Video-Assisted Thoracoscopic Lobectomy Is the Preferred Approach Following Induction Chemotherapy

Objective: A video-assisted thoracoscopic surgical (VATS) resection, after induction chemotherapy, has long been considered a relative contraindication. We report our experience with VATS lobectomy after induction chemotherapy for patients with nonsmall cell lung cancer (NSCLC), with propensity-matched group of patients, who underwent an open approach, to determine safety and oncological outcome. Methods: A retrospective review of a prospective database (2002-2014) was performed to identify patients undergoing potentially curative lobectomy for NSCLC after induction therapy. Propensity score matching (age, gender, and clinical stage) was performed (1: 2) to obtain a balanced cohort of patients undergoing VATS resection and thoracotomy. Results: A total of 285 patients underwent lobectomy after induction therapy, 114 were propensity matched (VATS, n= 40, thoracotomy, n= 74). There were no differences in the clinicopathological factors or type of induction therapy (conventional versus targeted) between VATS and thoracotomy groups. Similarly, no differences were found in the number of lymph nodes resected (12 versus 15, P=.94), the number of stations sampled (4 for each, P=.68), or in the rate of R0 resection (95% versus 96%, P=.81) between VATS and thoracotomy groups. Five VATS cases were converted to an open approach because of adhesions. VATS resection was associated with less estimated blood loss (EBL), shorter length of stay (LOS), and a trend toward fewer postoperative complications. There was no difference in 5 years disease-free survival (DFS) between VATS and thoracotomy groups (73% versus 48%, P=.09). Similarly, for patients who presented with cN2, there were no differences between thoracotomy and VATS groups in DFS (P=.37). On multi-variable analysis (MVA), only the clinical N1/2 status [Hazard ratio (HR): 4.86, P<.001] independently predicted poor DFS. Conclusions: A VATS lobectomy is a feasible, safe, and oncologically sound approach after induction therapy for NSCLC. When compared with thoracotomy, VATS lobectomy is associated with lower EBL, shorter LOS, and a trend toward fewer postoperative complications.