Keyhole Rivals Open Surgery for Lung Cancer Resection

Pam Harrison

September 10, 2019

BARCELONA, Spain — Video-assisted thoracic surgery (VATS) for the treatment of early lung cancer leads to better in-hospital patient outcomes than open lobectomy without compromising oncologic outcomes, concludes the largest randomized trial comparing the two surgical strategies.

The results come from a parallel group trial conducted across nine thoracic surgery centers in the United Kingdom.

Pain control was actually superior on day 2 following surgery in the VATS group than it was in the open surgery group, reported lead investigator Eric Lim, MD, from Royal Bromptom Hospital in London.

Length or hospital stay was also one day shorter in VATS patients compared with open surgical controls, and there were fewer in-hospital complications in VATS patients compared with patients treated with open surgery.

Moreover, oncologic outcomes as reflected by median number of lymph nodes harvested, as well as rates of lymph node upstaging, were comparable if not superior in patients managed with the VATS approach compared with open lobectomy, Lim said.

He was speaking here at the IASLC 2019 World Conference on Lung Cancer.  

The Video Assisted Thoracoscopic Lobectomy Versus Conventional Open Lobectomy for Lung Cancer (VIOLET) trial "achieved its positive results without any compromise to early oncologic outcomes in either pathologic complete resection [rates] or upstaging of mediastinal lymph nodes, nor was there any difference in serious adverse events in the early postoperative period either," Lim said in a statement.

VATS Underutilized in the US

VATS has been available as a surgical approach for many decades; in the United States, however, only about 20% of lung cancer patients undergo VATS rather than open surgery.

This is partially a reflection of the surgeon's age and place of practice. As Lim told Medscape Medical News during the press briefing, the simple reason why the keyhole approach seems to be underutilized in the US is that surgeons need to be familiar with the technology.

"For surgeons of my generation — the so-called 'Nintendo' generation — we are used to playing games on a console and watching big screen TVs," he explained.

On the other hand, surgeons who have been doing open surgery for a long time have little incentive to change to VATS, he suggested.

"That is why VIOLET is so important, because it is the first randomized trial that actually demonstrates a whole range of benefits with keyhole surgery," he noted.

In the United Kingdom, VATS is the most popular form of access for lung cancer resection; rates of VATS are at least twice as high in the UK as they are in the US.

Asked to comment on the findings, Giorgio Scagliotti MD, PhD, from the University of Torino, Italy, and past president of the International Association for the Study of Lung Cancer (IASLC),  said he would like to see another clinical study comparing the two approaches before deciding if VATS has any inherent advantages over open surgery.

Scagliotti said he was uncertain as to whether the findings from VIOLET would persuade surgeons in other clinical practices outside the UK to adopt the VATS approach to lung cancer resection.

"I believe the data are real in the context of this specific study," he told Medscape Medical News.

"But I do not believe that the use of VATS is common in other European countries. It is probably used even less than it is in the US — and for sure I can tell you that in Italy, it is not commonly used."

However, study discussant Jessica Donington, MD, University of Chicago Medicine Comprehensive Cancer Center, Illinois, was impressed with both the study design and the way in which it was conducted, calling the recruitment of patients into VIOLET "stellar" and noting that analyses, including those reflecting patient pain levels, were very sophisticated.

"My message to the authors is to congratulate them for this data. It is long overdue, and it clearly shows that VATS is associated with less toxicity and decreased pain while maintaining equivalent oncological outcomes," Donington said. These are all reasonable endpoints upon which surgeons may base their decision about how to approach lung cancer resection, she suggested.

Small Ports vs Large Incision

VIOLET enrolled a total of 503 participants with known or suspected primary lung cancer who were randomly assigned to either VATS (n = 247) or to open lobectomy (n = 256).

As Lim explained, the VATS procedure (also referred to as keyhole surgery) is carried out through small incisions or ports — ranging in number from 1 to 4 — from which a small camera transmits images of the chest onto a video monitor. This helps guide the surgeon throughout the procedure.

Open lobectomy involves a much larger incision so that the surgeon is able to visualize the surgical field. Open surgery also requires that the ribs be spread in order to gain access to the chest, which keyhole surgery does not require.

"We made sure that lymph node harvesting and pain management was standardized and after the operation we put a big dressing over the wound so you couldn't tell if the patient had had a keyhole operation or open surgery," Lim explained.

The quality of the surgery performed during the trial was very good across the nine involved centers, Lim commented. The benign resection rate was low at only 1.2%, as was the in-hospital mortality rate at 1.4%

Over half (58%) of all VATS procedures were done through three ports, but 21% of patients undergoing VATS had the procedure done through a single port.

Conversion rates as defined by allocation to VATS were also low at 5.7%, mostly due to pleural adhesions and bleeding, Lim pointed out.

Oncologic Outcomes Comparable

Oncologic outcomes were comparable between the two treatment groups. For example, the median number of lymph node stations harvested was five in each of the two surgical groups.

The median number of mediastinal node stations harvested was also identical at three in each of the two surgical groups, as Lim noted.

"Surprisingly," however, rates of lymph node upstaging were slightly higher at 6.2% in patients treated with VATS compared with 4.8% for those treated with the more traditional surgical approach.

Rates of complete resection were also virtually identical between the two groups (97.8% in the keyhole group and 97.4% in the open surgical group).

On the other hand, median pain scores as reflected by visual analogue scales on day 2 after the surgery were 3 for those treated with VATS compared with 4 for those treated with open surgery. As Lim emphasized, analysis of postoperative pain was done after adjusting for every single analgesic patients received in the study.

In-hospital complication rates — largely involving the kidneys and infections — were also lower in VATS patients at 32.8% compared with 44.3% for open surgical patients; length of hospital stay was shorter at a median of 4 days for VATS patients vs 5 days for open surgery patients (both endpoints P =.008).

In contrast, there was no difference in rates of serious adverse events between the two groups (8.1% for VATS and 7.8% for open surgery).

The study was funded by the National Institute for Health Research. Lim has disclosed no relevant financial relationships. Scagliotti reports receiving honoraria from Eli Lilly, Roche, Pfizer, AstraZeneca, Novartis, and MSD. Donington reports receiving honoraria from AstraZeneca.

IASLC 2019 World Conference on Lung Cancer: Abstract PL02.06. Presented September 8, 2019.

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