Optimum diagnostic pathway and pathologic confirmation rate of early stage lung cancer: Results from the VIOLET randomised controlled trial

Rosie A Harris ¹, Elizabeth A Stokes ², Tim J P Batchelor ³

¹Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.
²Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
³Thoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK.
⁴Thoracic Surgery, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
⁵Thoracic Surgery, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK.
⁶Cardiothoracic Surgery, The James Cook University Hospital, Middlesbrough, UK.
⁷Thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.
⁸Thoracic Services, Belfast City Hospital, Belfast Trust Hospitals, Belfast, UK.
⁹Thoracic Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
¹⁰Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
¹¹Cardiothoracic Surgery, Castle Hill Hospital, Hull, UK.
¹²Cardiothoracic Surgery, Edinburgh Royal Infirmary, Edinburgh, UK.

⁰Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.

Lung +

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January 6, 2025

View abstract on PubMed

Summary

Pre-operative tissue confirmation for lung cancer surgery is recommended, but acceptable outcomes can be achieved with lower rates through intraoperative biopsy and risk assessment. This study analyzed management and outcomes in a UK trial.

Area Of Science

Thoracic surgery
Surgical oncology
Diagnostic pathology

Background

Pathologic confirmation of lung cancer is crucial for guiding treatment in early-stage disease.
High pre-operative tissue confirmation rates are generally recommended.
The VIOLET trial investigated management and outcomes for primary lung cancer surgery in the UK.

Purpose Of The Study

To define the management and outcomes of patients undergoing surgery for primary lung cancer.
To evaluate diagnostic pathways and tissue confirmation methods in a multi-centre clinical trial.
To compare the outcomes of inappropriate resections (lobectomy for benign disease, wedge resection for cancer) based on pathologic diagnosis.

Main Methods

The VIOLET trial compared minimally invasive video-assisted thoracic surgery with open surgery.
Diagnostic patient pathways and tissue confirmation methods were documented.
Outcomes were analyzed concerning pre-operative diagnosis, intraoperative biopsy, and frozen section analysis.

Main Results

502 patients underwent surgery; only 52% had pre-operative pathologic confirmation of lung cancer.
Intraoperative biopsy and frozen section analysis were performed in 60% of patients lacking pre-operative confirmation.
The rate of inappropriate surgery was 3.6% (18/502), including lobectomy for benign disease and wedge resection for lung cancer.

Conclusions

Low rates of inappropriate resection (3.6%) were achieved even with pre-operative confirmation rates around 50%.
This was facilitated by intraoperative confirmatory biopsies and accurate pre-operative risk estimation.
Continuous monitoring of practice is necessary to maintain acceptable surgical outcomes.