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Peter Ellis brings to our attention through the linked paper some evidence that minimally invasive thoracic surgery (MITS) for early stage non-small cell lung cancer could achieve the same similar overall, cancer specific, and disease-free survival compared with patients undergoing thoracotomy lobectomy, and should be considered a safe alternative to open surgery.
The subtitle of Ellis's Editorial (1) says that for patients found to have operable lung cancer MITS should be performed by “experienced surgeons in high volume hospitals”. Certainly in the ideal world the simultaneous presence of high volume surgeons working in an high volume hospitals is advisable, but in the real world a high volume thoracic surgeon could work in a low volume hospital
Moreover the definition of MITS techniques is clearly more intricate than 15 years ago (2), and the term “thoracoscopic lobectomies” is confusing because a minithoracotomy of 4-8 cm is always mandatory. Some surgeons call the procedure VATS lobectomy, other uniportal or single-incision VATS lobectomy, others just thoracoscopic lobectomy. Generalizing the findings all the used minimally invasive techniques to perform a lobectomy need a thoracotomy, which is a mini-thoracotomy. All the above mentioned techniques used to perform pulmonary major resections are mini-thoracotomy with video assistance.
Dr. Paul et al. (3) wrote, "the practice of lung resection for lung cancer is not based on randomized evidence". No large randomized studies have been done in any directly comparable patient group that show resection to be superior to non-resection. Moreover they wrote that the use of stereotactic body radiation therapy instead of surgery for early stage non-small cell lung cancer is promising. So, it appears obvious that before answering the question: should surgery, open or VATS, be perfomed in early stage lung cancer ? We should answer if early lung cancers need to be surgically removed or, for example, treated by stereotactic body radiation therapy, and only a well designed RCT can answer this question.
Interestingly going through the recent literature there is evidence that as for other thoracic oncological diseases such as lung metastases (4) and mesothelioma (5), lung cancer surgery need a RCT to prove its efficacy. The promise of long survival based on “personal” surgical experience does not satisfy, and more convincing results from definitive randomized clinical trials comparing surgery versus no surgery are necessary before MITS are adopted in routine clinical practice. In the next decades large RCT studies such a PulMiCC, MARS 2 and VIOLET will demonstrate efficacy in some of the most common oncologic lung tumours.
Looking at the future, although the open questions are numerous, there is no doubt that early stage lung cancer will be performed using a mini-thoracotomy with video assistance until a RCT suggests a different treatment. From the data available in the literature the next decades will be devoted to large RCTs which will be designed to confirm or not the proper indications for surgery in oncologic thoracic diseases, and to confirm the efficacy, safety, and cost effectiveness of the MITS techniques.
References
1. Ellis P. Minimally invasive thoracic surgery for early stage non-small cell lung cancer. A safe alternative to open surgery for experienced surgeons in high volume hospitals. BMJ 2014;349:g5849
2. Migliore M, Deodato G. Thoracoscopic surgery, video-thoracoscopic surgery, or VATS: a confusion in definition. Ann Thorac Surg 2000;69 (6): 1990-1991
3. Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ 2014;349:g5575
4. Treasure, T., Fallowfield, L., Lees, B. Pulmonary metastasectomy in colorectal cancer: the PulMiCC trial. J thorac oncol, 2010;5(6), S203-S206.
5. Datta A., Smith, R., Fiorentino F, Treasure, T. Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position. Thorax, 2014; 69(2), 194-197.
Re: Minimally invasive thoracic surgery for early stage non-small cell lung cancer
Peter Ellis brings to our attention through the linked paper some evidence that minimally invasive thoracic surgery (MITS) for early stage non-small cell lung cancer could achieve the same similar overall, cancer specific, and disease-free survival compared with patients undergoing thoracotomy lobectomy, and should be considered a safe alternative to open surgery.
The subtitle of Ellis's Editorial (1) says that for patients found to have operable lung cancer MITS should be performed by “experienced surgeons in high volume hospitals”. Certainly in the ideal world the simultaneous presence of high volume surgeons working in an high volume hospitals is advisable, but in the real world a high volume thoracic surgeon could work in a low volume hospital
Moreover the definition of MITS techniques is clearly more intricate than 15 years ago (2), and the term “thoracoscopic lobectomies” is confusing because a minithoracotomy of 4-8 cm is always mandatory. Some surgeons call the procedure VATS lobectomy, other uniportal or single-incision VATS lobectomy, others just thoracoscopic lobectomy. Generalizing the findings all the used minimally invasive techniques to perform a lobectomy need a thoracotomy, which is a mini-thoracotomy. All the above mentioned techniques used to perform pulmonary major resections are mini-thoracotomy with video assistance.
Dr. Paul et al. (3) wrote, "the practice of lung resection for lung cancer is not based on randomized evidence". No large randomized studies have been done in any directly comparable patient group that show resection to be superior to non-resection. Moreover they wrote that the use of stereotactic body radiation therapy instead of surgery for early stage non-small cell lung cancer is promising. So, it appears obvious that before answering the question: should surgery, open or VATS, be perfomed in early stage lung cancer ? We should answer if early lung cancers need to be surgically removed or, for example, treated by stereotactic body radiation therapy, and only a well designed RCT can answer this question.
Interestingly going through the recent literature there is evidence that as for other thoracic oncological diseases such as lung metastases (4) and mesothelioma (5), lung cancer surgery need a RCT to prove its efficacy. The promise of long survival based on “personal” surgical experience does not satisfy, and more convincing results from definitive randomized clinical trials comparing surgery versus no surgery are necessary before MITS are adopted in routine clinical practice. In the next decades large RCT studies such a PulMiCC, MARS 2 and VIOLET will demonstrate efficacy in some of the most common oncologic lung tumours.
Looking at the future, although the open questions are numerous, there is no doubt that early stage lung cancer will be performed using a mini-thoracotomy with video assistance until a RCT suggests a different treatment. From the data available in the literature the next decades will be devoted to large RCTs which will be designed to confirm or not the proper indications for surgery in oncologic thoracic diseases, and to confirm the efficacy, safety, and cost effectiveness of the MITS techniques.
References
1. Ellis P. Minimally invasive thoracic surgery for early stage non-small cell lung cancer. A safe alternative to open surgery for experienced surgeons in high volume hospitals. BMJ 2014;349:g5849
2. Migliore M, Deodato G. Thoracoscopic surgery, video-thoracoscopic surgery, or VATS: a confusion in definition. Ann Thorac Surg 2000;69 (6): 1990-1991
3. Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ 2014;349:g5575
4. Treasure, T., Fallowfield, L., Lees, B. Pulmonary metastasectomy in colorectal cancer: the PulMiCC trial. J thorac oncol, 2010;5(6), S203-S206.
5. Datta A., Smith, R., Fiorentino F, Treasure, T. Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position. Thorax, 2014; 69(2), 194-197.
Competing interests: No competing interests