Thoracoscopic Lobectomy Facilitates the Delivery of Chemotherapy after
Resection for Lung Cancer
Rebecca P. Petersen, DuyKhanh Pham, William R. Burfeind, Steven I. Hanish, Eric M.
Toloza, David H. Harpole, Jr and Thomas A. D’Amico
Ann Thorac Surg 2007;83:1245-1250
DOI: 10.1016/j.athoracsur.2006.12.029
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Thoracoscopic Lobectomy Facilitates the Delivery of
Chemotherapy after Resection for Lung Cancer
Rebecca P. Petersen, MD, MS, DuyKhanh Pham, MD, William R. Burfeind, MD,
Steven I. Hanish, MD, Eric M. Toloza, MD, PhD, David H. Harpole, Jr, MD, and
Thomas A. D’Amico, MD
Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
Background. We conducted a study of patients who
underwent anatomic resection with adjuvant chemotherapy to determine if thoracoscopic lobectomy enables
more effective administration of adjuvant chemotherapy
than lobectomy by thoracotomy.
Methods. We reviewed the outcomes of 100 consecutive
patients with non-small cell lung cancer (NSCLC) who
underwent lobectomy and received adjuvant chemotherapy (1999 to 2004). The variables analyzed were time to
initiation of chemotherapy, percentage of planned regimen received, number of delayed or reduced chemotherapy doses, toxicity grade, length of hospitalization, chest
tube duration, 30-day mortality, and major complications
(pneumonia, respiratory failure, atrial fibrillation). The
␹2 test and Student t test were used to compare dichotomous and continuous variables, respectively.
Results. Complete resection was performed by thoracotomy in 43 patients and by thoracoscopy in 57 (no
conversions). All patients received adjuvant chemother-
apy, and 20 (20%) received adjuvant radiation therapy: 13
(30%) of 43 in the thoracotomy group and 7 (12%) of 57 in
the thoracoscopy group (p ⴝ 0.04). Patients undergoing
thoracoscopic lobectomy had significantly fewer delayed
(18% versus 58%, p < 0.001) and reduced (26% versus
49%, p ⴝ 0.02) chemotherapy doses. A higher percentage
of patients undergoing thoracoscopic resection received
75% or more of their planned adjuvant regimen without
delayed or reduced doses (61% versus 40%, p ⴝ 0.03).
There were no significant differences in time to initiation
of chemotherapy or toxicity. Patients undergoing a thoracoscopic lobectomy had a shorter median length of
hospitalization (4 days versus 5 days, p ⴝ 0.02).
Conclusions. Thoracoscopy was associated with an
overall higher compliance rate and fewer delayed or
reduced doses of chemotherapy in patients receiving
adjuvant chemotherapy.
(Ann Thorac Surg 2007;83:1245–50)
© 2007 by The Society of Thoracic Surgeons
T
patients such as elderly individuals and those with poor
performance status [2, 5, 12, 13].
The results of four prospective randomized trials have
demonstrated that adjuvant therapy improves the survival of patients with NSCLC after complete resection
[14 –17]. Although previous studies of adjuvant therapy
for early stage NSCLC failed to demonstrate improved
survival after complete resection, a closer analysis of the
recent studies may explain this advantage. For example,
in Cancer and Leukemia Group B protocol 9633 (CALGB
9633), all four cycles were delivered in 85% of patients,
and 55% received all four cycles at full dose [15]. In
addition, the chemotherapy was well-tolerated: no toxicityrelated deaths occurred, and grade 3 to 4 neutropenia, the
most significant toxicity, was observed in only 36% of
patients [15]. Thus, it is possible that improved delivery
of chemotherapy after complete resection for NSCLC will
result in improved outcomes. The purpose of this study
was to determine if thoracoscopic lobectomy enables
more effective administration of adjuvant chemotherapy
compared with lobectomy by thoracotomy.
horacoscopic lobectomy has been successfully performed worldwide for more than a decade and is
currently an accepted oncologic approach for patients
with non-small cell lung cancer (NSCLC). Single and
multiinstitutional studies have demonstrated that thoracoscopic lobectomy is not only a safe and feasible technique but is also associated with several advantages
compared with conventional thoracotomy, including
shorter length of hospitalization and chest tube duration,
decreased postoperative pain, improved preservation of
pulmonary function, reduced inflammatory response as
measured by lower postoperative cytokine levels, and
fewer overall complications [1–11]. This strategy has been
found to be particularly useful for specific subsets of
Accepted for publication Dec 18, 2006.
Presented at the Fifty-third Annual Meeting of the Southern Thoracic
Surgical Association, Tucson, AZ, Nov 8 –11, 2006.
Address correspondence to Dr D’Amico, Duke University Medical Center, Box 3496, Duke South Room 3589, Durham, NC 27710; e-mail:
[email protected].
© 2007 by The Society of Thoracic Surgeons
Published by Elsevier Inc
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0003-4975/07/$32.00
doi:10.1016/j.athoracsur.2006.12.029
GENERAL THORACIC
ORIGINAL ARTICLES: GENERAL THORACIC
GENERAL THORACIC
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CHEMOTHERAPY AFTER THORACOSCOPIC LOBECTOMY
Patients and Methods
Table 2. Baseline Characteristics of Thoracoscopic and
Thoracotomy Lobectomy Groups
Patient Selection
A retrospective analysis was performed of 100 consecutive patients with NSCLC who received adjuvant therapy
(chemotherapy with or without radiation therapy) after
lobectomy at Duke University Medical Center between
January 1, 1999 and July 1, 2004. The study received
Institutional Review Board approval in November 2005,
with individual patient consent being waived. Patients
were excluded if they received their adjuvant therapy at
an outside institution (n ⫽ 22).
The choice of postoperative therapy was determined
by the availability of adjuvant therapy protocols and
physician preference. Decisions about dose reduction or
dose delay were made by the treating medical oncologist
at the time of the scheduled dose using objective criteria
(including white blood cell count, absolute neutrophil
count, serum creatinine, gastrointestinal symptoms, and
neurologic symptoms) and subjective criteria (performance status). Radiation therapy was given sequentially
after chemotherapy in selected patients.
Lobectomy was performed by thoracoscopy in 57 patients and by conventional thoracotomy in 43 patients.
Patients considered appropriate for the thoracoscopic
approach included those with tumors smaller than 6 cm
in diameter and without evidence of chest wall or central
airway involvement on preoperative imaging.
Overall survival and cancer-free survival data were
available on all patients. Median follow-up was 19
months for the thoracoscopy group and 17 months for the
thoracotomy group. Baseline and outcome variables collected included demographics, comorbidities, tobacco
use, pulmonary function, histology, pathologic stage,
conversion rate, complete resection rate, chest tube duration, length of hospitalization, postoperative hemorrhage requiring reoperation, pneumonia, respiratory failure, other major complications, and adjuvant therapy
compliance.
The specific outcome variables of interest were time
interval to initiation of adjuvant chemotherapy after
resection, total percentage of planned regimen received,
percentage of patients who received 75% or more of the
full regimen without delayed or reduced doses of che-
Table 1. Adjuvant Therapy Regimen by Thoracoscopy and
Thoracotomy Lobectomy Groups
Chemotherapy
Platinum-based ⫹
vinca-alkaloid
Platinum-based ⫹
taxane
Platinum-based ⫹
gemcitabine
Other
Radiation therapy
Ann Thorac Surg
2007;83:1245–50
Thoracoscopy
n ⫽ 57 (%)
Thoracotomy
n ⫽ 43 (%)
26 (46)
26 (46)
17 (30)
17 (30)
3 (5)
3 (5)
1 (2)
7 (12)
1 (2)
13 (30)
p
Value
0.110
0.040
Characteristica
Thoracoscopy Thoracotomy
p
n ⫽ 57
n ⫽ 43
Value
Age (years)
median (range)
Sex: male
Tobacco use (pack-years)
Co-morbidities:
Hypertension
Diabetes mellitus
Coronary artery
disease
TIA/CVA
Pulmonary function
(% predicted)
FEV1
FVC
DLCO
63 ⫾ 10
64 (38, 83)
24 (42)
45 ⫾ 30
61 ⫾ 11
61 (42, 79)
19 (44)
48 ⫾ 29
0.244
21 (36)
7 (12)
9 (16)
16 (38)
5 (12)
4 (9)
0.97
0.92
0.34
0 (0)
2 (5)
0.10
71 ⫾ 22
84 ⫾ 16
78 ⫾ 22
72 ⫾ 17
90 ⫾ 17
80 ⫾ 16
0.85
0.19
0.71
0.835
0.690
a
Continuous data presented as mean ⫾ Standard Deviation; categoric
data as n (%).
CVA ⫽ cerebral vascular accident;
DLCO ⫽ diffusing capacity of
carbon monoxide;
FEV1 ⫽ forced expiratory volume in 1 second;
FVC ⫽ forced vital capacity;
TIA ⫽ transient ischemic attack.
motherapy, number of delayed and reduced chemotherapy doses, and a toxicity grade of 3 or more.
Staging and Surgical Technique
All patients were evaluated with computed tomography
(CT) of the chest and upper abdomen. Most were staged
with positron emission tomography (PET) and cervical
mediastinoscopy before resection. Indications for PET
and mediastinoscopy included any of the following: T2
status, suspicion of N1 or N2 disease on CT, or clinical
findings that suggested advanced disease.
In this series, all patients underwent lobectomy and
mediastinal lymph node dissection; no extended resections were included. Conventional lobectomy was performed without routine sectioning of a rib, and the
serratus anterior muscle was spared in all patients. Mediastinal lymph node dissection at thoracotomy and
thoracoscopy included the dissection of all hilar lymph
nodes and at least three ipsilateral mediastinal lymph
node stations.
Thoracoscopic lobectomy was performed as previously
described [1, 6, 18, 19]. Briefly, two incisions were used in
most patients in this series. The thoracoscope is placed in
the seventh or eighth intercostal space in the mid-axillary
line, and an anterior utility incision is placed in the fifth
intercostal space anteriorly (4 to 5 cm). This provides
access for complete hilar and mediastinal dissection.
Rib-spreading and retractor use was avoided in all patients. Preoperatively, the established indication for conversion to thoracotomy was an intraoperative finding or
the occurrence of an intraoperative event that the surgeon deemed would be managed more effectively with a
thoracotomy.
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PETERSEN ET AL
CHEMOTHERAPY AFTER THORACOSCOPIC LOBECTOMY
Table 3. Histology and Pathologic Stage of the
Thoracoscopic and Thoracotomy Lobectomy Groups
Histology
Adenocarcinoma
Squamous
Other
Pathologic Stage
I
II
III
IVa
Thoracoscopy
n ⫽ 57 (%)
Thoracotomy
n ⫽ 43 (%)
39 (68%)
11 (19%)
7 (12%)
19 (44%)
14 (33%)
10 (23%)
Table 5. Adjuvant Chemotherapy Compliance After
Lobectomy by Surgical Approach
p
Value
0.022
0.050
30 (53%)
12 (21%)
14 (24%)
1 (2%)
10 (23%)
12 (28%)
20 (47%)
1 (2%)
a
Isolated brain metastasis after metastasectomy before being evaluated
for lobectomy.
Compliancea
Time to initiation of
chemo (days)
Percentage of planned
regimen received
Pts with delayed
chemotherapy doses
Pts with reduced
chemotherapy doses
⬎75% of total planned
regimenb
Toxicity grade ⱖ2
Toxicity grade ⱖ3
Thoracoscopy
n ⫽ 57 (%)
Thoracotomy
n ⫽ 43 (%)
p
Value
58 ⫾ 31
54 ⫾ 35
0.277
88% ⫾ 24%
89% ⫾ 19%
0.835
10 (18)
25 (58)
⬍0.001
15 (26)
21 (49)
0.020
35 (61)
17 (40)
0.030
29 (51)
7 (12)
24 (56)
9 (21)
0.624
0.243
Data presented means ⫾ standard deviation, or as n (%).
delay or dose reduction.
a
Statistical Analysis
Baseline characteristics and outcomes were compared
between the thoracoscopy and thoracotomy groups. Categoric variables were compared using the Pearson ␹2 test,
the Fisher exact test, and R ⫻ C contingency tables when
appropriate. Continuous variables were compared using
the Student t test and Mann-Whitney test when appropriate. Statistical significance was defined as a value of
p ⬍ 0.05. All statistical analyses were performed using
Stata Intercool 8.0 software (StataCorp LP, College Station, TX).
Results
All patients received adjuvant chemotherapy, which generally consisted of a platinum-based agent combined
with either a taxane or vinca alkaloid. The chemotherapy
regimens did not differ significantly between the two
groups (Table 1). In addition to chemotherapy, 20 patients (20%) also received adjuvant combination radiation
therapy: 13 patients (30%) in the thoracotomy group and
7 (12%) in the thoracoscopy group (p ⫽ 0.04). A signifiTable 4. Postoperative Complications After Lobectomy
Complication
Chest tube duration,
mean
median (min, max)
Hospitalization LOS
mean
median (min, max)
30-day mortality
Hemorrhage
Pneumonia
Respiratory failure
Atrial fibrillation
Other major
complications
LOS ⫽ length of stay.
1247
Thoracoscopy
n ⫽ 57 (%)
Thoracotomy
n ⫽ 43 (%)
p
Value
3.1 ⫾ 2 days
4.7 ⫾ 7 days
0.098
3 (1, 11) days
4.2 ⫾ 2.0 days
3 (2, 8) days
5.3 ⫾ 2.4 days
0.013
4 (2, 11) days
0 (0%)
0 (0%)
1 (2%)
0 (0%)
8 (14%)
6 (11%)
5 (3, 15) days
0 (0%)
3 (7%)
3 (7%)
2 (5%)
3 (7%)
4 (9%)
1.00
0.043
0.187
0.100
0.264
0.840
b
Without
cantly higher percentage of patients received combination radiation therapy in the thoracotomy group than in
the thoracoscopy group.
Lobectomy was performed by thoracotomy in 43 patients and thoracoscopically in 57 patients, and complete
resection was achieved in all patients in both groups.
Three patients (5%) in the thoracoscopy group were
converted to open procedure: 2 because of dense adhesions and 1 for oncologic reasons.
No significant differences were noted in baseline demographics, including age, sex, tobacco use, medical
comorbidities, and preoperative pulmonary function
(Table 2). The thorascopic group had a higher percentage
of patients who had adenocarcinoma, and the thoracotomy group had a higher percentage of squamous cell
carcinomas and other histology types. Also, patients in
the thoracotomy group were more likely to have higher
stage disease (Table 3).
Patients in the thoracoscopic group had significantly
shorter length of hospitalization, with a median of 4
days compared with 5 days in the thoracotomy group
(p ⫽ 0.013), and were also less likely to be taken back to
the operating room for postoperative bleeding (0%
versus 7%, p ⫽ 0.04). No significant differences were
Table 6. Adjuvant Chemotherapy Compliance After
Lobectomy Stratified by Pathologic Stage
Compliancea
Stage I
n ⫽ 40
% of planned regimen received 84 ⫾ 26%
Pts with delayed chemotherapy 11 (28%)
doses
Pts with reduced chemotherapy 12 (30%)
doses
⬎75% of total planned
21 (53%)
regimen*
ⱖ Stage II
p
n ⫽ 60
Value
89 ⫾ 22%
24 (40%)
0.312
0.199
24 (40%)
0.307
31 (52%)
0.935
* Without delay or dose reduction.
a
Data presented as means ⫾ Standard Deviation or n, (%).
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PETERSEN ET AL
CHEMOTHERAPY AFTER THORACOSCOPIC LOBECTOMY
Table 7. Adjuvant Chemotherapy Compliance After
Lobectomy Stratified by the Use of Radiation Therapy
Compliance
% of planned regimen
received
Pts with delayed
chemotherapy doses
Pts with reduced
chemotherapy doses
⬎75% of total planned
regimen*
RT
n ⫽ 20 (%)
No RT
n ⫽ 80 (%)
p
Value
91% ⫾ 20%
85% ⫾ 24%
0.305
6 (30)
30 (38)
0.532
5 (25)
30 (38)
0.295
11 (55)
41 (51)
0.764
a
Data presented as means ⫾ standard deviation, or n (%).
delay or dose reduction.
b
Without
RT ⫽ radiation therapy.
identified for 30-day mortality, pneumonia, respiratory
failure, atrial fibrillation, or other major complications
(Table 4).
Chemotherapy compliance was better in patients undergoing thoracoscopic lobectomy. They had had significantly fewer delayed (18% versus 58%, p ⬍ 0.001) and
reduced (26% versus 49%, p ⫽ 0.02) chemotherapy doses.
In addition, a significantly higher percentage of patients
received 75% or more of their total planned adjuvant
regimen without delayed or reduced doses (61% versus
40%, p ⫽ 0.03). There were no significant differences in
time interval to initiation of chemotherapy after resection
or toxicity of grade 3 or 4 (Table 5). Also, neither the
pathologic stage nor the addition of adjuvant radiation
therapy was associated with overall chemotherapy compliance (Table 6 and Table 7).
Comment
Advantages of a thoracoscopic approach to anatomic
lung resection include decreased blood loss [20], decreased pain [2, 5, 11, 20], shorter length of hospitalization
and chest tube duration [1–11], more rapid return to
preoperative activity [2, 5, 20], preserved postoperative
pulmonary function [21, 22], decreased inflammatory
response (which may confer superior immunologic function) [4, 11], and fewer overall complications [3, 6]. These
benefits were achieved with equivalent oncologic effectiveness [3, 6 – 8]. Thoracoscopic lobectomy is now accepted as a viable surgical approach for selected patients
with lung cancer [23].
Historically, randomized trials of adjuvant chemotherapy for completely resected NSCLC failed to demonstrate a consistent benefit. Early trials suffered from poor
design, suboptimal compliance, and inactive drug regimens. Four recent studies, however, have demonstrated
improved outcomes with adjuvant therapy [14 –17],
which is now the standard of care for selected patients
with completely resected NSCLC [23].
In addition to the improvement in the design of the
recent trials, one explanation for the survival benefit in
these trials is improved chemotherapy compliance. It has
been demonstrated that the ability to administer com-
Ann Thorac Surg
2007;83:1245–50
plete regimens of adjuvant chemotherapy is associated
with improved survival outcomes [24, 25], and the recent
adjuvant chemotherapy trials reported higher chemotherapy compliance compared with previous studies. For
example, in CALGB 9633, all four cycles of adjuvant
chemotherapy were delivered in 85% of patients, and
55% of patients received all four cycles at the full dose
[15]. In another study, a median number of three cycles
was delivered, and 58% of the patients received three or
more cycles of cisplatin [16].
If improved compliance with adjuvant chemotherapy is associated with improved outcomes, technical
aspects of surgical resection that improve the delivery
of chemotherapy may also be associated with improved outcomes. This study analyzed the delivery of
adjuvant chemotherapy after 100 lobectomies for
NSCLC, comparing 57 patients who underwent thoracoscopic lobectomy with 43 those who underwent
lobectomy by conventional thoracotomy. Chemotherapy regimens included platinum in most patients in
both groups, and the doublet regimens were similar as
well. There was no difference in the time from surgery
to the initiation of therapy. Of note, the medical
oncologists involved in this study did not routinely
evaluate patients for adjuvant therapy until approximately 6 weeks postoperatively, although there may
have been patients in both groups who would have
been eligible to initiate therapy earlier.
For those who underwent thoracoscopic lobectomy,
the procedure resulted in a significant advantage in the
number of patients with delayed chemotherapy doses
and in the number of patients who received doses that
were reduced owing to toxicity-related issues. In addition, 61% of patients who underwent thoracoscopic lobectomy completed at least 75% of the planned regimen
compared with only 40% of those who underwent thoracotomy (p ⫽ 0.03).
Other factors may explain the difference in chemotherapy delivery in the two groups. Among the thoracotomy
lobectomy patients, significantly fewer patients had
stage I NSCLC compared with the thoracoscopic lobectomy group (Table 3). When chemotherapy delivery was
analyzed according to stage, however, no difference was
found in chemotherapy delivery for patients with stage I
NSCLC compared with patients with stage II disease or
greater.
A greater percentage of patients in the thoracotomy
group also received adjuvant radiation therapy, predominately for N1 disease (Table 1). Of note, the adjuvant
radiation therapy was given in accordance with National
Comprehensive Cancer Network guidelines [23] and was
delivered sequentially after chemotherapy rather than
concurrently. Currently, on the basis of recent data,
adjuvant radiation therapy is not used in these patients
[26]. When chemotherapy delivery was analyzed according to the use of adjuvant radiation therapy, no difference
was detected (Table 7). It is also possible that this analysis
does not account for biases among treating medical
oncologists.
The delivery of adjuvant chemotherapy depends on
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CHEMOTHERAPY AFTER THORACOSCOPIC LOBECTOMY
numerous variables, including those that are patientrelated, treatment-related, and surgery-related. This
study was a retrospective analysis of a series of 100
consecutive patients who underwent lobectomy for
NSCLC, followed by adjuvant chemotherapy, which was
designed to demonstrate whether the use of thoracoscopic lobectomy was associated with an improvement in
chemotherapy delivery.
Because of the relatively small size of the study, the
actual contribution of all possible variables cannot be
determined; however, it appears that the most powerful variable associated with chemotherapy delivery is
the use of thoracoscopic lobectomy. Larger prospective
studies would be required to ascertain the effect of
pathologic stage and use of radiation therapy. Furthermore, future trials might also take into account the
possibility of starting chemotherapy earlier after thoracoscopic lobectomy, which may also improve outcomes [27]. Eventually, the use of adjuvant chemotherapy will be compared with induction therapy for
patients with resectable lung cancer. These studies
should take into account the improved delivery of
postoperative chemotherapy associated with thoracoscopic lobectomy.
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Ann Thorac Surg
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DISCUSSION
DR JOHN A. HOWINGTON (Cincinnati, OH): Dr Petersen,
congratulations on an excellent presentation. I have a few
questions. First, a comment. This paper adds to the growing
body of work demonstrating the advantages to a minimally
invasive thoracoscopic lobectomy. First off, did you compare
stage I patients to the subset of stage III-only patients and the
outcomes as far as adjuvant chemotherapy? A significant number of your patients received adjuvant radiation therapy even
though you describe all your patients received a complete
resection. What were the common reasons for adjuvant radiation therapy, and was this administered concurrently or
consecutively?
Lastly, you demonstrated a significantly reduced median
chest tube duration and hospital days with your thoracoscopic
lobectomy group compared to open thoracotomy in your study.
In a recent report by Allen and colleagues of the morbidity and
mortality of over 1000 patients as part of the ACOSOG Z-30 trial,
the median chest tube duration was 5 days and hospitalization
was 6 days, significantly greater than your open thoracotomy
group. Do you feel the introduction of thoracoscopic lobectomy
in your practice has changed your approach to an open thoracotomy and lobectomy and thus reduced your chest tube duration and hospitalization in your open patients?
DR PETERSEN: Thank you, Dr Howington, for your thoughtful
questions. In regard to your first question where you asked if we
specifically compared the stage I-only patients to the stage III
patients, we did not, and this is largely due to the fact that we
had a smaller sample size that did not allow for additional subset
analyses. I think more appropriately in a larger prospective
study, a logistic regression analysis would be helpful in controlling for confounding factors, not only stage but radiation therapy, performance status, pulmonary function, etcetera. We did,
however, dichotomize by stage I versus stage II or higher and
did not find an association with the parameters of chemotherapy
compliance.
In regard to your question as to what are the indications for
radiation therapy and whether it was administered concurrently
or consecutively, there were 20 patients out of the 100 patients
who received adjuvant radiation therapy, and the main indications were close margins, presence of bulky N1 disease or
microscopic N2 disease. The radiation therapy was administered
sequentially.
In regard to your third question where you mentioned the
ACOSOG trial having a longer chest tube duration and hospitalization for the thoracotomy patients as compared to patients
undergoing thoracotomy in our study, I do believe that our
practice of performing the majority of lobectomies by thoracoscopy has led us to be more aggressive in discontinuing chest
tubes and discharging our thoracotomy patients home earlier.
DR DANIEL L. MILLER (Atlanta, GA): I enjoyed your talk. In
your patients that were found to have N2 disease at the time of
VATS lobectomy, did you do any type of a flap procedure to
protect the bronchial stump from a potential BPF if adjuvant
radiotherapy was going to be used postoperatively? The majority of time when we do an open lobectomy and find N2 disease
at the time of resection we place a tissue flap over the bronchial
stump to prevent a BPF that could develop if postoperative
radiation therapy is used. If so what tissue flap was used
thoracoscopically?
DR PETERSEN: None of the patients in this study received any
additional procedures, including muscle flap coverage of bronchial stumps, beyond an anatomic lobectomy. We do not have
extensive experience at Duke performing muscle flap coverage
of bronchial stumps via thoracoscopy.
DR ROBERT J. CERFOLIO (Birmingham, AL): A quick comment and perhaps out of order, but I rise to lambaste my good
friend and colleague, Dr Dan Miller, to ask him that when he
finds N2 disease at a VATS lobectomy, why don’t you stop and
give the patient neoadjuvant therapy? Why should the method
of the N2 detection change the management of the disease—if
you find N2 on a med, don’t you give neoadjuvant therapy—and
if so then why is the patient’s cancer treatment different just
because of how you discovered N2?
DR MILLER: I haven’t found N2 disease at the time of VATS
lobectomy yet. I have only done 225. Tommy has done over 500.
Twenty percent of these patients had VATS, so that is the big
question.
DR RODNEY LANDRENEAU (Pittsburgh, PA): I think the
biggest issue that I see from your data is that you have reduced
the hospital stay, potentially reflective of reduced morbidity
associated with these approaches, and therefore these patients
can have their chemotherapy with less morbidity, or with less
problems associated with the recovery from their surgery as
impacting their ability to have chemo.
But I think the stage differences is another issue that needs to
be determined. That really concerns me about the differences in
stage between the groups, and therefore, again, all your conclusions about limitations I think are important ones and I think a
big issue here with regard to this analysis. What are your
thoughts on that?
DR PETERSEN: We agree with you. We realize that stage, and
specifically radiation therapy, are both very important potential
confounding factors, as are many other variables that we cannot
necessarily control for due to small sample size. However, as
mentioned previously, we did perform statistical comparisons
between stage I versus stage II or higher in regards to chemotherapy compliance and found no significant association. We
also found no significant association between radiation therapy
and chemotherapy compliance as well.
Downloaded from ats.ctsnetjournals.org by on April 13, 2007
Thoracoscopic Lobectomy Facilitates the Delivery of Chemotherapy after
Resection for Lung Cancer
Rebecca P. Petersen, DuyKhanh Pham, William R. Burfeind, Steven I. Hanish, Eric M.
Toloza, David H. Harpole, Jr and Thomas A. D’Amico
Ann Thorac Surg 2007;83:1245-1250
DOI: 10.1016/j.athoracsur.2006.12.029
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