Node-related Upstaging of Lung Cancer Occurs More Often With Open vs Closed Procedures

Non-small cell lung cancer (NSCLC) stage is increased due to discovering a lymph node positive for cancer more often following open chest surgery. The procedure is done for lung lobe resection for early stage lung cancer. The closed chest procedure, which entails less frequent upstaging, is known as video assisted thoracic surgery (VATS). These findings were reported in the Journal of Thoracic Oncology (doi:10.1016/j.jtho.2015.10.007).

Open thoracotomy is the traditional method of choice for surgically removing the tumor and a portion of the lung. This is the standard and often most-effective treatment for early stage lung cancer. VATS is less invasive, has fewer complications, less pain, improved lung function, shorter recovery periods, and lower acute care costs.

The concern with VATS is that incomplete lymph node staging could leave residual cancer. This understaging could alter optimal postsurgical treatment and likely compromise survival.

The research team analyzed the National Cancer Database to identify patients with NSCLC who underwent lobectomy between 2010 and 2011 for tumors smaller than 7 cm and with no apparent lymph node involvement prior to surgery. They compared the occurrence of nodal upstaging with VATS vs open thoracotomy, and upstaging differences between types of surgical centers.

A total of 16 983 lobectomies were performed, with 29.1% using VATS. Among the 4935 VATS performed, 4.9% were performed at community centers, 50% at comprehensive community cancer programs, and 45.1% at academic or research centers.

Nodal upstaging because cancer was discovered in the lymph nodes occurred more frequently with open chest surgery (12.8%) than with VATS surgery (10.3%; P<.001). However, more lymph nodes were sampled when VATS was used. Also, nodal upstaging did not have a statistically significant difference between open and closed surgery when the operation occurred in an academic or research facility.

"Nodal upstaging appears to be affected by facility type, which may represent a surrogate for expertise in minimally invasive surgical procedures," suggested the authors.

"Standardized quality assurance of lymph node staging during VATS lobectomy is needed to achieve the goal of eliminating differences in staging and there needs to be an analysis of differences in long-term survival rates between VATS and open thoracotomy for lobectomy to ensure that minimally invasive approaches provide tumor control equivalent to that provided by open approaches."

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