Lung cancer surgery in the breathless patient - the benefits of avoiding the gold standard

Objective: Lung cancer resection in breathless patients with severe chronic obstructive pulmonary disease (COPD) remains controversial. Whilst open lobectomy remains the gold standard, alternative approaches have been described. We undertook a retrospective, observational study to compare the outcomes of a tailored strategy combining video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy against open lobectomy in these patients. Method: Clinical outcomes were studied in 84 consecutive patients (male:female ratio was 56:28, mean age 69.0 years, median preoperative-forced expiratory volume in 1 s (FEV1) 41%) with a predicted-postoperative FEV1 <= 40% (median 32.8% and range 14-40%) who underwent anatomical lung resection for lung cancer. The control group consisted of 35 patients who underwent open lobectomy. The study group comprised 27 patients who underwent anatomical segmentectomy, 18 who underwent VATS lobectomy and four who underwent VATS segmentectomy. Results: There were no significant inter-group differences in age (p = 0.87), gender (p = 0.49), preoperative FEV1 (p = 0.30) or cardiac co-morbidities (p = 0.78). There were more upper lobe resections in the control group (51% vs p < 0.0001). Tumour size tended to be smaller in the study group (p = 0.052). There were also more incidences of stage I cancers in the study group (90% vs 71%, p = 0.043). The median length of hospital stay was shorter in the study group (8 vs 12 days, p = 0.054). There was no significant difference in either in-hospital mortality (8% vs 14%, p = 0.48) or recurrence rate (26% vs 20%, p = 0.60). However, unadjusted survival was significantly longer in the study group (median survival 54 months vs 20 months, 5-year survival 42% vs 18%, p = 0.03). The survival benefit of this group remained significant in multivariate analyses (adjusted survival hazard ratio (HR) 2.39, 95% confidence interval (CI): 1.30-4.39, p = 0.005). A subgroup analysis on only uncomplicated stage I cancers found a similarly worse outcome in the control group (p = 0.002). After segregating surgical approach and the extent of resection, the VATS approach was identified as the critical factor conferring survival advantage to the study group (hazard ratio (HR) 2.78, 95% CI: 1.21-6.37, p = 0.016). Conclusions: Despite a tailored approach to patients with severe pulmonary dysfunction, there was still significant disparity in survival between groups. Patients who underwent open lobectomy have a worse outcome despite adjusting for confounders. This survival benefit was driven by thoracotomy avoidance through VATS resection. The use of operative techniques to reduce chest-wall dysfunction should be considered in the breathless patient. (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.