Photo Credit: Mohammed Haneefa Nizamudeen

Researchers compared perioperative complications and survival outcomes in patients who underwent either VATS or open surgery for NSCLC.

Although the benefits of using video-assisted thoracoscopic surgery (VATS) are well-documented, there is still some apprehension in the application of this approach versus traditional open lobectomy after neoadjuvant therapy for non-small cell lung cancer (NSCLC). To address this controversy, Jinlin Cao, MD, and colleagues conducted a multicenter, retrospective analysis to compare patient outcomes after surgery.

“There are limited data on the safety and efficacy of the VATS approach versus the open approach for treatment of NSCLC after neoadjuvant therapy,” Dr. Cao and coauthors explained. “It is paramount to obtain these data, as lymph node dissection performed subsequent to lymphatic metastasis may lead to poor oncological outcomes.”

Therapy Types & Surgical Interventions

The study included 685 patients with primary stage 1-3a NSCLC who underwent neoadjuvant therapy followed by surgical intervention between 2014 and 2020. The National Collaborative Lung Cancer Database, which draws information from 9 hospitals in Beijing, China, was the primary data source for this study.

A total of 436 patients underwent a VATS lobectomy, while 249 had an open lobectomy. For neoadjuvant therapy, 482 of the patients in the study received chemotherapy, 143 received an epidermal growth factor receptor–tyrosine kinase inhibitor-targeted therapy, 60 received chemotherapy combined with immunotherapy or anti-angiogenesis therapy, or treatment was unidentified.

The median follow-up was 24 months (range 0-63 months). Over a 30-day period, no deaths were reported in the VATS cohort, and 2 deaths were reported in the open lobectomy cohort (P=0.255).

In the VATS cohort, patients were more likely to be female, younger, and nonsmokers, with fewer comorbidities and smaller tumors. They were also more likely to be diagnosed with adenocarcinoma. To balance the pool of participants, researchers identified 132 propensity-score matched pairs across both cohorts.

The Benefits of VATS

Patients in the VATS cohort had fewer nodes removed than patients in the open lobectomy cohort. This finding emerged in the entire patient participant group (mean, 17.9 vs 22.2; P<0.001) as well as in the matched cohort (mean, 19.4 vs 22.9; P=0.005). The VATS cohort also experienced better perioperative outcomes, including a smaller loss of blood and shorter hospital stays, compared to the open lobectomy cohort.

Using Kaplan-Meier analysis based on log-rank, researchers determined that VATS lobectomy was associated with an improved overall survival (OS) rate (HR, 2.472; 95% CI, 1.678-3.641; P<0.001) compared to open lobectomy. Propensity-score matching showed no statistical differences in OS between the VATS and open lobectomy cohorts (HR, 1.238; 95% CI, 0.695-2.203; P=0.207).

Cox proportional hazards regression analysis of the whole patient participant group showed a significantly improved OS (HR, 1.997; 95% CI, 1.251-3.190; P=0.004) in the VATS cohort. However, both procedures had similar oncologic outcomes in the matched cohort (HR, 1.496; 95% CI, 0.800-2.797; P=0.207).

“In particular, after adjustment in a multivariable Cox model, only postoperative adjuvant therapy was independently associated with worse OS in the propensity score-matched cohort (HR, 2.637; 95% CI, 1.166-5.960; P=0.020),” Dr. Cao and colleagues noted.

There were no significant differences between cohorts in the duration of surgical procedures, postoperative complications, and Clavien–Dindo classification.

“In the current study, we demonstrated that VATS is useful for lymph node dissection…and that although the VATS group had fewer nodes removed than the open group, the oncological outcomes did not differ between the groups,” the team concluded.

Researchers noted several limitations of their study. The study was not a randomized controlled trial, the rationale driving neoadjuvant therapy selection varied widely between centers, and the types of clinical information available in the database were also limited.

Nevertheless, Dr. Cao and colleagues wrote that their “findings suggest that the VATS lobectomy approach is appropriate for patients with NSCLC who have previously received neoadjuvant therapy.”