Lymph Node Evaluation in Video-Assisted Thoracoscopic Lobectomy Versus Lobectomy by Thoracotomy

Background: With the emergence of video-assisted thoracic surgery (VATS) lobectomy, concern remains regarding the adequacy of nodal assessment versus thoracotomy. Methods: All clinical stage I non-small cell lung cancer patients treated with VATS or open lobectomy were retrospectively evaluated. Total nodes, N2 nodes, and nodes at each station were evaluated for associations with surgery type and location of involved lobe. Results: There were 79 VATS and 464 open lobectomy or segmental resections for stage I tumors. Overall, fewer lymph nodes were sampled with VATS compared with thoracotomy (7.4 ± 0.6 vs 8.9 ± 0.2, respectively; p = 0.029), and fewer N2 nodes were sampled with VATS versus thoracotomy as well (2.5 ± 3.0 vs 3.7 ± 3.3, p = 0.004). There were no differences in N1 node sampling between the two groups (5.2 ± 3.6 vs 4.9 ± 4.2, p = 0.592). Furthermore, there were more station 7 nodes with thoracotomy versus VATS (1.2 ± 0.1 vs 0.6 ± 0.1, p = 0.002). Among right-sided lesions, there was no difference in 4R nodes between groups (1.4 ± 0.4 vs 1.6 ± 0.2, p = 0.7) although there was a trend toward more level 7 nodes with thoracotomy (1.0 ± 0.2 vs 1.4 ± 0.2, p < 0.08). Among left-sided resections there were more station 7 nodes with thoracotomy versus VATS (1.0 ± 0.1 vs 0.4 ± 0.1, p < 0.001) and more station 5/6 nodes (1.1 ± 0.1 vs 0.5 ± 0.1, p < 0.04). For upper lobe resections, the total nodes (8.9 ± 0.3 vs 7.4 ± 0.7, p = 0.05) and station 7 nodes (1.0 ± 0.1 vs 0.6 ± 0.1, p < 0.01) were higher with thoracotomy than VATS. There was no difference in 2-year survival between groups (81% vs 83%, p = 0.4). Conclusions: Our early experience with VATS has been associated with fewer lymph nodes sampled compared with open lobectomy although there was no survival difference. Analysis of these differences has directed us toward a more focused lymph node sampling with VATS lobectomy.