Patient selection for video-assisted thoracic surgery pulmonary resection: a narrative review

VSports注册入口 - Introduction

Background

Lung cancer remained the leading cause of cancer death in the USA in 2024 (1) VSports在线直播. Surgery remains the primary treatment modality for patients with early-stage disease and the mainstay of curative therapy. However, the past one to two decades have seen significant changes in the operative and nonoperative treatment of lung cancer. The revolution in targeted therapy and immunotherapy has dramatically improved survival for patients with later-stage disease who are not surgical candidates (2-4). These drugs are now increasingly incorporated into the treatment protocols of patients with surgically resectable disease. Guidelines are also increasingly utilizing neoadjuvant chemotherapy and immune therapy to good effect in patients with resectable disease (5-7). This has changed the approach to lung cancer treatment, and a comprehensive review of available literature with a specific focus on patient selection and multidisciplinary tumor board has not been completed. Furthermore, video-assisted thoracic surgery (VATS) and the subsequent introduction of robot-assisted thoracic surgery (RATS) have reduced the morbidity and mortality associated with a thoracotomy, thereby increasing the number of patients who can tolerate a pulmonary resection (8-10).

VSports - Rationale and knowledge gap

Appropriate patient selection for surgery is key, as is thoughtful consideration of neoadjuvant and adjuvant treatment based on tumor board recommendations V体育2025版. Given these developments, every patient diagnosed with lung cancer warrants an individualized treatment protocol, which is best formulated by an expert multidisciplinary tumor board (11-13). It is clear in the literature that there remains a dearth of reviews that have sought to bring these thoughtful considerations in the approach to the patient requiring pulmonary resection for lung cancer.

Objective (VSports在线直播)

In this narrative review, we will evaluate the current indications for pulmonary resection for lung cancer, as well as how surgery fits into the overall treatment scheme for patients diagnosed with lung cancer at various stages. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats VSports. amegroups. com/article/view/10. 21037/vats-24-37/rc).

V体育2025版 - Methods

A narrative review of the literature was performed using a search of PubMed and ClinicalKey using a variable combination of the terms “video-assisted thoracic surgery”, “robot-assisted thoracoscopic surgery”, “patient selection”, “lung cancer resection”, “pulmonary resection”, “neoadjuvant therapy”, “neoadjuvant immunochemotherapy”, and “multidisciplinary tumor board”. Articles were hand-selected and citation chaining was performed to identify relevant studies VSports app下载. The articles cited were written in English between January 1995 and January 2024. See Table 1 for the search summary strategy.

"VSports app下载" Multidisciplinary thoracic tumor board

The oncologic care of patients with lung cancer is contingent upon the implementation of recommendations from a multidisciplinary tumor board V体育官网. Engagement of professionals includes radiation oncologists, surgeons, radiologists, medical oncologists, pathologists, and other support personnel (13). This allows for decisions to be made that reflect the consensus of the group and align with extant guidelines that are representative of the best available care for the patient. The objectives of the tumor board should include the creation of consensus decisions that are devoid of individual bias and improve the outcomes of evidence-based treatments to patients with lung cancer (11-13).

Following identification and diagnosis of lung cancer, appropriate selection of individuals who warrant treatment results in improved survival and outcomes from a quality of life perspective (14). A study published in 2010 notes that following the introduction of a thoracic tumor board improved the completion of a staging evaluation (79% vs. 93%, P<0.0001), multidisciplinary evaluation prior to therapy (62% vs. 96%, P<0.0001), and implementation of National Comprehensive Cancer Network (NCCN). treatment guidelines (81% vs. 97%, P<0.0001) (15). Furthermore, the average number of days from diagnosis to initiation of treatment significantly decreased in this study (29 vs. 17 days, P<0.0001) following initiation of a thoracic tumor board (15).

With specific regard to the utilization of chemotherapy and other therapies, appropriate utilization also improves with the implementation of a thoracic tumor board (16). A prospective study comparing the initial treatment plan of the managing physician found that thoracic tumor board recommendations resulted in a change in treatment in 40% of lung cancer patients (17). Furthermore, staging was adjusted in up to 40% of cases, and resulted in adherence to the recommendation of the thoracic tumor board in 97% of cases (17). There is clearly validity to the impact of a thoracic tumor board. When changes are made to the managing physicians’ original plan, complex thoracic oncology patients benefit from the multidisciplinary review that is uniquely available at a tumor board.

Patient selection for lung cancer resection

The development of increasingly effective targeted therapies and immunotherapies has dramatically improved survival for patients diagnosed with stage three or four non-small cell lung cancer (NSCLC) (2,4). This trend has subsequently carried over to patients with earlier-stage, surgically resectable disease, and the indications for neoadjuvant chemoimmunotherapy are rapidly expanding (5-7). With these changing protocols, it is important to review the current recommendations for which patients warrant pulmonary resection, and at what stage in their treatment, resection is warranted.

NSCLC

NSCLC makes up about 85% of the lung cancer in the USA (18). Each patient’s treatment regimen is determined by their cancer’s stage, which is determined according to the American Joint Committee on Cancer (AJCC)’s revised 8th edition staging guidelines for NSCLC (19). Broadly, surgery is the mainstay of treatment for stage I and II NSCLC, and is an important component of the multimodal treatment for select patients with locally-advanced stage IIIA NSCLC (20).

In 2013, the American College of Chest Physicians published guidelines recommending that all patients with stage I or II NSCLC, without prohibitive medical comorbidities, undergo upfront surgical resection with mediastinal lymph node dissection (21). However, in the years since this publication, a growing body of data suggests that neoadjuvant chemotherapy, and now neoadjuvant immunotherapy plus chemotherapy, confers a survival benefit in appropriately selected patients (5-7). Today, the NCCN offers detailed recommendations for managing NSCLC diagnosed at each stage (22). The NCCN suggests that patients with a peripheral, stage IA tumor on imaging, without clinically positive lymph nodes, may be candidates to forgo tumor biopsy and instead proceed directly to curative resection (with associated lymph node dissection) and adjuvant treatment (22). However, the NCCN now recommends that all other patients with clinical stage I and II tumors (including centrally-located stage IA, stage IB, and stage IIA and IIB) be evaluated for neoadjuvant immunochemotherapy. This recommendation is listed under perioperative systemic therapy in the NCCN guidelines for NSCLC. Determining eligibility for neoadjuvant treatment requires a mediastinal lymph node biopsy to assess disease extent and tumor sampling, which can be accomplished via computed tomography (CT)-guided biopsy, endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS), or mediastinoscopy or mediastinotomy. If, after tumor sampling, there are no contraindications to neoadjuvant immunochemotherapy, the NCCN recommends a four-cycle course of a programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitor—either nivolumab, pembrolizumab, or durvalumab—with an associated doublet platinum-based chemotherapy before surgical resection, and then, in many cases, the continuation of the single-agent immunotherapy post-operatively (22-26). Contraindications to neoadjuvant immune therapy include a history of autoimmune disease, current immunosuppressants, or a tumor containing certain oncogenic drivers, like an EGFR and ALK mutation, that respond well to targeted therapies but poorly to PD-1/PD-L1 inhibitors. If the patient cannot receive immunotherapy, they are still recommended to receive neoadjuvant chemotherapy. For patients with advanced or metastatic NSCLC, or in patients with disease progression despite immunotherapy, chemotherapy, or both, definitive local radiation therapy may be considered per NCCN guidelines. NCCN guidelines also recommend consideration of neoadjuvant chemoradiotherapy in appropriately selected patients. Specifically, NSCLC tumors beyond T3 or noted to be invading adjacent structures should be considered for neoadjuvant chemoradiation per NCCN guidelines. These may be utilized in combination with immunotherapy in appropriate checkpoints, notably in stage IIIA disease that is deemed unresectable, where definitive chemoradiation is employed, followed by durvalumab.

Stage IIIA NSCLC comprises a heterogeneous group of locally advanced tumors, and the selection of patients for surgical resection depends upon the judgment of the thoracic surgeon and the evaluation of the multidisciplinary tumor board (20,27). However, in general, patients with T3N1 disease, which includes a primary tumor between 5 and 7 cm or a tumor involving resectable structures (i.e., chest wall, pericardium, parietal pleura), with lymph node involvement of ipsilateral pulmonary or hilar nodes, are potential candidates for resection—often after a course of neoadjuvant therapy. In some highly selected cases, patients with T2N2 disease, involving mediastinal lymph nodes or subcarinal nodes, may be candidates for an aggressive resection, such as a pneumonectomy, especially if they have a good response to neoadjuvant or induction immunochemotherapy (20,27). The NCCN recommendations for neoadjuvant therapy for this group are the same as for patients with stage I and II NSCLC (22).

Resection after preoperative immunochemotherapy and targeted therapy

While many studies are showing improved survival with neoadjuvant immunotherapy, many surgeons are noting that the pulmonary resection after immunotherapy treatment is more technically challenging. A growing body of literature documents increased pulmonary fibrosis after treatment with PD-1/PD-L1 inhibitors that make the mediastinal lymph node dissection more challenging (24,28-30). Several of these studies show a higher rate of conversion from a minimally invasive approach to an open thoracotomy in patients who received neoadjuvant immunotherapy (24,28). Nevertheless, these studies note that this difference is not prohibitive of an adequate resection, but strengthens the argument that these pulmonary resections have better outcomes in experienced hands.

Pre-operative immunochemotherapy may have a role in increasing the possibility of surgical resection in initially unresectable stage IIIB disease. A study by Zheng et al. stratified 59 patients with initially-unresectable stage IIIB NSCLC into two groups and administered pembrolizumab + chemotherapy. One group then went on to undergo pulmonary resection. All of the patients in this relatively small cohort had a successful R0 resection and ultimately had significantly longer progression-free and disease-free survival than the patients who received immunochemotherapy alone (31). This supports the use of induction immunochemotherapy with PD-1/PD-L1 inhibitors and may increase the number of patients who are candidates for surgery moving forward.

New evidence also points to the use of pre-operative targeted therapies for patients with NSCLC with targetable genetic mutations. For example, Lv et al. demonstrated that patients with locally-advanced (stage II through IIIB) EGFR + NSCLC benefit from preoperative osimertinib (32). A meta-analysis of 11 other studies investigating preoperative targeted therapy for EGFR+ NSCLC confirms these findings (33). Early data also suggests that preoperative targeted therapies for NSCLC with other targetable mutations, like ALK, MET, and RET mutations, may render more patients surgically resectable, and prolong survival (34-36). Neoadjuvant/induction therapy with molecular targeted therapies represents an exciting frontier in the treatment of previously-unresectable NSCLC.

V体育ios版 - Small cell lung cancer (SCLC)

There is comparatively less written about the surgical management of SCLC than NSCLC. It comprises approximately 15% of lung cancer diagnoses in the USA, and given its aggressive course and propensity to metastasize early, there have historically been fewer indications for surgical resection (37). However, over the past two decades, a growing number of studies have demonstrated a survival benefit for those who undergo pulmonary resection (38). It is notable that the meta-analysis demonstrating a survival benefit for patients undergoing pulmonary resection does include retrospective studies, introducing a degree of bias. The American Joint Committee on Cancer (AJCC) recommends the same TNM staging system for SCLC that is used for NSCLC. However, it is also common to classify SCLC by the less rigorously defined “limited disease” (LD) and “extensive disease” (ED), in which LD generally refers to SCLC contained to one hemithorax, the mediastinum, and ipsilateral supraclavicular nodes. Approximately two-thirds of patients initially present with widespread metastases, and about half of those without widespread metastases still have extensive lymph node involvement in the mediastinum and ipsilateral hilum and supraclavicular nodes (19,39).

The NCCN guidelines for SCLC recommend resection for patients with stage I–IIA disease (T1 or T2 primary tumors, and no nodal involvement nor distant metastases), but acknowledges that only about 5% of patients present with these early stages. For patients with limited-stage disease (stage II and III), the NCCN recommends only chemotherapy and radiation (40). However, this recommendation is based on older studies that reported no survival benefit between resection and chemoradiation for limited-stage disease (41-43). Newer studies, taking into account modern improvements in imaging, staging, and operative technique, have instead found a survival benefit for carefully-selected patients with stages I–IIIA SCLC (44-47). While overall survival is still low for patients with stage II and III disease, this data suggests that surgery may benefit the well-selected patient.

V体育安卓版 - Choice of surgical modality

The choice of surgical modality is a key aspect in the preparation for pulmonary resection, which has historically been a high-risk surgery with significant morbidity. Thankfully, the rise of minimally invasive pulmonary resections, with either VATS or RATS, has led to improved patient perioperative outcomes compared to open pulmonary resection while maintaining oncologic benefit.

When comparing VATS to open thoracotomy, there is a preponderance of lower-quality studies demonstrating significant improvements in patient pain, perioperative complications, and length of stay with VATS (48). There is comparatively less evidence from high-quality randomized controlled trials. However, a Danish study showed that patients who underwent VATS had reduced pain than those with thoracotomy, with similar surgical complications and oncologic outcomes (49). The VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer (VIOLET) trial examined 503 patients randomly assigned to either VATS or open lobectomy, and found that VATS results in decreased pain, decreased postoperative hospital stay, and improved physical function (50). Overall, the conclusion of high-quality literature appears concordant with that of published case reports and case series, that VATS provides improved pain control, better return to function, reduced perioperative complications, and short length of stay while maintaining oncologic outcomes.

The advent of RATS represents the ongoing evolution of minimally invasive thoracoscopic surgery. The DaVinci robot affords an improved field of view, intracorporeal maneuverability, and training capabilities when compared to VATS. In a retrospective review, Miyajima et al. found that RATS had significantly less blood loss compared to VATS, with otherwise similar operative times and postoperative length of stay (51). Using RATS at high-volume centers has been shown to have a lower rate of conversion to open thoracotomy than VATS [odds ratio, 0.71; 95% confidence interval (CI), 0.55–0.94; P=0.01. RATS surgery odds ratio, 0.59; 95% CI, 0.43–0.81; P=0.001] (52). Operative times are also similar to the robot-assisted approach.

Many detractors of the robot have incorrectly noted a slow learning curve. However, more recent published data demonstrates that it only takes 20 cases to become proficient using the DaVinci, while it takes 50 cases to become comparably proficient using VATS (53). Finally, there is mixed data regarding the cost-effectiveness of using RATS vs. VATS. Using the DaVinci robotic system is associated with significantly higher upfront costs, but many recognize that these costs are gradually offset by shorter operating times, reduced perioperative complications, and shorter overall patient length of stay once the surgeon has overcome the robotic learning curve (54-56).

Taken together, when preparing a patient for pulmonary resection, the evidence clearly supports the use of minimally invasive pulmonary resection over open thoracotomy. Both VATS and RATS offer improved patient pain, return to function, reduced perioperative complications, and shorter hospital length of stay compared to thoracotomy. Data is now trending towards supporting the use of RATS over VATS, given the improved operative visualization, intracorporeal maneuverability, and shorter time to develop proficiency, even despite higher upfront operative costs.

Conclusions

In the rapidly changing world of lung cancer care, the appropriate patient selection and timing for pulmonary resection is increasingly nuanced. The past decade has seen a significant shift towards the use of neoadjuvant immunochemotherapy with promising survival benefits. However, this leads to significantly more complicated and nuanced guidelines regarding the order of immunochemotherapy, targeted therapy, radiation, and the timing of surgical resection. As the field transitions to increasingly personalized lung cancer care, the input of an experienced multidisciplinary tumor board becomes ever more important. Furthermore, the revolution in VATS has improved patient pain, decreased complications, and reduced length of stay, thereby almost entirely supplanting open thoracotomy. The recent rise of RATS promises to further improve perioperative outcomes, with the higher initial cost gradually offset by a shorter training period, reduced operative times and reduced patient length of stay. However, either VATS or RATS can provide a safe, equitable, and oncologically equivalent outcome based on surgeon or institutional preference. The rapid changes in guidelines regarding personalized neoadjuvant therapy, timing of surgery, and the evolution in operative modalities require a nimble thoracic surgeon, constantly willing to learn new guidelines, operative modalities, and to evolve their practice to optimize their patients’ outcomes.

V体育2025版 - Strengths and limitations

This review provides a comprehensive document designed to assist thoracic surgeons in appropriately selecting patients with lung cancer for pulmonary resection via VATS or RATS. It facilitates a discussion of the benefits of neoadjuvant treatment, including recently developed immunotherapy strategies. It is limited by design that it is a retrospective review, and certain citations do not represent randomized controlled trials and are therefore potential sources of bias.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “Preoperative Planning and Assessment for VATS Lung Cancer Resection”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-24-37/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-37/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-37/coif). The series “Preoperative Planning and Assessment for VATS Lung Cancer Resection” was commissioned by the editorial office without any funding or sponsorship. G.D.T. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from February 2025 to December 2026. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work and ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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