Robotic-assisted thoracoscopic surgery for clinically stage IIIA (c-N2) NSCLC-is it justified?

Abstract

Transl Lung Cancer Res 2020 | http://dx.doi.org/10.21037/tlcr-20-647 Work-up as well as management of patients with nonsmall cell lung cancer (NSCLC) and clinically suspicious mediastinal lymph nodes (c-N2) should consider current guidelines (1), although the final implementation differs between several institutions and countries. The authors have selected upfront surgery without prior invasive or non-invasive mediastinal staging and assessed the short-term outcome of robotic assisted surgery (RATS) in comparison to thoracotomy in a multicenter randomized controlled trial (2). No meaningful differences were found in most of the parameters, besides significant differences in intraoperative blood loss, drainage time, and postoperative pain (2). The question, whether these short-term outcome parameters are relevant for the evaluation of treatment quality and efficacy of patients with locally advanced lung cancer, may lead to a controversial discussion, particularly in relation to the more relevant long-term outcome results. Patients and doctors most likely agree that overall(OS) and disease-free survival (DFS) in a lung cancer operation is most important and side effects from surgery such as drainage and hospitalisation time are clearly less meaningful. OS and DFS after surgery for clinical stage III (N2) depends on two main factors, such as complete resection of the tumor, a so called R0-resection and definitive pathological mediastinal lymph node stage. The latter guides the need for adjuvant therapy including adjuvant chemotherapy, targeted treatment, immunotherapy, and radiotherapy. OS and DFS were not assessed in the reported trial but R0 and R1 resection were equal in both groups indicating that radicality of surgery was comparable in both groups, and independent from the approach. This was found already in multiple studies before, which compared video-assisted thoracoscopic surgery (VATS) with thoracotomy in early stage lung cancer up to a tumor size of less than 3 cm (3,4). Furthermore, these studies showed that survival after resection was comparable for both approaches (5-10). In some studies, comprehensive reviews and meta-analyses, VATS was even comparing favorably to thoracotomy with survival advantage for VATS procedure. Two published comparisons of long-term oncologic outcomes of robotic lobectomy for early-stage NSCLC versus VATS and open thoracotomy approach show that RATS lobectomy was associated with durable freedom of recurrence and long-term survival equivalent to those achieved with VATS and the traditional open thoracotomy approach. As presented by the Italian group of Veronesi et al., RATS approach for locally advanced NSCLC with clinically evident or occult N2 is safe and feasible with 3and 5-year OS at 61.2% and 49% respectively (11). In term of radical R0-resection of early stage lung cancer with RATS compared with VATS, there were also no quality issues in the literature and comparison between minimally invasive (RATS and VATS) versus open lobectomy of locally advanced NSCLC achieved a similar R0 resection rate between the groups (12). Editorial