title: Nodal Upstaging Is More Common with Thoracotomy than with VATS During Lobectomy for Early-Stage Lung Cancer: An Analysis from the National Cancer Data Base.
abstract: BACKGROUND
  Questions remain regarding differences in nodal evaluation and upstaging between thoracotomy (open) and video-assisted thoracic surgery (VATS) approaches to lobectomy for early-stage lung cancer. Potential differences in nodal staging based on operative approach remain the final significant barrier to widespread adoption of VATS lobectomy. The current study examines differences in nodal staging between open and VATS lobectomy.
  
  
  METHODS
  The National Cancer Data Base was queried for patients with clinical stage T2N0M0 or lower lung cancer who underwent lobectomy in 2010-2011. Propensity score matching was performed to compare the rate of nodal upstaging in VATS with that in open approaches. Additional subgroup analysis was performed to assess whether rates of upstaging differed by specific clinical setting.
  
  
  RESULTS
  A total of 16,983 lobectomies were analyzed; 4935 (29.1%) were performed using VATS. Nodal upstaging was more frequent in the open group (12.8% versus 10.3%; p < 0.001). In 4437 matched pairs, nodal upstaging remained more common for open approaches. For a subgroup of patients who had seven lymph or more nodes examined, propensity matching revealed that nodal upstaging remained more common after an open approach than after VATS (14.0% versus 12.1%; p = 0.03). For patients who were treated in an academic/research facility, however, the difference in nodal upstaging between an open and VATS approach was no longer significant (12.2% versus 10.5%, p = 0.08).
  
  
  CONCLUSIONS
  For early-stage lung cancer, nodal upstaging was observed more frequently with thoracotomy than with VATS. However, nodal upstaging appears to be affected by facility type, which may be a surrogate for expertise in minimally invasive surgical procedures.
authors.affiliation: Section of General Thoracic Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Medbery
authors.affiliation: Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Theresa W
authors.initials: TW
authors.lastname: Gillespie
authors.affiliation: Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Liu
authors.affiliation: Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Dana C
authors.initials: DC
authors.lastname: Nickleach
authors.affiliation: Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA; Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Lipscomb
authors.affiliation: Section of General Thoracic Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Manu S
authors.initials: MS
authors.lastname: Sancheti
authors.affiliation: Section of General Thoracic Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Allan
authors.initials: A
authors.lastname: Pickens
authors.affiliation: Section of General Thoracic Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Force
authors.affiliation: Section of General Thoracic Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA. Electronic address: felix.fernandez@emoryhealthcare.org.
authors.forename: Felix G
authors.initials: FG
authors.lastname: Fernandez
mesh_terms: D000368:Aged; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D057216:Propensity Score; D020775:Thoracic Surgery, Video-Assisted; D013908:Thoracotomy
keywords: Lobectomy; Lung cancer surgery; Staging; Video-assisted thoracic surgery (VATS)