- Thoracoscopic lobectomy has been suggested, based largely on the results of nonrandomized studies, to have several advantages over conventional thoracotomy in patients with stage I NSCLC.
- A recent study found that thoracoscopic lobectomy was associated with higher rates of postoperative chemotherapy compliance.
- Since adjuvant chemotherapy improves survival in most patients with resected tumors beyond stage IA, these findings suggest that thoracoscopic lobectomy may enhance survival in patients with NSCLC.
The thoracoscopic approach has been demonstrated to be a safe method of completing pulmonary lobectomy in patients with nonâsmall-cell lung cancer (NSCLC). From an oncologic point of view, thoracoscopy likely provides an equivalent chance of cure as lobectomy by conventional thoracotomy, at least in patients with stage I tumors. Thoracoscopic lobectomy has also been fairly convincingly established, based primarily on nonrandomized studies, to have several other advantages when compared with lobectomy by thoracotomy; these include shorter length of chest tube duration and hospital stay, decreased postoperative pain and inflammatory response, increased preservation of pulmonary function, and fewer overall complications. Since studies have indicated that increased compliance with adjuvant chemotherapy improves survival outcomes after complete surgical resection in patients with nodal involvement or tumors >4 cm, improved ability to deliver chemotherapy may improve survival rates. A recent retrospective study from Duke University Medical Center therefore assessed whether thoracoscopic lobectomy results in more effective delivery of chemotherapy compared with lobectomy by conventional thoracotomy.
This single-center study included 100 consecutive patients with NSCLC who received chemotherapy, with or without radiation therapy, after lobectomy between January 1999 and July 2004. Of the 100 patients, 57 underwent thoracoscopic lobectomy and 43 underwent thoracotomy for lobectomy. Candidates for thoracoscopic lobectomy included patients with tumors <6 cm in diameter and without chest wall or central airway involvement. Median follow-up was 19 months in the thoracoscopy group and 17 months in the thoracotomy group. The primary outcome variables were postoperative time to initiation of adjuvant chemotherapy, percentage of planned chemotherapy regimen received, percentage of patients who received â¥75% of full chemotherapy regimen without delayed or reduced doses, numbers of delayed and reduced doses, and toxicity grades of 3 or higher.
The two groups were generally well matched demographically and clinically, including age, gender, tobacco use, medical comorbidities and preoperative pulmonary function. Chemotherapy regimens were also similar in the two groups, with most patients receiving a platinum-based agent combined with either a taxane or a vinca alkaloid. However, a significantly higher percentage in the thoracotomy group received radiation therapy (30% versus 12%, P = .04). Patients in the thoracotomy group were more likely to have higher-stage disease (P = .05), and this group had a lower percentage of patients with adenocarcinomas and higher percentages of patients with squamous cell carcinomas and other histologic types (P = .022) than the thoracoscopy group.
Patients in the thoracoscopy group had a significantly shorter median length of hospitalization than did patients in the thoracotomy group (4 versus 5 days, P = .013) and were less likely to be returned to the operating room for postoperative bleeding (0% versus 7%, P = .04). There were no significant differences between the two groups in 30-day mortality rate, or in rate of pneumonia, respiratory failure, atrial fibrillation, or other major complications.
Patients who underwent thoracoscopic lobectomy showed better compliance with chemotherapy than did patients who underwent thoracotomy, as shown by the percentages of delayed (18% versus 58%, P <.001) and reduced (26% versus 49%, P = .02) chemotherapy doses (Figure). In addition, a significantly higher percentage of patients in the thoracoscopy group received â¥75% of their total planned chemotherapy regimen without delayed or reduced doses (61% versus 40%, P = .03, Figure). The two groups, however, did not differ significantly in mean postoperative time to initiation of chemotherapy (58 Â± 31 days versus 54 Â± 35 days, P = .277), mean percentage of planned regimen received (88 Â± 24% versus 89 Â± 19%, P = .835), and the percentages of patients with toxicity grades of 3 or 4 (12% versus 21%, P = .243). Compliance with chemotherapy was also not affected by the pathologic stage of the tumor or by the addition of adjuvant radiation therapy.
Figure. Percentages of Patients in the Thoracoscopy and Thoracotomy Groups that had Delayed or Reduced Chemotherapy Doses, and Percentages that Received at Least 75% of Total Planned Doses Without Delayed or Reduced Doses
The findings of this study may have relevance to the surgical treatment of patients with NSCLC. Since improved compliance with adjuvant chemotherapy is associated with improved survival after resection in most patients with tumors beyond stage IA, methods of surgical resection that enhance or facilitate chemotherapy delivery may improve patient outcomes. Thoracoscopic lobectomy was associated with modestly improved chemotherapy compliance, measured as the percentages of delayed and reduced doses and the percentages of patients that received â¥75% of their total planned chemotherapy regimen without delays or reductions. Although the thoracoscopy and thoracotomy groups differed significantly in the percentages that received adjuvant radiation therapy and in tumor histology and pathologic stage, none of these factors was significantly associated with chemotherapy delivery. The unusually high rate of return to the operating room for postoperative bleeding in the thoracotomy group (7%)âeffectively requiring each of these patients to undergo two operations rather than oneâsuggests that this factor may have played a role in slowing the recovery of the thoracotomy patients. This, however, was unlikely to completely account for the differences observed in chemotherapy delivery.
Lastly, it should be noted that the Duke group apparently had less-stringent criteria for the application of thoracoscopic lobectomy than most other centers. Currently available data only support oncologic equivalence of the thoracoscopic approach in patients with clinical stage I lung cancer, but the Duke group here apparently applied thoracoscopic lobectomy also to patients with clinical evidence of N1 disease (stage II). Since in the vast majority of centers, patients beyond stage I wouldâI think appropriatelyânot even be considered for VATS lobectomy, and since only patients with stage IB tumors >4 cm in diameter and patients with N1 or N2 disease appear to benefit from adjuvant chemotherapy, the overall impact of any benefit of VATS lobectomy on delivery of chemotherapy would be very small.
Thus, while this study has several limitations, which require caution in interpreting its resultsâeven beyond its retrospective designâit nevertheless suggests that thoracoscopic lobectomy has the potential to provide a modest improvement in NSCLC cure rates by improving postoperative chemotherapy delivery.
Petersen RP, Pham DK, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the deliver of chemotherapy after resection for lung cancer. Ann Thorac Surg. 2007;83:1245-1250.