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Dr. Jack West is a medical oncologist and thoracic oncology specialist who is the Founder and previously served as President & CEO, currently a member of the Board of Directors of the Global Resource for Advancing Cancer Education (GRACE)

 

Video-Assisted Thoracic Surgery (VATS) for Early Lung Cancers
Author
Howard (Jack) West, MD

Historically, surgery for lung cancer has been through an open thoracotomy (thorax = chest; otomy = cutting/slicing), which involves a long incision around the side of the chest, removal of ribs, and spreading of the remaining ribs to get a good view of the area of the operation. Even with the most skilled surgeons, it's a procedure that is rigorous for a patient to get through and has a recovery period typically of weeks. Just as many other surgeries can now be done with video assistance through thin tubes with cameras to help a surgeon see what his happening in the chest through several small incisions, a growing number of thoracic surgeons are becoming trained to do video-assisted thoracoscopic surgery, or VATS. This is generally done through a small incision and a couple of small holes or "ports", just a centimeter or so, through which narrow tubes containing tools and amazingly small, very high quality cameras can be placed:

VATS incisions (click to enlarge)

Among the advantages of VATS vs. an open surgery are the ability to do a surgery as good as a more extensive one (the proponents believe), the ability to convert to an open procedure if there is a need, the ability to still resect lymph nodes, the opportunity to a good cancer surgery with less trauma, pain, and recovery time, and a potential to be better able to give post-operative chemotherapy more easily. One of the problems with the idea of post-operative chemotherapy is that it's very hard for patients to get through it (only about 2/3 of the motivated patients on clinical trials of adjuvant chemo get through a significant amount of it), partly because they are dealing with the recovery from a major surgery, so a less extensive surgery could make it easier to complete further treatments.

On the downside, there is the belief among some that VATS is inferior to an open surgery, that you can't see as much, and it's certainly true that you can't feel as much. Sometimes, with small tumors, a surgeon needs to get in with his or her hands to feel for a small nodule, which can't be done through tools that go through small holes in the chest. It's also generally not feasible for larger tumors -- it has been suggested that 5 cm may be a cut-off. It is also argued that it is not as feasible to perform a thorough lymph node dissection, so this could potentially compromise the outcomes of surgery. And there are certainly only a subset of thoracic surgeons who are well trained to do it, so it's not available everywhere.

The key question is whether it's as good as an open surgery. We have the results of several studies to give us guidance on what to expect from an open lobectomy. Here are the survival curve results, for instance, from a large collection of data on early stage resected patients who underwent open lobectomies (abstract here):

Open thoracotomy results resectable NSCLC

Looking at the results from a recently published large series by McKenna and colleagues (abstract here) of 1100 VATS lobectomies done at Cedars-Sinai Hospital in Los Angeles, the authors published very favorable low complication risks, with less than a 1% mortality (risk of dying from treatment) and a median length of hospitalization of just 3 days, with 20% of patients being able to leave the hospital just 1 or 2 days after surgery. The survival curve from their 12-year experience generally appears to be in the same ballpark as the open surgery experience and is shown here:

VATS Cedars Sinai experience

About 2/3 of the cases in that series were stage I tumors. Looking particularly at stage I cancers, the typical 5-year survival in many series of patients who underwent open thoracotomy was in the range of 60-70%. In the McKenna paper, the 5 -year survival for patients with stage I cancers resected by VATS was 75%, and other VATS series have reported a stage I 5-year survival of 78% (abstract here) and 90% (abstract here). Another article that was just published reviewed the entire published VATS experience in comparison with the open thoracotomy experience for early stage lung cancer and concluded that VATS produced comparable long-term results (free article here).

Like any new surgical technique, good results with VATS depend on working with a surgeon who is well trained in the technique. As experience with this approach increases, it is becoming more accepted and welcomed in the lung cancer community. In a world where there is now much more interest in giving chemotherapy and sometimes radiation after surgery than there used to be, based on mounting evidence of survival benefits, getting patients through a good lung surgery with as little pain and overall recovery time as possible becomes an even more important priority. VATS is not for every situation, but it is an option for more and more patients as this offering becomes more widespread and experience with it makes us all more comfortable that it doesn't compromise cancer treatment outcomes.

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