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T. Grodzki

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    SC20 - Small is Beautiful: Impact of Surgical Approach (ID 344)

    • Event: WCLC 2016
    • Type: Science Session
    • Track: Surgery
    • Presentations: 1
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      SC20.02 - What Have We Achieved? Should It Be Performed for Stages Higher Than Stage I Disease? (ID 6682)

      16:00 - 17:30  |  Author(s): T. Grodzki

      • Abstract
      • Presentation
      • Slides

      Since the introduction of the videothoracoscopic anatomical lung resections in the early 90-ties both indications and contraidications for this type of approach have changed dramatically (1,2). There is common agreement that the oncological principles during surgery for lung cancer have to be the same regardless the type of approach: standard, minimally invasive (MIS – VATS multiportal or uniportal, intubated or non-intubated) or robotic. It regards predominantly requirements such like careful and atraumatic dissection, sufficient free-of-neoplasm margins and proper lymphadenectomy (standard or extended). Keeping it in mind we have to admit that stage I NSCLC seems „ideal” indication for MIS, particularly for less experienced surgeons. This type of surgery (MIS for stage I) is widely accepted and performed worldwide in thousands of cases. However, many experienced centers and surgeons have moved the borders forward treating more advanced cases by MIS with acceptable results regarding complications, mortlity, conversion rate or quality of lymphadenectomy. Gonzalez-Rivas presented the series of 43 advanced patients (tumors bigger > 5cm, T3 or T4, treated by neoadjuvant chemo- or radiotherapy) who were treated by uniportal VATS with good results comparable with earlier stages (3). Authors stated that „Skilled VATS surgeons can perform 90% or more of their lobctomies thoracoscopically, reserving thoracotomy only for huge tumors or complex bronchovascular reconstructions”. Large multicenter series of more than 400 advanced cases treated by VATS approach compared with propensity score matched open thoracotomy group with no differences in overall survival was published by Cao et al. (4). According to the VATS Consensus Statement (among 50 international experts to establish a standardized practice of VATS lobectomy after 20 years of clinical experience) eligibility for VATS lobectomy should include tumors <7cm and N0 or N1 status. Chest wall involvement was considered contraindication while centrality of tumour was considered a relative contraindication when invading hilar structures (5). This important statement is widely accepted however some surgeons consider it too restrictive regarding chest wall invasion. Currently there is a relatively small (but growing) group of thoracic surgeons who are performing double-sleeve (pulmonary vessels and bronchi) and carinal resections by MIS – extremely complex procedures even in open surgery (6). It requires modern instruments, sutures and definitely is not a procedure for beginners. Published series are small and overall experience is limited but this initial efforts are good example of the continuos drive of thoracic surgeons community to move indications for MIS further and further. Advanced NSCLC cases started to be treated by MIS just few years ago and there are no prospective randomised studies available in medical literature therefore we cannot definitively compare and assess the long term results but keeping in mind that the main oncological principles should be preserved and remain the same in every type of surgical approach we can expect comparable and similar results as it was reported in currently published papers. We all know that generally speaking the future is unpredictable but inevitable from the other side. Considering MIS in advanced NSCLC cases we can state with just minimal exagerration that the future is now. Selected references: 1. Roviaro G, Varoli F, Vergani C et al.: Long term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 2004;126:725-732 2. Hanna JM, Berry MF, D`Amico TA: Contraindications of videoassisted thracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5:182-189 3. Gonzalez-Rivas D, Fieira E, Delgado M et al.: Is uniportal thoracoscopic surgery a feasible approach for advanced stages of NSCLC? J Thorac Dis 2014;6:641-648 4. Cao C, Zhu ZH, Yan TD et al.: Videoassisted thoracic surgery versus open thoracotomy for NSCLC: a propensity score analysis based on a multi-institutional registry. Eur J Cardiothorac Surg 2013;44:849-54 5. Yan TD, Cao C, D`Amico TA et al.: Videoassisted thoracoscopic surgery lobectomy at 20 years: a consensus statement. Eur J Cardiothorac Surg 2014;45:633-639 6. Lyscov A, Obukhova T, Ryabova V et al.: Double-sleeve and carinal resections using the uniportal VATS technique: a single centre experience. J Thorac Dis 2016;8 (suppl 3):235-241

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