International Society For Minimally Invasive Cardiothoracic Surgery

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Is Robotic Lobectomy For Nsclc Inferior To Open Lobectomy? Let The Oncologic Outcomes Decide
Usman Ahmad, MD, Andrew Tang, MD, Siva Raja, MD, PhD, Alejandro C. Bribriesco, MD, Daniel P. Raymond, MD, Sudish C. Murthy, MD, PhD.
Cleveland Clinic, Cleveland, OH, USA.

Objective: Complete staging of the hilum and mediastinum is a critical component of operative management of non-small cell lung cancer (NSCLC). Specifically, identification of unsuspected loco-regional lymph node disease is a surrogate for adequacy of resection. The goal of this study is to determine whether robotic lobectomy is associated with a worse, similar, or better rate of nodal upstaging compared to open lobectomy for clinical stage I NSCLC. We hope to understand whether robotic lobectomy should be considered an oncologically equivalent intervention. Methods: Patients with clinical stage I NSCLC (< cT2aN0M0, AJCC 7th) who underwent lobectomy from 2010 through 2015, were abstracted from the National Cancer Database (NCDB). 1:1 propensity matching was performed for robotic and open lobectomy. Groups were matched on demographic, facility type/location, comorbidities, year of diagnosis, time to surgery, tumor location and size, histology, lymphovascular invasion and grade. The primary outcomes were the number of lymph nodes examined, rates of nodal upstaging, defined as unexpected hilar (pN1) or mediastinal (pN2) lymph node involvement, and overall survival. Results: There were 50,186 open and 7,452 robotic lobectomy procedures for clinical stage I NSCLC (<cT2aN0M0) from 2010 through 2015. Matching generated 7,452 well matched pairs. In the matched cohort, mean age at diagnosis was 68 years with 54% female distribution. There was no statistically significant difference in nodal upstaging between robotic and open procedures (11.0% vs 11.6%, p=0.28). This is despite a higher median number of LNs examined in robotic lobectomy group (10 vs 8, p<0.001). The robotic group had lower 30-day (1.3% vs 1.9%, p=0.02), and 90-day mortality (2.3% vs 3.5%, p<0.001). Five-year overall survival for patients with pathologic stage I was similar between open and robotic groups (66.6% vs 65.6%, p=0.25). Conclusions: Robotic lobectomy for clinical stage I NSCLC appears oncologically equivalent to open lobectomy as demonstrated by similar nodal upstaging rates and overall survival. This suggests that robotic technology has been appropriately adopted for use in early stage NSCLC. Reluctance of widespread dissemination of minimally invasive platforms appears unfounded from an oncologic standpoint.

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