Robotic Approach to Lobectomy Safe and Feasible for Stage II–IIIA NSCLC

Video-assisted thoracoscopic surgery (VATS) is established as a safe and feasible approach to lobectomy in more locally advanced non–small cell lung cancer (NSCLC) and the early stage of the disease. More recent studies suggest robotic lobectomy for locally advanced NSCLC has short-term outcomes similar to open and VATS lobectomy.

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Chi-Fu Jeffrey Yang, MD, and Lana Schumacher-Beal, MD, of the Division of Thoracic Surgery at Massachusetts General Hospital, and colleagues recently became the first to compare short-term outcomes and long-term survival after open, VATS and robotic lobectomy for stage II–IIIA NSCLC.

One of the principal conclusions, reported in The Annals of Thoracic Surgery, is that VATS and robotic lobectomy were associated with similar 30-day mortality, 30-day readmission, and five-year overall survival rates.

Methods

The researchers searched the National Cancer Database, which collects information from >1,500 U.S. cancer centers. They identified 24,648 patients who underwent a lobectomy for clinical stage II or IIIA NSCLC (excluding T4 tumors) between 2010 and 2017:

• Open (n=15,311)
• Minimally invasive surgery (MIS)—VATS (n=6,836, 73%) or robotic (n=2,501, 27%)

To reduce selection bias, the team used propensity-score matching to construct well-matched groups in baseline characteristics. They compared:

• 4,652 patients who had an open approach with 4,652 who had MIS of either type
• 1,186 patients who underwent VATS with 1,186 who underwent a robotic approach

The primary outcome was overall survival from the time of diagnosis.

MIS vs. Open Lobectomy

In the first set of propensity score–matched analyses, the MIS group:

• Did not differ significantly from the open group in 30-day mortality, 30-day readmission rate, nodal upstaging, or nodal downstaging
• Had a shorter hospital stay (5 days vs. 6 days for open; P<0.001)
• Had a significantly higher number of nodes removed (12 vs. 11; P<0.001)
• Did not differ significantly in overall survival

VATS vs. Robotic Lobectomy

In the second set of propensity score–matched analyses, the robotic group:

• Did not differ significantly from the VATS group in 30-day mortality, 30-day readmission, nodal upstaging, or nodal downstaging
• Had a shorter hospital stay (median 4 days vs. 5 days for VATS; P<0.001)
• Did not differ significantly in overall survival

Conversions to Open Surgery

16% of patients in the VATS group versus 9% in the robotic group required conversion to open surgery (P<0.001):

• VATS converted to open—Compared with patients who underwent planned open surgery, there were no significant differences in 30-day mortality, 30-day readmission, median hospital length of stay, nodal upstaging/downstaging, or overall survival in the VATS group
• Robotic surgery converted to open—Compared with patients who underwent planned open surgery, there were no significant differences in 30-day mortality, the median length of stay, or nodal upstaging/downstaging. The 30-day readmission rate was significantly higher for the robotic group (8.2% vs. 4.6%; P=0.01). There was no significant difference between groups in overall survival

Importantly, the institutions represented in the National Cancer Database have a wide range of experience in performing MIS lobectomy for stage II-IIIA NSCLC. Outcomes may be different at institutions that have specialists in MIS.

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