Real-world oncologic outcomes of thoracoscopic and open tracheal cancer resection

Abstract

Background: Minimally invasive video-assisted thoracoscopic surgery (VATS) for tracheal cancer is gaining popularity. However, data are limited to single-center reports and short-term outcomes. In this context, we aim to compare short and long-term oncologic outcomes of VATS versus open tracheal cancer resection at the national level.

Methods: We used a national dataset to isolate primary tracheal cancers diagnosed between 2010-2021. Patients were stratified by operative approach into open and VATS resection groups. Cox analysis was used to estimate proportional effects of covariates in unmatched cohorts. We then used propensity score matching to minimize confounding bias from covariates. Kaplan-Meier survival analyses were used to estimate 5-year survival.

Results: Of 331 patients undergoing tracheal cancer resection, 147 (44.4%) were started VATS with 5 (3.4%) converting to open. Patients undergoing VATS tracheal resection were similar in age (62.4±14.5 vs. 59.9±14.2 years; P=0.12), race (White =81.0% vs. 84.8%; P=0.32) and Charlson-Deyo comorbidity (index =0, 59.2% vs. 68.5%; P=0.19), but were more likely to be male (57.8% vs. 46.2%; P=0.04) and have positive margins (58.1% vs. 41.0%; P=0.006) compared to open resection. Post-operative length of stay was shorter with VATS (median 2.5 vs. 7.0 days; P<0.001), but this came at the expense of higher rates of positive margins [adjusted odds ratio (aOR) =2.15, P=0.02] and worse median survival (74 vs. 106 months; P<0.001), which persisted after matching (79 vs. 100 months; P=0.01).

Conclusions: In this national observational study, we found that the short-term benefits of thoracoscopic tracheal resection come at the expense of increased positive margins and worse survival. Adoption of this approach for tracheal cancer should be met with caution.

Keywords: Tracheal cancer; open surgery; video-assisted thoracoscopic surgery (VATS).

Figure 1

Consort diagram for creation of study cohort. NCDB, National Cancer Database; PSM, propensity score match; VATS, video-assisted thoracoscopic surgery.

Figure 2

Adjusted probability of achieving negative resection margins stratified by approach across tracheal tumor size. This multivariable model adjusts for age, sex, race, ethnicity, comorbidities, insurance status, facility type, center volume, tumor size, histology, and extension of disease. R0: negative resection margin. VATS, video-assisted thoracoscopic surgery.

Figure 3

Open versus minimally invasive tracheal resection Kaplan-Meier survival curves. (A) All histology. (B) Squamous cell carcinoma. (C) Adenoid cystic carcinoma. (D) Other histology. VATS, video-assisted thoracoscopic surgery.

Figure 4

Cox proportional hazards model in the unmatched cohort. *, interaction term. CDI, Charlson-Deyo index; VATS, video-assisted thoracoscopic surgery.

Figure 5

Propensity score matched Kaplan-Meier survival curve. VATS, video-assisted thoracoscopic surgery.