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Role of Video-Assisted Thoracic Surgery in T4 NSCLC

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Role of Video-Assisted Thoracic Surgery in T4 NSCLC 11 Review Article Page 1 of 11 Role of video-assisted thoracic surgery in T4 NSCLC Debora Brascia1, Giulia De Iaco1, Marcella Schiavone1, Samuele Nicotra2, Francesca Signore1, Teodora Panza1, Alessandro Geronimo1, Doroty Sampietro1, Giuseppe Marulli1 1Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, Bari, Italy; 2Thoracic Surgery Unit, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova, Italy Contributions: (I) Conception and design: G Marulli, D Brascia; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Prof. Giuseppe Marulli. Thoracic Surgery Unit, Department of Organ Transplantation and Emergency University Hospital of Bari, Italy. Email: [email protected]; [email protected]. Abstract: For many years, T4 lung tumors have been considered less suitable for surgery, because of their local extension invading central structures or vertebral bodies. To date, many studies have confirmed the advantages in terms of survival of a multimodality approach made up of surgical resection associated with neoadjuvant and/or adjuvant therapy for selected patients with advanced lung cancer. In those patients, in fact, minimally invasive surgery could improve overall survival rates while promoting faster recovery, faster access to adjuvant therapies and preserving a better functionality of the immune system. Because of the difficulty in collecting data on patients with T4 lung tumors amenable to minimally invasive surgery, published evidences only come from case reports which prove the feasibility and the possible advantages of video-assisted thoracic surgery (VATS) procedures. The aim of this literature review is to collect the published experiences of skilled surgeons dealing with T4 tumors invading central structures or chest wall, to analyze concerns and new opportunities of treatment and proving the feasibility and advantages of the VATS approach. Keywords: T4 lung tumors; advanced lung cancer; video-assisted thoracic surgery (VATS); minimally invasive Received: 02 April 2020; Accepted: 03 June 2020; Published: 20 July 2021. doi: 10.21037/jovs-20-93 View this article at: http://dx.doi.org/10.21037/jovs-20-93 Introduction survival rate as the pN factor does, except in the case of the T4 disease, in which survival rates do not statistically differ The eighth edition of tumor, node and metastasis (TNM) in the setting of N1 or N2 node involvement (5). In this classification for lung cancer has defined T4 tumors those stage of the disease, 5-years survival rates range from 22 to >7 cm or invading the mediastinum, heart, diaphragm, great 47% in patients without lymph node involvement and after vessels, trachea, esophagus, spine, recurrent nerve, carina or complete surgical resection (6-13). separate tumor nodule(s) in a different ipsilateral lobe (1). Advantages of the thoracoscopic approach have been Because of the local extension of these tumors invading widely discussed and proved and include decreased central structures or vertebral bodies, for many years they postoperative pain, shorter hospitalization and faster have been considered less suitable for surgery. To date, recovery (14-19). Along with technical and surgeons’ skills many studies confirm the advantage in terms of survival acquirements, video-assisted thoracic surgery (VATS) has of a multimodality approach made up of surgical resection become a challenging opportunity to treat T4 lung tumors associated with neoadjuvant and/or adjuvant therapy for even if published evidence is still sparse. The availability of selected patients with locally advanced lung tumors (2-4). high definition cameras with wide-angle lens, new devices, In NSCLC, the pT factor does not significantly affect more angulated staplers and topical hemostatic tools, © Journal of Visualized Surgery. All rights reserved. J Vis Surg 2021;7:27 | http://dx.doi.org/10.21037/jovs-20-93 Page 2 of 11 Journal of Visualized Surgery, 2021 in fact, has made affordable the thoracoscopic approach Conversion rates vary from 0% to 23% for advanced even for locally advanced tumors (20,21). Under the lung tumors, depending on case selection and surgeon assumption that complex procedures as sleeve lobectomies, expertise (25). Conversion to thoracotomy could be vessel reconstructions, pneumonectomies, and chest wall necessary during VATS procedures for advanced stages; the resections should be done only by skillful surgeons (21), infiltration itself, in fact, can produce massive bleeding or Nakanishi et al. (22) have suggested a learning curve of 25 difficulty in achieving a wide oncological resection forcing cases for minimally-invasive T4 tumors resections for those the surgeon to convert to thoracotomy. Gonfiotti et al. (24) expert surgeons who had already performed more than 100 proved that patients requiring conversion had a significantly VATS lobectomies in their career. higher operative time, blood loss, hospital stay and positive surgical margins, but not a higher overall morbidity rate. Uniportal VATS (u-VATS) has also been proved to be VATS for T4 lung tumors: still few evidences a feasible approach for advanced lung tumors in skillful No randomized controlled trials have been published yet hands. Fan et al. (26) compared open and u-VATS groups in about perioperative and long-term outcomes of VATS their analysis and they found results similar to those above resections for T4 lung tumors. Because of the difficulty in mentioned, with significant differences in median blood collecting data on patients with T4 lung tumors amenable loss, hospital stay and time to access adjuvant chemotherapy to minimally invasive surgery, published evidences only after the operation (29.6 vs. 43.3 days). Gonzalez-Rivas come from case reports which prove the feasibility and the et al. (20) published an analysis on 43 u-VATS resections possible advantages of VATS procedures. Moreover, the for advanced stage of NSCLC compared to 87 resections few existing evidences refer to advanced lung tumors as for early-stage lung cancer. They found no significant defined by the 7th American Joint Committee on Cancer differences between the two groups in terms of in-hospital TNM staging system: tumors greater than 4 cm, T3 and stay, chest tube removal and rate of complications; overall T4 tumors or tumors requiring neoadjuvant therapy (20,21). 30-months survival was 73.7%. Hennon et al. (21) have published results about outcomes after thoracoscopic vs. open thoracotomy resection for VATS, T4 and (neo)adjuvant therapies advanced lung cancer. They proved no statistical differences in median blood loss, operative time, frequency of major The overall survival for patients with stage III NSCLC complications, in-hospital stay and overall survival between is less than 5% after 5 years in those undergoing single the two approaches. The two groups only differ in the modality therapy with either radiotherapy or surgery percentage of patients who could undergo adjuvant therapy alone (27). Induction therapy is considered the standard of postoperatively, which was significantly higher in the VATS care for patients with operable stage III NSCLC (28,29), group (37.2% vs. 5.3%); conversion rate was 23%. Similar with reported 5-year survival rates between 43% (30) and findings have been reported by Chen et al. (23) when 56% (31) in IIIB stage patients who underwent preoperative comparing thoracoscopic vs. open thoracotomy resection chemoradiotherapy. Despite surgeons’ concerns about for advanced lung cancer. Interestingly, they also found adhesions and the difficult hilar and mediastinal dissection, a significant difference between the median blood loss VATS and u-VATS has proved to be feasible and safe and length of hospital stay, in favor of the thoracoscopic procedures also after neoadjuvant therapies, showing no approach. It also seemed that more patients in the VATS differences in perioperative outcomes, 30-day mortality group could tolerate all chemotherapy cycles at the fully and overall survival when compared to open thoracotomy planned dose than those in the open group (51.7% vs. (28,32-34). 42.5%). Gonfiotti et al. (24) published their results on Moreover, VATS approach could also promote a faster 3,266 vs. 454 patients undergoing VATS resections for access to adjuvant therapies and to better tolerate them early and locally advanced lung tumors, respectively. The leading to improved survival rates. This is because VATS hospital stay, mortality and complication rates were not is less invasive and painful for patients, allowing a faster statistically different between the two groups, while VATS recovery. Many studies have highlighted the possible role resections for advanced-stage NSCLC were associated with of VATS in preserving a better functionality of the immune a longer procedure time, higher blood loss and an increased system, because of a less acute inflammatory response incidence of conversion. after a minimally invasive approach (21,35). Additionally, © Journal of Visualized Surgery. All rights reserved. J Vis Surg 2021;7:27 | http://dx.doi.org/10.21037/jovs-20-93 Journal of Visualized Surgery, 2021 Page 3 of 11 or transesophageal ultrasounds could guide the clinicians’ decision. Gdeedo et al. (38)
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