Video-assisted thoracic surgery: its place in lung cancer management


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Aman S Coonar

Papworth Hospital, Cambridge, UK

Abstract

Video assisted thoracic surgery (VATS) is used for diagnosis, staging, palliation and treatment. Most thoracic surgeons undertake some VATS operations particularly for pneumothorax and other pleural procedures. However, VATS anatomical lung resections are still not commonly performed. This relates to the learning curve, concern about oncological adequacy, costs of the kit and the relatively longer operative time required. VATS is not standardised and there are large variations in practice. VATS proponents cite reduced pain, faster recovery and a smaller scar amongst the advantages.

VATS is likely to become more widely used as equipment improves and skill increases. The identification of earlier disease, arising from screening, is also likely to contribute to this.

As we have learnt from some other areas of oncology such as breast cancer treatment, sometimes lesser resections combined with a lymph node dissection and multi-modal treatment provides the optimum results. For many years the standard resection for lung cancer has been an open thoracotomy and a lobectomy or pneumonectomy combined with a lymph node dissection. Does VATS allow us to re-examine this paradigm? An important challenge for thoracic surgical oncologists is to better define the role of VATS for this group. There are a number of subgroups to examine, for example if we consider smaller, more peripheral lesions.

Hypothesis
It is proposed that in well selected patients small peripheral lesions could be handled with either VATS resection, ablation or radiotherapy, combined with simultaneous or staged VATS lymph node dissection.

A trial is proposed to examine this issue.