NcXHF

SURGICAL MANAGEMENT OF STAGE IIIA NON–SMALL CELL LUNG CANCER
vival times than those who can be treated with lobectomy
alone.
WHEN IS VIDEO-ASSISTED THORACIC SURGERY
APPROPRIATE?
There is increasing data to show that larger pulmonary resections
can be safely performed with a minimally invasive
video-assisted thoracic surgery (VATS) technique and that
VATS is acceptable for stage IIIA disease. Initially, many
characteristics that defıned stage IIIA tumors—including
larger tumor size, involvement of adjacent structures, any
nodal involvement, centrally located tumors, and previous
chemotherapy or radiation—were considered relative contradictions
for VATS. However, increasing VATS experience
demonstrates that even tumors with these features can be
safely resected with a VATS approach. 20
There is also concern that complete oncologic mediastinal
lymph node dissections with VATS are more diffıcult to perform
and, therefore, that patients may receive inferior oncologic
resections. Merritt et al 21 performed a retrospective
review of lymph nodes sampled during VATS versus open
lobectomies for clinical N0 disease. They found signifıcant
differences in the mean number of lymph nodes sampled (15
nodes in open vs. 10 in VATS; p 0.003) and in the percentage
of patients whose tumors were upstaged to pathologic N1
or N2 status (25% after open vs. 10% after VATS; p 0.05).
The difference in pathologic upstaging would lead to important
differences in postoperative treatment and, potentially,
long-term survival outcomes for these patients. 21 Conversely,
others have shown no differences in the number of
total or mediastinal lymph nodes sampled and no differences
in disease-free survival or 5-year overall survival rates between
the two approaches. 22
Multiple nonrandomized studies have retrospectively examined
long-term survival after VATS compared with open
thoracotomy and shown no survival detriment with VATS in
stage IIIA disease. To examine VATS lobectomy, Yang et al 23
compared outcomes in a total of 621 patients. Of these, 67
patients has stage IIIA or greater NSCLC, and a VATS lobectomy
was feasible in 13% of those patients with later-stage
disease. In patients with stage IIIA disease who were undergoing
VATS lobectomy, Yang et al observed a 5-year overall
survival rate of 22% that was not different from the 24%
5-year overall survival rate for patients who underwent open
thoracotomy. 23 However, the study was not randomized, so
the patients selected by the surgeons for VATS lobectomy
likely had smaller disease burdens and, therefore, more favorable
prognoses.
Pneumonectomy in patients with stage IIIA disease also can
be performed via VATS. Battoo et al 24 recently published a report
of an 11-year, single-institution experience comparing
VATS versus an open approach in 107 consecutive pneumonectomies.
Among patients chosen for VATS pneumonectomy,
16% were converted to open. Patients with later-stage disease
made up a large proportion of the study; the fınal pathology was
stage III or stage IV for 27% of all patients who underwent VATS
and 38% of all open pneumonectomies. The authors recognize
that there was likely selection bias, because the study was not
randomized and surgeons would be more prone to offer VATS
to patients who had earlier-stage, less-invasive tumors. In the
open operations, patients received an R1, not R0, resection 23%
of the time, compared with only 10% of the time in the VATS
group, which suggests that patients who had more diffıcult resections,
closer margins, and more invasive disease were offered
open thoracotomies. The 30-day mortality rate was 7.5% for
VATS and was 5.0% for open, but this difference was not statistically
signifıcant. Locoregional recurrence rates were 10% for
both groups of patients, and recurrence at any site was 30% in
the VATS group and 38% in the open group without any statistically
signifıcant differences. Patients with clinical stages III and
IV disease who underwent pneumonectomy did not have different
overall survival rates; the median survival was 60 months
in patients who underwent VATS versus 41 months in those
who underwent VATS but converted to open and 13 months in
patients in the open group. There were also no differences in
overall survival based on pathologic stages III and IV disease.
Rates of median survival were 18 months in the VATS group, 41
months in the VATS-converted-to-open group, and 7 months
in the open group. The longer survival times in patients whose
were chosen to undergo VATS and then were converted to an
open operation reveal the inherent selection bias in the study,
because both groups ultimately had an open thoracotomy. 24
However, it appears that, in a select group of patients with laterstage
III and IV disease, complication rates and long-term survival
outcomes after VATS pneumonectomy were not inferior
to those of open pneumonectomy.
At our institution, we favor an open thoracotomy for patients
with stage IIIA lung cancer, because these patients with
stage III disease have had previous chemotherapy and radiation.
We believe that, in these patients, an open approach
ensures a complete lymph node dissection and optimizes
the opportunity for defınite local control. Without a randomized,
controlled trial, it is diffıcult to make unbiased
outcome comparisons between VATS and open resections.
However, it appears that, in experienced hands,
long-term survival outcomes for carefully selected patients
are no worse with VATS resection than for patients
who undergo an open approach.
MOLECULAR PROFILING IN LATE-STAGE DISEASE
An interesting new area of research in the management of
stage IIIA NSCLC is the molecular profıling of tumors to further
stratify patients by risk. Most of the current literature
surrounding genetic profıling in lung cancer has focused on
predicting recurrence in early-stage disease, but similar assays
may have prognostic value in later lung cancer stages as
well. Molecular assays of biopsy specimens could be used
preoperatively to help guide patient selection for surgery
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