Minimally Invasive Pneumonectomy Seems Safe, Effective for NSCLC

NEW YORK (Reuters Health) – Uniportal video-assisted thoracoscopic surgery (U-VATS) achieved similar morbidity and mortality rates to open pneumonectomy in patients with centrally located non-small cell lung cancer (NSCLC) in a retrospective, propensity-scored study in China.

As reported in Lung Cancer, Dr. Chang Chen of Tongji University School of Medicine in Shanghai and colleagues analyzed data on two cohorts of patients who underwent open or U-VATS pneumonectomy between 2011-2016. Overall, the mean age was about 60 and about 12% were women.

In one cohort, 501 patients (86.5%) underwent open pneumonectomy and 48 (13.5%), U-VATS; in the other cohort, 245 (90.4%) were in the open group and 26 (9.6%) in the U-VATS group.

After propensity score matching (1:3), morbidity rates and 30-day mortality rates were similar between the groups in both cohorts.

Further, overall survival (OS) rates did not differ significantly in either cohort between those who underwent open or U-VATS pneumonectomy.

Cox regression analysis showed that the surgical option was not a risk factor for the OS rate (hazard ratios, 0.925 in one cohort and 1.524 in the other).

Postoperative complication rates were also similar between the open and U-VATS groups; the primary complication in both cohorts was atrial fibrillation, for which rates were higher in the open groups.

The authors conclude, “U-VATS can be used to safely perform pneumonectomy in patients with centrally located NSCLC without compromising the perioperative and oncologic outcomes compared with an open approach.”

Dr. Michael Zervos, Director of Robotic Thoracic Surgery and Clinical Chief Division of Thoracic Surgery at NYU Langone Health in New York City, told Reuters Health by email that the use of U-VATS appears to be influenced by patient selection and surgeon discretion. For example, he said, “The paper states that Uniportal was chosen for distal endobronchial tumor and not central when thoracotomy was chosen.”

The NYU team uses robotics, he said, which “allows for a more uniform approach, including all patients that would normally require thoracotomy. In other words, we either believe they are resectable and do so with a completely portal robotic approach or we do not. We do not stratify based on severity of disease. Thus conversion is low.”

“I would like know why stage 1 and stage 2A-B tumors would require pneumonectomy and would be included in this study and thus are more likely to require a U-VATS approach?” he said. While the number of lymph nodes harvested and preoperative stage requiring induction chemotherapy and immunotherapy “appear equivalent or matched when looking at technique comparison alone,” he added, “which patients actually got treated with induction? Is immunotherapy included?”

Further, he said, “Why is length of stay 13-16 days for both approaches and chest tube duration similar? Uniportal without rib spreading should undoubtedly allow for quicker recovery.”

Dr. Travis Geraci, Assistant Professor of Cardiothoracic Surgery, also at NYU, added in a separate email, “The authors report a relatively high rate of conversion to open resection (40%), which reflects that not all patients may be appropriate candidates for a U-VATS pneumonectomy.”

“For example, despite propensity-matching, patients who underwent an open approach had larger, more advanced tumors. There is an inherent selection bias in this study, as surgeons were able to choose which patients undergo an open resection or U-VATS.”

Dr. Daniel Miller, a thoracic surgeon at Cancer Treatment Centers of America, Atlanta, also commented by email. “Over the five-year study period, less than 10% of pneumonectomies were performed via U-VATS. The criteria were extremely selective for (those) patients, which is warranted when initiating a new procedure.”

In addition, he said, “There was a significant difference in pathologic tumor status between the two approaches in favor of U-VATS cases, which may have skewed the results.”

“I would be curious to know if the number of bronchospastic cases changed during the study period,” he added. “Hopefully not, as it could indicate issues with postoperative lung function.”

“Also, I would thank the authors for opening discussion surrounding the 30 patients who underwent conversion to an open approach, but I would have removed them from the analysis,” Dr. Miller concluded.

Dr. Chen and co-corresponding author Dr. Dong Xie did not respond to requests for a comment.

SOURCE: Lung Cancer, online July 24, 2021.

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