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The Oncologist, Vol. 12, No. 10, 1205-1214, October 2007; doi:10.1634/theoncologist.12-10-1205
© 2007 AlphaMed Press

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Lung Cancer

Indications and Developments of Video-Assisted Thoracic Surgery in the Treatment of Lung Cancer

Piergiorgio Sollia, Lorenzo Spaggiaria,b

aDivision of Thoracic Surgery, European Institute of Oncology (IEO), Milan, Italy; bUniversity of Milan, Milan, Italy

Key Words. VATS • Video-assisted thoracic surgery • Thoracoscopy • Lung cancer

Correspondence: Correspondence: Lorenzo Spaggiari, M.D., Ph.D., University of Milan Faculty of Medicine and Division of Thoracic Surgery, European Institute of Oncology (IEO), Via Ripamonti 435–20141 Milan, Italy. Telephone: 39-2-57489665; Fax: 39-2-57489698; e-mail: lorenzo.spaggiari{at}ieo.it; Website: http://www.ieo.it

Received January 31, 2007; accepted for publication July 24, 2007.

Disclosure: No potential conflicts of interest were reported by the authors, planners, reviewers, or staff managers of this article.


   Learning Objectives
Top
 Learning Objectives
Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 
After completing this course, the reader will be able to:

  1. Discuss the role of thoracoscopy in the evaluation of pulmonary nodules and pleural effusion.
  2. Describe the role of thoracoscopy in the staging of lung cancer.
  3. Discuss the role of thoracoscopy in surgical resection of early-stage lung cancer.

Access and take the CME test online and receive 1 AMA PRA Category 1 CreditTM at CME.TheOncologist.com


   ABSTRACT
Top
 Learning Objectives
 Abstract
Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 
The term video-assisted thoracic surgery (VATS) is used to describe a modern minimally invasive surgical technique that nowadays represents a valid alternative to open procedures (i.e., thoracotomy) for many chest diseases. The VATS approach is presently used in many intrathoracic disorders, but while well established in benign chest disease, its role continues to evolve regarding the management of lung cancer. It is currently considered for the evaluation and treatment of suspected (or known) pleural effusion and in the diagnosis of indeterminate pulmonary nodules, and it has a complementary role to standard cervical mediastinoscopy in the invasive staging of mediastinal lymph nodes. It has also become an accepted approach for resection of peripheral early-stage lung cancer (stage I) in many centers worldwide and considerable experience has been accumulated in respect to this field, but absolute indications have yet to be firmly defined. This paper reviews indications and current data regarding minimally invasive approaches for the staging and treatment of lung cancer.


   INTRODUCTION
Top
 Learning Objectives
 Abstract
 Introduction
Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 
Technical advances during the 20th century have drastically revolutionized surgical practice, and as a result of this fact minimally invasive procedures have gained rapid diffusion. Thoracoscopy has changed a great deal since Jacobaeus [1] first introduced the technique for the management of pleural effusion and tuberculosis (TB) in the early 1900s. The advent of video technology, miniaturized cameras, and new automatic endoscopic stapling devices has expanded the operative possibilities and enabled more complex interventions that previously required open thoracotomy to be accomplished.

The term video-assisted thoracic surgery is used to describe these minimally invasive surgical techniques that nowadays represent a valid alternative to open procedures for many chest diseases. It should be regarded as a part of the basic armamentarium of the new generations of thoracic surgeons. This paper reviews indications and current data regarding minimally invasive approaches for the staging and treatment of lung cancer.


   HISTORICAL PERSPECTIVES
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 
H. C. Jacobaeus, a Swedish internist (interestingly not a thoracic surgeon), is generally accredited with the first endoscopic exploration of the thorax [1–3]. In an article appearing in 1910, he described a procedure that he referred to as "thorakoskopie," reporting the use of a primitive cystoscope to examine the pleural space and facilitate collapse therapy for pulmonary tuberculosis (TB) [1]. For the following 50 years, the technique was applied almost exclusively to treat pleural adhesions and facilitate pneumothorax ("Jacobaeus operation") as optimal treatment for TB, which was very common in that era [2–4].

However "thoracoscopy" is probably older. Grünfeld published an article in 1879 on the history of endoscopy and endoscopic instruments and reported that a certain Dr. Cruise "performed an endoscopic examination of a chest fistula using a binocular device" [5]. Sir Francis Richard Cruise (Dublin 1834–1912) was later considered a pioneer in this field in Ireland and when he died in 1912, Jacobaeus was just at the beginning of his experience [6, 7].

In 1865, The British Medical Journal published a report entitled "Endoscopy," about a meeting where Dr. Cruise presented a "new endoscope," which he used for cystoscopy and other examinations [8]. This instrument was actually a modification of an endoscope developed by the French physician A. J. Desormeaux, presented for the first time in 1853 at the Medical Academy in Paris [9], now ameliorated by improvement in the light source.

In 1866, Dr. Cruise performed a thoracoscopy with a binocular endoscope developed by himself [10]. The case was an 11-year-old girl admitted for a massive left pleural effusion, rapidly becoming infected and evolving in a chronic fistula. The author emphasized the value of regular inspection of the pleural cavity and its essential role in monitoring therapy, and this first published report demonstrates that thoracoscopy (diagnostic evaluation of the pleural space by an endoscope) was performed about 50 years before Jacobaeus.

Similar experiences can probably be attributed to the German Kelling, who performed endoscopic examinations of the abdominal and thoracic cavities in animals independently of Jacobaeus [11]; to the French Bariéty and Coury, even if they did not mention thoracoscopic examinations before Jacobaeus [12]; and to the Danish physician Fenger, who treated gunshot wounds during the French–German war in 1870 [13]. Yet, given the absence of any other published reports before Cruise, we can (thanks to his colleague Gordon) acknowledge Sir Francis Richard Cruise as the first physician to introduce thoracoscopy.

Enthusiasm for the thoracoscopic approach, especially for TB, ended in the late 1950s with the introduction of efficacious medication, and in the subsequent decades it was almost abandoned. It was only at the beginning of the 1990s, with marked and sensational advances in technology combined with general and renewed interest in many fields of surgery toward minimally invasive operations, that thoracoscopy was rediscovered.

It now represents a valid option for many situations, either as a staging procedure or as definitive treatment. The term video-assisted thoracic surgery (VATS) was subsequently introduced to better qualify the more complex procedures that involve conventional endoscopic instruments, a monitor, and small additional incisions for conventional instruments.


   DIAGNOSIS OF INDETERMINATE PULMONARY NODULES
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 
Because of the expanding power of new high-resolution helical computed tomography (CT) scans and the adoption of large-scale screening programs, incidental noncalcified solitary pulmonary nodules are found more frequently.

The potential for malignancy depends on several factors—age, smoking habit, size and growth rate, previous cancer, positron emission tomography (PET) scan behavior. Nevertheless, the most appropriate diagnostic strategy for small (<3 cm) peripheral lung nodules has been debated [14].

Obviously, lesions that can be endoscopically reached are first biopsied during bronchoscopy in order to obtain a diagnosis; but, unfortunately, this is not the routine case for small peripheral nodules without histological characterization.

Promising results were recently demonstrated by Schwarz et al. [15, 16] with the new technology of electromagnetic navigational bronchoscopy (SuperDimension®; SuperDimension Ltd, Herzliya, Israel). The technique is based on real-time three-dimensional CT images and on virtual bronchoscopy and has been shown to be a safe and effective tool, capable of reaching peripheral lung lesions beyond standard endoscopic vision.

This modern technique revealed encouraging results and has shown great potential in improving the diagnostic accuracy of standard bronchoscopy, but it still needs confirmation in large-scale studies.

Nevertheless, for small-sized lesions beyond the reach of the bronchoscope, at present, percutaneous CT-guided needle biopsy is the alternative less invasive option, and can represent, in selected situations, a specific diagnostic maneuver.

Controversy regarding its use is based on: (a) the false-negative rate, which is as high as 29% [17] and approaching 60% among patients with nonspecific benign cytological findings [18]; (b) an incidence of pneumothorax of up to 30%, although only a minority of patients require further treatment [17–22] (chest tube in 5%–7% of cases developing pneumothorax); and (c) philosophically, many physicians consider the technique as superfluous and expensive and as an intermediate step with potential morbidity and only a small impact on definitive treatment [23–25].

It has been reported that percutaneous biopsy avoids the need for subsequent surgery in only about 10% of patients who are physiologically able to directly undergo surgical resection [23]. In fact, if the lesion is proven to be malignant, surgery is indicated; if the lesion is diagnosed as nonspecific benign, surgical excisional biopsy is also considered.

Our current attitude is to recommend percutaneous biopsy only for patients with compromised cardiopulmonary function who cannot tolerate surgery and are assigned to alternative therapies, for centrally located isolated nodules or large lesions inaccessible by thoracoscopy, and finally for patients with otherwise inoperable oncologic disease who only need histological confirmation.

In contrast, patients with suspicion of potentially resectable lung cancer are considered for VATS excisional biopsy as a first diagnostic approach, thus rendering the maneuver the gold standard for diagnosis and, in selected cases, treatment of pulmonary nodules [18, 24–28].

Whenever a malignant primary tumor is found on frozen section, the patient is then submitted for thoracotomy and formal anatomic resection (Fig. 1). On the other hand, if a real benign or metastatic lesion is found, the morbidity of an exploratory thoracotomy is avoided.


Figure 1
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  		Figure 1. Computed tomography scan showing a positron emission tomography scan–negative coin lesion in the right upper lobe. This 63-year-old lady underwent a video-assisted thoracic surgery biopsy and the nodule proved to be malignant on frozen section. During the same anesthesia, a thoracotomy with lobectomy and nodal dissection was performed, and the final diagnosis was adenocarcinoma with bronchioloalveolar carcinoma components (pT1N0M0 stage IA).

 
A recent Spanish prospective study demonstrated a diagnostic power of 100% with no mortality and conversion to thoracotomy or cumulative morbidity in <5% of cases [29].

Recent reviews on this topic reveal that, as surgical morbidity and mortality decline, the strategy of proceeding directly to VATS is expected to become more effective than other diagnostic approaches [17].

Even for experienced surgeons, difficulties might be anticipated for very small nodules (i.e., a screening-detected lesion <10 mm in diameter) or for nonimmediate peripheral lesions (>5 mm in depth under the pleural surface), and the thoracoscopic localization of these small and central nodules is challenging. In this instance, visualization during thoracoscopy might become nearly impossible, and several localization techniques have been described: (a) needle wire vital or blue dye, (b) fluoroscopy-aided, (c) endofinger, (d) intraoperative CT, (e) finger palpation, (f) intrathoracoscopic ultrasound, (g) the radio-guided technique, and (h) real-time CT. A recent paper focusing on this issue [24] concluded that it is impossible to establish the superiority of one localization technique over the others or a gold standard for localizing pulmonary nodules, but the ultrasound technique appears to be preferable, in experienced hands, because it has been shown to have similar accuracy, compared with the other methods, without complications.

Similarly, a recent paper by Stiles et al. [22] reported remarkable results with the use of radiotracers (CT-guided injection of radiotracer solution, intraoperative thoracoscopic radioprobe localization, and excisional biopsy). This is the largest reported experience with the technique, capable of successful localization of the nodule in 96% of cases.


   MALIGNANT PLEURAL EFFUSION
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 
Evidence of pleural effusion concomitant with a proven or suspected lung cancer is a common occurrence and requires careful evaluation, considering that approximately 40% of such effusions are found to be malignant [30, 31].

About one half of the patients with metastatic disease develop malignant effusion during their medical history, with lung cancer being the most common neoplastic primary malignancy, followed by breast cancer and lymphoma. The prognosis in this case is very poor, with reported 1- and 6-month mortality rates of 54% and 85%, respectively [32, 33], and a mean survival time after effusion of <6 months [34, 35], ranging from 2.5 months for patients with lung carcinoma to 7 months for patients with breast carcinoma [36]. The main symptoms at diagnosis are dyspnea, pain, and cough, and they might be present even with only a small amount of pleural fluid (<500 ml), dramatically affecting exercise ability and quality of life [37].

VATS remains the most effective tool for patients with anticipated fluid in the pleural cavity on CT study, and offers the chance to both investigate the pleura and efficaciously palliate symptoms (chemical pleurodesis) at the same time.

Compared with the VATS approach, less invasive nonsurgical techniques (thoracentesis, pleural needle biopsy) for malignant pleural effusions have a lower overall diagnostic yield that is around 62% with cytology from the effusion, 44% with needle biopsy, and 95% with thoracoscopy, with the latter having a significantly higher sensitivity [38]. When these techniques are combined, then needle biopsy with cytological results from effusions was positive in 74% of cases, whereas all methods taken together were diagnostic in 97% of cases; value for thoracoscopy alone was 95%. Similar results were reported by a number of other investigators [39–42].

The diagnostic power of the VATS approach appears to overcome the problem of the up to 40% of patients with undetermined pleural effusions that are eventually found to be malignant after previous inconclusive cytologic evaluation for those in whom thoracoscopy proved to be effective in identifying the malignant etiology in nearly 90% of cases. In a series by Boutin et al. [38] of 1,000 consecutive patients with pleural effusions, 215 cases remained undiagnosed after repeated pleural fluid analyses and performance of pleural biopsies. This is in agreement with the results of several other authors who, without the use of thoracoscopy, reported that at least 20%–25% of pleural effusions remain undiagnosed [43, 44].

The superior capability of VATS is related to the extension of the exploration, the opportunity to discover any suspicious area along the entire pleural surface, and the ability to take larger and more representative biopsies, including biopsies of the visceral and diaphragmatic pleura, which are possible only under direct visualization, as well as producing more accurate intraoperative and pathological staging (Fig. 2).


Figure 2
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  		Figure 2. Computed tomography scan showing a 5-cm adenocarcinoma of the left lower lobe with associated homolateral pleural effusion and suspicion of chest wall invasion. Prior to thoracotomy the patient underwent video-assisted thoracic surgery exploration with pleural biopsy. This ascertained the absence of malignant pleural effusion, and without evidence of chest wall infiltration, pulmonary resection was subsequently accomplished.

 
In the case of large malignant lesions, VATS can clarify whether the tumor has spread to the pleura or if effusion is secondary to venous or lymphatic obstruction or to atelectasis or is a result of associated pneumonia [28]. This might result in both a reduction in the number of exploratory thoracotomies and the determination of operability.

Some authors have advocated the use of routine primary "video operative staging" [45–49] in all lung cancer cases just immediately before thoracotomy as conclusive judgment on resectability. In one study, 5% of otherwise operable non-small cell lung cancer (NSCLC) patients were spared unnecessary thoracotomy because previously unsuspected pleural metastatic deposits were found on routine prethoracotomy VATS inspection [50].

The other advantage—if pleural involvement is ascertained (stage T4)—is that it allows for the simultaneous administration of talc powder, thus resulting in homogeneous pleurodesis under visual control (compared with the talc slurry technique), which is currently considered the best option [51].


   STAGING OF MEDIASTINAL LYMPH NODES
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
VATS Major Pulmonary Resections
 Conclusion
 References
 
Among its different diagnostic indications [52–55], VATS also has been reported to provide accurate histological staging in lung cancer patients [56, 57] regarding mediastinal nodal assessment.

For patients with NSCLC showing enlarged lymph nodes on CT scan and/or metabolic deposits on PET scan images in the mediastinum, cervical mediastinoscopy is still considered to be the primary diagnostic tool for the evaluation of bilateral paratracheal and subcarinal adenopathy associated with a presumed or known lung cancer (evaluation of the upper mediastinum).

A limitation of standard cervical mediastinoscopy is its lack of ability to access suspected nodes when located in the anterior mediastinum (aortopulmonary window station #5 and para-aortic area #6) as well as in the paraesophageal station (#8) and in the pulmonary ligament (#9). This is especially mandatory in patients with left upper lobe or lower lobe tumors, respectively, which can spread to these stations at an earlier time.

Although, in this instance, additional approaches are available—at least for the anterior mediastinum (station #5 and #6)—many surgeons refer both to the extended cervical mediastinoscopy technique popularized by Ginsberg et al. [57] or to anterior mediastinotomy, also known as the Chamberlain procedure [58, 59]. VATS offers a reasonably more extensive view of the pleural cavity and can be considered as an alternative to either of these procedures to assess nodes in anatomic locations that are otherwise inaccessible by standard cervical mediastinoscopy [18, 20, 60–63].

Every mediastinal station, except the paratracheal nodes #2 and #4 on the left side, but including the pulmonary ligament and paraesophageal stations, can be clearly visualized and dissected for biopsy during VATS [52, 61], and in this sense it might be considered as complementary to, rather than a substitute for standard cervical mediastinoscopy.

The efficacy of VATS for station #5 and #6 nodal biopsy has been documented, and diagnostic accuracy rates of 92%–100% have been reported [63–66].

Despite these unquestionable advantages, routine staging of the node (N) factor by VATS is not carried out in all thoracic surgery departments, in favor of alternative approaches.

There are only a few reports available in the literature on the systematic use of VATS in mediastinal nodal staging [61, 62, 67, 68]. Regarding this topic, Roberts et al. [66] mentioned that VATS helps to establish the diagnosis of N2 involvement of the #8 and #9 nodes, especially in patients with lower lobe tumors and negative cervical mediastinoscopy.

A combination of standard cervical mediastinoscopy and VATS was also reported to increase the sensitivity of detection of lymph node metastases by Mouroux et al. [68] in inconclusive cases.

Finally, Landreneau et al. [17] reported their experience with the VATS approach in the evaluation of 55 lung cancer patients with enlarged nodes identified in the aortopulmonary window (n = 39) or the lower right subazygous plane (n = 16). The VATS approach identified positive nodes in 62% (n = 34) of patients who were assigned to neoadjuvant or definitive chemotherapy according to the local extent of disease, whereas immediate conversion to surgical resection was undertaken in all node-negative patients. At thoracotomy, the negative nodal status determined by the VATS assessment was correct in all but three of the remaining 21 patients. The authors concludes that primary VATS staging of suspicious mediastinal lymph nodes inaccessible by standard cervical mediastinoscopy offers the chance to correctly stage and treat patients with lung cancer, and in most circumstances avoided unnecessary exploratory thoracotomy.

Beside the use of VATS for the staging of mediastinal nodes, the endoscopic esophageal ultrasound–guided fine needle aspiration (EUS-FNA) technique and the endobronchial ultrasound–guided FNA technique were recently introduced for the evaluation of mediastinal involvement in NSCLC [69, 70].

Those authors concluded that mediastinoscopy and EUS-FNA should be considered complementary in their diagnostic reach, with EUS providing optimal access to lymph nodes located adjacent to the esophagus in the left paratracheal area (station #L2 and #L4), the aortopulmonary window (#5), the subcarinal area (#7), and the lower mediastinum (#8 and #9). In contrast, EUS has its limitations in visualization of the paratracheal area on the right (station #R2 and #R4) because of intervening air between the esophagus and the nodes in these areas, and therefore, mediastinoscopy remains the technique of choice.

In that study [69], the authors reported that the combination of EUS-FNA and mediastinoscopy identified more patients with tumor invasion or lymph node metastasis (36%) compared with either mediastinoscopy alone (20%) or EUS-FNA alone (28%), thus indicating that 16% of thoracotomies could have been avoided by using EUS-FNA in addition to mediastinoscopy.

They concluded that these preliminary findings suggest that EUS-FNA, when added to mediastinoscopy, improves the preoperative staging of lung cancer because of the complementary reach of EUS-FNA in detecting mediastinal lymph node metastases and the ability to directly assess mediastinal tumor invasion.

The role of these techniques is also under evaluation in restaging the mediastinum after induction chemotherapy in patients receiving pretreatment cervical mediastinoscopy [71].


   VATS MAJOR PULMONARY RESECTIONS
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
Conclusion
 References
 
Lung resections, in general (lobectomies in particular, but also even sleeve lobectomies or pneumonectomies have been reported), should be considered among the most complex and challenging operations to be performed thoracoscopically, and although many thoracic surgeons have occasionally done VATS resections, there are still only a few centers in Europe, Japan, or the U.S. where these procedures are routinely considered for the treatment of patients with early-stage lung cancer.

Lobectomy has been one of the most controversial VATS procedures since it was first performed in 1992 [72, 73]. So far, thousands of VATS lobectomies have been performed in many centers worldwide and more than a decade has passed. The impact of the procedure, however, remains unclear, and it is far from achieving widespread use. There are still strong proponents and solid opponents of VATS lobectomy as a cancer operation.

The expectation for minimally invasive procedures is that if the same operation can be performed safely via "keyhole" surgery, rather than through a more or less muscle-sparing thoracotomy, the patient will experience less pain, a shorter hospital stay, an earlier return to full activity, preserved pulmonary function, a lower inflammatory response, and a lower rate of postoperative atrial fibrillation [74–76].

Nevertheless, these presumed advantages over open surgery have neither been clearly assessed nor demonstrated in a systematic review of the evidence from randomized trials, rendering it impossible to make recommendations for best practice or to provide guidance for wider application of this minimally invasive technique [77–80].

The only accepted indication is for stage I lung cancer, with specific contraindications for lesions invading the chest wall, the fissure, the pericardium, or the diaphragm, or in the case of previous chemo- or radiotherapy. Some authors have proposed elective use in elderly patients and in patients with poor performance status, advocating better tolerance than an open procedure [81, 82].

Even the exact definition of the surgical procedure is controversial, and it includes a broad spectrum of operative techniques that ranges from complete endoscopic surgery to a "utility minithoracotomy" with the thoracoscope serving only as a light source and with the major operative maneuvers being performed by direct visualization with video assistance (better classified as "video-assisted" VATS lobectomy).

Although mass ligation of the hilar structures has been reported [82], this technique is not normally accepted in favor of individual isolation and suture of the vessels and bronchus, as in open surgery and as described by the proponents of this minimally invasive approach.

According to an international survey by Yim et al. [83], only 30% of surgeons never spread the ribs to perform a "pure endoscopic" VATS lobectomy, using a utility incision of 4–6 cm just to retrieve the specimen at the very end of the procedure, with visualization on the monitor (and not through the incision) and always using trocars and using only endoscopic instruments. The remaining surgeons are familiar with the so-called "video-assisted" procedure that also includes the use of conventional instruments (not necessary through trocars), carrying out the operation by also looking directly through a minithoracotomy incision and not only at the monitor, with or without a specific rib-spreader.

Results from large series show a very low mortality rate (Table 1), with an overall incidence of complications that is almost the same as, or even better than, published results for lobectomy via thoracotomy.


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  		Table 1. Reports from reported series of video-assisted thoracoscopic lobectomy

 
In a recent paper from McKenna et al. [84], the mortality rate was 0.8%, and 84.7% of patients had an uneventful postoperative outcome without complications. Similar results have been previously reported and are summarized in Table 1.

Other fields of comparison are: (a) the duration of the surgical procedure, which proved to be equivalent for experienced surgeons [77–80, 85] with a lower mean blood loss in favor of the VATS procedure [86, 87, 81]; (b) the length of the postoperative course, which, according to the recent review by McKenna et al. [84], appears to be the same or shorter for the endoscopic approach; and (c) the overall hospital costs, as measured by anesthesia charges, laboratory charges, and hospital charges, which are also reported to be lower with the VATS approach [88].

In terms of postoperative pain, all the available randomized prospective reports [77, 85, 89], except for a paper by Kirby et al. [78], demonstrated a general advantage of the endoscopic procedure over muscle-sparing thoracotomy [89]. Several nonrandomized series also reported less postoperative pain after VATS [74, 86, 87, 90–98]. Sugiura et al. [85] reported a shorter time that an epidural catheter was needed, while Demmy and Curtis [86] reported that pain 3 weeks postoperatively was dramatically better, thus stating that VATS lobectomy is less painful and may offer faster recovery, especially for the frail or high-risk patient.

Another specific aspect is related to the immunological impact that is expected after minimally invasive procedures. There are two papers focusing on this topic and showing a lower release of proinflammatory and anti-inflammatory cytokines. Although the release of tumor necrosis factor {alpha} (TNF-alpha) and interleukin (IL)-1ß was minimal for both groups, the levels of IL-6, IL-8, and IL-10 were higher in the open group, as was that of C-reactive protein [99, 100].

In the end, the main area of concern is the uncertainty regarding the oncologic effectiveness of the thoracoscopic approach.

Proponents suggest that, from a technical point of view, in the hands of skilled thoracoscopic surgeons, VATS lobectomy should consist of the same operation with nodal sampling or dissection as is performed with standard thoracotomy. Thus, despite the large series published, and although there are no prospective randomized studies comparing survival after open and thoracoscopic surgery, there is no evidence to support a difference. In their opinion, and according to published series of extensive experience with thoracoscopic lobectomy reporting stage-specific survival, this was proven to be at least equivalent to that seen in historical series [74, 76, 85, 101–103].

Recently, Shigemura et al. [103] demonstrated that even the effectiveness of thoracoscopic mediastinal lymph node dissection could be compared, and was in accordance with similar previously reported results [74, 76, 101].

In contrast, a recent review by Sedrakyan et al. [76], considering the only three available prospective randomized trials, concluded that it is not possible to make recommendations for best practice or to provide guidance for the wider application of thoracoscopic lobectomy. The evidence from randomized controlled trials of the benefits associated with VATS for lobectomy is controversial, with no studies reporting a substantial advantage.

Sugi et al. [77] found no difference in survival after VATS versus conventional surgery for lung cancer (90% versus 93% at 3 years and 90% versus 85% at 5 years). Two other studies [79, 80] reported information on outcomes of interest and found no substantial differences between the groups, except for fewer air leaks found in the study by Kirby et al. [78].

A Cancer and Leukemia Group B (CALGB) protocol sponsored by the Surgery Modality Committee is ongoing at the present time (the CALGB 140501 trial). It is a cooperative registry study with the aim of exploring the outcomes of patients with stage I lung carcinoma subjected to VATS lobectomy versus open surgical procedures. The protocol is accruing 450 cases and results will be available in the future [104].

There is still uncertainty surrounding evidence for the application of VATS, and further studies should determine if long-term results are comparable with those achieved with conventional thoracotomy.


   CONCLUSION
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
References
 
VATS has developed considerably over the past decade, to the point that nowadays many thoracic surgical procedures are being performed on a regular basis.

VATS is recognized as an accepted approach for many intrathoracic diseases previously requiring a thoracotomy, for a definitive diagnosis or for appropriate therapeutic management. This is accomplished with small wounds, a short hospital stay, and less pain according to the concept of minimally invasive surgery.

Its roles in the evaluation of peripheral indeterminate pulmonary nodules, the diagnosis and palliation of malignant pleural effusion, and in selected cases for additional evaluation and/or extensive staging of mediastinal lymph nodes have been firmly acknowledged, while its use in lung cancer resection (i.e., pulmonary lobectomy) is still a matter of debate.

Future studies and ongoing trials will clarify the exact role of such an approach for early-stage lung cancer in the next few years, presumably demonstrating not only the expected clinical equivalence compared with standard techniques but even favorable results in the oncological outcomes of patients.

The different proposed techniques have still not been universally standardized, and there are only a few experienced surgeons worldwide, with the available published large series reporting advantages over conventional open procedures and in oncological results.

Hypothetically, thoracoscopic lobectomy should consist of the same operation that is done with a standard thoracotomy, and results from the available published large series with data on long-term survival have proven it to be at least equivalent to historical series. In contrast, the lack of prospective randomized studies prevents supporting recommendations for best practice or providing guidance for wider application of this minimally invasive technique in lung cancer at present.


   REFERENCES
Top
 Learning Objectives
 Abstract
 Introduction
 Historical Perspectives
 Diagnosis of Indeterminate...
 Malignant Pleural Effusion
 Staging of Mediastinal Lymph...
 VATS Major Pulmonary Resections
 Conclusion
 References
 

  1. Jacobaeus HC. Über die Möglichkeit, die Zystoskopie bei Untersuchung seröser Höhlen anzuwenden. Münch Med Wochenschr 1910;40:2090–2092; In German.
  2. Jacobaeus HC. Die Thorakoskopie und ihre praktische Bedeutung. Ergebn ges Med 1925;7:112–166.
  3. Jacobaeus HC. The cauterization of adhesions in artificial pneumothorax therapy of tuberculosis. Am Rev Tuberc 1922;6:871–897.
  4. Braimbridge MV. The history of thoracoscopic surgery. Ann Thorac Surg 1993;56:610–614.[Abstract]
  5. Grünfeld J. Zur Geschichte der Endoskopie und der endoskopischen Apparate. Medizinische Jahrbücher, K.K Gesellschaft der Árzte, Wien: Wilhelm Braumüller, 1879:278.
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