Lymph node upstaging for non-small cell lung cancer after uniportal video-assisted thoracoscopy

Abstract

Background: Radical lymph node dissection (LND) plays a major role in the treatment of non-small cell lung cancer (NSCLC). This study presents the analysis of the results after uniportal video-assisted thoracoscopy (VATS) lymphadenectomy during anatomical lung resections for NSCLC, focusing on pathological nodal upstaging. Any possible risk factor affecting nodal upstaging was also investigated. Methods: The prospectively collected clinical data of 136 patients undergone uniportal VATS anatomical lung resections, from June 2012 to September 2017, were reviewed. In particular, all details inherent the clinical and pathological node stage and any possible risk factor affecting nodal upstaging were analyzed. Results: The patient population consisted of 90 males and 46 females; their mean age was 67.42±10.64 years. The mean number of lymph nodes retrieved during uniportal VATS lymphadenectomy was 20.14±10.73 (7.27±5.90 and 12.60±7.96 in N1 and N2 stations, respectively). The incidence of nodal upstaging was 13.3% (18 cases). In particular there was a N0-1 upstaging in 10 cases (7.4%), a N1-2 upstaging in 3 (2.2%) and a N0-2 in 4 (3%). The ROC analysis showed that the resection of 18 lymph nodes was the best predictor of a general upstaging with an AUC-ROC of 0.595, while the resection of 7 hilar lymph nodes was the best predictor of N1 upstaging (AUC-ROC: 0.554) and 11 mediastinal nodes was the best predictor of N2 upstaging (AUC-ROC: 0.671). The number of positive lymph nodes of stations 5-6 (OR: 2.035, 95% CI: 1.082-3.826, P=0.027) and stations 2-3-4 (OR: 6.198, 95% CI: 1.580-24.321, P=0.009) were confirmed to be the only independent risk factors for N2 upstaging by multivariate analysis. Conclusions: According to our experience, uniportal VATS allows a safe and effective radical lymphadenectomy, with a satisfactory pathological nodal upstaging, comparable to other minimally invasive techniques.

Sentinel Lymph Node in Non-Small Cell Lung Cancer: Assessment of Feasibility and Safety by Near-Infrared Fluorescence Imaging and Clinical Consequences

“…However, lymph node dissection can be related to postoperative morbidity, which is low but may occur due to bleeding, recurrent nerve paralysis, esophageal wounds, chylothorax, aggravation of bronchial congestion by pulmonary denervation, and bronchial fistula by devascularization of the stump [ 8 ]. Furthermore, routine pathological analysis techniques using hematoxylin-eosin-saffron (HES) staining can lead to the omission of up to 20 to 30% of micrometastases [ 9 , 10 , 11 , 12 ]. The lack of detection of these occult micrometastases can be responsible for an understaging of the disease, and most studies have found that lymph node micrometastases could adversely affect the prognosis of NSCLC patients [ 13 , 14 ].…”

Rate and Predictors of Unforeseen PN1/PN2-Disease in Surgically Treated cN0 NSCLC-Patients with Primary Tumor > 3 cm: Nationwide Results from Italian VATS-Group Database

“…The number of retrieved nodes predictive of pathological upstaging is also an argument of debate among the authors. Ismail and colleagues [ 15 ] concluded that the resection of 18 nodes could be the best predictor of general nodal upstaging (13.3%) in a single-centre VATS series of 136 patients and suggested the removal of at least seven nodes from hilar stations and eleven from mediastinal ones to enhance the possibilities of detecting an unforeseen nodal disease.…”

Surgical Effectiveness of Uniportal-VATS Lobectomy Compared to Open Surgery in Early-Stage Lung Cancer

“…Ismail et al (28) showed how, in the hands of expert U-VATS surgeons, the mean number of lymph nodes retrieved during U-VATS lobectomy can be satisfactory (20.14 ± 10.73) and comparable to the mean reported in the literature for other techniques (13.42 ± 8.24 in Triportal-VATS, 9.44 in open surgery, 17 in RATS), as well as the incidence of nodal upstaging (13.3% in U-VATS vs. 6.7-12.8% reported in other approaches). In particular, the pN1-upstaging (7.4%) and pN2-upstaging (3%) were also in line with the literature (27).…”