The Role of Lung Cancer Surgical Technique on Lymph Node Sampling and Pathologic Nodal Upstaging

BACKGROUND The role of operative approach in surgical lymphadenectomies and pathologic nodal upstaging for lung cancer remains unclear. METHODS This study retrospectively reviewed patients who underwent lobectomy for non-small cell lung cancer from January 2015 to December 2020 at 16 centers within a statewide quality improvement collaborative in Michigan. Pa-tients were stratified by operative approach, and our primary end points were number of LN recovered, number of LN stations sampled, and rates of nodal upstaging with nodal upstaging defined as a higher final pathologic nodal stage compared with preoperative clinical nodal staging. RESULTS A total of 3036 patients were included: 608 (20.0%) with open lobectomies, 1362 (41.3%) with video-assisted thoracoscopic surgery (VATS), and 1233 (37.4%) with robot-assisted thoracoscopic surgery (RATS) lobectomies. Using multivariable logistic regression, study investigators found that VATS was associated with lower rates of nodal upstaging (odds ratio [OR], 0.71; 95% CI, 0.54-0.94; P = .015) and harvesting >= 10 LNs (OR, 0.40; 95% CI, 0.31-0.50; P < .001) as compared with open surgery, whereas no significant difference was found between RATS and open techniques. Compared with open surgery, VATS had lower rates of sampling at >= 5 nodal stations (OR, 0.66; 95% CI, 0.53-0.84; P = .001), whereas RATS rates were higher (OR, 2.38; 95% CI, 1.85-3.06; P < .001). CONCLUSIONS VATS lobectomies were associated with lower rates of harvesting >= 10 LNs, sampling >= 5 LN stations, and pathologic nodal upstaging compared with open and RATS lobectomies. Compared with open procedures, RATS lobectomies were associated with higher rates of sampling >= 5 LN stations, but there was no significant difference between open and RATS approaches in rates of nodal upstaging or harvesting >= 10 LNs. (Ann Thorac Surg 2023;115:1238-46) (c) 2023 by The Society of Thoracic Surgeons

Automated summary

This study investigated the impact of different operative approaches (open surgery, VATS, and RATS) on lymphadenectomies and pathologic nodal upstaging for lung cancer. The results showed that VATS was associated with lower rates of nodal upstaging and harvesting >= 10 LNs compared to open surgery, while RATS did not differ significantly from open surgery. VATS also had lower rates of sampling at >= 5 nodal stations, while RATS had higher rates.