Is radical mediastinal lymphadenectomy necessary for elderly patients with clinical N-negative non–small-cell lung cancer? A single center matched-pair study

Prognostic Impact of Mediastinal Lymph Node Dissection in Octogenarians With Lung Cancer: JACS1303

INTRODUCTION

The prognostic significance of mediastinal lymph node dissection (MLND) in elderly patients with non-small cell lung cancer (NSCLC) remains unclear. This post hoc analysis of a nationwide multicenter cohort study (JACS1303) evaluated the prognostic significance of MLND in octogenarians with NSCLC.

MATERIALS AND METHODS

We included 622 octogenarians with NSCLC who underwent lobectomy. The median follow-up duration was 41.1 months. We compared survival and perioperative outcomes between patients who did and did not undergo MLND.

RESULTS

In total, 414 (67%) patients underwent MLND (ND2 group), whereas 208 (33%) did not undergo MLND (ND0-1 group). The disease stage was more advanced in the ND2 group than in the ND0-1 group. Disease-free survival was slightly greater in the ND0-1 group with marginal significance (P= .079). In the matched cohort (N = 228), which mainly consisted of patients with clinical stage I disease (96%), there was no significant difference between the 2 groups regarding overall and disease-free survival (P= .908 and P = .916, respectively). Operative time and blood loss were significantly lower in the ND0-1 group than in the ND2 group in the entire cohort (P< .001 and P = .050, respectively) and in the matched cohort (P = .003 and P= .046, respectively).

CONCLUSION

Based on a nationwide prospective database, we found limited prognostic impact of MLND, suggesting that MLND can be omitted for octogenarians with early-stage NSCLC.

Mediastinal lymph node dissection in older patients with non-small cell lung cancer

PURPOSE

We evaluated the impact of omitting mediastinal lymph node dissection (MLND) from the surgical treatment of non-small cell lung cancer (NSCLC) in older patients.

METHODS

We collected data retrospectively on 2475 patients who underwent pulmonary resection for NSCLC at our hospital between June, 2006 and December 2018. The subjects of this analysis were 209 patients aged ≥ 75 years who underwent lobectomy for cN0-1 NSCLC. The patients were divided into two groups based on whether they underwent MLND (ND2 group) or not (group ND0-1).

RESULTS

There were more patients aged ≥ 80 years in the ND0-1 group than in the ND2 group (p < 0.001). Patients in the ND0-1 group had clinically earlier stage lung cancers than those in the ND2 group (p = 0.053). We matched patient characteristics in the ND0-1 and ND2 groups by age, tumor diameter, cN, histology, and radiological findings. There were no significant differences in overall survival between the groups (p = 0.295). More patients in the ND2 group suffered complications (41.6% vs. 27.3%, p = 0.061) and arrhythmia episodes than those in the ND0-1 group (14.3% vs. 3.9%, p = 0.021).

CONCLUSION

MLND in older patients may not extend survival but it could lead to complications. Thus, the omission of MLND may be considered for patients of advanced age.

Outcomes after thoracoscopic surgery in octogenarian patients with clinical N0 non-small-cell lung cancer

OBJECTIVE

The number of surgeries for elderly patients with lung cancer is increasing. In our institute, thoracoscopic lobectomy and hilar lymph node dissection are the standard procedure for octogenarian patients with clinical N0 non-small-cell lung cancer. The aim of this study was to determine the outcome of our strategy for octogenarian patients.

METHODS

Seventy octogenarian patients with clinical N0 non-small-cell lung cancer who underwent surgery were enrolled (O group). As a control group, 205 septuagenarian patients were also enrolled (S group). We compared several clinicopathological factors and outcomes.

RESULTS

The median age of the O group was 82. There was no significant difference in the comorbidity ratio between the two groups. The 5-year overall survival ratio for the O group (72.8%) was significantly worse than that for the S group (88.3%). However, multivariate analysis proved age was not an independent predictor of outcome. The rates of recurrences involving ipsilateral mediastinal lymph nodes were equal in the two groups. After propensity score matching, clinical T1 patients were dominant (85%) in two matched group and no statistically significant differences were observed in the 5-year overall survival between the two groups.

CONCLUSIONS

Our strategy for octogenarian patients with non-small-cell lung cancer, including omission of mediastinal lymph node dissection, was determined to be feasible, in particularly with cT1N0 disease.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Treatment strategy and decision-making for elderly surgical candidates with early lung cancer

Among elderly cancer patients of the same chronological age, there is a wide range of heterogeneity in their ability to tolerate surgery. When an elderly patient comes to a thoracic surgeon, the surgeon first considers how healthy the patient is. If the patient looks healthy or in fit condition, the surgeon offers lobectomy plus mediastinal lymph node dissection. On the other hand, if the patient looks frail, the surgeon may offer, instead of a standard treatment, lobectomy without lymph node dissection, sublobar resection, or radiotherapy or may not offer any kind of treatment. This review was conducted to obtain an overview of these options and compare the treatment outcomes reported in the literature for the purpose of making a good decision for elderly surgical candidates with early lung cancer.

Lymph node metastasis in Chinese patients with clinical T1 non-small cell lung cancer: A multicenter real-world observational study

Background

Approximately 8.3–15.9% of patients with clinical stage I non‐small cell lung cancer are subsequently shown to have lymph node metastasis. However, the clinical characteristics of patients with lymph node metastasis in China are not fully understood.

Methods

This is a multicenter retrospective analysis of pathological T1 non‐small cell lung cancer patients who underwent surgical resection from 2 January 2014 to 27 December 2017. Clinical and pathological information was collected with the assistance of the Large‐scale Data Analysis Center of Cancer Precision Medicine‐LinkDoc database. The clinical and pathological factors associated with lymph node metastasis were analyzed by univariate and multivariate logistic regression.

Results

A total of 10 885 participants (51.6% women; 15.3% squamous cell carcinoma) were included in the analysis. The median age was 60.0 years (range 12.9–86.6 years). A total of 1159 patients (10.6%) had metastases in mediastinal nodes (N2), and 640 patients (5.9%) had metastasis in pulmonary lymph nodes (N1). Most patients had T1b lung cancer (4766, 43.8%). Of the patients, 3260 (29.9%) were current or former smokers. The univariate and multivariate analyses showed that younger age, squamous cell carcinoma, poor differentiation, larger tumor size, carcinoembryonic antigen level ≥5 ng/mL, and vascular invasion (+) were significantly associated with higher percentages of lymph node metastases (P < 0.001 for all).

Conclusion

This real‐world study showed the significant association of lymph node metastasis with age, tumor size, histology and differentiation, carcinoembryonic antigen levels, and status of vascular invasion. Female patients with T1a adenocarcinoma in the right upper lobe barely had lymph node metastasis.

Lymph node metastasis according to primary tumor location in T1 and T2 stage non-small cell lung cancer patients

BACKGROUND

To evaluate the pattern of lymph node metastasis (LNM) according to primary tumor location in T1 and T2 stage non-small cell lung cancer (NSCLC) patients.

METHODS

The data of 1916 NSCLC patients with LNM who underwent surgery with systematic nodal resection between November 2008 to December 2014 were included in the study. Analyses of tumor location, pathological T stage, and nodal metastasis were performed.

RESULTS

In T1a stage patients, superior mediastinum, aortopulmonary, and inferior mediastinum lymph node metastases were observed in primary tumors present in the right upper lobe (RUL), left upper lobe (LUL) and right middle lobe (RML), respectively. In T1b-stage patients, superior mediastinum, aortopulmonary, and inferior mediastinum lymph node metastases were observed in the RML, LUL, and right lower lobe (RLL), respectively. In patients with T2a-stage, superior mediastinum, aortopulmonary and inferior mediastinum lymph node metastases were observed in the RUL, LUL, and RLL, respectively. However, in T2b-stage patients, RUL, LUL and RML locations were associated with superior mediastinum, aortopulmonary, and inferior mediastinum lymph node metastases, respectively. Multivariable logistic regression showed that T stage was significantly associated with mediastinal and intrapulmonary lymph node metastases. In addition, tumor location was significantly associated with N2 station LNM.

CONCLUSION

LNM varied according to tumor location and T-stage, which are independent factors influencing N2 station LNM.

A retrospective comparative analysis of elderly and younger patients undergoing pulmonary resection for stage I non-small cell lung cancer

Background

Age has been a critical predictor for immediate postoperative and long-term results after the pulmonary resection for lung cancer. In this study, we evaluated and compared surgical outcome of stage I non-small cell lung cancer and associated predictive factors between elderly and younger groups.

Methods

Short- and long-term outcomes of elderly group (≥70 years) who were surgically treated and pathologically diagnosed as stage I non-small cell lung cancer from 2004 to 2010 were compared to the results of younger group (<70 years).

Results

Total of 1340 patients were included in this study, and the patients were divided into the elderly group (n = 285) and the younger group (n = 1055). The proportions of squamous cell carcinoma (36.8 vs. 20.0 %, p < 0.001) and stage IB cancer (58.3 vs. 40.6 %, p < 0.001) were significantly higher in the elderly group than the younger group. The 30-day and 90-day mortalities were significantly higher in the elderly group (1.8 vs. 0%; p = 0.014, 3.9 vs. 0.5 %; p < 0.001, respectively). The elderly patients also had significantly worse long-term outcomes than the younger group (5-year overall survival rate, 69.0 vs. 91.1 %; p < 0.001, 5-year disease-free survival rate, 53.3 vs. 80.2 %; p < 0.001). Decreased diffusion capacity less than 70 % was an important predictive factor for short- and long-term outcomes in both the younger and the elderly group.

Conclusions

Elderly patients with low diffusion capacity are at risk for significantly worse outcome, indicating that patient selection should include assessment of pulmonary function, including diffusion capacity.