For stage 1 nonsmall cell lung cancer (NSCLC), lobectomy is the preferred treatment with optimal oncologic outcomes for most patients.1,2 Five-year survival rates range from 45 to 65 percent in those undergoing a lobectomy,2 but only about six percent in those who go untreated.3
Traditionally, lobectomy has been performed with a thoracotomy, which requires a large incision in the chest and the use of a rib spreader to gain visual and physical access to the chest cavity. The use of a rib spreader can result in rib fractures, which are very painful and require several weeks to heal, delaying recovery.
When performed by an appropriately trained surgeon in a high-volume center, video-assisted thoracoscopic surgery (VATS) achieves oncologic outcomes as good as those obtained with thoracotomy in patients with stage 1 NSCLC,4 with decreased pain, reduced hospital length of stay, more rapid return to function and fewer complications.5 For patients with stage 1 NSCLC who have no anatomic or surgical contraindications, the National Comprehensive Cancer Network guidelines recommend VATS as standard of care.5
“More than 95 percent of our surgical cases for stage 1 lung cancers are performed with VATS,” says MUSC Health thoracic surgeon Chadrick E. Denlinger, M.D. “That is far higher than at most U.S. centers that treat lung cancer and on par with most major medical centers across the country.”
VATS uses an endoscopic camera inserted through a 2-cm “port” to visualize the surgical field and special instruments to perform the lobectomy through one or two additional 5-8-cm ports. Surgeons watch a monitor displaying the endoscopic images to guide them as they perform surgery through the small ports. Because a rib spreader is not required and incision sizes are much smaller, patients experience less pain and can resume normal activities much sooner than after a thoracotomy.
“Patients recognize that the incisions are much smaller and the postoperative pain is significantly less,” says Denlinger. “A fair amount of the pain from thoracic surgery comes from spreading the ribs, which we don’t do with VATS.”
The ideal patient for VATS has a smaller, more peripheral tumor. Because VATS causes less surgical trauma, it can be used in patients with NSCLC older than 65 who might not otherwise qualify for surgery, with improved overall and lung cancer–specific survival, decreased intensive care admissions and shorter hospital stays.6 However, patients with more central tumors and those who require reconstruction of the bronchus or pulmonary artery are better served by a thoracotomy.
Whether performed by thoracotomy or VATS, it is crucial that the surgeon harvest sufficient lymph nodes from the affected lung and from the area between the lungs for pathology. Failure to obtain sufficient lymph nodes for analysis can mean missed opportunities for upstaging (e.g., from clinical stage 1 to pathological stage 2 or 3) that could affect treatment, leading to poorer outcomes. Questions about whether VATS could obtain sufficient lymph nodes for proper pathological staging were put to rest by a retrospective study of 4,215 patients with NSCLC from the NCCN database, which showed that most patients undergoing either procedure had sufficient (three or more) lymph node stations harvested for pathology.7
Because they experience less surgical trauma, patients who undergo VATS may be able to better tolerate adjuvant chemotherapy. A recent study reconfirmed that VATS patients experienced significantly less morbidity after surgery than those undergoing thoracotomy and showed that they were more likely to be able to complete a full regimen of chemotherapy without the need for dose adjustments, though differences did not meet statistical significance.8
The bottom line, according to Denlinger, is that VATS resection is the standard of care for stage 1 NSCLC. “If patients are receiving something other than that for routine cancers, it is probably suboptimal,” says Denlinger. “The recovery is slower and return to work is delayed.”
To watch a video interview with Dr. Chadrick E. Denlinger about VATS, visit the MUSC Health Medical Video Center (MUSChealth.org/medical-video) and choose “Oncology” from the dropdown list of specialties.
1 Ginsberg RJ, Rubinstein LV. Lung Cancer Study Group. Ann Thorac Surg. 1995; 60:615-622.
2 Ettinger DS, et al. J Natl Compr Canc Netw. 2010; 8:740-801.
3 Raz DJ, et al. Chest 2007;132:193-199.
4 Berry MF, et al. Ann Thorac Surg. 2014 Jul;98(1):197-202.
5 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Non-Small Cell Lung Cancer. Version 7.2015. Available at NCCN.org.
6 Smith CB. Seminars in Thoracic and Cardiovascular Surgery Summer 2017;
7 D’Amico TA, et al. Ann Thorac Surg. 2011 Jul;92(1):226-31; discussion 231-232.
8 Tane S, et al. Asian Cardiovascular & Thoracic Annals 2015; 23(8):950-957.