Optimal Radiation Dose for Stage III Lung Cancer-Should "Definitive" Radiation Doses Be Used in the Preoperative Setting?

INTRODUCTION: There are currently two recommended radiation strategies for clinical stage III NSCLC: a lower "preoperative" (45-54 Gy) and a higher "definitive/nonsurgical" (60-70 Gy) dose. We sought to determine if definitive radiation doses should be used in the preoperative setting given that many clinical stage III patients planned for surgery are ultimately managed with chemoradiation alone. METHODS: Using the National Cancer Database data from 2006 to 2016, we performed a comparative effectiveness analysis of stage III N2 patients who received chemoradiotherapy. Patients were stratified into subgroups across 2 parameters: (1) radiation dose: lower (45-54 Gy) and higher (60-70 Gy); and (2) the use of surgery (i.e., surgical and nonsurgical treatment approaches). Long-term survival and perioperative outcomes were evaluated using multivariable Cox proportional hazards and logistic regression models. RESULTS: A cohort of 961 patients received radiation before surgery including 321 who received a higher dose and 640 who received a lower dose. A higher preoperative dose revealed similar long-term mortality risk (hazard ratio = 0.99, 95% confidence interval: 0.82-1.21, p = 0.951) compared with a lower dose. There was no significant association between radiation dose and 90-day mortality (p = 0.982), 30-day readmission (p = 0.931), or prolonged length of stay (p = 0.052) in the surgical cohort. A total of 17,904 clinical-stage IIIA-N2 patients were treated nonsurgically, including 15,945 receiving higher and 1959 treated with a lower dose. A higher dose was associated with a reduction in long-term mortality risk (hazard ratio = 0.64, 95% confidence interval: 0.60-0.67, p < 0.001) compared with a lower dose. CONCLUSIONS: For clinical stage III NSCLC, the administration of 60 to 70 Gy of radiation seems to be more effective than the lower dose for nonsurgical patients without compromising surgical safety for those that undergo resection. This evidence supports the implementation of 60 to 70 Gy as a single-dose strategy for both preoperative and definitive chemoradiotherapy.

Learning Curve of Robotic Lobectomy for Early-Stage Non-Small Cell Lung Cancer by a Thoracic Surgeon Adept in Open Lobectomy.

OBJECTIVE: The aim of the study was to characterize the clinical outcomes and learning curve during the adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by a thoracic surgeon experienced in open thoracotomy. METHODS: Retrospective review of 157 consecutive patients (57 open thoracotomies, 100 robotic lobectomies) treated with lobectomy for clinical stage I or II non-small cell lung cancer between 2007 and 2014. Clinical outcomes were compared between the open thoracotomy group and five consecutive groups of 20 robotic lobectomies. We used the following six metrics to evaluate learning curve: operative time, conversion to open, estimated blood loss, hospitalization duration, overall morbidity, and pathologic nodal upstaging. RESULTS: The robotic and open thoracotomy groups had equivalent preoperative characteristics, except for a higher proportion of clinical stage IA patients in the robotic cohort. The robotic group, as a whole, had lower intraoperative blood loss, less overall morbidity, shorter chest tube duration, and shorter length of hospital stay as compared with the open thoracotomy group. Operative time demonstrated a bimodal learning curve. Conversion rate diminished from 22.5% in the first two robotic groups to 6.7% in the latter three groups. The rate of pathologic nodal upstaging was statistically equivalent to the open thoracotomy group. CONCLUSIONS: Adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by an experienced open thoracic surgeon is safe and feasible, with fewer complications, less blood loss, and equivalent nodal sampling rate even during the learning curve. The conversion to open rate significantly dropped after the first 40 robotic lobectomies, and operative time for robotic lobectomy approached open thoracotomy after 60 cases, after a bimodal curve.

Robotic Transthoracic Primary Repair of a Diaphragmatic Hernia and Reduction of an Intrathoracic Liver.

This case involves a 70-year-old woman who presented after a low-speed motor vehicle collision with a traumatic right hemidiaphragm rupture and herniation of the liver into the right chest. She was brought to the operating room for a robotic-assisted minimally invasive transthoracic repair of this hernia with diaphragm plication. The case and video described in this report highlight the utility of the robotic platform in performing a transthoracic diaphragm repair and plication after a right-sided traumatic diaphragm rupture in a patient without concomitant abdominal injuries.