Role of video-assisted thoracic surgery in T4 NSCLC

Abstract

For many years, T4 lung tumors have been considered less suitable for surgery, because of their local extension invading central structures or vertebral bodies. To date, many studies have confirmed the advantages in terms of survival of a multimodality approach made up of surgical resection associated with neoadjuvant and/or adjuvant therapy for selected patients with advanced lung cancer. In those patients, in fact, minimally invasive surgery could improve overall survival rates while promoting faster recovery, faster access to adjuvant therapies and preserving a better functionality of the immune system. Because of the difficulty in collecting data on patients with T4 lung tumors amenable to minimally invasive surgery, published evidences only come from case reports which prove the feasibility and the possible advantages of video-assisted thoracic surgery (VATS) procedures. The aim of this literature review is to collect the published experiences of skilled surgeons dealing with T4 tumors invading central structures or chest wall, to analyze concerns and new opportunities of treatment and proving the feasibility and advantages of the VATS approach.

Uniportal video-assisted thoracoscopic surgery (UVATS) right lower lobectomy for a giant T4 squamous cell lung tumour

“…In skilled hands, UVATS has been shown to be a viable approach for advanced lung tumours. 2 A previous study demonstrated that advanced patients operated upon by VATS had similar results when compared with open surgery. 6 The successful execution of complicated UVATS lobectomy is dependent upon the expertise and experience gained through doing UVATS over time.…”

“… 9 , 10 VATS resection for large lung tumours is rarely undertaken or discussed because of adhesions, narrow spaces and the difficulty of moving the lobe, so it remains a difficult operation to undertake using a UVATS approach. 2 The difficulty associated with T4 lung cancer is related to the size of the tumour, which occupies the chest cavity, reduces the field of vision and requires more time to resect. Another difficulty is adhesion to the surrounding structures, which also takes more time and may cause more incidental injuries when compared with a smaller sized tumour.…”

“… 1 T4 lung tumours have long been considered unsuitable for surgery because they spread locally to the central organ structures. 2 Therefore, many studies have confirmed the survival benefit of a multimodal approach consisting of surgical resection in combination with neoadjuvant therapy and/or adjuvant therapy for selected patients with locally advanced lung tumours. 1 …”

“…1 T4 lung tumours have long been considered unsuitable for surgery because they spread locally to the central organ structures. 2 Therefore, many studies have confirmed the survival benefit of a multimodal approach consisting of surgical resection in combination with neoadjuvant therapy and/or adjuvant therapy for selected patients with locally advanced lung tumours. 1 Uniportal video-assisted thoracic surgery (UVATS) is one of the unique methods that have revolutionized the discipline of minimally-invasive thoracic surgery in the last two decades.…”

“…5 However, with the advancement of technology and surgical skills, UVATS has become a challenging option for treating T4 lung tumours, even though published data remain limited. 2 It is assumed that complex procedures such as lobectomy, revascularization, pneumonectomy, and chest wall resection should be performed only by experienced surgeons. 6 A previous report proposed a 25-case learning curve for minimally-invasive T4 tumour resection for professional surgeons that have performed more than 100 VATS surgeries during their careers.…”