Factors and outcomes associated with successful minimally invasive pneumonectomy

To test the hypothesis that patients undergoing minimally invasive pneumonectomy at high-volume minimally invasive lung surgery centers have improved survival compared with patients who undergo open pneumonectomy.

Patients from the National Cancer Database who underwent pneumonectomy for lung cancer between 2010 and 2020 were stratified into 3 groups according to surgical technique (open, minimally invasive, converted from minimally invasive to open). Institutions were categorized as low-, mid-, or high-volume minimally invasive lung surgery centers according to percentage of total anatomic lung resections performed by video-assisted or robotic-assisted thoracoscopic surgery. Outcomes were compared using Cox regression, Kaplan-Meier survival analysis, and propensity score matching.

In total, 5750 patients from 850 facilities were included, with 4597 (79.9%) undergoing upfront open pneumonectomy. Among the 1153 attempted minimally invasive pneumonectomies, 364 (31.6%) required conversion to open pneumonectomy. Surgery at a non-high-volume center was associated with greater conversion risk (adjusted odds ratio, 4.16; P < .001), whereas neoadjuvant therapy was associated with lower risk (adjusted odds ratio, 0.60; P = .015). Similar 5-year overall survival was seen among the 3 groups (open 45.2%, minimally invasive 48.3%, converted 43.3%); however, conversion from minimally invasive to open pneumonectomy demonstrated a trend towards increased risk of death (hazard ratio, 1.16; P = .058).

Minimally invasive pneumonectomy for lung cancer had similar 5-year survival compared with open pneumonectomy. However, conversion from minimally invasive to open pneumonectomy showed a trend toward increased risk of death, and conversion rates were high irrespective of institutional minimally invasive lung surgery volume. Careful patient selection is necessary when considering minimally invasive pneumonectomy so that long-term outcomes are not compromised.