Breakthrough for VATS in Early Lung Cancer?

BARCELONA -- Video-assisted thorascopic surgery (VATS) matched open lobectomy for surgical and early oncologic outcomes in early-stage lung cancer and did so with less pain, fewer in-hospital complications, and a shorter hospital stay, a randomized trial showed.

Both surgical techniques were associated with low in-hospital mortality and rates of benign resection. The extent of lymph node sampling was identical, and complete resection rates (R0) exceeded 97% with each technique.

Patients who underwent VATS had significantly less pain by the second postoperative day despite receiving less pain medication. On average, patients randomized to VATS left the hospital a day earlier than those who underwent open surgery.

"VATS lobectomy is associated with less pain, significantly lower in-hospital complications, leading to a shorter length of stay," Eric Lim, MD, of the Royal Brompton Hospital in London, reported here at the World Conference on Lung Cancer. "This was achieved without any compromise to early oncologic outcomes or serious adverse events, compared to open thoracotomy and lobectomy for early-stage lung cancer."

Importantly, the frequency of lymph node upstaging from clinical N0 or N1 to pathologic N2, a reflection of the quality of lymph node dissection, was higher with VATS than with open thoracotomy, he noted.

The results made a compelling case for VATS as the preferred approach to lobectomy for early lung cancer, suggested Jessica Donington, MD, of the University of Chicago Lurie Comprehensive Cancer Center.

"I think going forward that we cannot accept thoracotomy as a standard of care for early-stage lung cancer," she said during an invited review of the trial. "Our patients need to have minimally invasive resections. Not only as surgeons but as the lung cancer community, we need to push this going forward."

She had special praise for the lymph node upstaging data, noting that multiple published studies in this decade consistently showed lower rates of lymph node upstaging with VATS.

"N1 upstaging has been the Achilles heel of VATS lobectomy," said Donington. "As we look back on that data, it probably had a lot more to do with our early going on the VATS learning curve and the limitation of the technology itself. I think these numbers are important, not only for this analysis, but as our discussions evolve to comparisons between VATS and robotics or traditional VATS versus single-hole."

Limited Randomized Data

Available since the 1990s, VATS has a mixed following in the surgical community despite its attractive underlying premise: Smaller incisions without rib spreading (limiting trauma to soft tissue and intercostal nerves) lead to improved recovery. Case series and observational studies have provided much of the supporting data, as a limited number of randomized trials yielded conflicting evidence on pain and in-hospital outcomes, Lim noted.

Investigators in the U.K. Thoracic Surgery Research Collaborative sought to conduct the largest-ever multicenter randomized trial of VATS, bolstered by high-quality design and good statistical power. The trial, known as VIOLET, involved patients with known or suspected early-stage lung cancer (cT1-3, cN0-1, M0). Randomization was stratified by surgeon to reduce variation and allow each surgeon to act as his or her own control, Lim continued.

VATS was defined as surgery through a telescope with instruments in as many as four "keyhole" incisions without rib spreading. Open surgery comprised direct visualization through a single thoracotomy incision, with or without rib resection, with rib spreading. Lymph node dissection and pain management were standardized for both procedures.

The trial's primary outcome was physical function at 5 weeks, a "holistic" measure that captured recovery after surgery. Lim reported the in-hospital outcomes for 503 randomized patients.

Overall, the trial had a benign resection rate of 1.2% and in-hospital mortality of 1.4%. VATS most often was performed with use of three ports (58%), and 21% of the procedures were performed with a single port. Conversion to open surgery occurred in 14 cases, most often because of pleural adhesions and bleeding, said Lim.

In the open-surgery group, surgeons performed posterolateral thoracotomy in 70% of cases. Surgery was performed without muscle sparing in 52% of cases.

Key Findings

Patients rated pain on a visual analog scale. Noting that pain "is a function of the total amount of analgesics required to achieve the score," Lim said investigators used regression analysis for pain scores on days 1 and 2, adjusted by the type of analgesic patients received.

Patients in both groups had a median pain score of 4 on day 1. The median declined to 3 in the VATS group by day 2 but remained at 4 in the open-surgery group (P=0.044). A treatment/time interaction analysis confirmed the significant difference in favor of VATS (P=0.043).

VATS procedures led to a 4-day median length of stay versus 5 days for the open surgery. The difference translated into a hazard ratio of 1.34 in favor of VATS (P=0.006).

"What this means is that at any point in time after surgery, patients who underwent VATS were more likely to leave the hospital," said Lim.

With respect to early oncology outcomes, both groups had a median of five lymph node stations harvested and three mediastinal node stations. Lymph node upstaging occurred more often with VATS, 6.2% vs 4.8%, but the difference did not achieve statistical significance. Complete resection occurred in 97.8% of VATS patients and 97.4% of patients who had open surgery.

VATS was associated with a 26% reduction in the relative risk of in-hospital adverse events (32.8% vs 44.3%; HR 0.74, 95% CI 0.66-0.84, P<0.001). Serious adverse events occurred in 8% of each group.

The results should persuade even hard-core skeptics of the potential advantages of VATS, according to Ramon Rami-Porta, MD, PhD, of Hospital Universitari Mutua Terrassa in Barcelona.

"I think the results will make those surgeons who are still reluctant to do VATS lobectomies more comfortable with the procedure," Rami-Porta told MedPage Today. "I think these results have the potential to change practice, especially for surgeons who do not perform VATS."

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