patients are encouraging, with a mortality of 1.8% and morbidity of 18% having been reported in a single-institution series. Similarly, patients with compromised pulmonary function who would be expected to have significant pulmonary morbidity from a thoracotomy can safely undergo a VATS lobectomy. No large multi-institutional randomized trial of open lobectomy versus VATS lobectomy has been performed that conclusively confirms its perceived advantages. However, considering all the available clinical evidence, VATS lobectomy is recommended as the procedure of choice and should now be considered the gold standard for patients with early-stage NSCLC.
Video-assisted thoracic surgery lobectomy
Video-assisted thoracic surgery (VATS) lobectomy represents the further evolution in the surgical management of early-stage lung cancer. Initial reports of VATS lobectomy from the early 1990s were highly criticized because it was believed that both oncologic principles and patient safety might be compromised during lung resections without a thoracotomy. In the first single-institution randomized trial of VATS lobectomy, Kirby and colleagues randomized 61 patients to either VATS lobectomy (n = 31) or muscle-sparing thoracotomy (n = 30). The complication rate was lower in the VATS group (6% vs 16%), indicating that VATS lobectomy could be performed safely. Sugi and colleagues randomized 100 patients with clinical stage I lung cancer to either VATS lobectomy or a standard thoracotomy and lobectomy. There was no significant difference in 5-year survival between VATS lobectomy and open lobectomy (90% vs 85%), indicating that VATS lobectomy did not compromise oncologic principles.
McKenna and colleagues reported the largest single-institution study of VATS lobectomy. In their series of 1100 patients with various stages of lung cancer, mortality was 0.8%, and morbidity 15.3%, with a conversion rate to open thoracotomy of 2.5%. As a result of this and other large series, there has been a gradual acceptance within the surgical community of VATS lobectomy, for patients with early-stage NSCLC. CALGB 39,802, a prospective multi-institution study of the feasibility of total video-assisted resection reported that VATS lobectomy is safe and associated with low morbidity. Comparative studies between VATS lobectomy and open lobectomy are primarily single-institution retrospective reviews ( Table 2 ). VATS lobectomy compares favorably in regards to surgical morbidity, mortality, and the incidence of serious complications. As surgeons became more experienced with performance of VATS lobectomy and recognized its benefits compared with open lobectomy, establishing a large intergroup randomized trial to compare the 2 operations became difficult because of difficulty in enrolling patients. A multi-institution registry designed to collect data prospectively comparing open and VATS lobectomy (CALGB 140,501) failed to proceed as well. The review by Whitson and colleagues of publications between 1992 and 2007 yielded 39 articles comparing open with VATS lobectomy. Although the reduction in surgical morbidity was not statistically significant, the reductions in both length of stay (absolute reduction 5 days) and duration of chest tube drainage (absolute difference 1.5 days) were both statistically significant. VATS lobectomy can be performed safely and does not increase the surgical risk of anatomic lobectomy. However, the most important outcome when comparing cancer treatments is survival. Although there are no large randomized trials comparing the 2 operations, the published data indicate that long-term survival and locoregional recurrence are not compromised by VATS lobectomy ( Table 3 ). In the meta-analysis by Yan and colleagues, 21 comparative studies were reviewed. VATS lobectomy had no significant impact on locoregional recurrence. There was a statistically significant decrease in systemic recurrence and improved 5-year survival with VATS lobectomy compared with open lobectomy. Data suggest that the improved 5-year survival in early-stage NSCLC may result from modulation of the inflammatory and cellular immune responses after VATS lobectomy, similar to that seen in other minimally invasive surgical procedures. In a randomized controlled trial by Craig and colleagues, VATS lobectomy was associated with decreased acute phase inflammatory response. More data are necessary before any conclusions regarding the relationship between immune response and survival after VATS lobectomy can be made.
| Study | Conversion Rate (%) | n | Blood Loss | Complication Rate (%) | Chest Tube (d) | Length of Stay (d) | Mortality (%) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| VATS | Open | VATS | Open | VATS | Open | VATS | Open | VATS | Open | VATS | Open | ||
| Kirby et al, 1995 prospective | 10 | 25 | 30 | <250 | <250 | 24 | 53 | 6.5 | 4.6 | 7.1 | 8.3 | 0 | 0 |
| Petersen et al, 2007 retrospective | 5 | 43 | 57 | NR | NR | 9 | 11 | 3.1 | 4.7 | 4.2 | 4.3 | 0 | 0 |
| Whitson et al, 2007 retrospective | 15.7 | 59 | 88 | 251 | 255 | NR | NR | 5.0 | 6.1 | 6.4 | 7.7 | 0 | 0 |
| Villamizar et al, 2009 retrospective | 4.6 | 284 | 284 | NR | NR | 31 | 51 | 3 | 4 | 4 | 5 | 3 | 5 |
| Flores et al, 2009 retrospective | 17.5 | 398 | 343 | NR | NR | 23 | 33 | NR | NR | 5 | 7 | 0.3 | 0.3 |
| Whitson et al, 2008 Systematic review | NR | 3114 | 3256 | 251 | 255 | 16.4 | 32 | 5 | 6.1 | 6.4 | 7.7 | NR | NR |
| Yan et al, 2009 Systematic review | 8.1 | 1391 | 1250 | 146 | 235 | NR | NR | 4.6 | 5.3 | 12 | 12.2 | 0.4 | 0.7 |
| Scott et al, 2010 retrospective | 6.7 | 74 | 62 | NR | NR | 34 | 39 | 3 | 5 | 4 | 7 | 1.6 | 1.4 |
Related posts:
Screening for Lung Cancer: Challenges for the Thoracic Surgeon
Epidemiology of Lung Cancer: Smoking, Secondhand Smoke, and Genetics
The Changing Pathology of Lung Cancer
A Review of Noninvasive Staging of the Mediastinum for Non–Small Cell Lung Carcinoma
Role of Surgery Following Induction Therapy for Stage III Non–Small Cell Lung Cancer
Extensive Resections: Pancoast Tumors, Chest Wall Resections, En Bloc Vascular Resections
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
