|Year : 2015 | Volume
| Issue : 6 | Page : 130-133
Quality of life and survival after II stage nonsmall cell carcinoma surgery: Video-assisted thoracic surgery versus thoracotomy lobectomy
J Zhao, Y Zhao, T Qiu, W Jiao, Y Xuan, X Wang, Y Wang, Y Luo
Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003, P. R, China
|Date of Web Publication||24-Dec-2015|
Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266003
Source of Support: None, Conflict of Interest: None
Purpose: Due to the improvement of thoracoscopic thchnology and surgeon's ability, plenty of nonsmall cell lung cancer (NSCLC) was treated by video-assisted thoracic surgery (VATS). This study was designed to evaluate the quality of life (QOL) and survival in II stage NSCLC patients following lobectomy, comparing VATS with thoracotomy. Methods: Between 2010 and 2012, 217 II stage NSCLC patients (VATS: 114 patients, OPEN: 103 patients) were enrolled in a long-standing, prospective observational lung cancer surgery outcomes study. Short-form 36 health survey (SF-36) and time to progression (TTP) were measured to evaluate the QOL and postoperative survival. Results: There were significant differences between the two groups in the preoperative radiation therapy and differentiation, and the VATS group had less postoperative complication, blood loss, intraoperative fiuid administration, and shorter length of stay. Statistical analysis of SF-36 questionnaire revealed that VATS group score was higher on seven health dimensions: Bodily pain (BP), energy (EG), general health, physical functioning, mental health, SF, and role-physical (RP), but only BP, EG, and RP have statistical signifiance. Using survival analysis, there was no significant difference between VATS and OPEN group, in which the mean TTP of VATS group is 18.5 months, while OPEN group is 20 months. Conclusions: VATS lobectomy tends to score higher on the QOL and functioning scales and has equivalent postsurgical survival compared with OPEN lobectomy for II stage nonsmall cell carcinoma patients.
Keywords: Nonsmall cell carcinoma, postsurgical survival, quality of life, short-form-36 questionnaire, video-assisted thoracic surgery
|How to cite this article:|
Zhao J, Zhao Y, Qiu T, Jiao W, Xuan Y, Wang X, Wang Y, Luo Y. Quality of life and survival after II stage nonsmall cell carcinoma surgery: Video-assisted thoracic surgery versus thoracotomy lobectomy. Indian J Cancer 2015;52, Suppl S2:130-3
|How to cite this URL:|
Zhao J, Zhao Y, Qiu T, Jiao W, Xuan Y, Wang X, Wang Y, Luo Y. Quality of life and survival after II stage nonsmall cell carcinoma surgery: Video-assisted thoracic surgery versus thoracotomy lobectomy. Indian J Cancer [serial online] 2015 [cited 2019 Aug 25];52, Suppl S2:130-3. Available from: http://www.indianjcancer.com/text.asp?2015/52/6/130/172510
Zhao Jinpeng and Zhao Yandong contributed equally to this paper
| » Introduction|| |
Nonsmall cell lung cancer (NSCLC), accounting for 1.2 million deaths each year, is the primary cause of cancer mortality in both sexes. Undoubtedly, surgical resection remains the most effective therapeutic method for the NSCLC patients. In the past 20 years, pulmonary resection by video-assisted thoracic surgery (VATS) has become an alternative approach for early-stage NSCLC, and VATS has been used with increasing frequency worldwide to perform anatomic resections for lung cancer, including a series of II stage lung carcinoma., The goal of surgery is to improve not only survival, but also quality of life (QOL) and QOL assessments become increasingly important in the evaluation of these treatment options. Previous large series and case–control studies provide strong evidence that patients undergoing VATS lobectomy are associated with short-term benefits such as decreased postoperative pain, decreased perioperative morbidity, better postoperative pulmonary function, reduced length of hospital stay, and earlier return to normal activities,,,,, with the building evidence that survival after VATS lobectomy is similar to the survival after lobectomy by thoracotomy. However, to our knowledge, no study has been undertaken on postoperative time-related QOL of II stage NSCLC patients after lobectomy by VATS in comparison to thoracotomy. Thus, we conducted a nonrandomized prospective questionnaire-based study comparing postoperative time-related QOL and postoperative survival after pulmonary resection by VATS to that after posterolateral thoracotomy to assess the benefit of the VATS approach.
| » Materials and Methods|| |
From 2010 to 2012, 121 II NSCLC patients (69 males, 45 females), with median age of 60.6 years (range from 34 to 86 years) underwent completely video-assisted thoracic lobectomy for lung carcinoma at the Department of Thoracic Surgery in Affiliated Hospital of Qingdao University. Of these, 7 (5.9%) required intraoperative conversion to open thoracotomy, mainly for bleeding, location/local extent of tumor, and adhesions. During this period, 103 II NSCLC patients chose posterolateral thoracotomy as the type of operation. The tumor node metastasis (TNM)-stage and differentiation type were validated by pathologist of our hospital postsurgically. The clinical and pathological characteristics of the 217 patients are standardized according to the World Health Organization (WHO, 1981) and the Union for International Cancer Control (UICC, 2009). All patients (VATS: 114 patients, OPEN: 103 patients) were enrolled in a long-standing, prospective observational lung cancer surgery outcomes study (LCSOS). Written and informed consent was obtained from all patients, and the investigation was approved by ethical committee of our hospital.
In our investigation, functional health status was measured by the administration of the short-form 36 health survey (SF-36), a standardized, validated, and widely used instrument. Data were collected from the SF 36-item questionnaire (SF-36), which was mailed to and completed by patients at 1, 6, and 12 months after surgery. The SF-36 measures eight scales: physical functioning (PF), role functioning-physical, role functioning-emotional, social functioning, bodily pain, mental health (MH), energy (EG), and general health (GH). Raw scores range from 0 to 100, with a higher score indicating a more positive health attribute. Time to progression (TTP) was used as a recurrence index to evaluate the postoperative survival. Moreover, survival of 36 months was adopted for this study on the basis that recurrence is most likely within 3 years of operation and used to describe survival after resection for lung cancer.
| » Operative Technique|| |
All patients underwent general anesthesia with epidural analgesia and intubation with a double lumen endotracheal tube to allow selective lung ventilation. They were placed in the full lateral decubitus position. The thoracoscope was introduced through the 6th or 7th intercostal space on the mid-axillary line with a trocar. Through the thoracoscope port, the surgeons decided on the proper placement of the longitudinal axillary skin incision. A 3–4 cm, long utility incision was made through the 4th or 5th intercostal space on the anterior axillary line. A third retraction incision located on the 6th or 7th intercostal space posterior axillary line was made to assist the chief surgeon. For open lobectomy, we performed the standard posterolateral thoracotomy with division of the latissimus dorsi and serratus anterior muscles. Hilar and mediastinal lymph node dissection was performed in all patients, and the extent of the mediastinal lymph node dissection was the same of VATS and thoracotomy. One chest tube was placed through the thoracoscope port.
For comparison of categorical variables, the Fisher's exact or Chi-squared test was used. Independent samples t-test was used to compare the change of SF36 for VATS versus OPEN. Furthermore, we used TTP as the recurrence index to evaluate the prognostic significance using the cox hazard model. All statistical analyses were performed with the SAS 9.2 Software, and statistical tests were two sided with P < 0.05 as the significant level unless otherwise specified.
| » Results|| |
From 2010 to 2012, 217 II stage NSCLC patients underwent lobectomy (VATS: 114 patients, OPEN: 103 patients) at the Department of Thoracic Surgery in our hospital and entered the LCSOS. All the patients completed the questionnaires during the follow-up after they underwent surgery. Preoperative and hospital outcome characteristics of the 217 study patients are shown in [Table 1]. There was a significant difference between the two groups in the preoperative radiation therapy and differentiation, and the VATS group had less postoperative complication, blood loss, intraoperative fluid administration, and shorter length of stay. However, VATS and OPEN groups did not differ statistically regarding the age, sex, smoking status, TNM-stage, preoperative chemotherapy, operation time, and postoperative chest tube.
|Table 1: Characteristics of preoperative and hospital outcome (VAT S versus OPEN lobectomy)|
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As shown in [Table 2] and [Figure 1], statistical analysis of SF-36 in our study revealed that VATS group score higher on seven health dimensions: bodily pain (BP), EG, GH, PF, MH, SF, and role-physical (RP), but only BP, EG, and RP have statistical significance. The mean TTP of all patients was 19.2 months (range 1–36 months). Using survival analysis, we found no significant difference (P = 0.2538) between VATS and OPEN group that the mean TTP of VATS group is 18.5 months, while OPEN group is 20 months [Figure 2].
|Figure 1: Health-related quality of life (social functioning-36 scores) at 1, 6, and 12 months after surgery: Video-assisted thoracic surgery versus OPEN. BP: Bodily pain, EG: Energy, GH: General health, MH: Mental health, PF: Physical functioning, RE: Role-emotional, RP: Role-physical, SF: Social functioning. 0 = worst; 100 = best, *P < 0.05|
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|Figure 2: Postsurgical survival curves from a cox model, (video-assisted thoracic surgery vs. OPEN, P = 0.2538)|
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| » Discussion|| |
Pulmonary resection has been established as the most effective treatment for the NSCLC patients, including II stage carcinoma. Partly because of concerns about its safety, VATS lobectomy remains controversial for lung cancer and remains an infrequently performed operation accounting for a low percentage of all lobectomies. Within the STS General Thoracic Surgery Database, only 20% of lobectomies were performed through VATS, although the proportion is increasing annually. Due to the improvement of thoracic thoracoscope technology and surgeon's ability, 70% lobectomy was performed by VATS at the thoracic department of our hospital. All the lobectomies of the patients involved in our investigation were performed by the same surgical team.
Expert clinical series and multiple theoretical reasons suggest the superiority of VATS to OPEN lobectomy for lung cancer resection. Reported benefits of VATS lobectomy includes diminished operative blood loss, decreased postoperative inflammatory response, decreased postoperative pain, and fewer overall complications.,, Having a similar conclusion with the previous case–control studies, our retrospective analysis suggests multiple short-term benefits of VATS lobectomy: blood loss, intraoperative fluid administered, postoperative length of stay, and postoperative complication, which have statistical difference. Large case series have shown an acceptable morbidity rate (19%) for the institutions that are performing VATS lobectomy. Muraoka et al. also compared patients who underwent VATS lobectomy or open lobectomy and noted lower total morbidities of VATS group. In our study, among the most common postoperative complications of arrhythmias, air leak, and pneumonia in VATS group, only arrhythmias has statistically significant difference compared with OPEN group.
Due to the side effect (pneumonia or adhesion) caused by the chest radiation therapy, patients received preoperative chest radiation therapy preferred to the OPEN approach (posterolateral thoracotomy), while preoperative chemotherapy patients are not, in disagreement with that of Handy et al. We also report equivalent endpoints for VATS versus OPEN: operation time and postoperative chest tube. Among other analyzed clinical-pathological data, only differentiation has a significant difference between the VATS group and OPEN group that adenocarcinoma individuals preferred VATS approach (48.2%), while squamous individuals preferred OPEN (48.5%).
Because SF-36 is thought to be the most sensitive scale and is greatly influenced by the type of surgery and timing of postoperative follow-up, we used SF-36 questionnaires to assess QOL over a 12-month period after surgery (VATS versus OPEN). In our study, we found that patients undergoing VATS lobectomy tend to score higher on BP, EG, GH, PF, MH, SF, and RP in QOL subscale after surgery, and BP (1 month and 6 month), EG (1 months), and RP (1, 6 and 12 month) were significantly higher in the VATS group than in the OPEN group. Whereas having opposite conclusion with previous reports in our study, RE scale has a lower QOL score in VATS group compared to OPEN group, although the comparison did not reveal any significant difference. On the basis of data obtained from SF-36 questionnaires, we can reveal that functional recovery of VATS lobectomy for lung cancer is superior to OPEN approaches. Finally, we use the TTP to compare the survival prognosis postsurgically between VATS and OPEN lobectomy. Although no large randomized prospective series has compared the two approaches, several studies have shown benefits to patients with a VATS lobectomy and at least equivalent morbidity and mortality in both the short-term and long-term., In the present investigation, the mean TTP of VATS patients is 18.5 months, while TTP in the OPEN group is 20 months, which has no statistical significance, indicating VATS lobectomy has equivalent postsurgical survival compared with OPEN lobectomy.
Several limitations to the interpretation of our study should be discussed. First, as initial levels of QOL were not compared, we cannot determine whether patients in the VATS and thoracotomy groups had comparable preoperative baseline data. Second, our study is a single-center study, having regional restriction. To our knowledge, this study represents a first step in documenting postsurgical QOL and survival in II stage patients following surgery using standardized and validated questionnaires. Despite the mentioned limitation, our findings offer valuable information in clinical. Further comprehensive and systematic studies, having large sample size, are needed to validate our results.
| » Conclusion|| |
In summary, our prospective case–controlled study has shown VATS lobectomy patients who tended to score higher on the QOL and functioning scales and has equivalent postsurgical survival compared with OPEN lobectomy for II stage non-small cell carcinoma patients.
| » Acknowledgments|| |
This article was written for a project financed by a grant of Shandong Excellent Young Scientist Research Award Fund Project (BS2010YY013), Shandong Tackle Key Problems in Science and Technology (2010GSF10245).
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[Figure 1], [Figure 2]
[Table 1], [Table 2]