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VATS lobectomy to treat early-stage non-small cell lung cancer

Andrea McNiel, MS, PA-C; Shanda Blackmon, MD, MPH

Andrea McNiel and Shanda Blackmon practice in the Department of Thoracic Surgery at The Methodist Hospital, Houston, Texas. The authors have indicated no relationships to disclose relating to the content of this article.

The bad news is that in 2008, lung cancer still remains the leading cause of cancer deaths in the United States: almost 162,000 deaths are expected and more than 200,000 new cases are anticipated this year alone.¹ The good news is that as screening modalities such as low-dose spiral CT and molecular markers in sputum become available, the possibility of diagnosing lung cancer in earlier stages is increasing. Earlier diagnosis means improved survival for patients with lung cancer. Surgery at an earlier stage of disease has been proven to be the optimal treatment for non-small cell lung cancer (NSCLC) and can yield a 40% to 70% 5-year survival.²

The traditional surgical approach of thoracotomy with lobectomy for NSCLC is not without significant risk, however; patients may experience infection, bleeding, chronic pain due to nerve impingement, bronchopleural fistula, cardiac arrhythmias, and death. Patients undergoing traditional open resection may also have the start of their chemotherapy delayed by longer postoperative recovery times. Morbidity and mortality rates for open thoracotomy vary according to the age of the patient and the presence of comorbid conditions; morbidity rates range from 30% to 50%, and mortality rates are 4% to 12%.³ As a result, many thoracic surgeons are now advocating the use of minimally invasive video-assisted thoracoscopic surgery (VATS) to perform lobectomies for early-stage primary NSCLC, with the objective of lessening postoperative morbidity while still providing a good oncologic outcome.

This article reviews a case in which this procedure was utilized and provides a brief summary of the benefits, risks, and outcomes for VATS lobectomy as detailed in the current literature.

CASE

A 77-year-old African-American male with a moderate smoking history (20 pack-years) presented to his primary care provider (PCP) with a complaint of chronic cough. He was otherwise in good health. The PCP ordered a chest film, which demonstrated a right upper lobe infiltrate. The patient was given an initial diagnosis of pneumonia and treated with a course of antibiotics. A follow-up evaluation failed to demonstrate resolution of the infiltrate, however, and so a further workup was initiated.

CT of the chest revealed a 2.732.5-cm right upper lobe mass that was suspicious for malignancy (see Figure 1). There was no significant mediastinal or hilar adenopathy. Positron-emission tomography (PET) was also performed, and the PET scan revealed a metabolically active right upper lobe lesion and no other identified disease. CT-guided biopsy of the lesion demonstrated moderately differentiated adenocarcinoma of the lung. Our examination of this patient revealed a relatively healthy gentleman with normal cardiac, pulmonary, gastrointestinal, musculoskeletal, and neurologic findings. Lung function was evaluated with spirometry, which revealed an FEV₁ (forced expiratory volume) of 2.16 L (97% of predicted function). The patient’s cardiac surgical risk was minimal, so we proceeded to VATS right upper lobectomy to resect his clinical stage IA T1N0M0 lung cancer.

The procedure Under general anesthesia, a double lumen endotracheal tube was placed, allowing for single lung ventilation. The patient was placed in the left lateral decubitus position, and normal sterile draping and preparation were performed (see Figure 2). The patient was positioned to lean anteriorly, and the table was flexed to open the intercostal spaces and lower the iliac crest.

Four incisions were made: two 10-mm instrument ports at the fifth intercostal space of the anterior axillary line and the seventh intercostal space posterior to the scapula, a 10-mm camera port at the eighth intercostal space in the anterior axillary line, and a 4-cm working port in the fourth intercostal space (see Figure 3). The location of these incisions for VATS lobectomy varies depending on which lobe is being removed. The larger working port is for placement of large instruments like a stapler and also allows for removal of the lobe once it has been dissected. This incision can be much smaller than a standard “mini-thoracotomy” incision, as the endoscopic instruments allow for good visualization and mobilization of the thoracic structures. The ribs are not spread for this incision.

During the procedure, the right lung was made atelectatic with single-lung ventilation, allowing for good visualization of the hilum. The dissection of the hilum was performed with standard thoracotomy instruments to isolate, in proper order, the pulmonary vein, artery, and bronchus (see Figure 4). The vascular structures were transversed with a 2.5-mm surgical stapler (see Figure 5 and Figure 6); and the bronchus was isolated and transversed with a 4.8-mm surgical stapler. The stapler was placed through the working port to access the hilar structures. Finally, the fissures were divided with additional 4.8-mm surgical staplers.

After the right upper lobe was free from attachments, an endoscopic bag was placed to remove the specimen from the thorax. This technique prevents any chest wall contamination from the tumor. Attention was then turned to the mediastinum, where a complete lymph node dissection was performed by removing the lymph node packages from the paratracheal, subcarinal, inferior pulmonary ligament, paraesophageal, and hilar lymph node stations. The lymph nodes were sent for biopsy. Two chest drains were placed through the inferior chest incisions for drainage of air and blood. The other two incisions were closed in standard fashion.

Postoperative course The patient was transferred to the surgical ICU overnight and transferred to a surgical floor on postoperative day (POD) 1. Pain control was achieved by way of a thoracic epidural with infusion of bupivacaine 0.1% and fentanyl. The patient reported minimal incision pain, which was well-controlled with the epidural. On POD 3, the epidural was removed and the patient was transitioned to oral hydrocodone/acetaminophen. His chest tubes had an air leak, which sealed on POD 4, and the tubes were removed on POD 5. The patient was discharged home in good condition on POD 5. His only complication was a postoperative urinary tract infection, which was treated with oral antibiotics. He has subsequently been examined in clinic twice for routine postoperative visits; he continues to do well and experiences minimal pain (see Figure 7).

DISCUSSION

Although minimally invasive techniques for thoracic surgery have been used for many years, experts have debated the safety of such procedures in cancer surgery because of fears that they might decrease disease-free survival times. After looking at the data, however, it is clear that VATS lobectomy offers outcomes similar to those achieved with open thoracotomy and, when performed in experienced centers, can also lead to decreased postoperative pain, shorter hospital stays, earlier resumption of daily activities, and improved cosmetic results.²

In a retrospective review of 66 patients with clinical stage I primary lung cancer, Nomori and colleagues compared intraoperative factors, such as the number of resected lymph nodes, operating time, and blood loss, as well as postoperative recovery in 33 patients who received VATS lobectomy and 33 control patients who underwent anterior limited thoracotomy.⁴ The authors found no significant difference in any of the factors studied except the amount of postoperative pain. Reported pain (using a visual analog scale) was significantly lower in the group undergoing the VATS lobectomy. (P < .05-.001). Pain remained significantly lower until POD 14, when the pain levels were similar in both groups. The study found no significant difference between length of time for chest tube drainage, postoperative atelectasis, pneumonia, arrhythmia, or wound infection.⁴ Other studies have demonstrated similar outcomes, with an overall decrease in postoperative pain and decreased time until return to preoperative activity, no significant difference in number of dissected lymph nodes, and no differences in postoperative complications such as wound infection or pneumonia or in mortality.^5-7

Although these benefits for patients are important, the most important factor in oncology surgery is increasing patient survival. Lobectomy with complete mediastinal lymph node dissection for early-stage lung cancer is known to improve survival. Does VATS lobectomy perform as well in this regard as open lobectomy? A number of studies have asked this question.^2,5-8

In the study by Nomori and colleagues, the number of resected lymph nodes were similar in the open and thoracoscopic groups.⁴ Additional studies have demonstrated that 5-year survival is similar in patients who receive open lobectomy with complete lymph node dissection and in those who undergo a thoracoscopic procedure.^6-9 A large, Japanese multicenter study looked at 5-year survival outcomes in stage IA lung cancer in 145 patients who underwent either open lobectomy or VATS lobectomy; the researchers found comparable Kaplan-Meier survival at 5 years (96.7% for VATS lobectomy versus 97.2% for open lobectomy).⁷

In addition, intraoperative complications and operative length have not been shown to be significantly different between VATS lobectomy and open lobectomy when the procedure is performed by experienced surgeons, even though the learning curve for VATS lobectomy is steep.¹⁰ Furthermore, morbidity and mortality for VATS lobectomy is reduced when the procedure is done in experienced centers. A recent publication from investigators for the prospective, multicenter Cancer and Leukemia Group B 39802 trial looking at outcomes for VATS lobectomy found that postoperative morbidity was 7% and mortality was 2.7%.³ Minimally invasive surgery also appears to reduce tissue damage and decrease impairment of immunologic function—and thus possibly improve delivery of chemotherapeutic drugs to the tumor site postoperatively.^6,7

Careful preoperative evaluation is critical when deciding whether to perform VATS lobectomy. The indications for a VATS procedure include tumors smaller than 6 cm and a negative mediastinal lymph node evaluation either by node sampling or imaging studies. Contraindications to VATS lobectomy include the presence of T3 lesions, endobronchial involvement, central (hilar) tumors, and lobar or hilar nodes adherent to pulmonary vessels.² Performing advanced reconstructive procedures like sleeve resections is difficult but possible with VATS lobectomy. The need for chest wall reconstruction precludes thoracoscopic lobectomy because of the large incision required to obtain clear margins and reconstruct the chest wall.

In conclusion, VATS lobectomy has been demonstrated to reduce postoperative pain and allow for earlier return to normal activity when compared to open thoracotomy, and it may improve the delivery of postoperative chemotherapeutic drugs to tissue. Studies have reported decreased postoperative morbidity and mortality in experienced centers. VATS lobectomy also has been shown to have similar oncologic outcomes with regard to survival and time to disease progression when compared to open thoracotomy. In summary, VATS lobectomy has been proven to be an adequate surgical approach to lung cancer and should be considered as a viable approach to treating selected patients with early-stage NSCLC. JAAPA

Steve Wilson, PA-C, department editor

REFERENCES

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