The video-assisted thoracoscopic approach (video-assisted thoracic surgery (VATS)) to lobectomy for non-small-cell lung cancer (NSCLC) is not standardised. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out using only two incisions. We have analysed retrospectively, the characteristics and postoperative evolution of patients undergoing VATS lobectomies using two ports.

Methods: From June 2007 to November 2009, we carried out 131 major pulmonary resections by VATS, of which 40 (February 2009 to November 2009) were realised using only two incisions: one 1-cm incision through the 7th/8th intercostal space in the mid-axillary line, and a 3–5-cm anterior utility incision in the 5th intercostal space. The patients’ mean age was 60.8 ± 11.4 years (75% male, 25% female).

Results: The conversion rate was 10% (four patients). Of the remaining 36 cases, the diagnosis in six patients was benign, and in four was metastatic disease. Of the 26 cases with NSCLC, the most frequent stage was that of interactive application (IA) (58%) and histology mostly revealed adenocarcinoma (33%). Mean duration of surgery in the 36 resections completed by VATS was 168.6 ± 54.0 min (range 80–300 min). The median chest tube duration was 2.5 days and the median length of stay in hospital was 3 days. There was no perioperative mortality in completed VATS cases, and no patient needed to be re-operated. Those patients with chronic obstructive pulmonary disease (COPD) needed longer hospital stays (p = 0.046). Similarly, extreme cases of adhesion during surgery needed more days of thoracic drainage (p = 0.040) and longer hospital stays (p = 0.011), as well as displaying a higher percentage of postoperative complications (p = 0.008). If the group of patients is divided in two periods (February to July 2009 and August to November 2009), more extended lymphadenectomies are observed among those performed during the latter period.

Conclusions: VATS lobectomy with two incisions is a safe and reliable procedure producing good postoperative results. As we obtain more experience over time, results improve, especially in the performance of more extended lymphadenectomies.

Prognostic information known preoperatively allows stratification of patients to surgery; induction therapy and surgery; or definitive chemoradiotherapy and may prevent a futile thoracotomy. Attention has focussed on the standard uptake value (SUV) of the primary tumour but less has been described regarding the ¹⁸F-fluoro-2-deoxy-d-glucose (¹⁸F-FDG) avidity of mediastinal nodes. We aimed, in a group of surgically resected cN0-1 but pN2 tumours, to compare the survival of patients with and without ¹⁸F-FDG avid mediastinal nodes.

Methods: Retrospective review of a surgical database identified cN0-1 non-small-cell lung cancer (NSCLC) patients with pN2 disease after resection. Survival of non-FDG avid N2 versus FDG avid N2 groups was compared after stratification according to variables found on univariate analysis to affect survival.

Results: From January 1993 to December 2006, 42 patients were identified; 27 (64%) had non-FDG avid N2 disease. Five-year and median survival were better in the non-FDG avid N2 disease group, 25% versus 0% and 30 (16–44) versus 13 (10–16) months, respectively (p = 0.02). After 1998, the difference in survival was 41% versus 0% and 35 (14–56) versus 12 (16–18) months, respectively (p = 0.02).

Conclusions: After resection, patients with non-FDG avid N2 disease have better survival than patients with FDG avid N2 disease. Exploratory thoracotomy alone (after frozen section analysis) cannot be advocated in patients with non-FDG avid N2 disease as survival after resection appears at least equivalent to alternate therapeutic approaches in this group. This assertion may be tempered if right pneumonectomy is required or R0 resection is unachievable. Mediastinal nodal avidity may improve stratification in future studies of long-term survival in NSCLC.