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(Chest. 2004;125:1742-1746.)
© 2004 American College of Chest Physicians

Is Major Pulmonary Resection by Video-Assisted Thoracic Surgery an Adequate Procedure in Clinical Stage I Lung Cancer?*

Takashi Ohtsuka, MD; Hiroaki Nomori, MD; Hirotoshi Horio, MD; Tsuguo Naruke, MD and Keiichi Suemasu, MD

* From the Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan.

Correspondence to: Takashi Ohtsuka, MD, Department of Thoracic Surgery, Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo 108-0073, Japan; e-mail: t-oh{at}remus.dti.ne.jp


   Abstract
TOP
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Objective: Although several studies have shown that video-assisted thoracic surgery (VATS) for major pulmonary resection is less invasive than open thoracotomy, VATS for lung cancer has been performed in only a limited number of institutions. We aimed to review our experience of VATS for major pulmonary resections, and to determine its safety and adequacy in stage I lung cancer.

Methods: Between August 1999 and March 2003, we performed major pulmonary resection by VATS in 106 patients with lung cancer and preoperatively determined clinical stage I disease. We evaluated the number of procedures converted to open thoracotomy and the reasons for conversion, the intraoperative blood loss, interval between surgery and chest tube removal, length of postoperative hospital stay, postoperative complications, mortality rate, prognoses, and patterns of recurrence.

Results: We successfully performed VATS in 95 patients, whereas in another 11 patients (10%) conversion to open thoracotomy was required. The operative procedures were lobectomy in 86 patients, segmentectomy in 8 patients, and bilobectomy in 1 patient. In 95 patients who underwent VATS, postoperative complications developed in 9 patients (9%), and 1 patient (1%) died from pneumonia. In the 86 patients without complications, the mean postoperative hospital stay was 7.6 days (range, 4 to 15 days). In a mean follow-up period of 25 months (range, 6 to 48 months) in patients with non-small cell lung cancer (NSCLC), including the one perioperative death, the 3-year survival rate was 93% in 82 patients with clinical stage I disease, and 97% in 68 patients with pathologic stage I disease. The 3-year disease-free survival rate was 79% in patients with clinical stage I disease, and 89% in patients with pathologic stage I disease. Local recurrence was observed in six patients (6%): recurrence in mediastinal lymph nodes in five patients, and in the bronchial stump in one patient.

Conclusions: Major pulmonary resection by VATS is acceptable in view of its low perioperative mortality and morbidity, and is an adequate procedure for the achievement of local control and good prognosis in patients with clinical stage I NSCLC.

Key Words: lobectomy • lung cancer • thoracoscopy • video-assisted thoracic surgery


   Introduction
TOP
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
Over the past few years, video-assisted thoracic surgery (VATS) has become a well-established procedure. Several studies of the use of VATS for major pulmonary resection in lung cancer have been published. The advantages of VATS over open thoracotomy are accepted as decreased postoperative pain, reduced cytokine production, better preservation of pulmonary function, and good postoperative quality of life.12345678 However, the adequacy of VATS in terms of lung cancer prognosis is still controversial, and for this reason many thoracic surgeons are reluctant to use the procedure in lung cancer. They are uncertain of the curability of lung cancer by this method and of their ability to deal with emergent troubles such as massive bleeding during the procedure. Therefore, VATS lobectomy for lung cancer is currently performed in only a limited number of institutions. As lymph node metastasis can occur even in patients with small peripheral non-small cell lung cancer (NSCLC),910 lobectomy with lymph node dissection should be performed with the VATS procedure. Our aim was to evaluate the safety and oncologic efficacy of major pulmonary resection by VATS in patients with lung cancer.


   Patients and Methods
TOP
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
Between August 1999 and January 2003 at Saiseikai Central Hospital, Tokyo, Japan, we performed major pulmonary resection by VATS in 106 patients with clinical stage I primary lung cancer. Our indications for VATS for lung cancer were as follows: (1) no invasion of neighboring organs, (2) no hilar or mediastinal lymph node involvement on preoperative examination by chest CT, (3) no neoadjuvant chemotherapy or radiation therapy received, and (4) no pneumonectomy required. We did not make tumor size a criterion. We had 106 patients with clinical stage I lung cancer altogether, and did not exclude the patients who fit our criterion. When we judged positive mediastinal lymph node involvement during the operation, we converted to open thoracotomy. Before surgery, we obtained informed consent for the VATS procedure and explained the potential necessity of converting the procedure to open thoracotomy. There were 67 men and 39 women (mean age, 64 years; range, 34 to 83 years). The VATS procedure was performed as described previously.811 Briefly, we used three ports and a lateral minithoracotomy approximately 5-cm long on the midaxillary line, generally at the fourth intercostal space. The serratus anterior muscle was divided, but the latissimus dorsi muscle did not require division. Until December 2001, the minithoracotomy was opened to approximately 2 x 5 cm with a metallic chest retractor. Since January 2002, we have used a silicon rubber instrument that consists of two flexible rings (Lap-Protector; Hakko; Nagano, Japan),12 which makes the minithoracotomy widely opened and helps to prevent wound dehiscence at the thoracotomy site. The operating surgeon usually divided the pulmonary vessels and bronchus under direct vision through the minithoracotomy site. For mediastinal lymph node dissection, the surgeon dissected the lymph nodes under monitor guidance. The resected lung was removed in a surgical bag. The skin incision was lengthened anteriorly when open thoracotomy was required.

The stage of disease was based on the TNM classification of the International Union Against Cancer; tumors with p2 (penetration through to the surface of the visceral pleura) were classified as T2, tumors with p3 (involvement of the parietal pleura) as T3, and tumors that had intrapulmonary metastasis within the same lobe as T4.13 All of the patients were followed up by CT examination every 3 to 6 months after surgery.

We evaluated the number of procedures converted to open thoracotomy and the reasons for conversion, the duration of surgery, intraoperative blood loss, interval between surgery and chest tube removal, length of postoperative hospital stay, pathologic stage, postoperative complications, mortality rate, prognoses, and patterns of recurrence. Local recurrence was defined as recurrence at the surgical margin or lymph node metastasis within the operated thoracic cavity. All the patients take respiratory function test in seventh postoperative day before discharge. The chest tube was removed if the drainage volume was < 300 mL/d and no air leak was observed. We counted the number of the cracked lymph nodes as a one united lymph node. The probability of survival in patients with NSCLC after VATS major pulmonary resection was estimated by the Kaplan-Meier method.14


   Results
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
VATS major pulmonary resections were completed in 95 patients, whereas in 11 patients (10%) we needed conversion to open thoracotomy. The reasons for conversion to thoracotomy were mediastinal lymph node involvement (five patients), massive bleeding (two patients), containing cancer in the surgical margin (two patients), adhesions (one patient), and anomaly of the pulmonary vein (one patient). The anatomic locations of the lobes or segments resected by VATS are shown in Table 1 . We performed lobectomy in 86 patients, segmentectomy in 8 patients, and bilobectomy in 1 patient. Of the 95 patients with primary lung cancer in whom VATS was successfully completed, 93 patients also underwent systematic mediastinal lymph node dissection. In the remaining two patients, mediastinal lymph node dissection was contraindicated because of the patients’ poor medical condition (low respiratory function) and their old age (79 years old and 83 years old, respectively). The mean number of lymph nodes dissected was 21. Table 2 shows the histologic diagnoses of the lung tumors. The tumor pathologic stages of the 93 patients with lung cancer who underwent systematic lymph node dissection are shown in Table 3 . The pathologic diagnosis was N0 in 79 patients (85%), N1 in 9 patients (10%), and N2 in 5 patients (5%). The maximum diameter of tumors ranged from 0.8 to 7.0 cm (mean, 2.6 cm). Four patients were classified with T4 disease, due to intrapulmonary metastasis in the same lobe (three patients) or pleural dissemination (one patient). The mean duration of surgery was 264 ± 68 min (± SD), and the intraoperative blood loss was 156 ± 139 mL. Seventy-two patients underwent thoracoscopic biopsy of the tumor followed by major pulmonary resection after the diagnosis of malignancy. The mean time to chest tube removal after surgery was 1.1 days (range, 1 to 4 days), and the mean length of postoperative hospital stay in patients without complications was 7.6 days (range, 4 to 15 days). There was one perioperative death (1%), an 82-year-old man who died of pneumonia 23 days after surgery. Postoperative complications developed in nine patients (9%). Two patients (including the one perioperative death) had postoperative pneumonia. Atrial fibrillation was seen in two patients. Chylothorax, asthma, venous thrombosis, cerebral infarction, and prolonged air leak were observed, each in one patient. In a mean follow-up period of 25 months (range, 6 to 48 months, until July 2003) in 82 patients with NSCLC who could be followed up > 6 months (including the one perioperative death), the 3-year survival rate was 93%; if only patients with pathologic stage I disease (n = 68) were included, the rate was 97% (Fig 1, 2 , ). Disease-free survival at 3 years was 79% in all patients, and 89% in patients with pathologic stage I disease. Tumors recurred in 10 patients (Table 4 ). Six patients had local recurrence: (in the mediastinal or hilar lymph nodes in five patients, and at the bronchial stump in one patient). One of them was the patient who underwent segmentectomy and had recurrence in the mediastinal lymph node 5 months after the operation. There was one patient with pathologic stage I disease with recurrence in the bronchial stump 10 months after the operation, although we confirmed a negative surgical margin at the operation. This patient died 16 months after the operation. There was recurrence in three other patients with pathologic stage I disease, and they were still alive 44 months, 36 months, and 30 months, respectively, after the operation. Distant metastasis was observed in five patients.


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  		Table 1.. Anatomic Location of Lobes Resected by VATS

 

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  		Table 2.. Pathologic Diagnosis of 95 Patients Successfully Treated by VATS

 

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  		Table 3.. Pathologic Stage of Patients With Primary Lung Cancer

 


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  		Figure 1.. Survival curve after VATS major pulmonary resection in 82 patients with clinical stage I NSCLC who could be followed up > 6 months.

 


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  		Figure 2.. Survival curve after VATS major pulmonary resection in 68 patients with pathologic stage I NSCLC who could be followed up > 6 months.

 

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  		Table 4.. Sites of Recurrence, Stages, and Histologies in 10 Patients

 

   Discussion
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
Several studies have shown that VATS major pulmonary resection is superior to open thoracotomy in terms of postoperative pain, pulmonary function, and cytokine release.123458 These results mean that VATS is a less invasive procedure than open thoracotomy. However, some groups have pointed out the technical problems of VATS with regard to adhesions, fused fissures, and massive bleeding. We needed to switch to open thoracotomy in 11 patients (10%); the frequency of conversion was similar to those in previous reports (6 to 19.5%).15161718 One of the technical reasons for conversion to open thoracotomy in our study was massive bleeding (in two patients). In these patients, by pressing the bleeding point with a sponge stick we could easily control the bleeding during the conversion to open thoracotomy. For patients with largely fused fissures, we conducted a unique approach to each lobe to complete the VATS lobectomy without any difficulty, as described before.11 Therefore, we consider that intraoperative massive bleeding and the presence of fused fissures are not major problems in VATS lobectomy. We previously reported our intraoperative data on anterior limited thoracotomy.8 In terms of operating time, blood loss, number of lymph nodes resected, and duration of chest tube drainage, there were no significant differences between VATS and anterior limited thoracotomy.

The operative mortality in VATS major pulmonary resections has been reported to be zero to 2.7%.1718192021 Our perioperative mortality rate was 1% (one patient), and our morbidity rate was 9% (nine patients). The rate of complications in conventional open thoracotomy has been reported > 15%.2223 These results show VATS is an acceptable and safe procedure.

From an oncologic standpoint, the adequacy of VATS for lung cancer is still controversial, especially when systematic mediastinal lymph node dissection is necessary. It is currently suggested that systematic lymph node dissection may improve local control and prognosis in patients with lung cancer and limited mediastinal lymph node metastases.142425 Sagawa et al,26 in a prospective trial of systematic nodal dissection by VATS, reported that they missed few lymph nodes with VATS as compared with conventional open thoracotomy. We also reported previously that the mean number of lymph nodes dissected by VATS was not significantly different from that by open thoracotomy.8 However, Yamashita et al27 showed that, in pathologic stage I NSCLC, the risk of seeding tumor cells into the circulation was higher with the VATS procedure than with open thoracotomy. They considered that the spatial and visual limitations of the VATS procedure and the need for frequent attempts to pull on the forceps grasping the tumor in the thoracic cavity to get a better view through the monitor might be more likely to disseminate malignant tumors than the type of manipulation that occurs during open thoracotomy. However, some studies192829 have observed good prognoses after VATS lobectomy for early stage lung cancers (78 to 97% 5-year survival for patients with pathologic T1N0M0), equivalent to those provided by open thoracotomy.

Local recurrence was observed in six patients with clinical stage I disease (6%), and their 3-year survival rate was 93% with our VATS procedure. These results were not inferior to the previously reported study30 with open thoracotomy. Local recurrence was observed in three patients with pathologic stage I disease (4%); one of them died after 16 months after the operation, and their 3-year survival rate was 97%. In previous reports, the rate of local recurrence and the anticipated 3-year survival rate in patients with pathologic T1 NSCLC treated with open thoracotomy have been reported to be approximately 6%1031 and 80%,3032 respectively. These results show that VATS major pulmonary resection for lung cancer can produce prognoses equivalent to those with open thoracotomy. We consider that VATS major pulmonary resection is an appropriate procedure in terms of local control of cancer and prognosis, not only in patients with pathologic stage I disease, but also in patients with clinical stage I NSCLC. We conclude that VATS major pulmonary resection is safe and acceptable in patients with clinical stage I NSCLC, although long-term follow- up and prospective studies are required.


   Footnotes
 
Abbreviations: NSCLC = non-small cell lung cancer; VATS = video-assisted thoracic surgery

Received for publication June 10, 2003. Accepted for publication October 30, 2003.


   References
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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