Invited Commentary

Abstract

In 1995, the landmark study written by Ginsberg and Rubinstein [1Ginsberg R.J. Rubinstein L.V. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group.Ann Thorac Surg. 1995; 60 (discussion 22–3): 615-622Abstract Full Text PDF PubMed Scopus (2341) Google Scholar] for the Lung Cancer Study Group evaluating the efficacy of a lobectomy versus limited resection set the stage for the ensuing two decades. In recent years, it has become standard practice for parenchymal resection of non-small-cell lung cancer (NSCLC) to be performed with video-assisted thoracoscopic surgery (VATS). The VATS approach has emerged as a superior approach to early-stage NSCLC [2Whitson B.A. Groth S.S. Duval S.J. Swanson S.J. Maddaus M.A. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy.Ann Thorac Surg. 2008; 86: 2008-2016Abstract Full Text Full Text PDF PubMed Scopus (513) Google Scholar]. The published benefits of VATS have been an improved oncologic outcome, less pain and morbidity, and improved pulmonary function. As instrumentation and technique improved, VATS resections became more commonplace, with the lobectomy being the treatment of early-stage NSCLC. As proficiency was attained with VATS techniques, the role of sublobar resections (ideally anatomic segmentectomy for small nodules) has been revisited with concomitant improvements in imaging, critical care, and pulmonary medicine. These improvements extended the benefits of surgical resection for high-risk, frail patients, once thought to have limited physical or pulmonary reserve. In the appropriate setting, a sublobar resection has been demonstrated to be equivalent to a lobectomy [3Schuchert M.J. Kilic A. Pennathur A. et al.Oncologic outcomes after surgical resection of subcentimeter non-small cell lung cancer.Ann Thorac Surg. 2011; 91: 1681-1687Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. The current study by Kim and colleagues [4Kim S.J. Lee Y.J. Park J.S. et al.Changes in pulmonary function in lung cancer patients after video-assisted thoracic surgery.Ann Thorac Surg. 2015; 99: 210-217Abstract Full Text Full Text PDF Scopus (43) Google Scholar] adds an additional layer of complexity to the decision algorithm. In their analysis of 300 patients undergoing VATS resection of NSCLC by lobectomy (n = 227) and sublobar resections (n = 73), an interesting observation was made. As one would expect, initially at 3 months postoperatively, the lobectomy patients experienced a greater decrease in their pulmonary function, as compared with the patients with sublobar resections. Differences in pulmonary function remained at 12 months when viewed in aggregate. This finding is intuitive based on the proportion of segments being removed. What was interesting, however, was when the effect was segregated by side (right versus left), the effect was negated at 1 year. That is to say that the effects of the additional parenchymal resection on the side with more parenchyma on pulmonary function were equivalent to those of the lesser sublobar resection. These data are potentially important. As the authors noted, “Because lobectomy showed a better prognosis than sublobar resection, except for patients with stage IA disease, clinicians should consider these results when determining the surgical method, especially in high-risk patients.” The treatment paradigm needs to take into account the confounders and effects of VATS, anatomic resections, and preservation of pulmonary function on the approach to surgically treating early-stage NSCLC, especially in high-risk patients. A multicenter, larger-scale study to further elucidate these effects would be beneficial. Changes in Pulmonary Function in Lung Cancer Patients After Video-Assisted Thoracic SurgeryThe Annals of Thoracic SurgeryVol. 99Issue 1PreviewVideo-assisted thoracoscopic surgery (VATS) is widely performed in patients with resectable non-small cell lung cancer. However, it is unknown whether VATS sublobar resection has advantages compared with VATS lobectomy in preserving pulmonary function. Full-Text PDF