JOURNAL OF CLINICAL ONCOLOGY O R I G I N A L R E P O R T Minimally Invasive Lung Cancer Surgery Performed by Thoracic Surgeons as Effective as Thoracotomy Daniel J. Boffa, Andrzej S. Kosinski, Anthony P. Furnary, Sunghee Kim, Mark W. Onaitis, Betty C. Tong, Patricia A. Cowper, Jessica R. Hoag, Jeffrey P. Jacobs, Cameron D. Wright, Joe B. Putnam Jr, and Felix G. Fernandez A B S T R A C T Purpose The prevalence of minimally invasive lung cancer surgery using video-assisted thoracic surgery (VATS) has increased dramatically over the past decade, yet recent studies have suggested that the lymph node evaluation during VATS lobectomy is inadequate. We hypothesized that the minimally invasive approach to lobectomy for stage I lung cancer resulted in a longitudinal outcome that was not inferior to thoracotomy. Patients and Methods Patients . 65 years of age who had undergone lobectomy for stage I lung cancer between 2002 and 2013 were analyzed within the Society of Thoracic Surgeons General Thoracic Surgery Database, which had been linked to Medicare data, as part of a retrospective-cohort, noninferiority study. Results A total of 10,597 patients with clinical stage I lung cancer who underwent lobectomy were evaluated (4,448 patients underwent thoracotomy, and 6,149 underwent VATS). VATS patients had a more favorable distribution of all health-related variables, including pulmonary function (59% of VATS patients had intact spirometry v 51% of thoracotomy patients; P , .001). Cox proportional hazards models were performed over two eras to account for an evolving practice standard. The mortality risk associated with the VATS approach was not greater than thoracotomy in either the earlier era (2002 to 2008; hazard ratio, 0.97; 95% CI, 0.87 to 1.09; P = .62) or the more recent era (2009 to 2013; hazard ratio, 0.84; 95% CI, 0.75 to 0.93; P , .001). Kaplan-Meier survival estimates of 2,901 propensity-matched VATS-thoracotomy pairs demonstrated that the 4-year survival associated with VATS (68.6%) was modestly superior to thoracotomy (64.8%; P = .003). The analyses detailed above were replicated in a separate cohort of pathologic stage I patients with similar findings. Conclusion The long-term efficacy of lobectomy for stage I lung cancer performed using the VATS approach by board-certified thoracic surgeons does not seem to be inferior to that of thoracotomy. J Clin Oncol 36:2378-2385. © 2018 by American Society of Clinical Oncology INTRODUCTION Over the past two decades, the surgical man- agement of solid organ malignancies has been transformed by the widespread adoption of minimally invasive surgical (MIS) techniques. MIS approaches generally allow patients to recover with less pain, 1 fewer complica- tions, 2,3 and expedited return to their baseline functionality. 4 However, for lung cancer, the nation’ s leading cancer killer, the MIS approach has recently been challenged as being oncologically inferior to the traditional surgical approach (thoracotomy). 5,6 This controversy has been fueled by several large observational reports of radiographically occult lymph node metastases being less likely to be found in the surgical specimens (nodal upstaging) of patients with lung cancer treated using MIS (video- assisted thoracic surgery [VATS]) compared with those treated using thoracotomy. 7-10 The obvious concern is that radiographically occult nodal metastases are being left behind in VATS patients, presumably because the VATS approach does not allow surgeons to perform as complete a surgical lymph node evaluation. Not only would failure to remove lymph node metastases leave patients with residual cancer (itself a poor prognosticator), 11 but potentially more importantly, patients with Author affiliations and support information (if applicable) appear at the end of this article. Published at jco.org on May 23, 2018. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Corresponding author: Daniel J. Boffa, MD, Yale School of Medicine, PO Box 208062, New Haven, CT 06520-8062; e-mail: Daniel.boffa@ yale.edu. © 2018 by American Society of Clinical Oncology 0732-183X/18/3623w-2378w/$20.00 ASSOCIATED CONTENT See accompanying Editorial on page 2361 Appendix DOI: https://doi.org/10.1200/JCO. 2018.77.8977 DOI: https://doi.org/10.1200/JCO.2018. 77.8977 2378 © 2018 by American Society of Clinical Oncology VOLUME 36 • NUMBER 23 • AUGUST 10, 2018 Downloaded from ascopubs.org by 3.236.249.245 on June 16, 2022 from 003.236.249.245 Copyright © 2022 American Society of Clinical Oncology. All rights reserved.