Upstaging and survival after robotic-assisted thoracoscopic lobectomy for non-small cell lung cancer

doi:10.1016/j.surg.2016.08.003

Surgery

Volume 160, Issue 5, November 2016, Pages 1211-1218

Presented at the 11th Annual Academic Surgical Congress in Jacksonville, FL, February 3, 2016.

https://doi.org/10.1016/j.surg.2016.08.003 Get rights and content

Background

Mediastinal involvement in resected non-small-cell lung cancer mandates adjuvant therapy and affects survival. This study investigated lymph node dissection efficacy, lymph node metastasis detection, and survival after robotic-assisted lobectomy for non-small-cell lung cancer.

Methods

We retrospectively analyzed patients who underwent robotic-assisted lobectomy for non-small-cell lung cancer. Survival was assessed through chart reviews, Social Security Death Registry, and national obituary searches. Kaplan-Meier survival curves by clinical and pathologic stage were compared by log-rank and Cox regression analysis.

Results

In 249 patients (mean age, 67.8 ± 0.6 years), mean individual mediastinal lymph nodes retrieved was 7.7 ± 0.3 lymph nodes, with mean of 13.9 ± 0.4 N1+ mediastinal lymph nodes. There were 159 (63.9%) clinical stage I versus 134 (53.8%) pathologic stage I patients, with 67 (26.9%) patients upstaged (20 cN0 to pN1; 17 cN0 to pN2; 4 cN1 to pN2) and 37 (14.9%) downstaged. One-year and 3-year survival rates, respectively, changed between clinical stage I (clinical stage I, 91% and 70%; clinical stage II, 80% and 64%; clinical stage III, 78% and 57%; clinical stage IV, 71% and 45%) and pathologic stage (pathologic stage I, 92% and 75%; clinical stage II, 83% and 73%; pathologic stage III, 75% and 44%; and pathologic stage IV, 67% and 0%).

Conclusion

Mediastinal lymph node dissection during robotic-assisted lobectomy adequately assesses lymph node stations and detects occult lymph node metastasis. Stage-specific survival is affected by upstaging.

Section snippets

Material and methods

This retrospective analysis included prospectively collected data from all patients who underwent R-VATS pulmonary lobectomy, including those who first underwent R-VATS wedge resection followed by R-VATS completion lobectomy and those converted to open lobectomy, for NSCLC by one surgeon at our institution from September 2010 through January 2015. We excluded patients who underwent R-VATS lobectomy for other pathology, such as small-cell carcinoma, pulmonary metastasis, or benign lesions and

Results

A total of 287 patients underwent robotic-assisted pulmonary lobectomy between September 2010 and January 2015. Thirty-eight patients were excluded after the final pathology report, leaving 249 patients with NSCLC for evaluation. The mean age for the final cohort was 67.8 ± 0.6 years, with additional demographics reported in Table I.

The most common pulmonary lobe resected was the right upper lobe (Table II). Our median skin-to-skin operative time was 178 minutes, and our overall conversion rate

Discussion

Analysis of our cohort of patients who underwent R-VATS lobectomy revealed a median skin-to-skin operative time, overall and emergent conversion rates, and rates of major perioperative outcomes comparable to those that have been previously described for R-VATS as well as for conventional VATS and open lobectomy.10, 11, 12 A meta-analysis on robotic-assisted pulmonary lobectomy, including data from 326 patients, showed a pooled average operative time of 215 minutes and overall conversion rate of

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Cited by (39)

The Role of Lung Cancer Surgical Technique on Lymph Node Sampling and Pathologic Nodal Upstaging
2023, Annals of Thoracic Surgery
The role of operative approach in surgical lymphadenectomies and pathologic nodal upstaging for lung cancer remains unclear.
This study retrospectively reviewed patients who underwent lobectomy for non-small cell lung cancer from January 2015 to December 2020 at 16 centers within a statewide quality improvement collaborative in Michigan. Patients were stratified by operative approach, and our primary end points were number of LN recovered, number of LN stations sampled, and rates of nodal upstaging with nodal upstaging defined as a higher final pathologic nodal stage compared with preoperative clinical nodal staging.
A total of 3036 patients were included: 608 (20.0%) with open lobectomies, 1362 (41.3%) with video-assisted thoracoscopic surgery (VATS), and 1233 (37.4%) with robot-assisted thoracoscopic surgery (RATS) lobectomies. Using multivariable logistic regression, study investigators found that VATS was associated with lower rates of nodal upstaging (odds ratio [OR], 0.71; 95% CI, 0.54-0.94; P = .015) and harvesting ≥10 LNs (OR, 0.40; 95% CI, 0.31-0.50; P < .001) as compared with open surgery, whereas no significant difference was found between RATS and open techniques. Compared with open surgery, VATS had lower rates of sampling at ≥5 nodal stations (OR, 0.66; 95% CI, 0.53-0.84; P = .001), whereas RATS rates were higher (OR, 2.38; 95% CI, 1.85-3.06; P < .001).
VATS lobectomies were associated with lower rates of harvesting ≥10 LNs, sampling ≥5 LN stations, and pathologic nodal upstaging compared with open and RATS lobectomies. Compared with open procedures, RATS lobectomies were associated with higher rates of sampling ≥5 LN stations, but there was no significant difference between open and RATS approaches in rates of nodal upstaging or harvesting ≥10 LNs.
Long-Term Oncologic Outcomes After Robotic Lobectomy for Early-stage Non–Small-cell Lung Cancer Versus Video-assisted Thoracoscopic and Open Thoracotomy Approach
2020, Clinical Lung Cancer
Citation Excerpt :
The lymph node harvest is measured by the number of lymph nodes removed, and the rate of upstaging has been exemplary in reported studies, which has been attributed to the ease of precise dissection in remote mediastinal locations using the robotic instruments. Studies have frequently reported lymph node counts that have far exceeded the quality benchmark of harvesting 10 lymph nodes, and the rate of lymph node usptaging has been at least comparable to that of VATS.6,21,22 However, long-term survival and disease control remain the most important objective measures of oncologic efficacy.
Although robotic-assisted lobectomy has been increasingly used for resection of non–small-cell lung cancer (NSCLC), the long-term oncologic outcomes compared with video-assisted thoracoscopic surgery (VATS) and the open thoracotomy approach have remained ill-defined.
Society of Thoracic Surgeons outcomes data and surveillance records of patients with stage I-IIIa NSCLC who had undergone lobectomy by robotic-assisted, VATS, or the open approach at a single center from 2012 to 2017 were reviewed. Propensity score adjustment by inverse probability of treatment weighting was used to balance the baseline characteristics. Recurrence and survival were analyzed and compared by the operative approach.
The inverse probability of treatment weighting-adjusted cohort included 514 patients with NSCLC who had undergone robotic-assisted (n = 245), VATS (n = 118), and open (n = 151) lobectomy, with similar patient and disease characteristics. The minimally invasive procedures were associated with a shorter median hospital length of stay (robotic, 5.2 days; VATS, 4.9 days; open, 7.3 days; P < .001) and 0-adjusted 30-day mortality rate. With a median follow-up period of 45 months, the incidence for locoregional recurrence (robotic, 7%; VATS, 6%; open, 8%; P = .9) and distant failure (robotic, 14%; VATS, 18%; open, 17%; P = .9) was similar. The 5-year overall survival for robotic-assisted, VATS, and open lobectomy was 63%, 55%, and 65%, respectively (P = .56). No difference was found in stage-specific survival for stage I, II, and IIIa. On multivariate analysis, the robotic approach was associated with no differences in overall survival and recurrence-free survival compared with VATS and open lobectomy.
Robotic lobectomy was associated with durable freedom of recurrence and long-term survival equivalent to those achieved with VATS and the traditional open thoracotomy approach.
Propensity-score adjusted comparison of pathologic nodal upstaging by robotic, video-assisted thoracoscopic, and open lobectomy for non–small cell lung cancer
2019, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
The adequacy of LN dissection with minimally invasive thoracoscopic resections has been controversial for as long as they have existed. Most recently, the use of robotic lung surgery is increasing rapidly, and several studies have reported good experiences with LN dissection, and nodal upstaging ranging from 10% to 16.4%.12-14,16,17 The relative ease of LN dissection is credited to the high-definition robotic camera and the wristed robotic instrumentation with increased freedom of motion and maneuverability in the chest.18
To assess the effectiveness of intraoperative lymph node (LN) staging by comparing upstaging between robotic-assisted surgery, video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach for lobectomy for non–small cell lung cancer.
We retrospectively analyzed 1053 patients with clinical stage N0/N1 non–small cell lung cancer who underwent lobectomy at 2 centers between 2011 and 2018. Propensity score adjustment by inverse probability of treatment weighting was used to balance baseline characteristics. The primary end point was LN upstaging.
A total of 911 patients (254 robotic, 296 VATS, and 261 open) were included in the inverse probability of treatment weighting adjusted analysis. The overall rate of LN upstaging was highest with open lobectomy (21.8%), followed by robotic (16.2%), and VATS (12.3%) (P = .03). Mediastinal N2 upstaging was observed in similar frequencies (open 6.9% vs robotic 6.3% vs VATS 4.4%; P = .6). No differences were seen for total LN counts, but were observed in the number of stations sampled (mean, open 4.0 vs robotic 3.8 vs VATS 3.6; P = .001). On multivariate analysis, LN upstaging was lower for VATS compared with open (odds ratio, 0.50; 95% confidence interval, 0.29-0.85), but not different between robotic and open (odds ratio, 0.72; 95% confidence interval, 0.44-1.18). No significant differences were seen in mediastinal N2 upstaging between groups.
Pathologic LN upstaging following lobectomy for clinically N0/N1 NSCLC remains high. Compared with a traditional thoracotomy approach, robotic lobectomy was associated with similar and VATS with lower overall nodal upstaging. A thorough evaluation of hilar and mediastinal LNs remains critical to ensure accurate staging by detection of occult LN metastases.
Long-term oncologic results for robotic major lung resection in non-small cell lung cancer (NSCLC) patients
2019, Surgical Oncology
Citation Excerpt :
Currently, significant studies with long term survival data for NSCLC advanced stage patients, are lacking. Recently, Toosi et al. analyzed the oncological outcomes of 247 NSCLC patients, not only in early stages (134 pI, 44 pII, 59 pIII, 10 pIV), who underwent robotic surgery and reported a 3-year OS of 75%, 73%, 44% and 0% for pI, pII, pIII and pIV respectively [17]. The latest NCCN guidelines, considering the effectiveness of procedure, suggest that minimally-invasive approach should be proposed to all patients whenever possible [18]; for this reason, thanks to the advanced robotic technology and the standardization of surgical procedure, is considerable to extend the indications of robotic surgery also to advanced stage NSCLC patients.
Robotic lobectomy is becoming a widespread surgical procedure in NSCLC treatment, but data on oncologic outcomes is still lacking. The aim of this study was to analyze long term oncologic results of robotic lobectomy for non small lung cancer.
Clinical records of consecutive NSCLC patients underwent robotic major surgery, between January 2010 and December 2015, were collected and analyzed.
We analyzed data of 212 patients (127 male and 85 female), with a median age of 66.3 years. The median follow-up time was 40.3 months (range 4–83).
The median disease free survival was 66.3 months. Free disease survival stage-correlated was 75.6 months for stage I, 42.3 months for stage II, 51.2 months for stage III and 10.3 months for stage IV. The median overall survival was 78.6 months. Overall survival stage-correlated was 82 months for stage I, 73.5 months for stage II, 61.4 months for stage III and 41.3 months for stage IV.
This study suggests high safety level, positive post-operative and oncologic outcomes for patients NSCLC underwent robotic major surgery, also in advanced stages.
Long-term outcomes of robotic versus video-assisted pulmonary lobectomy for non-small cell lung cancer: systematic review and meta-analysis of reconstructed patient data
2023, Journal of Thoracic Disease
A Comparison of Total Thoracoscopic and Robotic Surgery for Lung Cancer Lymphadenectomy
2023, Cancers

View all citing articles on Scopus

: E.M.T. and J.P.F. have had financial relationships with Intuitive Surgical Corporation in form of honoraria as robotic thoracic surgery proctors and observation sites. No other authors have any actual or potential financial or non-financial conflicts of interest to disclose.

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Presented at the Academic Surgical Congress 2016Upstaging and survival after robotic-assisted thoracoscopic lobectomy for non-small cell lung cancer

Background

Methods

Results

Conclusion

Section snippets

Material and methods

Results

Discussion

J Thoracic Oncol

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Semin Thorac Cardiovasc Surg

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Presented at the Academic Surgical Congress 2016
Upstaging and survival after robotic-assisted thoracoscopic lobectomy for non-small cell lung cancer