Surgical Techniques Continue to Evolve in NSCLC

Jason M. Long, MD

Video-assisted thoracoscopic surgery (VATS) accounts for 40% to 50% of minimally invasive surgical approaches in non—small cell lung cancer (NSCLC), says Jason M. Long, MD. And while robotic resections account for just 14% of all minimally invasive approaches, he anticipates that, “We are going to see an increase in robotic and a decrease in open approaches.”

OncLive: How has the use of VATS and robotic surgery impacted the surgical landscape in NSCLC?

In an interview during the 2018 OncLive^® State of the Science Summit^TM on Advanced Non—Small Cell Lung Cancer, Long, assistant professor of surgery, Division of Cardiothoracic Surgery, University of North Carolina at Chapel Hill, discussed the latest developments with minimally invasive surgical approaches in the treatment of patients with NSCLC.Long: Generally, VATS is the minimally invasive approach in lung cancer. However, there is a high and steep learning curve. Unless you undergo that training in fellowship, it’s very hard to convert from an open approach to a VATS approach in practice.

How many fellowships include VATS training?

How have biomarkers directed surgical approaches, if at all?

You have performed both VATS and robotic surgeries in lung cancer. Do you have a preference?

When do you envision we will see a widespread adoption of these approaches?

Can you elaborate on the case study you presented at the State of the Science SummitTM?

Can you speak to some surgery-focused trials and neoadjuvant approaches?

Can you speak to a scenario in which VATS or robotic surgery was successfully complemented by chemotherapy and or targeted therapy?

What advice can you provide to surgeons who are interested in implementing these approaches into their practice?

How will the landscape evolve as time goes on? Are surgery, chemotherapy, and targeted therapy integral to efficacious treatment?

Robotic surgery has less of a learning curve than VATS; it’s a little easier to learn. It offers a better ability to see and get around structures safely. That has been the approach in minimally invasive surgery for the past 5 to 10 years. However, one of the difficulties with robotic surgery is you can’t palpate small lung nodules, and navigational bronchoscopy can assist with that.There are 2 types of cardiothoracic fellowship programs. There are traditional programs, which are 2 to 3 years after general surgery, and there are integrated programs. Approximately 60% of training programs now include robotic surgery; it may even be more than that. The majority include VATS training. They haven’t so much directed approaches yet. I haven’t found a way to incorporate that into my practice. That may be something coming down the pipeline. I've done about 75 major cases on the robot. I'm starting to become convinced that robotic surgery is a little easier. However, I did many more VATS than I did robotic surgeries as a fellow. After working with and learning the dissection techniques of VATS, I feel much more comfortable with it.It is happening as we speak. Robotic resections account for 14% of all minimally invasive approaches. VATS will most likely continue to account for 40% to 50% of minimally invasive approaches. We are going to see an increase in robot and a decrease in open approaches.We discussed locating, navigating to, and resecting a small lung nodule that was suspicious for primary lung cancer versus metastatic disease versus a benign nodule with a robotic approach. This would have been difficult to find without an open approach, so what we did was incorporate navigational bronchoscopy to mark and tattoo the nodule on a visceral plural surface. We were then able to do a better diagnostic wedge resection versus diagnostic segmentectomy, therefore preserving lung tissue. There have been little data with regard to robotic surgery. It's still young, but there are some papers coming out now on neoadjuvant chemoradiotherapy for stage IIIA or locally advanced disease using a robot to achieve the same outcomes as you would with VATS and an open approach. This is likely going to evolve as time goes on. Most of these papers are forwarded by some of the most experienced authors, including Robert J. Cerfolio, MD, of NYU Langone Health. In my own experience, I have not robotically operated on a post-neoadjuvant patient yet. There are, however, case examples presented at national meetings that cover the use of robotic surgery in patients who have undergone neoadjuvant therapy. These are patients who are in need of an advanced resection, such as a lobectomy, segmentectomy, or sleeve resection. They nicely demonstrate how the robot can be used to achieve that without having to open the patient. You have to be careful with new technology. You don't want to just blindly adopt it. When you start using the robot, you should start with simple cases and work your way up as you become more comfortable with it. It’s also important to adopt technology that will help you achieve that; navigational bronchoscopy is one example of that. We're seeing that the use of surgery, chemotherapy, and targeted therapy are coming full circle, especially with immunotherapy and targeted therapy. These agents will be important for locally advanced tumors, and minimally invasive approaches will help facilitate their efficacy.