Thoracoscopic lobectomy for early-stage non-small cell lung carcinoma: initial experience from a newly established Israeli center

Abstract

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has emerged as the standard surgical procedure for early-stage non-small cell lung cancer (NSCLC). This article presents the initial experience of a newly established thoracic surgery department with a residency program, evaluating surgical, oncologic and safety outcomes while implementing a learning environment.

Methods

This single-center retrospective study analyzed medical records of patients who underwent VATS lobectomy for early-stage NSCLC between 2019 and 2024. Inclusion criteria were age over 18 years, NSCLC pathology, and clinical stage IA–IIB. The patient population was divided into two subgroups, the first consisting of procedures performed exclusively by senior surgeons and the second consisting of those performed by residents under direct supervision. Key outcomes were mortality, overall complication, and overall survival rates.

Results

A total of 460 patients were evaluated, with a mean age of 69.7 years; the cohort was predominantly male. Adenocarcinoma was the most common pathology (81.1%), with right upper lobe resection being the most frequent procedure. The conversion rate to thoracotomy was 4.1%, with senior surgeons reporting a rate of 8.7% compared to 0.7% among residents. Thirty-day mortality was 1.73%, with senior surgeons at 1.02% and residents at 2.26%. Overall complication rate reached 26.7% without a difference in the subgroups. Prolonged hospitalization occurred in 26.9% of cases. Five-year overall survival was 90.42% among the 94 patients with adequate follow-up, demonstrating favorable outcomes for minimally invasive surgery in early-stage lung cancer.

Conclusions

This single-center experience demonstrates that VATS lobectomy is a safe and effective treatment for early-stage NSCLC, yielding outcomes comparable to those reported globally. The study findings reaffirm VATS as a current standard of care, providing robust postoperative survival and manageable complication rates. Furthermore, study indicates that VATS lobectomy is also a safe procedure for training surgical residents, supporting its role in surgical education.

Highlight box.

Key findings

• This single-center retrospective study evaluated outcomes of 460 patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for early-stage non-small cell lung cancer (NSCLC) over 5 years. The cohort had a mean age of 69.7 years, with Charlson Comorbidity Index of 5.8 and adenocarcinoma as the most common pathology (81.1%). The conversion rate was 4.1%, 30-day mortality was low at 1.73%. Comparison of subgroups of surgeries performed by senior surgeons and by residents showed rate of conversion of 8.7% and 0.7%, respectively. Thirty-day mortality was 1.02% and 2.26%, respectively. The overall complication rate 26.7%, was similar in the two groups (27.69% vs. 26.04%). Prolonged hospitalization occurred in 26.9% of cases. Notably, 5-year overall survival reached 90.42%.

What is known and what is new?

• VATS lobectomy is internationally recognized as the standard surgical approach for early-stage NSCLC, offering reduced morbidity and similar oncological results compared to open surgery.

• This manuscript adds new data from a newly established thoracic surgery department, confirming world-data outcomes in population with significant comorbid burden. The results further validate the safety and efficacy of VATS lobectomy for early-stage lung cancer, indicating its safety for training surgical residents.

What is the implication, and what should change now?

• These findings reinforce the adoption of VATS lobectomy as the standard of care for early-stage NSCLC, even in newly established surgical centers, and its early inclusion in educational program of young professionals. The robust survival rates and manageable complication profile suggest that minimally invasive surgery should remain the preferred approach.

Introduction

Since the middle of the previous century lung cancer continues to be a challenging public health problem accounting for 2.2 million new cases and 1.8 million deaths annually (1) and is currently forecasted to grow significantly to over 4 million new cases annually in 2050 according to World Health Organization (WHO) GLOBOCAN (2). At the same time a Surveillance, Epidemiology, and End Results (SEER) Review shows decrease of incidence of new cases, slightly increased survival rates and for the first time a dominance of localized form over regional since 2016 (3).

Non-small cell lung cancer (NSCLC) accounted for about 80% of all lung cancer cases (4), with adenocarcinoma as the most common histology (54.7%) followed by squamous cell carcinoma (29.4%) (5). According to the SEER database analyses by Ganti et al. in 2017, the proportion of early-stage NSCLC (IA–IIB) was approximately 37%, with a trend toward increasing incidence (5).

Screening programs leading to early-stage diagnosis and adequate following multimodal and surgical treatment are the cornerstone of successful NSCLC management giving the 5-year survival rates over 60% (3).

Depending on size and localization different types of anatomical and non-anatomical lung resections are performed, but anatomic lobectomy is still standard pulmonary resection for NSCLC (4). The preferred surgical approaches for lobectomy have been minimally invasive since the first application of video-assisted thoracoscopic surgery (VATS) techniques (6) providing better quality of life with the same extent of resection.

In our study we summarized our single-center experience of the previous 5 years in minimally invasive early-stage lung cancer treatment. We performed an evaluation of surgical results, oncological outcomes and safety of the training surgical process. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2466/rc).

Methods

To evaluate surgical results of VATS lobectomies for early-stage lung cancer treatment between 24/03/2019 and 14/01/2024 we performed a single-center retrospective study in General Thoracic Surgery Department of Tel Aviv Medical Center, Israel since the department’s establishment. This department is accredited to provide a 6-year residency program in thoracic surgery, with operative procedures performed by senior surgeons as well as residents working under direct supervision.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was performed with medical documentation and was approved by the Helsinki Committee of Tel Aviv Sourasky Medical Center (Ichilov) (approval No. 0618-25-TLV). The requirement for informed consent was waived due to the retrospective nature of the study.

Patients were included if they (I) were ≥18 years old; (II) had pathologically confirmed NSCLC in early clinical stage IA–IIB; and (III) underwent VATS lobectomy.

Patients were excluded if they (I) were <18 years; (II) had a pathological diagnosis other than NSCLC; (III) had a Pancoast tumor or other active malignancy; (IV) presented with clinical stage IIIA–IV; or (V) underwent a surgical procedure other than VATS lobectomy.

For assessment of our surgical results, we analyzed the following primary outcomes: 30-day mortality rate, complication rate, and R0 resection.

Secondary goals were late mortality assessment (90-day mortality rate), prolonged hospital stay over 7-day, 3-year, and 5-year survival rates depending on available follow-up.

Surgical outcomes were further stratified by operator experience, comparing two subgroups: (I) procedures performed by senior surgeons and (II) those performed by residents under direct supervision.

The surgeries were performed in accordance with modified multiportal VATS McKenna technique (7).

Statistical analysis

Only descriptive statistics were calculated for all relevant variables, including means and standard deviations for continuous data, and frequencies with percentages for categorical data. Categorical variables were analyzed using the modified Wald method to estimate confidence intervals. The standard deviation (SD) was applied for continuous data where appropriate. All statistical analyses were conducted using established methods to ensure rigorous assessment of both binary and continuous outcomes.

Results

After the analysis of 2,287 patients, 460 were enrolled in the study. The cohort comprised 257 (55.9%) males and 203 (44.1%) females. The mean age was 69.7±9.31 years in the whole cohort, 69.9±9.02 years in male, 69.5 7±9.66 years in female.

The cohort demonstrated a notable comorbidity burden, with a mean Charlson Comorbidity Index (CCI) of 5.8±1.95. Based on CCI scores, the estimated 10-year survival probability ranged from 21% for patients with a score of 5 to 2% for those with a score of 6.

A further demographic analysis of the subgroups of surgeries performed by senior surgeons and those carried out by residents under supervision is detailed in Table 1.

Table 1. Subgroups characteristics.

Characteristics	Senior surgeons (N=195)	Resident surgeons (N=265)
Gender, male/female, n	89/106	168/97
Age, years, mean ± SD	69.10±9.68	70.25±9.33
CCI, mean ± SD	5.64±2.02	5.41±1.80
Lobectomy, n
RUL	58	97
LUL	45	52
RML	7	12
RLL	48	55
LLL	37	49
Conversion rate (95% CI), %	8.71 (5.44–13.59)	0.75 (0.03–2.89)
Complication rate (95% CI), %	27.69 (21.87–34.54)	26.04 (21.11–31.65)
30-day mortality rate (95% CI), %	1.02 (0.04–3.90)	2.26 (0.92–4.97)
90-day mortality rate (95% CI), %	1.54 (0.32–4.63)	3.39 (1.70–6.42)

CCI, Charlson Comorbidity Index; CI, confidence interval; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe; SD, standard deviation.

During this period surgeries were performed by three senior surgeons and four residents with mean number of surgeries of 65 and 66.25, respectively.

Early mortality within 30 days following surgery was observed in 8 cases, representing an incidence of 1.73% (95% CI: 0.82–3.46%). It was more prevalent among surgeries performed by residents, with an incidence of 2.26% (Table 1).

Among the patients who underwent minimally invasive VATS procedures, conversion to posterolateral thoracotomy was necessary in 19 (4.1%) cases with a higher conversion rate observed in the senior surgeon group (8.71%), primarily due to intraoperative adhesions or bleeding complications.

The overall complication rate for the cohort was 26.7% (95% CI: 22.89–30.97%) with similar result in group of senior surgeons and residents (Table 1). The most frequently observed complication was postoperative pneumonia, occurring in 11.3% of patients (95% CI: 8.71–14.54%), followed by prolonged air leak lasting more than 5 days in 6.52% (95% CI: 4.58–9.19%) and atelectasis in 5.65% (95% CI: 3.85–8.18%). Mechanical ventilation support was necessary in 5.65% of cases (95% CI: 3.85–8.18%), while acute respiratory distress syndrome was documented in 1.95% of patients (95% CI: 0.97–3.73%). Wound infections were identified in 1.30% of cases (95% CI: 0.53–2.89%), and postoperative empyema developed in 1.95% (95% CI: 0.97–3.73%) of patients.

Late mortality within 90 days was observed in 2.17% (95% CI: 1.13–4.01%). A subgroup comparison noted a better outcome in the senior surgeon group with rate of 1.54% versus 3.39% in residents group (Table 1).

Prolonged hospitalization, defined as a hospital stay exceeding 7 days, occurred in 26.9% of patients. The mean length of stay was 8.06±7.81 days. Hospital readmission within 30 days postoperatively was required in 3.69% of patients (n=18).

Of the lobes resected (Figure 1), there was seen the prevalence of right upper lobe 33.7%, followed by right lower lobe 22.4%, left upper lobe 21.1%, left lower lobe 18.7% and right middle lobe 4.1%. The mean number of lymph nodes harvested during lobectomies was 8.88±6.18, the lymph nodes sampling pattern is presented in Table 2.

Figure 1.

Anatomical distribution of resected pulmonary lobes among patients undergoing VATS lobectomy. LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe; VATS, video-assisted thoracoscopic surgery.

Table 2. The nodal sampling depending on lobectomy type.

Lobectomy	Nodal station
	4	5	6	7	9	10	11	12
RUL	88.4%	–	–	70.3%	9.0%	81.3%	62.6%	–
RML	94.7%	–	–	84.2%	5.3%	47.4%	15.8%	–
RLL	66.0%	–	–	73.8%	23.3%	15.5%	62.1%	–
LUL	2.0%	92.8%	10.3%	19.6%	14.4%	76.3%	42.3%	66.0%
LLL	–	75.6%	9.3%	40.7%	53.5%	2.3%	12.8%	2.3%

LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.

Pathological results showed adenocarcinoma in 81.1% (95% CI: 77.2–84.4%) followed by squamous cell carcinoma in 15.9% (95% CI: 12.8–19.5%).

Clinical staging assessment according the TNM 9^th edition demonstrated that the majority of patients were classified as stage IA (77.39%), followed by stage IB (11.95%), stage IIA (4.13%), and stage IIB (6.52%). Pathological staging revealed that 97.2% of patients (95% CI: 95.18–98.39%) were classified as early stage (IA–IIB), while advanced pathological stages (IIIA–IIIB) were identified in 2.8% of cases (95% CI: 1.61–4.82%) upon examination (Figure 2). Nodal stations for N1 were positive in 5.43% (95% CI: 3.68–7.93%) of cases, N2A and N2B were positive in 3.26% (95% CI: 1.93–5.35%) and 1.30% (95% CI: 0.53–2.89%), respectively.

Figure 2.

Distribution of clinical stages versus pathological identified upon examination.

It is noteworthy that pathological assessment confirmed the absence of tumor invasion within the surgical resection field for all patients in the study.

Survival analysis (Figure 3) demonstrated that among 94 patients with adequate follow-up, the 5-year overall survival rate was 90.42% (95% CI: 82.60–95.08%). Additionally, in a cohort of 264 patients with sufficient follow-up, the 3-year overall survival rate accounted 89.39% (95% CI: 85.06–92.60%).

Figure 3.

Survival curve illustrates overall survival for the study cohort, with 95% confidence intervals shown. The curve demonstrates postoperative survival outcomes following VATS based on the available follow-up. VATS, video-assisted thoracoscopic surgery.

Discussion

The demographic profile of our study cohort closely mirrors that observed in large-scale databases such as SEER. As described by Ganti et al., approximately 53% of lung cancer cases occur in men, with most patients being over 65 years of age (5). Similarly, the CALGB 31001 study reported a mean age of 68.1 years, though it did not find a predominance of male patients (8). Data from the Italian National VATS Database, published by Bertolaccini et al., indicated a mean age of 67.6 years with a male predominance of 59% (9). These findings suggest that our study population is representative of global demographic trends, as evidenced by multiple national databases and independent studies.

A high comorbidity burden was noted in our study. The comorbidity burden within similar population has been characterized in several studies. Nakada et al. reported a mean Charlson Comorbidity Index (CCI) of 2±1.4 (10), while Scott described a mean CCI of 1.7 for patients undergoing both VATS and open lobectomies (11). These references highlight the substantial presence of comorbid conditions in our cohort, which likely influences both short-term and long-term clinical outcomes.

Reported conversion rates during surgery range widely, from 0% in the Gharagozloo series (12) to as high as 23% (9). A recent systematic review and meta-analysis by Power et al. (13), encompassing retrospective data from 72,932 lobectomies, estimated a median conversion rate of 9.6%. The most common reasons for conversion were intraoperative bleeding, difficult hilar lymph node dissection, or extensive adhesions. In contrast, some larger single-center series, such as the McKenna group’s experience with 1,100 lobectomies, reported a significantly lower conversion rate of 2.5% (14). Therefore, the observed conversion rate of 4.1% in our cohort represents an outcome that is slightly better than the average expected for this surgical approach. Notably, the analyses of subgroups in our study revealed unexpectedly high rate of conversion in senior surgeons group compared to a markedly lower rate among residents. Although both rates remain within acceptable thresholds, further exploration into the underlying causes of this difference did not yield additional information as age and comorbidity burden were similar in both subgroups.

Early mortality rates following VATS lobectomy have been reported as 0.8% by McKenna et al. in their series (14), while Swanson reported a rate of 2.7% in the CALGB 39802 study (15), and Augustin et al. noted a rate of 3% (16). A comprehensive analysis by Brunelli et al. demonstrated mortality rates of 3.7% among high-risk patients and 1% among low-risk patients, with the Eurolung-predicted mortality index showing high accuracy for mortality prediction (17). Additionally, in a series of 733 patients, Brunelli et al. reported a 30-day mortality of 1.9% and a 90-day mortality of 2.5% (18). More recently, Imperatori et al. identified male sex, diffusing capacity for carbon monoxide (DLCO) less than 60%, and an operative time exceeding 150 minutes as significant risk factors associated with increased 90-day mortality, as determined by a five-class aggregate risk score (19). The mortality rates observed at our center in the entire cohort and subgroups for both 30-day and 90-day intervals are consistent with those reported in these studies.

Complication rates following VATS lobectomy have varied across major studies, with McKenna et al. reporting a rate of 15.3% (14), Swanson documenting 9.5% (15), and Gharagozloo et al. noting 20.6% (12). More contemporary evidence from the PORTaL study, which compared open, robotic, and VATS lobectomy approaches, reported complication rates of 27.9% in the VATS group, 26.8% in the robotic group, and 35.6% in the thoracotomy group (20). Pulmonary complications were most prevalent at 17.9%, followed by cardiac complications at 10.7%. Wound complications were comparatively rare, occurring in only 0.2% of cases. The mean hospital stay for the VATS group was 5.1±4.4 days, with prolonged hospitalization observed in 15.9% of patients (20). In contrast, Nwogu et al. defined prolonged hospitalization as a stay exceeding 14 days and found it occurred in 6.3% of cases (8). Catelli et al. compared robotic-assisted thoracic surgery (RATS) and VATS lobectomy, finding a complication rate of 46% in the VATS group, with prolonged air leak seen in 22% of patients and a mean hospital stay of 7±3.6 days (21). The results observed in our cohort are consistent with those reported in the literature. However, the calculated rates of prolonged hospitalization may be affected by the inclusion of an additional 1–2 days of preoperative admission for evaluation, which tends to shorten the recorded duration of postoperative hospital stay. This methodological difference may partly explain why the incidence of prolonged hospitalization in our study appears higher than that reported in other published cohorts.

Considering the subgroup analyses, although senior surgeons demonstrated somewhat better outcomes, both groups achieved results within acceptable parameters. These findings support the safety of this procedure as a training opportunity for surgical residents and early-career professionals.

A recent publication by Vieira et al. (22) examined the uniportal VATS learning curve, categorising it into three distinct phases: initial (0–60 procedures), transition (61–140 procedures), and proficient (over 140 procedures). The authors reported progressive improvements in procedure time, conversion rates, and blood loss as surgeons transitioned through each phase. Based on the mean number of surgeries performed per resident with acceptable surgical outcomes, we can suppose that the learning curve for multiportal VATS is shorter than that for the uniportal approach.

Variability in overall survival rates after surgical treatment for early-stage NSCLC is well documented in the literature, reflecting differences in patient populations, staging, and study methodology. Stamatis et al. reported a 5-year overall survival rate of 86.52% following lobectomy (23), while Ng et al. observed a rate of 71.5% (24). Montagne et al. found a 5-year overall survival of 61.2% for VATS lobectomies in comparison of VATS versus RATS lobectomy and segmentectomy outcomes, though in their VATS group, approximately 10% of patients had pathological stage greater than IIB (25). In the CALGB 140503 study, Altorki et al. reported a 5-year overall survival rate of 78.9% for stage I NSCLC after lobectomy (26). In 2018, Albano et al. (27) compared stereotactic body radiation therapy (SBRT) with lobectomy for early-stage NSCLC, reporting markedly inferior survival outcomes in the SBRT group, with 3-year overall survival of 59.0% vs. 92.8% and 5-year overall survival of 29% vs. 59%, respectively, demonstrating the superiority of surgical resection over radiation therapy.

The elevated survival rates in our cohort, compared to previously reported outcomes, may be explained by the predominance of early-stage (IA) disease and the relatively small sample size. Such factors likely contributed to improved postoperative prognosis among study participants.

Our investigation is subject to inherent limitations, including the single-center study style, which may affect cohort size and lead to outcome estimation restrictions. Additionally, the relatively short duration of follow-up limits the capacity to draw robust conclusions regarding oncological results. The retrospective study design introduces susceptibility to selection bias and incomplete data, potentially impacting the accuracy and applicability of our findings.

Conclusions

In summary, this study presents the experience of a newly established thoracic surgery department with an educational residency program, predominantly treating elderly patients with significant comorbidities. Our analysis of primary and secondary outcomes demonstrates compatibility with data previously published in the literature. Video-assisted thoracoscopic (VATS) lobectomy is shown to be a safe and effective surgical option and remains the current standard of care for early-stage NSCLC. Furthermore, evidence from subgroup analyses indicates that VATS lobectomy is also a safe procedure for training surgical residents, supporting its role in surgical education.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was performed with medical documentation and was approved by the Helsinki Committee of Tel Aviv Sourasky Medical Center (Ichilov) (approval No. 0618-25-TLV). The requirement for informed consent was waived due to the retrospective nature of the study.

Data Sharing Statement

Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2466/dss

jtd-18-03-236-dss.pdf ^{(70.5KB, pdf)}

DOI: 10.21037/jtd-2025-1-2466