The Musician, Instrument, or Orchestra?
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EDITORIAL – THORACIC ONCOLOGY
The Musician, Instrument, or Orchestra? Todd L. Demmy1,2 1
Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY; 2Department of Surgery, University at Buffalo, Buffalo, NY
The article by Liu and colleagues should be applauded for adding to the body of evidence that minimally invasive approaches, especially complex ones, have oncologic equivalence to open.1 Like other reports, retrospective single institutional and cancer registry data suffice because high-quality, randomized studies of our approaches have been impractical to conduct.2 Research participants and investigators find equipoise difficult without clear signals of oncologic failures in anecdotal or retrospective research to justify going back to open approaches. Even a consortium of lobectomy centers in China that do thousands of cases each year took time to complete accrual of a randomized video-assisted thoracoscopic surgery (VATS) versus axillary thoracotomy study.3 This trial reported fewer perioperative VATS complications, like Liu and colleagues, and long-term survival data are pending. One VATS lobectomy signal for oncologic concern occurred with nodal upstaging which was more likely in open patients, according to a report using the Society of Thoracic Surgeons’ database.4 Such concerns were addressed by subsequent studies, but perhaps most convincingly by a report that reanalyzed lobectomy data from a European thoracic database consortium.5 When VATS was deemed feasible originally, it was generally recommended for smaller peripheral tumors less likely to have upstaging.6 Over time, as surgeons became comfortable with performing more complex surgery like minimally invasive sleeve resections, they ventured toward node dense central or larger tumors having main airway and
Ó Society of Surgical Oncology 2020 First Received: 23 June 2020 Accepted: 24 June 2020; Published Online: 8 July 2020 T. L. Demmy e-mail: [email protected]
vascular invasions. When added as a variable, centrality became the overwhelming predictor of nodal upstaging and approach was no longer significant in multivariable analysis.5 While generally central, surgeons may not document the specific nuanced tumor imaging effects on hilar structures that prompt scheduling open sleeve resections rather than VATS. Validated tools to systematically classify central invasion are lacking. Until there are such mandatory descriptors, it will be difficult to propensity match cohorts in institutional or consortium databases to answer oncologic validity questions. One way to do this indirectly would be to find out the rate at which minimally invasive approaches are applied to all cases. Some centers of excellence have a 90% application of VATS for all their lobectomies, which generally means that they are also wading into bronchoplastic work, minimally invasive pneumonectomy, etc.7 It is difficult to compare their outcomes with centers plateauing at 50% VATS because of imponderable selection biases. For institutions that upload all thei
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