title: Long-term survival following open versus thoracoscopic lobectomy after preoperative chemotherapy for non-small cell lung cancer.
abstract: OBJECTIVE
  Video-assisted thoracoscopic (VATS) lobectomy is increasingly accepted for the management of early-stage non-small cell lung cancer (NSCLC), but its role for locally advanced cancers has not been as well characterized. We compared outcomes of patients who received induction therapy followed by lobectomy, via VATS or thoracotomy.
  
  
  METHODS
  Perioperative complications and long-term survival of all patients with NSCLC who received induction chemotherapy (ICT) (with or without induction radiation therapy) followed by lobectomy from 1996-2012 were assessed using Kaplan-Meier and Cox proportional hazard analysis. Propensity score-matched comparisons were used to assess the potential impact of selection bias.
  
  
  RESULTS
  From 1996 to 2012, 272 patients met inclusion criteria and underwent lobectomy after ICT: 69 (25%) by VATS and 203 (75%) by thoracotomy. An 'intent-to-treat' analysis was performed. Compared with thoracotomy patients, VATS patients had a higher clinical stage, were older, had greater body mass index, and were more likely to have coronary disease and chronic obstructive pulmonary disease. Induction radiation was used more commonly in thoracotomy patients [VATS 28% (n = 19) vs open 72% (n = 146), P < 0.001]. Thirty-day mortality was similar between the VATS [3% (n = 2)] and open [4% (n = 8)] groups (P = 0.69). Seven (10%) of the VATS cases were converted to thoracotomy due to difficulty in dissection from fibrotic tissue and adhesions (n = 5) or bleeding (n = 2); none of these conversions led to perioperative deaths. In univariate analysis, VATS patients had improved 3-year survival compared with thoracotomy (61% vs 43%, P = 0.010). In multivariable analysis, the VATS approach showed a trend towards improved survival, but this did not reach statistical significance (hazard ratio, 0.56; 95% confidence interval, 0.32-1.01; P = 0.053). Moreover, a propensity score-matched analysis balancing patient characteristics demonstrated that the VATS approach had similar survival to an open approach (P = 0.56).
  
  
  CONCLUSIONS
  VATS lobectomy in patients treated with induction therapy for locally advanced NSCLC is feasible and effective and does not appear to compromise oncologic outcomes.
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Chi-Fu Jeffrey
authors.initials: CF
authors.lastname: Yang
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Robert Ryan
authors.initials: RR
authors.lastname: Meyerhoff
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Nicholas Ryan
authors.initials: NR
authors.lastname: Mayne
authors.affiliation: Emory University, Atlanta, GA, USA.
authors.forename: Terry
authors.initials: T
authors.lastname: Singhapricha
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Toomey
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Speicher
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Hartwig
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Betty C
authors.initials: BC
authors.lastname: Tong
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Onaitis
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Harpole
authors.affiliation: Duke University, Durham, NC, USA.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: D'Amico
authors.affiliation: Stanford University, Stanford, CA, USA berry037@stanford.edu.
authors.forename: Mark F
authors.initials: MF
authors.lastname: Berry
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000009:adverse effects / Q000379:methods*; D057216:Propensity Score; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects / Q000379:methods*; D013908:Thoracotomy / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents
keywords: Lung cancer; Thoracoscopic lobectomy; VATS