Can the rest of the world replicate excellent segmentectomy outcomes with lower volume thoracic surgeons?

Since the JCOG0802 and CALGB140503 trials, sublobar resection for early-stage lung cancers has become increasingly common for those that meet the criteria of peripheral tumor size ≤2 cm and consolidation tumor ratio >0.5 (1,2). While lobectomy remains the gold standard for lung cancer resections, the outcomes after sublobar resection appear overall similar. The article by Qiu et al. (3) describes anatomical partial lobectomy (APL), which focuses on oncologic margin and territory of corresponding bronchi or vessels. Their technique includes 3D reconstruction of the lung based on preoperative computed tomography images. The authors reviewed 3,336 patients who underwent APL at a single institution and found a morbidity rate of 10.8% and no mortality. Given these findings, APL was deemed a safe surgical procedure.

While the authors share their impressive experience with APL, the ability to apply its use to a broader population must be considered. The authors state that APL is performed by high volume surgeons (reported as more than 300 thoracic surgical procedures per year). Given its apparent significant learning curve, this raises some concern on the ability of surgeons in other countries, including the United States (US), to become well trained in the procedure. Many lung resections in the US are performed by lower volume thoracic surgeons, who may perform less than 50 pulmonary resection cases per year and with some operations performed even by general surgeons in more rural areas (4,5). It is not surprising that with more experience comes less operation time and lower complication rate, but this may not be achievable for the lower volume surgeon. Former data from the Premier Healthcare database in 2011–2015 suggests that approximately 70% of lobectomies performed in the US are done by surgeons who perform <20 lobectomies annually (6), which is significantly less than the surgeons reported in the current study.

The authors state that a 3D reconstruction software is used for preoperative planning; however, further details are not provided. It is unclear whether this software was developed internally or whether it is a commercially available product. We agree with the authors that this technology is likely beneficial; however, the cost of the technology must also be considered. Recent quotes to use similar software are estimated to be $250–300 per case in the US market (personal communications between Dr. Reddy and multiple companies), without it being clear who would pay for this service, as this may come out of the surgeon’s pocket in a capitation payment system. This is not feasible for the surgeons to take on, despite its helpfulness in operative planning.

APL, as described by Qiu et al. (3), is promising for patients requiring pulmonary resection and may become the future preferred operation for all small tumors. This is a strongly powered study with a large sample size suggesting that APL is a safe and feasible operation; however, some challenges arise when considering applicability to other countries and regions due to surgeon volume and experience.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-341/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-341/coif). R.M.R. receives grants to the institution from On Target Labs, Atricure; payment to the institution from Intuitive Surgical; serves as the advisory board of Genentech, Medtronic; serves as the Exec Board Member of General Thoracic Surgical Club, Michigan Society of Thoracic and Cardiovascular Surgery. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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