Comparing open and closed chest surgery for early-stage lung cancer: still relevant?

In a remarkably short time—about 15 years—the thoracic surgeon community has moved from great skepticism about minimally invasive techniques to acceptance and progressive adoption. Long et al. are right to point out in the introduction to their study (1) that the dispute created by the arrival of video-assisted thoracic surgery (VATS) was unprecedented. In 1993, when some pioneers published the first results of video-assisted lobectomies (2-6), the Video-Assisted Surgery Study Group (7) wrote “Video-assisted lobectomy remains experimental with the potential for major complications” and concluded that “Further studies will be required to define its precise role in thoracic surgery”. In 2010, 13 years after the first publications (2) and 4 years after the first large series (8) Anthony Yim wondered in an editorial why video-assisted lobectomies raised so much reluctance (9). Gradually, as Long et al. points out, the technique was considered by the American College of Chest Physicians (ACCP) as an acceptable alternative for treating early-stage non-small cell lung cancer (NSCLC) (10) and in 2013 as the preferred technique (11). In a way, thoracic surgeons have confirmed this well-known adage when a new technique appears: the reaction to this technique evolves in three stages: (I) this cannot be done; (II) this should not be done; (III) I can do it.

This preamble may seem a little far from the purpose of this editorial, which is to comment on the work of Long et al., but it is necessary to address one of the points raised by this team: there have so far been only four randomized controlled trials (RCTs) comparing VATS lobectomies to open lobectomies. Their study is only the 5^th and, to my knowledge, 2 others are in progress. The low number of RCTs is well explained by this paradox: on the one hand, expert centres are convinced of the superiority of closed chest surgery and would consider a controlled trial as “unethical” and on the other hand, high-volume centres, which until now have not done VATS, could not, by nature, participate in a trial.

The controlled trial whose results are reported by Long et al. (1) is very interesting both in its results and in the questions it raises. Let’s begin with the results.

The study shows that morbidity and mortality are no different between the two groups. If we assume that the length of hospitalization is an indirect measure of the complication rate, we can observe that it is identical in both techniques (we notice that the average postoperative stay is long—14 and 15 days—compared to some western standards but this is possibly explained by the geographical distance of a part of the patients). The conversion rate is also an indirect indicator of the intraoperative complication rate (12). It is 3.7%, which is low and compares favorably to other large series. Two results reflect the fact that VATS has entered a phase of maturity: the operating time is significantly shorter in the VATS group and the average bleeding is also significantly lower in this group. It is remarkable to note that there was no major bleeding in either group, a difference from a number of retrospective studies (12-16). Indeed, in the European survey, the vascular complication rate was 2.9% and the majority of these complications led to conversion (12). Overall, morbidity in this trial is low, also in the thoracotomy group (10%), whereas it is between 30% and 40% in most studies, including the National Cancer Database (NCDB) analysis of 120,000 patients (17).

Due to insufficient follow-up, the authors have not yet analyzed survival. But from an oncological standpoint, their results confirm the complete resection rate is identical in both groups and mediastinal lymphadenectomy is comparable with the two techniques. A few years ago, some had shown that lymphadenectomy was less radical by thoracoscopy than by thoracotomy (18), but this was probably due to a weaker experience (19) and a less efficient equipment. Most recent studies do not find any significant difference (20,21). It would have been interesting to see if the authors confirmed the results of the Boffa et al. study, i.e., the rate of N1 upstaging is lower after VATS than after open surgery, but this difference disappears after the learning curve (19). In total, it is likely that the study by Long et al. will soon confirm survival is identical, if not superior, between the two approaches, as shown in 2009 by the meta-analysis by Yan et al. (22), whose results were confirmed in 2014 by the study by Paul et al. (23).

In summary, the study confirms that the thoracoscopic approach for major pulmonary resections (MPR) does as well as the thoracotomy approach in terms of morbidity and oncological value, and even better on some points (operative time, bleeding).

But this work raises other questions for the future.

The first question is the real value of this type of study. Theoretically, the multicentric nature of the trial is an advantage since it increases the number of inclusions and its results are closer to real life than those of a unicentric study from a so-called expert-centre. But in practice, this benefit is not so obvious. Indeed, if we can assume that the lobectomy and lymphadenectomy techniques are more or less identical from one surgeon to another, we know that the lobectomy-VATS technique is very heterogeneous by the number of trocars used, by the presence or not of an access incision, by the nature of the video equipment and instrumentation used. This is without considering the potential use of a robot. Also, the comparison is not that of an orange with an apple but of an orange with a wide variety of apples, which introduces a significant bias.

The second question raised by this type of study is its relevance at a time when lung cancer surgery is rapidly evolving and changing, so that what was true yesterday is no longer necessarily true today. Thus, the study was initiated at a time when sublobar resections (SLR) were rarely performed in most centres. However, since the work only concerns early stage tumors, it should have a high rate of SLR, which is not the case. We know that the morbidity of SLRs is less than that of lobectomies (24,25), especially when they are performed by thoracoscopy (26). And we also know that they allow the same survival as lobectomies when performed for early stage tumors and when they are associated with lymphadenectomy (24,27). Knowing that performing complex closed chest segmentectomies is a real challenge for many teams, this will complicate future RCTs.

But the main issue in the near future will not be to compare surgical resection techniques with each other, but to evaluate surgery against non-surgical techniques, such as stereotactic body radiation therapy (SBRT), radiofrequency, cryotherapy and destruction techniques by electromagnetic bronchial navigation (ENB) or any other mean. The comparisons of surgical techniques could then become obsolete. Until this next step is reached, it is advisable to stay focused on the technique that is most mastered by respecting the best compromise between minimally invasive approach and oncological radicality.

Acknowledgements

None.

Footnote

Conflicts of Interest: The author is consultant for an instrument manufacturer (Delacroix Chevalier).

References

1. Long H, Tan Q, Luo Q, et al. Thoracoscopic Surgery Versus Thoracotomy for Lung Cancer: Short-Term Outcomes of a Randomized Trial. Ann Thorac Surg 2018;105:386-92. [Crossref] [PubMed]
2. Walker WS, Carnochan FM, Pugh GC. Thoracoscopic pulmonary lobectomy: early operative experience and preliminary clinical results. J Thorac Cardiovasc Surg 1993;106:1111-7. [PubMed]
3. Giudicelli R, Thomas P, Lonjon T, et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58:712-7; discussion 717-8. [Crossref] [PubMed]
4. Kirby TJ, Mack MJ, Landreneau RJ, et al. Lobectomy--video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995;109:997-1001; discussion 1001-2. [Crossref] [PubMed]
5. Yim AP, Ko KM, Chau WS, et al. Video-assisted thoracoscopic anatomic lung resections. The initial Hong Kong experience. Chest 1996;109:13-7. [Crossref] [PubMed]
6. Roviaro G, Varoli F, Rebuffat C, et al. Video-assisted thoracoscopic surgery (VATS) major pulmonary resections: the Italian experience. Semin Thorac Cardiovasc Surg 1998;10:313-20. [Crossref] [PubMed]
7. Hazelrigg SR, Nunchuck SK, LoCicero J 3rd. Video Assisted Thoracic Surgery Study Group data. Ann Thorac Surg 1993;56:1039-43; discussion 1043-4. [Crossref] [PubMed]
8. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421-5; discussion 425-6. [Crossref] [PubMed]
9. Yim AP. Video-assisted thoracic lung surgery: is there a barrier to widespread adoption? Ann Thorac Surg 2010;89:S2112-3. [Crossref] [PubMed]
10. Scott WJ, Howington J, Feigenberg S, et al. Treatment of non-small cell lung cancer stage I and stage II: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132:234S-242S.
11. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e278S-e313S.
12. Decaluwe H, Petersen RH, Hansen H, et al. Major intraoperative complications during video-assisted thoracoscopic anatomical lung resections: an intention-to-treat analysis. Eur J Cardiothorac Surg 2015;48:588-98; discussion 599. [Crossref] [PubMed]
13. Fournel L, Zaimi R, Grigoroiu M, et al. Totally thoracoscopic major pulmonary resections: an analysis of perioperative complications. Ann Thorac Surg 2014;97:419-24. [Crossref] [PubMed]
14. Flores RM, Ihekweazu U, Dycoco J, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy: catastrophic intraoperative complications. J Thorac Cardiovasc Surg 2011;142:1412-7. [Crossref] [PubMed]
15. Yamashita S, Tokuishi K, Moroga T, et al. Totally thoracoscopic surgery and troubleshooting for bleeding in non-small cell lung cancer. Ann Thorac Surg 2013;95:994-9. [Crossref] [PubMed]
16. Mei J, Pu Q, Liao H, et al. A novel method for troubleshooting vascular injury during anatomic thoracoscopic pulmonary resection without conversion to thoracotomy. Surg Endosc 2013;27:530-7. [Crossref] [PubMed]
17. Rosen JE, Hancock JG, Kim AW, et al. Predictors of mortality after surgical management of lung cancer in the National Cancer Database. Ann Thorac Surg 2014;98:1953-60. [Crossref] [PubMed]
18. Denlinger CE, Fernandez F, Meyers BF, et al. Lymph node evaluation in video-assisted thoracoscopic lobectomy versus lobectomy by thoracotomy. Ann Thorac Surg 2010;89:1730-5; discussion 1736.
19. Boffa DJ, Kosinski AS, Paul S, et al. Lymph node evaluation by open or video-assisted approaches in 11,500 anatomic lung cancer resections. Ann Thorac Surg 2012;94:347-53; discussion 353. [Crossref] [PubMed]
20. Ramos R, Girard P, Masuet C, et al. Mediastinal lymph node dissection in early-stage non-small cell lung cancer: totally thoracoscopic vs thoracotomy. Eur J Cardiothorac Surg 2012;41:1342-8; discussion 1348. [Crossref] [PubMed]
21. D'Amico TA, Niland J, Mamet R, et al. Efficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. Ann Thorac Surg 2011;92:226-31; discussion 231-2. [Crossref] [PubMed]
22. Yan TD, Black D, Bannon PG, et al. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol 2009;27:2553-62. [Crossref] [PubMed]
23. Paul S, Isaacs AJ, Treasure T, et al. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ 2014;349:g5575. [Crossref] [PubMed]
24. Kodama K, Higashiyama M, Okami J, et al. Oncologic Outcomes of Segmentectomy Versus Lobectomy for Clinical T1a N0 M0 Non-Small Cell Lung Cancer. Ann Thorac Surg 2016;101:504-11. [Crossref] [PubMed]
25. Gulack BC, Yang CJ, Speicher PJ, et al. A Risk Score to Assist Selecting Lobectomy Versus Sublobar Resection for Early Stage Non-Small Cell Lung Cancer. Ann Thorac Surg 2016;102:1814-20. [Crossref] [PubMed]
26. Traibi A, Grigoroiu M, Boulitrop C, et al. Predictive factors for complications of anatomical pulmonary segmentectomies. Interact Cardiovasc Thorac Surg 2013;17:838-44. [Crossref] [PubMed]
27. Lutz JA, Seguin-Givelet A, Grigoroiu M, et al. Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer. Eur J Cardiothorac Surg 2019;55:263-70. [Crossref] [PubMed]