title: High Risk for Thoracotomy but not Thoracoscopic Lobectomy.
abstract: BACKGROUND
  Pulmonary lobectomy is the standard of care for resection of non-small cell lung cancer (NSCLC). Patients with compromised lung function who are considered high risk may be denied surgical treatment; thus, proper identification of those truly at high risk is critical. Video-assisted thoracic surgery (VATS) may reduce the operative risk. This study reviews our institutional experience of pulmonary lobectomy by open thoracotomy or VATS techniques in patients deemed to be high risk.
  
  
  METHODS
  A retrospective review of an institutional database was performed for all patients undergoing lobectomy from 2002 to 2010. Patients were grouped into high-risk (HR) and standard-risk (SR) cohorts according to the American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021 criteria.
  
  
  RESULTS
  From 2002 to 2010, 72 HR and 536 SR patients underwent lobectomy. Mean age was 73 years for HR and 66 years for SR (p < 0.0001). Rates of overall (p < 0.0001) and pulmonary complications (p < 0.0001) were significantly higher in the HR group. However, when HR patients were resected by VATS, there was no significant difference in overall (p = 0.1299) or pulmonary complications (p = 0.2292) compared with the SR VATS group. Moreover, overall survival was significantly lower for HR patients who had an open operation compared with VATS lobectomy or SR open (p = 0.0028).
  
  
  CONCLUSIONS
  VATS lobectomy offers patients who are considered to be at increased risk for open lobectomy a feasible procedure, with no difference in overall survival compared with SR patients, and decreased morbidity compared with open lobectomy. VATS lobectomy should be considered for patients who historically may not have been considered for surgical resection.
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada. Electronic address: laura.donahoe@uhn.ca.
authors.forename: Laura L
authors.initials: LL
authors.lastname: Donahoe
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Moira
authors.initials: M
authors.lastname: de Valence
authors.affiliation: Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Eshetu G
authors.initials: EG
authors.lastname: Atenafu
authors.affiliation: Division of Thoracic Surgery, St. Joseph's Health Care, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Waël C
authors.initials: WC
authors.lastname: Hanna
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Waddell
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Pierre
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Yasufuku
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: de Perrot
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Cypel
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Shaf
authors.initials: S
authors.lastname: Keshavjee
authors.affiliation: Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Gail E
authors.initials: GE
authors.lastname: Darling
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000601:surgery*; D006801:Humans; D008175:Lung Neoplasms / Q000601:surgery*; D008875:Middle Aged; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies; D012306:Risk; D016019:Survival Analysis; D020775:Thoracic Surgery, Video-Assisted; D013908:Thoracotomy