Sergi Call

Background: Reliable mediastinal restaging after neoadjuvant treatment to rule out persistent nodal disease is essential to select patients for resection. Main endpoints of this study are: to analyse the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and to determine the rate of persistent N2–3 in patients with clinical N2–3 (cN2–3) non-small cell lung cancer (NSCLC) after neoadjuvant treatment. Methods: Prospective observational single-centre study of patients with NSCLC and histologically proven mediastinal involvement (cN2–3), treated with neoadjuvant therapy who underwent VAMLA for restaging. Patients with negative VAMLA underwent lung resection. Systematic nodal dissection (SND) was considered the reference test to confirm negative VAMLAs. Staging values were calculated based on pathologic findings using the standard formulas. Results: From 2017 to 2023, 41 patients with cN2–3 NSCLC received neoadjuvant therapy and thereafter underwent VAMLA for restaging. Neoadjuvant treatments: concomitant cisplatin-based chemotherapy and radical radiotherapy (n=33), chemoradiotherapy and immunotherapy (n=2), chemotherapy (n=2), chemotherapy and immunotherapy (n=2), tyrosine kinase inhibitor and immunotherapy (n=1) and immunotherapy (n=1). VAMLA was feasible in all patients. Restaging values with VAMLA were: sensitivity, 1 [95% confidence interval (CI): 0.72–1]; negative predictive value (NPV), 1 (95% CI: 0.89–1); and diagnostic accuracy, 1 (95% CI: 0.91–1). Rate of persistent N2 of the whole series: 29% (12/41). Complication rate was 9.7%. Conclusions: This preliminary series of patients with cN2–3 NSCLC treated with neoadjuvant treatment and restaged by VAMLA demonstrated high accuracy and high rate of persistent N2. VAMLA should be included in restaging algorithms to select patients with potentially resectable cN2–3 NSCLC.

The aim of this study was to know the treatment effect of video-assisted thoracic surgery (VATS) on 90-day mortality after anatomical lung resection based on a nationwide cohort. This is a multicentre prospective cohort of 2721 anatomical resections for lung cancer from December 2016 to March 2018. Treatment and intention-to-treat (ITT) analyses were performed after inverse probability score weighting and different propensity score matching algorithms. Covariate balance was assessed by standardized mean differences. The estimators reported were the average treatment effect, the average treatment effect on the treated and odds ratios after conditional logistic models with 95% confidence intervals. The unconfoundedness assumption was evaluated by sensitivity analysis for average treatment effect (c-dependence) and average treatment effect on the treated (Γ). VATS was the initial approach in 1911 patients (70.2%), though 273 cases (14.3%) had to be converted to thoracotomy. Ninety-day mortality rates were: treatment analysis (VATS 1.16% vs open 3.9%, P < 0.001), ITT analysis (VATS 1.78% vs open 3.36%, P = 0.012). After inverse probability score weighting and propensity score matching, in the treatment analysis, VATS meant absolute risk reductions between 2.25% and 2.96% and relative risk reductions between 65% and 70% [OR = 0.34 (95% confidence interval 0.15–0.79), all P-values <0.004). However, all the estimators turned out to be non-significant in the ITT analyses. A high sensitivity to unobservable confounders was proved (c-dependence 0.135, Γ = 1.5). VATS can reduce the risk of 90-day mortality after anatomical lung resection. However, the implications of conversion to thoracotomy, comparing ITT versus treatment analysis, and the potential impact of hidden bias should deserve further attention in the future.

After the first wave of COVID-19, the Spanish Society of Thoracic Surgeons (SECT) surveyed its members to assess the impact of the pandemic on thoracic oncology surgery in Spain. In May 2020, all SECT members were invited to complete an online, 40-item, multiple choice questionnaire. The questionnaire was developed by the SECT Scientific Committee and sent via email. The overall response rate was 19.2%. The respondents answered at least 91.5% of the items, with only one exception (a question about residents). Most respondents (89.3%) worked in public hospitals. The reported impact of the pandemic on routine clinical activity was considered extreme or severe by 75.5% of respondents (25.5% and 50%, respectively). Multidisciplinary tumour boards were held either with fewer members attending or through electronic platforms (44.6% and 35.9%, respectively). Surgical activity decreased by 95.7%, with 41.5% of centers performing surgery only on oncological patients and 11.7% only in emergencies. Nearly 60% of respondents reported modifying standard protocols for early-stage cancer and in the preoperative workup. Most centers (≈80%) reported using full personal protective equipment when operating on COVID-19 positive patients. The COVID-19 pandemic severely affected thoracic oncology surgery in Spain. The lack of common protocols led to a variable care delivery to lung cancer patients.