Trends and Outcomes in Minimally Invasive Surgery for Locally Advanced Non-Small-Cell Lung Cancer With N2 Disease

Abstract

Few studies examine outcomes by surgical approach in non-small-cell lung cancer (NSCLC) with N2 disease. We examined time trends in surgical approach and outcomes among patients undergoing minimally invasive (MIS, robotic and video-assisted thoracoscopic surgery [VATS]) vs open lobectomy in this patient population. We performed a retrospective analysis of patients from the National Cancer Database diagnosed with clinical Stage IIIA-N2 NSCLC from 2010 to 2016. We examined the yearly proportion of MIS vs open resections. Multivariable regression was used to assess the association of surgical approach with length of stay, unplanned readmissions, 30-day and 90-day mortality. Multivariable Cox proportional hazards modeling was used to assess the association of surgical approach with 5-year overall mortality. We identified 5741 patients who underwent lobectomy for Stage IIIA-N2 NSCLC (459 robotic, 1403 VATS, 3879 open). From 2010 to 2016, the proportion of minimally invasive procedures increased from 20% to 45%. MIS patients, on average, stayed 1 day less in the hospital (95% confidence interval [CI] 0.7, 1.5) and had lower odds of 90-day (odds ratio [OR] 0.74; 95% CI 0.54, 0.99) and 5-year mortality (OR 0.82; 95% CI 0.75, 0.91), compared to open resections. There was no difference in odds of readmission by surgical approach (OR 0.97; 95% CI 0.71, 1.33). Among MIS procedures, robotic resections had lower odds of 90-day mortality (OR 0.42; 95% CI 0.18, 0.97) than VATS. Among patients undergoing lobectomy for locally advanced N2 NSCLC robotic and VATS techniques appear safe and effective compared to open surgery and may offer short- and long-term advantages.

Keywords: Locally advanced non–small-cell lung cancer; Minimally invasive surgery.

Figure 1.

Surgical approach for lobectomy by Stage IIIA N2 disease subtype, 2010–2016; each column displays the percentage of robotic, VATS, and open approaches for each TNM group of Stage IIIA-N2 disease (T1N2M0, T2N2M0, T3N2M0). For every TNM group, the most common was an open approach, followed by VATS and robotic. TNM, tumor node metastasis; VATS, video-assisted thoracoscopic surgery.

Figure 2.

Trends in surgical approach to Stage IIIA N2 NSCLC, 2010–2016. Yearly percent of patients undergoing MIS and Open approaches are shown over the entire study period. The MIS approach increased significantly over time. MIS, minimally invasive surgery (video-assisted thoracoscopic and robotic approach combined).

Figure 3.

Trends and outcomes in minimally invasive surgery for locally advanced NSCLC with N2 disease. Among patients with Stage IIIA N2 disease undergoing lobectomy, the use of MIS approach increased over time. Patients had better 90-day and 5-year survival in the MIS group compared to the open group, suggesting this approach is at least as safe as open surgery in this complex population. MIS, minimally invasive surgery (video-assisted thoracoscopic and robotic approach combined).