Advocate the implementation of video-assisted thoracoscopic surgery lobectomy program for early stage lung cancer treatment: time to transfer from why to how

Doctor Yang et al. (1) did a retrospective analysis of the National Cancer Data Base including a huge number of patients from thousands of hospitals in the United States receiving lobectomy for an early stage non-small cell lung cancer (NSCLC). As a national database, it essentially has an extraordinary multi-institutional spectrum, they compared patient characteristics, short-term and long-term 5 years survival results between the video-assisted thoracoscopic surgery (VATS) group and open thoracotomy group using the propensity score system to reduce the selection bias. The results not surprisingly showed that the VATS group had shorter length of stay after the surgery and noninferior long-term survival when compared with open lobectomy, which is consistent with Higuchi et al. and Kuritzky et al.’s former reports (2,3). The long-term follow-up data further strengthened the therapeutic value of VATS lobectomy in patients with early-stage NSCLC. As to the concern upon oncologic efficiency (4), the author’s study did not show a significant difference in lymph node upstaging between the VATS group and the thoracotomy group, which is different from another report from Decaluwé et al. based on the same database. This is possibly due to the well-performed propensity score analysis that improved the comparability between the two groups. Besides, except for tumor size, tumor location (central versus peripheral) (5) might also be an important cofactor for clinical nodal-negative patients.

The application of VATS technique for lobectomy has been spotlighted for above 26 years (6), a huge number of clinical observational studies have been undertaken since then. However, the debate started with the initiation of VATS in thoracic surgery, concerns mainly focused on the feasibility, safety, lymph node upstaging, perioperative comorbidity and mortality, oncologic result and the long-term follow-up results after the surgery. Several important studies including multi-institutional research and randomized controlled trials (RCTs) have supplied persuading evidence on most of them, except long-term results. Cancer and Leukemia Group B (CALGB) (7) study clearly defined the standard of VATS surgical technique, avoidance of the forcibly rib-spreading, incision shorter than 8 cm and indirect vision of the surgical field became the fundamental character of VATS. This study prospectively verified the technical feasibility and safety of VATS lobectomy for peripheral lung nodules < or =3 cm. Concerning the oncologic results, several studies consistently confirmed the efficacy of the video-assisted approach compared with the open thoracotomy approach (8,9), including RCTs. Scott et al. (10) reported fewer respiratory complications and shorter length of stay. Palade et al. (11) reported beneficial results of VATS approach in terms of performing mediastinal lymph node dissection, compared with open thoracotomy. The RCT of Bendixen et al. (12) reported less postoperative pain and better quality of life after VATS as compared to thoracotomy for the first year after surgery”. The VIOLET RCT Study (ISRCTN13472721: VATS versus conventional open lobectomy for lung cancer) has just finished and the results will supply more evidence on the superiority of VATS group’s quality of life (QOL) 5 weeks after surgery. As to the long-term survival, available data with high-level evidence was limited, Sugi et al.’s (13) monocentric randomized study was the only RCT that evaluated long-term survival, and found similar 5-year survival rates between VATS and thoracotomy. The dispute upon this issue, however, persisted due to the small scale and monocentric nature of this clinical trial. The results from Yang et al.’s study added substantial evidence on this issue.

The application rate of VATS for lobectomy showed an overall growing trend in the last two decades but the growth rate is not as fast as expected (14), a European multinational database showed an application rate of 23% in 2013, and the average rate from 2007 to 2013 is merely 10.4% (15). Yang showed a rate of 21.7% for lobectomy performed by VATS in his article, which cannot be satisfying for the specialty of thoracic surgery. Besides, it’s different from the Society of Thoracic Surgeons (STS) data (44.7%) investigated at the same time which is likely because different institutes contributed to these databases with different cohorts. Recently the STS themselves conducted a penetration study and different 30-day mortality rate have been seen between nonparticipants and STS participants (3.3% versus 1.6%, P<0.001) (16). Differences exist among different institutes also different thoracic surgery societies. Therefore, the generalisability still cannot be derived from Yang et al.’s study, and there might be more surgeons not preferring VATS lobectomy in clinical practice than the current database showing to us.

Why is the utilization rate of thoracoscopic lobectomy still so low after 27 years?

The reasons also changed over time. Cross-sectional Survey on Lobectomy Approach (X-SOLA) study (17) undertook an international survey on thoracic surgeons, there are still surgeons who were not ready to try VATS lobectomy, oncologic concerns persisted due to limited data on its long-term oncologic efficacy, thus 54% of them voted an RCT for VATS lobectomy versus Thoracotomy lobectomy. However, because of the seemly obvious advantages of VATS, a randomized controlled multicenter project is difficult to ensure a blind principle without ethical issues. One imperfect but possible solution would be a well-designed real world study based on a strictly controlled prospective database.

Actually, the debate on the safety and efficacy of thoracoscopic lobectomy has gradually subsided. The latest NCCN guideline explicated minimally invasive surgery (MIS) including VATS or robotic-assisted approaches should be strongly considered with no anatomic or surgical contraindications, and VATS lobectomy for patients with resectable NSCLC have improved early outcomes and without compromise of cancer outcomes (18). The training of VATS lobectomy should be more widely available for thoracic surgeons. Among those surgeons have ever performed less complicated procedures through the VATS approach, 92% reported their willingness to try VATS lobectomy and half of them needed mentorship (17). The situation might be better for the new generation of thoracic surgeons who have more opportunities to attend the VATS lobectomy symposiums and to get individual instruction.

Interestingly, thoracoscopic lobectomy was safer when performed by thoracic surgeons as compared to cardiac surgeons or general surgeons (19), which further demonstrates that professional training is the key to the successful implementation of a new surgical technique. Now our attention should transfer from why we should use this technology to how to widespread the VATS lobectomy training.

Acknowledgments

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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