Outcomes of unexpected pathologic N1 and N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I non-small cell lung cancer

Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
The Journal of thoracic and cardiovascular surgery (Impact Factor: 4.17). 12/2010; 140(6):1288-93. DOI: 10.1016/j.jtcvs.2010.06.011
Source: PubMed


The objective of this study was to assess early and late outcomes of pathologic N1 or N2 disease unexpectedly detected in patients undergoing video-assisted thoracic surgery lobectomy for clinical stage I non-small cell lung cancer.
We retrospectively reviewed the clinical and pathologic features of patients with unexpected N1 or N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I disease and their early and late outcomes, including survival and recurrence pattern.
Between 2004 and 2008, 547 patients with clinical stage I disease underwent video-assisted thoracic surgery lobectomy, and of these, 89 were found to have pathologic N1 (n = 49) or N2 (n = 40) disease. No in-hospital mortality was noted during the postoperative period. For patients receiving adjuvant treatment, the median time interval between discharge from surgical intervention and start of adjuvant treatment was 24 days. The median follow-up time was 21.3 months. The 3-year overall survival was 98% for patients with N1 disease and 89% for patients with N2 disease. During follow-up, 33 (37%) patients had a recurrence. The pattern of recurrence was locoregional in 7, distant in 21, and both in 5 patients. The 3-year disease-free survival was 59% for patients with N1 disease and 33% for patients with N2 disease.
For patients with pathologic N1 or N2 disease after video-assisted thoracic surgery lobectomy, survival was comparable with that after lobectomy through a thoracotomy. Even if lymph node metastasis is unexpectedly detected during video-assisted thoracic surgery lobectomy for clinical stage I disease, there is no need to convert to conventional thoracotomy.

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    • "The corresponding outcomes and post-operative treatments for patients in each stage are different. Kim et al.[14] defined minimal N2 as unexpected medistinal lymph nodes metastasis observed during an operation, but undetected in pre-operative evaluations. Minimal N2 patients have better and clearer surgical results than multi-level N2 patients. "
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    ABSTRACT: This study compares early and late outcomes for treatment by video-assisted thoracic surgery (VATS) versus treatment by thoracotomy for clinical N0, but post-operatively unexpected, pathologic N2 disease (cN0-pN2). Clinical records of patients with unexpected N2 non-small cell lung cancer (NSCLC) who underwent VATS were retrospectively reviewed, and their early and late outcomes were compared to those of patients undergoing conventional thoracotomy during the same period. VATS lobectomy took a longer time than thoracotomy (P < 0.001), but removal of thoracic drainage and patient discharge were earlier for patients in the VATS group (P < 0.001). There was no difference in lymph node dissection, mortality and morbidity between the two groups (P > 0.05). The median follow-up time for 287 patients (89.7%) was 37.0 months (range: 7.0-69.0). The VATS group had a longer survival time than for the thoracotomy group (median 49.0 months vs. 31.7 months, P < 0.001). The increased survival time of the VATS group was due to patients with a single station of N2 metastasis (P = 0.001), rather than to patients with multiple stations of N2 metastasis (P = 0.225). It is both feasible and safe to perform VATS lobectomy on patients with unexpected N2 NSCLC. VATS provides better survival rates for those patients with just one station of metastatic mediastinal lymph nodes.
    No preview · Article · Jul 2013 · Annals of Thoracic Medicine
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    • "In the present study, it was not possible to draw conclusions on this topic, since there were no comparisons made with thoracotomic lobectomy. However, according to the Kim et al's [30] results in the past 4 years, and reports by Watanabe et al. [28] over 9 years, there has been no difference in prognosis, and we have concluded that conversion to thoracotomic surgery is not necessary even if N2 lymph node metastasis is observed during surgery. In order to minimize pathologic upstaging, efforts to improve the accuracy of preoperative diagnosis are necessary. "
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    ABSTRACT: Video-assisted thoracic surgery (VATS) lobectomy has been performed with increasing frequency over the last decade. However, there is still controversy as to its indications, safety, and feasibility. Especially regarding lung cancer surgery, it is not certain whether it can reduce local recurrences and improve overall survival. We retrospectively reviewed 1,067 cases of VATS lobectomy performed between 2003 and 2009, including the indications, postoperative morbidity, mortality, recurrence, and survival rate. ONE THOUSAND AND SIXTY SEVEN PATIENTS UNDERWENT VATS LOBECTOMY FOR THE FOLLOWING INDICATIONS: non-small cell lung cancer (NSCLC) (n=832), carcinoid tumors (n=12), metastatic lung cancer (n=48), and benign or other diseases (n=175). There were 63 cases (5.9%) of conversion to open thoracotomy during VATS lobectomy. One hundred thirty one (15.7%) of the 832 NSCLC patients experienced pathologic upstaging postoperatively. The hospital mortality rate was 0.84% (9 patients), and all of them died of acute respiratory distress syndrome. One hundred forty-nine patients (14.0%) experienced postoperative complications. The median follow-up was 22.9 months for patients with NSCLC. During follow-up, 120 patients had a recurrence and 55 patients died. For patients with pathologic stage I, the overall survival rate and disease-free survival rate at 3 years was 92.2±1.5% and 86.2±1.9%, respectively. For patients with pathologic stage II disease, the overall survival rate and disease-free survival rate at 3 years was 79.2±6.5% and 61.9±6.6%, respectively. Our results suggest that VATS lobectomy is a technically feasible and safe operation, which can be applied to various lung diseases. In patients with early-stage lung cancer, excellent survival can be also achieved.
    Full-text · Article · Apr 2011 · Korean Journal of Thoracic and Cardiovascular Surgery
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    ABSTRACT: BACKGROUND: Accurate patient selection is crucial when initiating a VATS (Video Assisted Thoracoscopic Surgery) lobectomy program. Benign and malignant indications comprise different technical problems: while tumor stage and location determine feasibility in malignant cases, severity of adhesions and size and consistency of hilar lymph nodes are limiting factors in benign diseases. METHODS: Based on a retrospective analysis of prospectively collected data on the initial 81 patients, the institutional experience of a recently introduced VATS-lobectomy program with regard to patient selection, lobe-specific technique, and short- (mid-) term results is presented. RESULTS: Stage I non-small cell lung cancer and small intralobar aspergilloma are ideal indications to start a VATS lobectomy program. Conversion rate, mortality rate, major and minor complication rate, and median hospital stay in the study group was 11%, 3%, 5% and 12%, and 9 days, respectively. After a follow-up of median 8 months, 93% of patients with malignant disease have no local or distant tumor recurrence. CONCLUSIONS: Appropriate preoperative workup and careful patient selection are important to keep conversion rate low and morbidity and mortality rates comparable to open surgery. With increasing experience and confidence a stepwise expansion of benign and malignant indications may be considered.
    No preview · Article · Oct 2010 · European Surgery
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