Surgery is the standard of care for early-stage lung cancer, but the best surgical approach is yet to be determined. Minimally invasive surgery, such as Video-Assisted Thoracoscopic Surgery (VATS), is now the preferred approach over traditional open surgery.1 In a study presented at the International Association for the Study of Lung Cancer (IASLC) 2019 World Conference on Lung Cancer (WCLC) at Barcelona, Spain, the data showed VATS is equivalent to open lobectomy for early-stage lung cancer in terms of oncologic outcomes and patients’ quality of life.2
VATS in the early-stage lung cancer
Complete anatomic resection via open thoracotomy has been the conventional approach in the early-stage lung cancer, but since the introduction of VATS, better clinical outcomes can be achieved. Nowadays, VATS is being performed more commonly as a first-line treatment for the early-stage lung cancer.3
The VATS procedure is conducted through small incisions, called “key holes” in the chest wall. Then, a tiny camera (thoracoscope) and surgical instruments are inserted into the chest through these small incisions. The thoracoscope captures video inside of the lung, which is then displayed in a video monitor, guiding the surgeon to perform the procedure.
VATS was introduced in the 1990s. Since then, it has been used to perform major lung resections using a single hole or uniportal VATS approach. Recently, natural orifice access has been used to achieve a “no port” approach. With the advancements in the bronchoscopic techniques, the “no port” approach is gaining its popularity.4
In a meta-analysis that compared VATS with open thoracotomy for early-stage lung cancer has shown a significant reduction in the perioperative mortality, in which the incidences of post-operative complications, such as prolonged air leak and sepsis, were significantly lower. Patients who underwent VATS were also found to have a significantly lower overall perioperative morbidity rate, and their quality of life after surgery was improved with less incidences of pneumonia or atrial arrhythmias. A shorter duration of hospitalization was observed in patients who underwent VATS in comparison to patients who underwent open thoracotomy.5 However, these results were only observational and more evidences with carefully planned controlled trials are needed for clinical applications.
VIOLET trial: Comparing VATS and open lobectomy
At the IASLC 2019 WCLC conference, results from The VIOLET trial, the largest randomized trial comparing the VATS and open lobectomy strategies, were presented.2 This parallel group trial was conducted across nine thoracic surgery centers in the United Kingdom. A total of 503 participants with known or suspected primary lung cancer were randomly assigned to either VATS (n=247) or open lobectomy (n=256).2 The VATS procedure was carried out through small incisions or ports ranging in number from 1 to 4 and the open lobectomy procedure followed traditional approach.2
Prof. Eric Lim, the lead investigator of the study from the Royal Brompton Hospital in London, UK, stated, “The VIOLET trial achieved its positive results without any compromise to early oncologic outcomes in either pathologic complete resection or upstaging of mediastinal lymph nodes, nor was there any difference in serious adverse events in the early postoperative period either.”6,7
Better pain management by less invasive VATS
In comparison to VATS, open lobectomy involves a much larger incision allowing to visualize the surgical field and requires the ribs to be spread in order to gain access to the chest.8 The invasiveness in this procedure increases the rate of perioperative morbidity as well as post-operative complications.9
The standards of these surgical procedures were maintained across the nine involved centers. According to the study, in VATS, the in-hospital mortality rate was 1.4% and benign resections were as low as 1.2%.2 More than half (58%) of all VATS procedures were done through three ports, but 21% of patients undergoing VATS had the procedure done through a single port.2
In the VIOLET trial, in order to avoid the psychological impact on the pain measurement, patients were kept blind to the type of surgery performed. Prof. Lim explained, “We made sure that lymph node harvesting and pain management were standardized and after the operation, we put a big dressing over the wound so that you couldn’t tell if the patient had had a keyhole operation or open surgery.”7
The post-operative pain was assessed by visual analogue scale (VAS) and analyzed after statistically adjusting the analgesics received by patients during the study. The median pain score measured by VAS on day 2 after surgery was lower in those treated with VATS compared to those treated with open surgery (Figure 1).2
There was a significant reduction in the in-hospital complication rates involving the kidneys and infections (VAS – 32.8% vs. open lobectomy – 44.3%).2 Moreover, the length of hospital stay was shorter with a median of 4 days for patients with VATS versus 5 days for patients with open lobectomy (p=0.008) (Figure 2). None of the procedures tested showed significant adverse events over the other.2
VATS has comparable oncologic outcomes with open lobectomy
Both the VATS and open surgery have shown equal efficiency on the tumor resection, having the complete resection rate of 97.8% for VATS and 97.4% for open lobectomy.2 The median number of lymph node stations harvested was 5 in each of the two groups.2 Furthermore, equal number of mediastinal node stations was harvested in each of the two groups.2 When unsuspected lymph node metastases are found during the final evaluation of surgically resected lymph nodes, nodal upstaging occurs, which is an indication of the sensitivity of the surgery carried out. In VIOLET trial, the rates of lymph node upstaging were 6.2% in patients treated with VATS compared with 4.8% in those treated with open lobectomy.2 The higher frequency of lymph node upstaging from clinical N0 or N1 to pathologic N2 by VATS, is a reflection of the quality of lymph node dissection.2
Is VATS a new standard of care?
In light of the evidence presented by the VIOLET trial, Dr. Jessica Donington, from the University of Chicago Lurie Comprehensive Cancer Center, remarked, “The results made a compelling case for VATS as the preferred approach to lobectomy for early lung cancer.”6 She further emphasized, “I think going forward, we cannot accept thoracotomy as a standard of care for early-stage lung cancer.”6
Considering the data on decreased post-operative pain and complications by VATS, Dr. Donington highlighted, “Our patients need to have minimally invasive resections. Not only as surgeons but as the lung cancer community, we need to push this going forward.”6
Unlike most of the studies in the past decade, VIOLET trial has demonstrated the lymph node upstaging via VATS. Dr. Donington further discussed the lymph node upstaging data, mentioning, “As we look back on that data, it probably had a lot more to do with our early going on the VATS learning curve and the limitation of the technology itself. I think these numbers are important, not only for analysis,.”6
VATS lobectomy was associated with superior perioperative and post-operative outcomes compared to open lobectomy as a minimally invasive procedure, VATS provides long-term quality of life benefits for patients. VATS has also demonstrated a similar oncologic outcome with open lobectomy and a better quality of lymph node resection. In view of this positive evidence, thoracic surgeons can consider this minimum invasive surgery for patients with early lung cancer.
1. U Ujiie H, Gregor A, Yasufuku K. Minimally invasive surgical approaches for lung cancer. Expert Rev Respir Med. 2019 Jun;13(6):571-578.
2. IASLC | International Association for the Study of Lung Cancer. (Accessed September 24, 2019, at: https://library.iaslc.org/conference-program?product_id=15&author=&category=&date=2019-09-09&session_type=Plenary%20Session&session=&presentation=&keyword=&cme=undefined&)
3. Cheng AM, Wood DE. VATS versus open surgery for lung cancer resection: moving beyond the incision. J Natl Compr Canc Netw. 2015 Feb;13(2):166-70.
4. Siu ICH, Li Z, Ng CSH. Latest technology in minimally invasive thoracic surgery. Ann Transl Med. 2019 Jan;7(2):35.
5. Cao C, Manganas C, Ang SC et al. A meta-analysis of unmatched and matched patients comparing video-assisted thoracoscopic lobectomy and conventional open lobectomy. Ann Cardiothorac Surg. 2012 May;1(1):16-23.
6. Breakthrough for VATS in Early Lung Cancer? (2019). Medpagetoday.com. (Accessed September 24, 2019, at https://www.medpagetoday.com/meetingcoverage/iaslc/82065)
7. Keyhole Rivals Open Surgery for Lung Cancer Resection. Medscape.com. (Accessed September 24, 2019, at, http://www.medscape.com/viewarticle/918017)
8. Klapper J, D’Amico TA. VATS versus open surgery for lung cancer resection: moving toward a minimally invasive approach. J Natl Compr Canc Netw. 2015 Feb;13(2):162-4.
9. Bendixen M, Jørgensen OD, Kronborg C et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016 Jun;17(6):836-844.