A Proposal for Combination of Total Number and Anatomical Location of Involved Lymph Nodes for Nodal Classification in Non-small Cell Lung Cancer

Saji, Hisashi; Tsuboi, Masahiro; Shimada, Yoshihisa; Kato, Yasufumi; Yoshida, Kôichi; Nomura, Masatoshi; Matsubayashi, Jun; Nagao, Toshitaka; Kakihana, Masatoshi; Usuda, Jitsuo; Kajiwara, Naohiro; Ohira, Tetsuya; Ikeda, Norihiko

doi:10.1378/chest.12-0750

Cited by 84 publications

(72 citation statements)

References 24 publications

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“…Despite substantial data that the eradication of tumor from mediastinal lymph nodes is strongly associated with overall survival, the prognostic value of lymph node burden both at initial diagnosis and after induction chemoradiation is less clear [11–14]. Alexander et al reported a significant association between increased lymph node volume and decreased survival [15], however Dehing-Oberije et al demonstrated a lack of association between lymph node size and survival [13].…”

Section: Introductionmentioning

confidence: 99%

Lymph node volume predicts survival but not nodal clearance in Stage IIIA-IIIB NSCLC

et al. 2017

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BackgroundLocally advanced non-small cell lung cancer (LA-NSCLC) patients have poorer survival and local control with mediastinal node (N2) tumor involvement at resection. Earlier assessment of nodal burden could inform clinical decision-making prior to surgery. This study evaluated the association between clinical outcomes and lymph node volume before and after neoadjuvant therapy.Materials and methodsCT imaging of patients with operable LA-NSCLC treated with chemoradiation and surgical resection was assessed. Clinically involved lymph node stations were identified by FDG-PET or mediastinoscopy. Locoregional recurrence (LRR), distant metastasis (DM), progression free survival (PFS) and overall survival (OS) were analyzed by the Kaplan Meier method, concordance index and Cox regression.Results73 patients with Stage IIIA-IIIB NSCLC treated with neoadjuvant chemoradiation and surgical resection were identified. The median RT dose was 54 Gy and all patients received concurrent chemotherapy. Involved lymph node volume was significantly associated with LRR and OS but not DM on univariate analysis. Additionally, lymph node volume greater than 10.6 cm3 after the completion of preoperative chemoradiation was associated with increased LRR (p<0.001) and decreased OS (p = 0.04). There was no association between nodal volumes and nodal clearance.ConclusionFor patients with LA-NSCLC, large volume nodal disease post-chemoradiation is associated with increased risk of locoregional recurrence and decreased survival. Nodal volume can thus be used to further stratify patients within the heterogeneous Stage IIIA-IIIB population and potentially guide clinical decision-making.

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Section: Introductionmentioning

confidence: 99%

Lymph node volume predicts survival but not nodal clearance in Stage IIIA-IIIB NSCLC

et al. 2017

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“…Thirty-three were T1 and 60 were T2. We resected a median number of 6 lymph node stations (lower quartile and upper quartile, 4-8) and 15 nodes per patient (lower quartile and upper quartile, [11][12][13][14][15][16][17][18][19][20]; in detail, 6 (lower quartile and upper quartile 4-7) were hilar nodes and 9 (lower quartile and upper quartile 6-14) were mediastinal nodes.…”

Section: Resultsmentioning

confidence: 99%

“…[9] compared 4 proposed lymph node staging systems [7,[18][19][20] (based on the metastatic nodal zone, number of lymph nodes involved, lymph node ratio and combination of the number and location of metastatic lymph nodes) and found no significant difference among them in terms of predictive power using the C-index, but they found a higher C-index value for the classification based on the number of metastatic lymph nodes. This evidence should be used to complete the current nodal staging system rather than radically change it.…”

Section: Discussionmentioning

confidence: 99%

N2 lung cancer is not all the same: an analysis of different prognostic groups†

Bertoglio

Ricciardi

Alì

et al. 2018

Interactive CardioVascular and Thoracic Surgery

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OBJECTIVES:The International Association for the Study of Lung Cancer (IASLC) recently proposed a change in the staging system for N2, based on the metastatic station number: N2a1 (a single metastatic station with no hilar involvement), N2a2 (a single metastatic station with hilar involvement) and N2b (multiple metastatic stations). The aim of our study was to validate the IASLC proposal in a cohort of patients with pathological N2 disease. METHODS:All patients with pathological T1-T2 N2 non-small-cell lung cancer who were operated on between 2006 and 2010 in our department were enrolled. The patients had lobectomy, bilobectomy or pneumonectomy without induction therapy; patients with any type of extended resection were excluded. All patients had adjuvant treatment. The impact of the new IASLC proposal on the overall and disease-free survival rates was then analysed. RESULTS:Ninety-three patients were selected. The median follow-up period and overall survival time were 92 and 28.8 months, respectively. According to the new IASLC proposal, we observed 22 cases of N2a1, 54 N2a2 and 17 N2b. Patients with N2a1 had a significantly better overall survival than those with N2a2 and N2b (P = 0.041); the difference between N2a2 and N2b was not significant (P = 0.19). Patients with N2a1 squamous cell carcinoma had a significantly better overall survival than those with other histological diagnoses (P = 0.046). The disease-free interval was longer in patients with N2a1 than those in other groups (P = 0.021).CONCLUSIONS: Our experience partially validates the IASLC proposal; the introduction of quantitative criteria for N staging might improve stratification of patients and the assignment to the correct therapeutic path.

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“…On the other hand, other authors reported the possibility of the number of involved nodes instead of the locationbased cN or pN in lung cancer (10,11). These studies compared the two categorizations, by location and number of metastatic nodes and showed that the number of involved nodes is a better prognostic determinant than the locationbased pN classification.…”

Section: Editorialmentioning

confidence: 99%

The “N”—factor in non-small cell lung cancer: staging system and institutional reports

Rena¹

2016

J. Thorac. Dis.

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Lymph node (LN) status is a highly significant component of staging of non-small cell lung cancer (NSCLC). Staging of NSCLC provides prognostic data related to the risk of recurrence as well as overall survival (1). Lymph node metastasis alters the treatment decisions, including surgical resectability and appropriateness of adjuvant interventions.According to the TNM rules, at least six lymph nodes need to be removed, three from N1 and three from N2 stations. This is the minimum requirement for a diagnosis of N0 when lymph nodes are negative (2).Currently, the 7 th edition of NSCLC staging system defines the nodal status as N0 (no nodal involvement), N1 (peribronchial, interlobar, hilar node involvement), N2 (ipsilateral nodal involvement), N3 (contralateral mediastinal, contralateral hilar or supraclavicular nodal involvement) depending only on the location of the metastatic lymph nodes and the actual definition of nodal categorization not varied in the last revision from the 6 th to the 7 th edition.Differently from other organs, in the case of lung cancer, the principle that the nodal status is based on the location of the nodal metastasis and not on the number of metastatic nodes has been maintained.The principle that raise the N staging of lung cancer on the base of the anatomic location of the involved nodes is accepted because: the lymph nodes location is easy to be determined on CT-scan or PET/CT (that is fundamental for the determination of the clinical N status), it has an high prognostic impact, and its categorization is anatomically reasonable from the perspective of a lymphatic pathway from the lung parenchyma through the hilum, the mediastinum and the supraclavicular fossa. Whereas the IASLC Staging and Prognostic FactorsCommittee was analyzing the collected database to define the above cited staging system, many authors from single institutions researched about the impact on long-term outcome of the number of involved nodes coming up to interesting results.In a recent study by Smeltzer et al. (3), "Missed intrapulmonary lymph node metastasis and survival after resection of non-small cell lung cancer", a specialized technique of intrapulmonary LN sampling is utilized to identify possible previous not detected LN metastasis; the impact on overall survival of the presence of cancer metastasis to the intrapulmonary LNs is analyzed too. In their study, the initial pathological staging after routine dissection was pN0 69%, pN1 16% and pN2 15%. After re-dissection, additional LN metastasis was found in 23% patients. This caused a lowering of the pN0 rate from 69% to 65% and an augmented rate of pN1 cases from 16% to 22%. As second end-point the above mentioned paper reported an augmented risk of death for patients with more than two missed metastatic nodes at intrapulmonary stations.Despite some limitations due to the small number of patients and the short follow-up period, the paper, like others in the recent literature (4-7), has the great value to instill two doubts: the number of metastatic LNs shoul...

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A Proposal for Combination of Total Number and Anatomical Location of Involved Lymph Nodes for Nodal Classification in Non-small Cell Lung Cancer

Cited by 84 publications

References 24 publications

Lymph node volume predicts survival but not nodal clearance in Stage IIIA-IIIB NSCLC

Lymph node volume predicts survival but not nodal clearance in Stage IIIA-IIIB NSCLC

N2 lung cancer is not all the same: an analysis of different prognostic groups†

The “N”—factor in non-small cell lung cancer: staging system and institutional reports

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