Objective: To compare the long-term outcomes among robotic, video-assisted thoracic surgery (VATS), and open lobectomy in stage I nonsmall cell lung cancer (NSCLC). Background: Survival comparisons between robotic, VATS, and open lobectomy in NSCLC have not yet been reported. Some studies have suggested that survival after VATS is superior, for unclear reasons. Methods: Three cohorts (robotic, VATS, and open) of clinical stage I NSCLC patients were matched by propensity score and compared to assess overall survival (OS) and disease-free survival (DFS). Univariate and multivariate analyses were performed to identify factors associated with the outcomes. Results: From January 2002 to December 2012, 470 unique patients (172 robotic, 141 VATS, and 157 open) were included in the analysis. The robotic approach harvested a higher number of median stations of lymph nodes (5 for robotic vs 3 for VATS vs 4 for open; P < 0.001). Patients undergoing minimally invasive approaches had shorter median length of hospital stay (4 d for robotic vs 4 d for VATS vs 5 d for open; P < 0.001). The 5-year OS for the robotic, VATS, and open matched groups were 77.6%, 73.5%, and 77.9%, respectively, without a statistically significant difference; corresponding 5-year DFS were 72.7%, 65.5%, and 69.0%, respectively, with a statistically significant difference between the robotic and VATS groups (P = 0.047). However, multivariate analysis found that surgical approach was not independently associated with shorter OS and DFS. Conclusions: Minimally invasive approaches to lobectomy for clinical stage I NSCLC result in similar long-term survival as thoracotomy. Use of VATS and robotics is associated with shorter length of stay, and the robotic approach resulted in greater lymph node assessment.

The distinction of synchronous primary lung cancers (SPLC) from primary lung cancer with pulmonary metastasis is important because the prognosis and treatments are markedly different. The outcome achieved by medical treatment alone for an additional lesion of the same histology in the ipsilateral chest (T4 or M1 in the current staging system) is poor.¹ x 1 Nakata, M, Sawada, S, Yamashita, M et al. Surgical treatments for multiple primary adenocarcinoma of the lung. Ann Thorac Surg. 2004; 78: 1194–1199 Abstract | Full Text | Full Text PDF | PubMed | Scopus (98) | Google Scholar See all References Nevertheless, the diagnosis of SPLC presents a clinical dilemma because there are no rigorous clinical or histopathological criteria by which such a distinction can be made.² x 2 Detterbeck, FC, Jones, DR, Kernstine, KH et al. Lung cancer. Special treatment issues. Chest. 2003; 123: 244S–258S Crossref | PubMed | Scopus (77) | Google Scholar See all References ^{, 3} x 3 Flieder, DB. Commonly encountered difficulties in pathologic staging of lung cancer. Arch Pathol Lab Med. 2007; 131: 1016–1026 PubMed | Google Scholar See all References Therefore, it is not surprising that estimates of the incidence of SPLC vary, with published rates ranging between 0.2% and 20% of all patients with non-small cell lung cancer.⁴ x 4 Adebonojo, SA, Moritz, DM, and Danby, CA. The results of modern surgical therapy for multiple primary lung cancers. Chest. 1997; 112: 693–701 Crossref | PubMed | Scopus (94) | Google Scholar See all References ^{, 5} x 5 Rea, F, Marulli, G, Callegaro, D et al. Prognostic significance of main bronchial lymph nodes involvement in non-small cell lung carcinoma: N1 or N2?. Lung Cancer. 2004; 45: 215–220 Abstract | Full Text | Full Text PDF | PubMed | Scopus (26) | Google Scholar See all References The most commonly used criteria to define synchronous or metachronous malignant lung disease were proposed by Martini and Melamed⁶ x 6 Martini, N and Melamed, MR. Multiple primary lung cancers. J Thorac Cardiovasc Surg. 1975; 70: 606–612 PubMed | Google Scholar See all References more than 30 years ago. These guidelines suggest that for lesions of similar histology, in the absence of extrathoracic metastases and lymphatic metastases in the common drainage basins, it is reasonable to treat patients for second primary disease. These criteria were based mainly on metachronous lesions, because only 18 of the patients in that study had SPLC but have proven to be durable and provide the basis for the American College of Chest Physicians lung cancer clinical practice guidelines from 2007.⁷ x 7 Shen, KR, Meyers, BF, Larner, JM et al. Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007; 132: 290S–305S Crossref | PubMed | Scopus (139) | Google Scholar See all References In addition, a number of recent, small case series have supported the role of resection of SPLC as defined by these criteria.¹ x 1 Nakata, M, Sawada, S, Yamashita, M et al. Surgical treatments for multiple primary adenocarcinoma of the lung. Ann Thorac Surg. 2004; 78: 1194–1199 Abstract | Full Text | Full Text PDF | PubMed | Scopus (98) | Google Scholar See all References ^{, 8} x 8 Okada, M, Tsubota, N, Yoshimura, M et al. Operative approach for multiple primary lung carcinomas. J Thorac Cardiovasc Surg. 1998; 115: 836–840 Abstract | Full Text | Full Text PDF | PubMed | Scopus (84) | Google Scholar See all References ^{, 9} x 9 Ferguson, MK, DeMeester, TR, DesLauriers, J et al. Diagnosis and management of synchronous lung cancers. 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