Robotic surgery for locally advanced non-small cell lung cancer

Stage III non-small cell lung cancer (NSCLC) is a heterogeneous group of diseases including large masses, mediastinal lymph node involvement, and invasion of major mediastinal structures. Robotic surgery is a minimally invasive approach recognized as an equivalent alternative to open surgery in case of early stage NSCLC. An increasing number of studies also assert that robotics is a reasonable option for the treatment of locally advanced disease in the setting of multimodality therapy. Major advantages of the technique are increased radicality compared to video-assisted thoracic surgery (VATS), fast postoperative recovery and better compliance to adjuvant therapies compared to open. In this paper we present some technical aspects of the robotic lobectomy in locally advanced disease, we discuss different robotic approaches and review the literature of robotic treatment of lung cancer patients. To describe the technique, we use two case studies of patients affected by locally advanced NSCLC operated with robotic surgery. A patient with right upper lobe (RUL) pulmonary adenocarcinoma and single N2-station metastasis underwent robotic lobectomy following response to induction chemo-radiotherapy. A radical excision of the tumor was obtained with clear margins and no evidence of residual disease at pathologic examination. In the second case, a diagnosis of N2 lymph node metastasis (station R4) from pulmonary adenocarcinoma was made in a patient with primary occult tumor. After induction treatment, the patient underwent robotic radical mediastinal lymph node dissection with curative intent. Unexpected partial invasion of the wall of superior vena cava (SVC) was safely managed with tangential resection. Despite the problems of costs, availability, and learning curve, the Authors believe that robotic surgery has indisputable advantages to obtain a radical resection in case of locally advanced NSCLC.