Missed Intrapulmonary Lymph Node Metastasis and Survival After Resection of Non-Small Cell Lung Cancer

Smeltzer, Matthew P.; Faris, Nicholas R.; Yu, Xinhua; Ramirez, Robert A.; Ramirez, Laura E.M.; Wang, Christopher G.; Adair, Courtney A.; Berry, Allen D.; Osarogiagbon, Raymond U.

doi:10.1016/j.athoracsur.2016.03.096

Cited by 52 publications

(39 citation statements)

References 37 publications

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“…In most cases, however, only the hilar and mediastinal LNs of lung cancer patients are routinely examined after surgery. Intrapulmonary LNs are usually not considered because they are located deep in the pulmonary parenchyma and are rarely isolated for pathological examination . But intrapulmonary LN metastasis, like hilar metastasis, is also defined as stage N1.…”

Section: Discussionmentioning

confidence: 90%

Intrapulmonary lymph node metastasis is common in clinically staged IA adenocarcinoma of the lung

et al. 2018

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BackgroundIntrapulmonary lymph nodes (LNs, stations 11–14) are usually omitted in postoperative pathological examination. Some non‐small cell lung cancer (NSCLC) patients with intrapulmonary LN metastasis are incorrectly diagnosed as N0 cases. Furthermore, underestimation of intrapulmonary LN involvement in clinically early stage NSCLC may lead to the incorrect choice of surgical procedure: lobectomy or sublobar resection. This study was conducted to determine the status of intrapulmonary LN involvement in clinically staged IA (c‐T1N0M0) peripheral adenocarcinoma of the lung.MethodsSeventy‐five lobectomy specimens of c‐T1N0M0 peripheral adenocarcinoma of the lung were carefully dissected to find intrapulmonary LNs. The longest diameter of each intrapulmonary LN was measured and sent for pathological examination, together with hilar and mediastinal LNs, to investigate the relationship between LN metastasis and primary tumor size.ResultsIntrapulmonary LN metastasis was detected in 22.7%(17/75) of patients. Positive LNs were detected in 21.7% (10/46) of T1b patients and 45% (11/24) of T1c patients, while no metastasis (0/5) was observed in T1a patients (P = 0.036). The mean longest diameter of the 17 involved intrapulmonary LNs was only 6.5 ± 2.1 mm, which was not significantly different to the size of negative intrapulmonary LNs (5.2 ± 1.4 mm).ConclusionsIntrapulmonary LN metastasis is common in clinically staged IA peripheral adenocarcinoma of the lung. LN metastasis is related to tumor size, and this should be taken into account to determine appropriate surgical procedures and postoperative treatment. Computed tomography is not a reliable method to judge LN metastasis, particularly intrapulmonary LN metastasis.

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Section: Discussionmentioning

confidence: 90%

Intrapulmonary lymph node metastasis is common in clinically staged IA adenocarcinoma of the lung

et al. 2018

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“…For example, in the IASLC's Lung Cancer Staging Project database, intercontinental pathologic N1 5-year survival rates ranged from 54% in Asia to 34% in Europe (4). Some have proposed that this survival heterogeneity is partly driven by heterogeneity in staging accuracy caused by heterogeneity in the thoroughness of hilar and intrapulmonary LN retrieval (33)(34)(35). The value of the LNR may be in partially adjusting for this heterogeneity in thoroughness of nodal evaluation.…”

Section: Discussionmentioning

confidence: 99%

Prognostic value of lymph node ratio in patients with pathological N1 non-small cell lung cancer: a systematic review with meta-analysis

Zhan

Yuan

et al. 2016

Transl. Lung Cancer Res.

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Background: Non-small cell lung cancer (NSCLC) patients with N1 disease have variable outcomes, and additional prognostic factors are needed. The number of positive lymph nodes (LNs) has been proposed as a prognostic indicator. However, the number of positive LNs depends on the number of LNs examined from the resection specimen. The lymph node ratio (LNR) can circumvent this limitation. The purpose of this study is to evaluate LNR as a predictor of survival and recurrence in patients with pathologic N1 NSCLC. Methods:We systematically reviewed studies published before March 17, 2016, on the prognostic value of LNR in patients with pathologic N1 NSCLC. The hazard ratios (HRs) and their 95% confidence intervals (CIs) were used to combine the data. We also evaluated heterogeneity and publication bias.Results: Five studies published between 2010 and 2014 were eligible for this systematic review with metaanalysis. The total number of patients included was 6,130 ranging from 75 to 4,004 patients per study. The combined HR for all eligible studies evaluating the overall survival (OS) and disease-free survival (DFS) of N1 LNR in patients with pathologic N1 NSCLC was 1.53 (95% CI: 1.22-1.85) and 1.64 (95% CI: 1.19-2.09), respectively. We found no heterogeneity and publication bias between the reports.Conclusions: LNR is a worthy predictor of survival and cancer recurrence in patients with pathological N1 NSCLC. Multiple investigators have demonstrated the heterogeneity in survival of patients with pN0 resections, suggesting the possibility that a significant proportion of these patients are understated, probably because LN metastasis is missed (5-8). However, the survival of patients with pathologic N1 is also heterogenous, ranging from a 5-year survival of 54% to 34% in the International Association for the Study of Lung Cancer (IASLC) Lung Cancer Staging Project database (4). The reported risk of recurrence for patients with pathologic Stage IIA-IIB disease ranges from 7% to 55% (9). Keywords: Lymph node ratio (LNR);These results suggest a need to identify patterns of LN involvement that more accurately predict survival, particularly of patients with N1 disease (10,11). Because the thoroughness of nodal examination interacts with the likelihood of detecting nodal metastasis, the number of positive LNs may depend on by the number of LNs examined from the resection specimen. Therefore, the prognostic accuracy of the actual number of positive LNs is potentially restricted (12). The lymph node ratio (LNR)-the number of positive LNs divided by the number of LNs examined-has been suggested to be a more accurate prognostic indicator than the number of LNs with metastasis in different types of cancer including thyroid, gastric, colorectal, and cancer (13)(14)(15)(16)(17)(18)(19).The prognostic value of the LNR in N1 NSCLC remains controversial. We conducted a meta-analysis of published reports in order to evaluate the LNR as a predictor of survival and recurrence in patients with pathological N1 NSCLC. Methods Search strategyW...

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“…Same day admission and noninvasive chest pain management should also be considered first election. Although powerful, randomized trials are still lacking, some studies suggest that immediate postoperative course and moreover, late postoperative results may be no so different and even worse in using VATS, provided a valid comparison is made (17), as it is its relationship with long term survival (18). Recent publications suggest technical ways to improve this crucial aspect of surgical lung cancer management (19,20).…”

Section: Preoperative Choosing Surgical Approach and Postoperative Comentioning

confidence: 99%

Nowadays open-chest surgery in the era of fast-track management

Navarro

Benavidez

2017

J. Vis. Surg.

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In more than a century, approaches to perform thoracic surgical procedures have had profound changes. A milestone of those changes has been the advent of video-assisted techniques which rapidly Small, muscle-sparing thoracotomiesTwo surgical innovations and technological advances changed the situation in a relative short period of time. From the end of eighties, the concept of muscle-sparing thoracotomy took relevance, once proved its technical feasibility and positive effect on immediate and late postoperative course (5,6). Full posterolateral thoracotomy as initially conceived, was only considered for those cases were the need for a wide thoracic aperture was preoperatively obvious (Figure 1).But by the early nineties, the application of video-assisted techniques to thoracic surgical procedures was also a reality.As usually happens with successful innovations, beginning present century two facts appeared: (I) widespread attempts to perform by video as much procedures as possible. Perhaps unconsciously, many surgeons were suspicious that open chest surgery was coming to an end and nobody wanted to remain in the past; (II) comparative studies between videoassisted thoracic surgery (VATS) and open chest performed procedures began to flourish in the literature. Some of them valuable, many others with severe limitations and arguable conclusions, not to mention the scarcity of randomized trials.When analyzing those comparative studies, besides common limitations as retrospective analysis, not homogeneous series of patients and participation of different surgeons, two main drawbacks in many of them are worth to mention: The identification of open chest procedures simply as "thoracotomy", with no additional information on what type of chest aperture had been performed;  Limitation of the study to the immediate postoperative course. Contributions of those studies to general knowledge of the problem and to the design of recommendations have been variable and somehow confusing.Superiority of VATS was clearly demonstrated in several studies (7,8), others reported only subtle differences favoring VATS (9) or still others found the advantages of VATS limited to special situations like surgery on the elderly (10).Although Hartwig and D'Amico (11) make clear their view that VATS lobectomy should be considered the gold standard for "early-stage" lung cancer, they also consider VATS a "reasonable option" for lung cancer management, implicitly recognizing the existence of other options. Moreover, they correctly highlight an important point: some surgeons may not be trained and experience enough to perform VATS lobectomy independently.Finally, it is difficult to understand Nagahiro's finding (12) of a mean drop of just 5% in forced expiratory volume in one second after VATS lobectomy, in comparison with the known mean drop of 20% after thoracotomy lobectomy. If such a huge difference become the general experience, it would be almost impossible to find a place for open chest lobectomy, not to say of patients with limi...

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Missed Intrapulmonary Lymph Node Metastasis and Survival After Resection of Non-Small Cell Lung Cancer

Cited by 52 publications

References 37 publications

Intrapulmonary lymph node metastasis is common in clinically staged IA adenocarcinoma of the lung

Intrapulmonary lymph node metastasis is common in clinically staged IA adenocarcinoma of the lung

Prognostic value of lymph node ratio in patients with pathological N1 non-small cell lung cancer: a systematic review with meta-analysis

Nowadays open-chest surgery in the era of fast-track management

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