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OBJECTIVE: Robot-Assisted Thoracic Surgery (RATS) is an innovative minimally invasive surgical technique in the treatment of non-small cell lung cancer (NSCLC). RATS has been designed to improve visibility and dexterity over the Video-Assisted Thoracoscopic Surgery (VATS) technique. As there is a relation between the completeness of lymphadenectomy and survival, we sought to investigate the accuracy of RATS lymphadenectomy. Surgical results were compared to preoperative clinical staging results and postoperative follow-up data were collected from the hospital database.
METHODS: This single institutional retrospective cohort study was conducted in patients that underwent RATS for NSCLC. Excluded were patients with a history of concurrent malignant disease or other previous primary neoplasms; patients with Small Cell Lung Cancer (SCLC), patients in whom the RATS was converted to thoracotomy (before LN dissection) and patients who did not give consent for research. Baseline characteristics of patients, tumor and surgical procedures as well as survival data were obtained from a local surgery database. Preoperative clinical staging results were compared with surgically derived pathologic staging results. Mediastinal recurrence was studied with follow-up Computed Tomography (CT).
RESULTS: From November 2011 until May 2016, 227 patients underwent RATS at Isala hospital. 132 of those (mean age, 69.6 years ± 9.2) met our aforementioned eligibility criteria. Mean N2 lymph node stations assessed according to IASLC was 3.6 ± 1.2. There were 14 patients (10.6%) with unforeseen N2: 6 patients (4.5%) were upstaged from cN0 to pN2 and 8 patients (6.1%) from cN1 to pN2. Nine out of 14 unforeseen N2 patients were clinically staged by EUS/EBUS (all enlarged and/or positron emission tomography avid N2 stations were sampled); in 4 patients EUS/EBUS was not performed (no suspected lymph nodes on imaging). Mediastinal recurrence was found in 7 patients (5.3%), 2 patients (1.5%) confirmed by histology (all LNs involved were sampled at lymphadenectomy), with a median follow-up of 14.3 months ± 13.1.
CONCLUSIONS: In this retrospective study, mediastinal upstaging was found in 10.6 percent of patients after RATS lymphadenectomy for NSCLC. Mediastinal recurrence was found in 5.3 percent of patients. This rate of mediastinal recurrence is comparable with previously reported recurrence after VATS.