Impact of lymph node management on resectable non-small cell lung cancer patients

Tantraworasin, Apichat; Saeteng, Somcharoen; Siwachat, Sophon; Jiarawasupornchai, Tawatchai; Lertprasertsuke, Nirush; Kongkarnka, Sarawut; Ruengorn, Chidchanok; Patumanond, Jayanton; Taioli, Emanuela; Flores, Raja M.

doi:10.21037/jtd.2017.02.90

Cited by 11 publications

(12 citation statements)

References 26 publications

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“…1 In 2014, the CoC endorsed a removal of at least 10 regional LNs for early-stage NSCLC. 7 Meanwhile, a number of studies also proposed the optimal numbers for LN evaluation, with the suggestions ranging from four to 20, based on the analyses of survival advantage and/or nodal upstaging (Table 3 2,[8][9][10][16][17][18][19][20][21][22][23][24][25][26] ). Previous studies indicated that the possibility of LN metastasis increases with greater tumor size.…”

Section: Discussionmentioning

confidence: 99%

Optimal Lymph Node Examination and Adjuvant Chemotherapy for Stage I Lung Cancer

Dai

Liu

Yang

et al. 2019

Journal of Thoracic Oncology

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Objective: To determine the optimal number of lymph nodes (LNs) examined and the role of adjuvant chemotherapy in stage I lung cancer.Methods: The National Cancer Database was queried for surgically treated patients with pathologic stage I lung cancer between 2006 and 2014 (N ¼ 65,438). The optimal LN numbers were determined in the multivariate Cox model and were further validated in the cohort with clinical stage I disease (N ¼ 117,112) in terms of nodal upstaging and prognostic stratification. The role of adjuvant chemotherapy in patients with suboptimal staging (number of LNs examined was less than than the optimum) was evaluated in each T stage.Results: The number of LNs examined correlated with tumor size (p < 0.001). There were increasing survival benefits with each additional LN examined-up to eight, nine, 10, and 11 nodes for patients with T1a, T1b, T1c, and T2a, respectively. Validation from the cohort with clinically staged disease showed that the threshold of eight to 11 LNs was an independent predictor of nodal upstaging (OR ¼ 1.706, 95% confidence interval [CI] 1.608-1.779) and survival outcome (hazard ratio ¼ 0.890, 95% CI: 0.865-0.916). After propensity matching, adjuvant chemotherapy was associated with improved survival in patients with stage T2a disease having suboptimal staging (hazard ratio ¼ 0.841, 95% CI: 0.714-0.990), but not in patients with stage T1a to T1c disease. Conclusion:LN evaluation was important for accurate staging and adequate treatment, and examinations of an increasing number of nodes for progressively higher T components (i.e., eight, nine, 10, and 11 nodes for T1a, T1b, T1c, and T2a tumors, respectively) seemed crucial to predict upstaging and survival outcomes. Adjuvant chemotherapy might be beneficial to patients with stage T2a disease who have suboptimal nodal staging.

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Section: Discussionmentioning

confidence: 99%

Optimal Lymph Node Examination and Adjuvant Chemotherapy for Stage I Lung Cancer

Dai

Liu

Yang

et al. 2019

Journal of Thoracic Oncology

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“…As compared with techniques used in previous studies, the present ALT technique enables en bloc dissection of three times as many lymph nodes, which increased the nodal upstaging rate (Table 5) (10,(12)(13)(14). Dissection of fewer than 11 lymph nodes is associated with a poor prognosis (15); thus, extended mediastinal LND might improve outcomes for left NSCLC with micrometastases. However, adapting LND via ALT is not practical for all patients with left NSCLC.…”

Section: Discussionmentioning

confidence: 99%

Left mediastinal node dissection after arterial ligament transection via video-assisted thoracoscopic surgery for potentially advanced stage I non-small cell lung cancer

et al. 2018

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Background: Left mediastinal node dissection during lung cancer surgery can be difficult because paratracheal and subcarinal lymph nodes are concealed by mediastinal structures. Arterial ligament transection (ALT) offers a wide surgical view of concealed mediastinal spaces, thus enabling extended en bloc lymph node dissection (LND). We analyzed surgical outcomes of patients who underwent extended LND after ALT via video-assisted thoracoscopic surgery (VATS) for potentially node-positive clinical stage I nonsmall cell lung cancer (NSCLC). Methods: We retrospectively investigated the medical records of 75 patients who had undergone extended mediastinal node dissection after ALT via VATS for potentially node-positive NSCLC at our centers during the period from September 2008 through November 2015. Operative data and rates of overall survival (OS), in addition to mortality and morbidity, were analyzed in relation pathological stage and nodal stage. Results: Operative time was 238±58 minutes, and an average of 32.7±12.9 hilar and mediastinal lymph nodes were dissected. Lymph node metastases were detected in 34 patients (6 pN1 patients, 27 pN2 patients, and 1 pN3 patient). Mediastinal lymph node metastases were detected around the carina (stations 2L, 4L, and 7) in 19 of 27 patients with pN2 cancer. Nineteen patients had a total of 24 postoperative complications.Recurrent nerve paralysis was the most frequent complication (n=11) but resolved in eight patients during follow-up. Survival rates at 3 and 5 years were 92.2%/88.4%, 100.0%/60.0%, and 87.7%/81.0% for p-stage I, II, and III, respectively, and 92.2%/88.4%, 100.0%/60.0%, and 87.4%/80.7% for pN0, pN1, and pN2, respectively. Conclusions: Extended mediastinal node dissection after ALT allowed detection of lymph node micrometastases in selected patients with potentially node-positive left NSCLC and may improve outcomes.

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“…The recommended number of nodes or stations for accurate nodal staging varies among sources. Some authors have proposed that 11-14 lymph nodes or at least 5 stations be resected [25,26]. The guidelines of the European Society of Thoracic Surgeons recommend systematic MLND for all resectable lung cancer, including at least 3 N2 stations [5].…”

Section: Kjtcvsmentioning

confidence: 99%

“…Many researchers have explored risk factors for nodal upstaging, including those pertaining to patients (such as diabetes mellitus, history of tuberculosis, and connective tissue disorders) and to tumor-related factors (such as central location, higher T stage, higher standardized uptake value, and histotype) [23,26]. We did so as well and found that only tumor-related factors (namely serum CEA levels, lesion size, and tissue-confirmed pleural invasion) heightened the risk of nodal upstaging.…”

Section: Kjtcvsmentioning

confidence: 99%

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer

Choi

Lee

Moon

et al. 2020

Korean J Thorac Cardiovasc Surg

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Background: Accurate intraoperative assessment of mediastinal lymph nodes is a critical aspect of lung cancer surgery. The efficacy and potential for upstaging implicit in these dissections must therefore be revisited in the current era of uniportal video-assisted thoracoscopic surgery (VATS). Methods: A retrospective study was conducted in which 544 patients with stage I (T1abc-T2a, N0, M0) primary lung cancer were analyzed. To assess risk factors for nodal upstaging and to limit any imbalance imposed by surgical choices, we constructed an inverse probability of treatment-weighted (IPTW) logistic regression model (in addition to non-weighted logistic models). We also evaluated risk factors for early locoregional recurrence using IPTW logistic regression analysis. Results: In the comparison of uniportal and multiportal VATS, the resected lymph node count (14.03±8.02 vs. 14.41±7.41, respectively; p=0.48) and rate of nodal upstaging (6.5% vs. 8.7%, respectively; p=0.51) appeared similar. Predictors of nodal upstaging included tumor size (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.12-2.70), carcinoembryonic antigen level (OR, 1.11; 95% CI, 1.04-1.18), and histologically confirmed pleural invasion (OR, 3.97; 95% CI, 1.89-8.34). The risk factors for locoregional recurrence within 1 year were found to be number of resected N2 nodes, age, and nodal upstaging. Conclusion: Uniportal and multiportal VATS appear similar with regard to accuracy and thoroughness, showing no significant difference in the extent of nodal dissection.

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Impact of lymph node management on resectable non-small cell lung cancer patients

Cited by 11 publications

References 26 publications

Optimal Lymph Node Examination and Adjuvant Chemotherapy for Stage I Lung Cancer

Optimal Lymph Node Examination and Adjuvant Chemotherapy for Stage I Lung Cancer

Left mediastinal node dissection after arterial ligament transection via video-assisted thoracoscopic surgery for potentially advanced stage I non-small cell lung cancer

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer

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