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More NSCLC Upstaging Seen With Thoracotomy

By: By Mark S. Lesney, Frontline Medical Communications

03/13/12

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FT. LAUDERDALE, FLA. – Pretreatment staging of presumed N0 non–small cell lung cancer (NSCLC) misses unsuspected lymph node metastases that are subsequently discovered during surgical specimen evaluation in 10%-25% of cases. Thus it is critically important that surgical node dissection be done sufficiently completely to capture these misses, providing the appropriate upstaging for treatment decisions.

With the increasing movement to video-assisted thoracic surgery (VATS) approaches to lobectomy and segmentectomy, it is important to evaluate the comparative efficiency of VATS vs. thoracotomy (Open) in capturing this upstaging.

Martin Allred/Elsevier Global Medical News
VATS led to less nodal upstaging, potentially affecting choice of NSCLC treatment, said Dr. Daniel Boffa

 

To this end, an examination of the Society of Thoracic Surgeons (STS) General Thoracic Database was performed to determine the frequency of nodal metastases identified in clinically node-negative tumors by Open and VATS approaches to compare completeness of surgical nodal dissections, according to Dr. Daniel J. Boffa.

A total of 11,531 clinical stage I primary lung cancers resected from 2001 to 2010 were analyzed from the STS General Thoracic Database. These comprised 7,137 Open and 4,394 VATS procedures.

The researchers found significantly greater nodal upstaging in the Open groups (14.3%) as compared with the VATS group (11.6%).

Dr. Boffa stated that this was primarily due to the significantly greater upstaging from N0 to N1 that was seen in the Open (9.8%) versus the VATS group (7.0%). In contrast, upstaging from N0 to N2 was found to be similar in both groups (5.5% Open vs. 5.2% VATS, a non-significant difference).

Dr. Boffa presented this research at the annual meeting of the Society of Thoracic Surgeons.

When a multivariate analysis controlling for T status, laterality, body mass index, age, and sex was performed, N0 to N1 upstaging remained significantly less common with VATS than with Open surgery.

In a separate analysis, pathologic confirmation of clinical N1 also occurred significantly less often in the VATS group (42%) as compared with the Open group (54%), according to Dr. Boffa, who is an assistant professor of surgery at the Yale School of Medicine, New Haven, Conn.

"Mediastinal nodal evaluation by VATS and thoracotomy results in equivalent upstaging. However, lower rates of N1 upstaging and stage confirmation in the VATS group may indicate variability in the completeness of the peribronchial and hilar lymph node evaluation," according to Dr. Boffa.

"Systematic hilar dissection is encouraged, particularly as more surgeons adopt the VATS approach," he concluded, reiterating the importance of appropriate staging in the planning of patient treatment.

Dr. Boffa presented his research as one of the Richard E. Clark database papers during the STS annual meeting.

Dr. Boffa reported that he had no relevant conflicts of interest.

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