Which extent of surgical resection thoracic surgeons would choose if they were diagnosed with an early-stage lung cancer: a European survey

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The recent publication of 3 randomized trials has established segmentectomy as a valuable alternative to lobectomy in peripheral lymph node-negative stage IA1 and IA2 non-small-cell lung cancer [1–3]. There are still unmet knowledge gaps including the level of functional benefit provided by sublobar resections compared to lobectomy [1, 4, 5], the most adequate lymph node dissection, the relative merits of video-assisted thoracic surgery (VATS) versus robotic approach, the prognostic role of spread through air spaces (STAS) and the appropriate distance of the tumour from the resection margin among others. In addition, segmentectomies are often perceived as technically complex procedures and a longer learning curve is needed to ensure adequate technical standards and respect for oncologic principles for a lung cancer operation [6]. Despite recent evidence that has generated some enthusiasm among the thoracic surgical community, the general adoption of this procedure remains unexplored. In particular, the risk perception of surgeons playing the role of patients and undergoing segmentectomy in different hypothetical scenarios appears an interesting point of view which may help to identify knowledge and evidence gaps for future investigations or educational activities. Therefore, the ESTS approved a survey to disseminate to thoracic surgeons to capture the individual preferences of undergoing segmentectomy as opposed to lobectomy in case the surgeon was diagnosed with early-stage lung cancer with different hypothetical scenarios. The rationale is to provide a more personalized representation of the current acceptance of this procedure among the thoracic surgical community based on a subjective standpoint. No patients were involved in this study and Institutional Review Board approval was not necessary. A core group of 5 surgeons (Alessandro Brunelli, Rene Horsleben Petersen, Dominique Gossot, Herbert Decaluwe, Michel Gonzalez) with expertise in sublobar resections, minimally invasive surgery and guidelines generated the questions of the present survey. The questions were designed to explore the preferred extent of resection (segmentectomy or lobectomy) in case the hypothetical scenario the respondent was diagnosed with lung cancer and was proposed both procedures (segmentectomy versus lobectomy) by a treating surgeon (assuming that surgeon had a large experience in both procedures, equal experience in open, VATS and robotic surgery and worked in a high-volume thoracic surgical centre). The questions covered several broad topics such as type of surgical approach, location of the tumour, size of the tumour, intraoperative lymph node dissection, morphology of the tumour, postoperative pathology, tissue diagnosis and three-dimensional (3D) CT scan planning. These topics were used to generate 7 demographic questions and 18 procedural questions, which are shown in Supplementary Material, Table SA1. The questions were collated into a questionnaire, which was electronically sent by email to a group of 219 thoracic surgeons using a commercially available platform (www.surveymonkey.com). The selection criteria to participate to the survey was being a member of the Board, committees or working groups of the European Society of Thoracic Surgeons or being a member of the Thoracic Domain of the European Association of Cardiothoracic Surgery. The initial survey was sent on 28 June 2023 and 2 additional reminders were sent on 8 July 2023 and 22 July 2023. The survey was closed on 30 July 2023. Descriptive statistics were used to summarize the results. There were no missing answers since all the answers were mandatory. There was no confidential information required for this study. Data were reported as frequency, number and percentage. The analysis was performed using Stata 15.1 statistical software (Stata Corp. College Station, TX). A total of 123 surgeons from 32 countries completed the survey (56% response rate). The completion rate of the responders was 100% (all responders completed all questions). Eighty-three percent identified themselves as men. 28% were younger than 45 years of age and 10% were older than 65 years of age. Twenty percent were in practice for 10 years or less, whilst 46% were in practice for >20 years. Thirty-one percent of surgeons declared to have performed <50 segmentectomies during their career, whilst 40% performed at least 100 (with 18 surgeons reporting an experience of >200 segmentectomies). Only 2 surgeons reported not to have performed any segmentectomy. Eighty-two percent of respondents considered themselves at low risk for surgery, whilst 16% and 2% at moderate and higher risk, respectively. All respondents preferred the surgical treatment (as opposed to non-surgical alternatives) in case they were diagnosed with a peripheral 1.5-cm solid tumour. Eighty-three percent would prefer a minimally invasive approach, with the majority of them not having a preference between robotic, multiport VATS or single-port VATS as long as the operation was performed through a minimally invasive approach. Among those who expressed a preference for a specific approach, the respondents were substantially equipoised between the 3 minimally invasive choices. Seventeen percent stated that they would not mind the approach as long as the surgeon had appropriate experience with the approach or procedure; however, none of the respondents specifically favoured an open approach. Most of the respondents (57%) would prefer to have a preoperative ‘tissue diagnosis’ before considering any treatment. However, 24% and 14% of them still prefer to go ahead with the proposed segmentectomy or lobectomy based on serial imaging only. The majority of respondents valued very much the experience of the surgeon/centre with the procedure. Only 6% would still prefer a segmentectomy even in case the surgeon/centre has of low experience with the procedure. However, 50% would ask to be referred to a centre with large experience in segmentectomy and 39% would ask to have a lobectomy instead. Twenty-five percent of surgeons would be reluctant to have a segmentectomy without a ‘3D reconstruction and planning’ whilst a similar proportion would proceed to segmentectomy without 3D reconstruction as they believe CT scan would be sufficient. Twenty percent chose a lobectomy and thought 3D reconstruction would not add much and change their choice, whilst 11% chose a lobectomy but believed that 3D planning might make them change their mind. Eighteen percent of respondents were unsure on the necessity of 3D modelling and planning as it may depend on tumour size and location. Table 1 shows the preferences in terms of ‘extent of resection’ in case of a diagnosis of a peripheral 1.5-cm solid tumour according to different locations. From 19% to 55% of respondents would still prefer a lobectomy. The highest frequency of preferred segmentectomy occurred when tumour was located in the apex of the left upper lobe with 57% of respondents favouring an upper division segmentectomy and 23% favouring a left apico-posterior segmentectomy (S1–S2). In case the tumour was located in the right lower lobe (S10), 45% of those choosing a segmentectomy would favour a complete basilar segmentectomy whilst 55% would favour a S9–S10 segmentectomy. Preferred extent of resection in case of a diagnosis of a peripheral 1.5-cm solid tumour without enlarged lymph nodes according to different locations LUL: left upper lobe; RLL: right lower lobe; RUL: right upper lobe. Preferred extent of resection in case of a diagnosis of a peripheral 1.5-cm solid tumour without enlarged lymph nodes according to different locations LUL: left upper lobe; RLL: right lower lobe; RUL: right upper lobe. Table 2 summarizes the responses about changing the selected procedure according to increased or reduced tumour size or different morphology (sub-solid lesion). Possible change of preferences according to increased (2.2 cm) or reduced (1 cm) tumou

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