Outcomes of minimally invasive lung resection with concomitant chest wall resection in non-small cell lung cancer (NSCLC)

Introduction

Approximately 5% of patients with newly diagnosed non-small cell lung cancer (NSCLC) will present with chest wall (CW) involvement (1). This population remains small, however poses a unique challenge in the surgical management of NSCLC. Surgical management of NSCLC with CW involvement was first described in 1947, with case reports detailing radical resection of the ribs, CW, and lymph nodes (LNs) in addition to a total pneumonectomy or lobectomy (2). Since this initial description, CW resection has become a treatment standard with an acceptable safety profile (1). The survival of patients with CW involvement is highly dependent on extent of nodal involvement, completeness of resection, and depth of invasion (3).

Surgical treatment of NSCLC with CW involvement has been examined in a limited capacity. A retrospective analysis of 110 patients at a single institution in Italy showed acceptable morbidity and a 47% survival rate for those with N0 disease (4). A similar retrospective review of patients out of Memorial Sloan Kettering demonstrated that among 334 patients who underwent surgery for NSCLC with CW resection, survival was highly dependent on an R0 resection and extent of LN involvement (3). An incomplete resection conferred no curative benefit, and survival among these patients compared to those who did not undergo surgery was almost indistinguishable (3). These data highlight the importance of both the characteristics of the tumor and quality of resection in the survival of patients with NSCLC with CW involvement.

While it is clear that a complete resection in T3N0 disease confers a survival benefit, limited data have examined the manner of resection with respect to survival and outcomes. Historically, surgery in NSCLC with CW involvement was approached in an open fashion. With the increase in popularity of minimally invasive (MIS) techniques, there is a need to research the quality of resection in this specific cohort. The robotic approach offers several advantages, including magnification, precise dissection, and minimizing intraoperative blood loss (5). The ability to spare the overlying chest musculature as well as keeping rib spreading to a minimum, also provides an advantage with postoperative pain levels. A retrospective study in 2023 examining both benign CW tumors and locally advanced lung cancer found acceptable short- and long-term outcomes for those undergoing robotic CW resection (5). Similarly, video-assisted thoracoscopic surgery (VATS) with CW resection has shown comparable outcomes with fewer chest tube days, length of stay (LOS), and reduced postoperative pain (6-9). A retrospective review of 3 patients by Demmy et al. (10) found that thoracoscopic lobectomy with en bloc CW resection is appropriate in select candidates when compared with patients undergoing open or partially open approaches (6). Literature in this population has been largely confined to descriptive case reports and limited sample size. To date, however, no study has directly compared the outcomes of MIS CW resection in NSCLC with open surgery.

In this study, we hope to assess the safety profile and oncologic outcomes of MIS lung resection (video-assisted and robotic) with concomitant CW resection in NSCLC using a large national cohort. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1577/rc).

Methods

This is a retrospective cohort study using the National Cancer Database (NCDB) from 2021. The database is a national cancer registry formed by the American College of Surgeons’ Commission on Cancer and the American Cancer Society. This is an aggregate of cancer data from 1,500 hospitals with Commission on Cancer-accredited cancer programs. Pathologic staging is classified by the current edition at time of diagnosis of the American Joint Commission on Cancer (AJCC) guidelines. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was deemed exempt from the Institutional Review Board approval at Thomas Jefferson University.

The study examined patients >18 years old who underwent MIS (robotic or video-assisted) or open lobectomy or bilobectomy with CW resection for NSCLC, between 2010 and 2020. The study excluded nodal or metastatic disease (Figure 1).

Figure 1 Inclusion criteria flow chart. M, metastasis; N, node; NCDB, National Cancer Database; NSCLC, non-small cell lung cancer.

Patient demographics and outcomes were examined for MIS and open resections. Variables included tumor characteristics, facility information, and comorbidity status [Charleson-Deyo Comorbidity Score (CDCC)]. Outcome variables included 30-day mortality, 90-day mortality, readmission, margins and 5-year overall survival (OS). LN variables, such as the number of nodes examined and nodal upstaging, were also studied. Propensity score matching (PSM) was also done by matching data points based on characteristics, in order to control for possible confounding variables.

Statistical analysis

Data was analyzed using Stata SE 17.0. A P value less than 0.05 was considered statistically significant. Categorical variables, presented as frequencies and percentages, were compared using Chi-squared tests. Patients with missing data were excluded from the final analysis in that specific variable.

Results

A total of 1,722 patients were included in the study; 352 were MIS resections and 1,370 were open resections (Table 1). The average age at diagnosis was 66 (P=0.21). Males made up 59.3% (n=1,022) of the cohort and 40.7% (n=700) were females (P=0.15). White patients made up 85.3% (n=1,469) of the cohort and 9.2% (n=158) were Black (P=0.36). The average tumor size was 4.8 cm (3.2–6.5 cm) in the MIS group and 5.7 cm (4.2–7.3 cm) in open group (P<0.001). There were 47.9% (n=825) of patients who had a CDCC score of 0 and 34.8% (n=599) had a CDCC score of 1 (P=0.08). The proportion of patients treated at an academic facility was 40.7% (n=701), followed by 35.4% (n=609) treated at a comprehensive facility, and 20.6% (n=354) at integrated (P=0.20). Clinical stage I patients made up 35.6% of patients in the MIS cohort and 55.5% were clinical stage II. Clinical stage I patients made up 21.9% of the open cohort and 66.0% were clinical stage II (P<0.001). Surgical inpatient stay was 7 days (4–9 days) among MIS patients and 7 days (5–11 days) among open patients (P<0.001). The P value is significant here due to the interquartile ranges being significantly different.

The 30-day mortality was 5.7% (n=20) among patients who received MIS resection and 2.4% (n=33) among patients who received an open resection (P=0.002). The 90-day mortality was 7.7% (n=27) among patients who underwent MIS resection and 6.7% (n=92) among patients who underwent open resection (P=0.53). Readmission rates were 7.4% (n=26) in the MIS cohort and 8.2% (n=112) in the open cohort (P=0.64). Margins were positive in 15.1% (n=53) of patients who received MIS resection and 18.9% (n=254) of patients who received open resection (P=0.10) (Table 2).

The median number of regional LNs examined was 14 [interquartile range (IQR): 8–22] nodes in MIS resection patients and 11 (IQR: 7–18) nodes in open resection patients (P<0.001). There was nodal upstaging in 15.6% (n=48) of patients in the MIS group and 13.0% (n=153) of patients in the open group (P=0.23). Adjuvant radiation therapy was received in 3.7% (n=13) of MIS resection patients, while 3.2% (n=44) of open resection patients received adjuvant radiation therapy (P=0.65). Adjuvant systemic therapy was received in 7.1% (n=25) of MIS resection patients, while 6.6% (n=91) of open resection patients received adjuvant systemic therapy (P=0.76).

A Kaplan-Meier 5-year OS curve showed no significant difference in 5-year OS between the MIS and open cohorts [MIS: 52.6% (46.97–57.99%); open: 45.3% (42.54–48.04%)] (Figure 2).

Figure 2 Pre-PSM Kaplan-Meier curve. MIS, minimally invasive; PSM, propensity score matching.

A PSM was performed to control for year of diagnosis, sex, age, comorbidity score, histology, and tumor size. This was to adjust for possible confounding variables, specifically histology and tumor size, as these play a significant role in surgical decision-making. The post-PSM cohort had 560 patients: 280 in both MIS and open cohorts. The average age at diagnosis was 68 (P=0.29). Males comprised 58.9% (n=330) of the cohort and females 41.1% (n=230). Tumor size was 4.8 cm (3.4–6.8 cm) in the MIS cohort and 5.0 cm (3.5–6.7 cm) in the open cohort (P=0.77).

Post-PSM 30-day mortality was 6.1% (n=17) in the MIS cohort and 2.1% (n=6) in the open cohort (P=0.02). The 90-day mortality was 7.1% (n=20) in MIS and 6.8% (n=19) in the open cohort (P=0.87). Readmission rates, post-PSM, were 9.0% (n=25) in the MIS cohort and 6.8% (n=19) in the open cohort (P=0.34). Margins were positive in 17.1% (n=48) of the MIS cohort and 18.2% (n=50) of the open cohort (P=0.75). The median number of regional LNs examined was 13 (IQR: 7–21) nodes in the MIS cohort and 11 (IQR: 7–17) nodes in the open cohort, post-PSM (P=0.15). The proportion of patients with nodal upstaging was 15.3% (n=38) of the MIS cohort and 14.6% (n=34) of the open cohort (P=0.82). The proportion of patients who received adjuvant radiotherapy was 4.3% (n=12) of the MIS cohort and 2.9% (n=8) of the open cohort (P=0.36). The proportion of patients who received adjuvant chemotherapy was 7.1% (n=20) of the MIS cohort and 7.5% (n=21) of the open cohort (P=0.87).

The Kaplan-Meier 5-year OS curve, post-PSM, showed no significant difference in 5-year OS between MIS and open cohorts [MIS: 50.9% (44.66–56.90%); open: 45.5% (38.94–51.85%)] (Figure 3).

Figure 3 Post-PSM Kaplan-Meier curve. MIS, minimally invasive; PSM, propensity score matching.

Discussion

In this retrospective study, we found that MIS lung resection with concomitant CW resection did not appear to be associated with worse outcomes than the open approach. In our cohort, we found no significant differences in 90-day mortality and readmission rates between open and MIS approaches for clinical N0M0 NSCLC with CW involvement. Additionally, we found no differences in margin positivity between groups. A MIS approach did demonstrate a comparable overall LOS (7 vs. 7 days, P<0.001), and benefit in number of regional LNs examined (14 vs. 11, P<0.001). There were additionally no differences in receipt of adjuvant radiation or systemic therapy.

In our cohort, there was a significant difference in regional LNs examined between MIS and open approaches. This is in concordance with prior research on robotic and video-assisted lung resection (1). These findings were also seen in a retrospective analysis of 222 patients at a US center comparing robotic segmentectomy or lobectomy to VATS (2). The ROMAN study in 2021 additionally demonstrated a superior LN dissection in robotic-assisted vs. VATS lung resection (3). In this trial, the mean number of LN sampled in the robotic arm was 7.8 compared to 4.5 for VATS (P<0.001) (3). It is evident that there is a growing body of literature supporting the quality of LN dissection in robotic lung surgery (4). The need for this in lung cancer with CW involvement is underscored, as node positivity correlates with deteriorating survival (5). Further research is needed to understand the independent impact of an improved LN dissection on oncologic outcomes in this specific patient population.

In our study population, there were no significant differences in 90-day mortality rates between MIS and open surgery. Prior research has demonstrated improved OS in patients undergoing MIS lung resection compared to open. A retrospective study of 24,257 patients from the 2023 NCDB demonstrated that patients in the robotic and VATS-assisted lobectomy groups had lower 30- and 90-day mortality rates as compared to open (6). Similarly, we found no significant differences in 30-day readmission between MIS and open surgery. Our cohort had a comparable LOS in the MIS arm compared to open. In the prior study, the robotic lobectomy cohort had a significantly shorter LOS compared to open (P<0.001) (6). A 2019 retrospective study out of China, demonstrated a shorter LOS for robotic patients compared to VATS (4 vs. 5 days, P<0.01) (7). These data again highlight the comparable safety profile of video-assisted lung surgery. The robotic approach has additionally at times proven to be superior in these measures. Our data specifically show that these findings are also demonstrated in the context of CW involvement.

In this analysis, the 30-day mortality was higher in the MIS cohort compared to open (5.7% vs. 2.4%, P=0.002). Post-PSM, this was 6.1% vs. 2.1% (P=0.02). One explanation for this is that patients with more severe comorbidities may have been more likely to undergo a MIS resection. This may additionally represent standard variations in modern practice. This database does not provide pulmonary function or performance status of the patients. We do acknowledge that there is no specific way to explain this finding. It is unexpected, given the findings in the remainder of the study. Future analysis may focus on how these measures affect outcomes.

We found no significant difference between cohorts with respect to margin positivity (15.1% MIS, 18.9% open, P=0.10). An R0 resection remains an important factor in survival in this population. Downey et al. noted that even if only microscopic disease is not resected, there is no curative benefit to resection (5). They found that 4% of incompletely resected patients and 0 of unresected patients were alive 3 years after their operation (5). This is compared to 32% 5-year OS in those who had an R0 resection (5). This highlights the importance of the quality of resection on outcomes. It is important to note that certain tumor characteristics may favor an open vs. a MIS approach and therefore influence the rates of margin positivity. For example, our data show that there was statistically significant difference in primary tumor size between MIS and open cohorts (4.7 vs. 5.7 cm, P<0.001). Future research should focus on rates of R0 resection within this population while matching patient and tumor specific characteristics.

Robotic and video-assisted surgery may confer other benefits not highlighted by our data. Previous studies have demonstrated that patients undergoing robotic-assisted pulmonary resection have improved recovery and less pain compared to VATS in the immediate postoperative period (8). Similar findings are seen in a retrospective study of 498 patients in 2017, where a MIS anatomic pulmonary resection was associated with less acute pain and chronic numbness as opposed to open (9). In this study, median chest tube duration was longer, and more perioperative narcotics were used in the open cohort compared to MIS (9). Although this study does not examine CW resection, it may be extrapolated to our cohort to examine the benefit of MIS resections overall. The use of a MIS approach confers the benefit of being able to spare chest musculature and minimize rib spreading, which can contribute to lower pain levels. Future research should examine the above parameters as they specifically relate to lung resection with concomitant CW resection.

As MIS techniques and the robotic approach become more common in lung resection, the question of whether CW invasion mandates an open approach will need to be answered. Not only in a prospective manner when CW invasion is known but also when it is found incidentally at the time of resection. As always, careful and judicious decision-making will lead to optimal outcomes with approach being only one of the many considerations.

Limitations exist in this study population. There is certainly a selection bias as surgeons may be more likely to favor an open approach for specific tumor biology, location or due to patient characteristics. It is likely that surgeons who choose to approach these resections in an MIS fashion are likely highly experienced in this approach. There is a limited sample size in the MIS arm of our cohort compared to the open arm. We are additionally not able to gather any information on disease-free survival or quality of life postoperatively from the NCDB. This data is critical to examining the benefit of one surgical approach over another. The NCDB draws information from hospitals with certain accreditations, which makes the data difficult to generalize. Overall health of the patients in each cohort was stratified by CDCC score, and we are unable to differentiate how comorbid conditions may impact resection choice and quality. There was limited ethnic variability in our cohort.

Conclusions

Our data suggest that a MIS approach to lung resection with concomitant CW resection may demonstrate a similar safety profile and comparable outcomes to open in several outcome measures. We found comparable LOS and improved nodal sampling in the MIS cohort, although tumor size was smaller. Additionally, rates of margin positivity were not significantly different between cohorts. However, we do note an increased 30-day mortality in the MIS group compared to open. Future research in this population should focus on comparing MIS vs. open surgery with respect to postoperative pain, quality of life, and disease-free survival.

Acknowledgments

Part of the article was presented as a poster at the 2025 General Thoracic Surgical Club Meeting.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1577/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1577/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1577/coif). N.R.E. received research funding from the Bristol Myers Squibb Foundation, paid to his institution. He also received speaker and consultant honoraria from Intuitive, Merck, Bristol Myers Squibb, and Astrazeneca. O.T.O. received research funding from the Bristol Myers Squibb Foundation, paid to his institution. He also received speaker honoraria from Intuitive Surgical, Medtronic, Johnson & Johnson. The other 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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hurley PD, Fabbri G, Berjaoui N, et al. Lymph node dissection in lung cancer surgery: a comparison between robot-assisted vs. video-assisted thoracoscopic approach. Front Surg 2024;11:1395884.
2. Deeb AL, De Leon L, Mazzola E, et al. Early adoption of robotic lung resection in an established video assisted thoracic surgery practice. Surg Open Sci 2024;20:189-93.
3. Veronesi G, Abbas AE, Muriana P, et al. Perioperative Outcome of Robotic Approach Versus Manual Videothoracoscopic Major Resection in Patients Affected by Early Lung Cancer: Results of a Randomized Multicentric Study (ROMAN Study). Front Oncol 2021;11:726408.
4. Martin JL, Mack SJ, Rshaidat H, et al. Wedge Resection Outcomes: A Comparison of Video-Assisted and Robot-Assisted Wedge Resections. Ann Thorac Surg 2024;118:683-90.
5. Downey RJ, Martini N, Rusch VW, et al. Extent of chest wall invasion and survival in patients with lung cancer. Ann Thorac Surg 1999;68:188-93.
6. Merritt RE, Abdel-Rasoul M, D'Souza DM, et al. Lymph Node Upstaging for Robotic, Thoracoscopic, and Open Lobectomy for Stage T2-3N0 Lung Cancer. Ann Thorac Surg 2023;115:175-82.
7. Li C, Hu Y, Huang J, et al. Comparison of robotic-assisted lobectomy with video-assisted thoracic surgery for stage IIB-IIIA non-small cell lung cancer. Transl Lung Cancer Res 2019;8:820-8.
8. Qsous G, Downes A, Carroll B, et al. A Comparison of the Differences in Postoperative Chronic Pain Between Video-Assisted and Robotic-Assisted Approaches in Thoracic Surgery. Cureus 2022;14:e31688.
9. Kwon ST, Zhao L, Reddy RM, et al. Evaluation of acute and chronic pain outcomes after robotic, video-assisted thoracoscopic surgery, or open anatomic pulmonary resection. J Thorac Cardiovasc Surg 2017;154:652-659.e1.
10. Demmy TL, Nwogu CE, Yendamuri S. Thoracoscopic chest wall resection: what is its role? Ann Thorac Surg 2010;89:S2142-5.