The influence of the number of lymph nodes removed on the accuracy of a newly proposed N descriptor classification in patients with surgically-treated lung cancer

[Review for N2 Sub-staging in Non-small Cell Lung Cancer]

Patients with N2 non-small cell lung cancer (NSCLC) were heterogeneous groups and required further stratification. The International Society for the Study of Lung Cancer (IASLC) divided N2 into three sub-stages: N2 at a single station without N1 involvement (N2a1), N2 at a single station with N1 involvement (N2a2), and N2 at multiple stations (N2b). These new descriptors significantly distinguished the overall survival (OS), disease-free survival (DFS), and recurrence pattern of patients with different N2 sub-stages. The OS and DFS of N2a1 were not sufficiently distinguished from N1 at multiple stations (N1b). The OS and DFS of N2a2 were intermediate between those of N2a1 and N2b. Current evidence did not support the further subdivision of the N2b. The main recurrence pattern of N2a1, N2a2 and N2b were distant metastasis, and the risks of distant metastasis increased successively. N2a1 patients were at low risk of locoregional recurrence, which could not be reduced by postoperative radiotherapy (PORT). N2a2 and N2b patients had a similar higher risk of locoregional recurrence, which could be reduced to a similar level of N2a1 patients by PORT.
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The Clinical Characteristics and Treatments for Large Cell Carcinoma Patients Older than 65 Years Old: A Population-Based Study

Background: Pulmonary large cell carcinoma, a type of non-small cell lung cancer (NSCLC), is a rare neoplasm with poor prognosis. In this study, our aim was to investigate the impact of radiation sequences with surgery for stage III/IV LCC patients between different age groups, especially in the elderly patients. Patients and Methods: The patients with LCC and other types of NSCLC in the Surveillance, Epidemiology and End Results (SEER) database from 2004 to 2015 were retrospectively analyzed. Then we divided the LCC patients into two age groups: <65 years old group and ≥65 years old group. Propensity score method (PSM) was used to control potential differences between different groups. The overall survival (OS) of LCC patients and other types of NSCLC patients were evaluated by Kaplan−Meier analysis. Univariate and multivariate Cox regression analysis were employed to explore the independent risk factors of OS. The forest plots of HRs for OS were generated to show the above outcomes more visually. Results: In total, 11,349 LCC patients and 129,118 other types of NSCLC patients were enrolled in this study. We divided LCC patients into <65 years old group (4300) and ≥65 years old group (7049). LCC patients was more common in whites (81.4%), males (58.3%), elderly (≥65 years old: 62.1%), east regions (52.7%), upper lobe (51.6%), right-origin of primary (55.4%), with advanced grade (54.2%) or stage (76.7%). After PSM, Kaplan−Meier analysis and multivariate Cox analysis showed significantly worse survival prognosis for LCC patients compared to other types of NSCLC, especially in the group ≥65 years old (HR: 1.230; 95% CI: 1.171−1.291; p < 0.001). For LCC patients, there were some risk survival factors including whites, males, not upper lobe, advanced stage, elder age at diagnosis, bone metastasis, liver metastasis, singled status, no lymphadenectomy, no surgery, and no chemotherapy (p < 0.05). In LCC patients ≥65 years old, radiation after surgery had significantly better impact on overall survival outcomes (HR: 0.863, 95% CI: 0.765−0.973, p = 0.016), whereas radiation prior to surgery (HR: 1.425, 95% CI: 1.059−1.916, p = 0.019) had significantly worse impact on prognosis of patients. In LCC patients <65 years old, radiation sequences with surgery had no significant impact on the OS of patients (p = 0.580), but ≥4 LNRs had significantly survival benefits to prognosis (HR:0.707, 95% CI: 0.584−0.855). Elderly LCC patients had worse malignant tumors than young patients, of which the majority were diagnosed as stage III/IV tumors. Conclusions: Postoperative radiotherapy may achieve a better prognosis for stage III/IV LCC patients older than 65 years old compared to other radiation sequences with surgery.

Association of metastatic nodal size with survival in non-surgical non-small cell lung cancer patients: Recommendations for clinical N staging

Background

This study aims to analyze the prognostic significance of the metastatic lymph node (mLN) size in non-small cell lung cancer (NSCLC) patients receiving chemoradiotherapy (CRT) to provide some information for the optimization of clinical nodal (cN) staging.

Methods

A retrospective study with 325 NSCLC patients was conducted between January 2011 and December 2018 at two participating institutes. We evaluated the potential relationship between the mLN size and the survival to propose a potential revised nodal (rN) staging.

Results

Kaplan–Meier analyses showed significant differences in the overall survival (OS) based on the cN staging and the size of mLNs (N0, ≤2 cm, and >2 cm). We found that the nodal size correlated statistically with the response to CRT. The HRs of OS for patients with bulky mLNs increase significantly compared with patients in the non-bulky mLNs group in the cN2-3 group. Interestingly, the HRs of patients with bulky cN2 disease and non-bulky cN3 disease were similar to each other. We classified the patients into five subsets: N0, rN1(cN1), rN2(non-bulky cN2), rN3a(bulky cN2, and non-bulky cN3), and rN3b(bulky cN3). In our study, the rN stage showed better prognostic discrimination than the 8th IASLC cN staging and was an independent prognostic factor for survival.

Conclusions

In addition to the anatomic location, the size of mLNs correlated statistically with the response to CRT and should be incorporated into the cN staging system to predict survival more accurately.

Predictive Risk Factors for Early Recurrence of Stage pIIIA-N2 Non-Small Cell Lung Cancer

Purpose

Inflammatory biomarkers and clinical pathological factors have been reported to predict survival of patients with non-small cell lung cancer (NSCLC). The goal of this study was to identify risk factors for early recurrence in patients with pIIIA-N2 NSCLC who had undergone radial resection.

Methods

A retrospective analysis was conducted on 238 patients with pIIIA-N2 NSCLC who underwent surgical treatment at the First Affiliated Hospital of Wenzhou Medical University between December 2006 and August 2018. The early recurrence (ER) group included patients who recurred within one year of curative resection, while the non-early recurrence (NER) group included patients who did not recurrence or recurrence beyond one year. The univariate and multivariate Cox proportional risk analyses were used to identify prognostic factors associated with early recurrence, while the chi-square test was used for categorical data. Overall survival and recurrence-free survival were assessed by Kaplan–Meier estimates.

Results

A total of 69 patients experienced an early recurrence, while the remaining 169 patients did not relapse within one year. ER patients had a much worse prognosis than NER patients, with median survival times of 20.6 and 83.1 months, respectively. Multivariate analysis showed that smoking status, tumor size, metastatic lymph node ratio (LNR) and platelet-to-lymphocyte ratio (PLR) were independent risk factor of early recurrence. Patients with early recurrence were more likely to develop bone metastases.

Conclusion

Smoking history, large tumour size, and elevated LNR and PLR values in pIIIA-N2 NSCLC patients after complete resection may have a significant risk of early recurrence. Based on these independent risk indicators, this prediction model may successfully predict early recurrence and advise individual treatment.

Pathological response to neoadjuvant therapy with chemotherapy vs chemoradiotherapy in stage III NSCLC-contribution of IASLC recommendations

BACKGROUND

Neoadjuvant treatment (NT) with chemotherapy (Ch) is a standard option for resectable stage III (N2) NSCLC. Several studies have suggested benefits with the addition of radiotherapy (RT) to NT Ch. The International Association for the Study of Lung Cancer (IASLC) published recommendations for the pathological response (PHR) of NSCLC resection specimens after NT.

AIM

To contribute to the IASLC recommendations showing our results of PHR to NT Ch vs NT chemoradiotherapy (ChRT).

METHODS

We analyzed 67 consecutive patients with resectable stage III NSCLC with positive mediastinal nodes treated with surgery after NT Ch or NT ChRT between 2013 and 2020. After NT, all patients were evaluated for radiological response (RR) according to Response Evaluation Criteria in Solid Tumours criteria and evaluated for surgery by a specialized group of thoracic surgeons. All histological samples were examined by the same two pathologists. PHR was evaluated by the percentage of viable cells in the tumor and the resected lymph nodes.

RESULTS

Forty patients underwent NT ChRT and 27 NT Ch. Fifty-six (83.6%) patients underwent surgery (35 ChRT and 21 Ch). The median time from ChRT to surgery was 6 wk (3-19) and 8 wk (3-21) for Ch patients. We observed significant differences in RR, with disease progression in 2.5% and 14.8% of patients with ChRT and Ch, respectively, and partial response in 62.5% ChRT vs 29.6% Ch (P = 0.025). In PHR we observed ≤ 10% viable cells in the tumor in 19 (54.4%) and 2 cases (9.5%), and in the resected lymph nodes (RLN) 30 (85.7%) and 7 (33.3%) in ChRT and Ch, respectively (P = 0.001). Downstaging was greater in the ChRT compared to the Ch group (80% vs 33.3%; P = 0.002). In the univariate analysis, NT ChRT had a significant impact on partial RR [odds ratio (OR) 12.5; 95% confidence interval (CI): 1.21 - 128.61; P = 0.034], a decreased risk of persistence of cancer cells in the tumor and RLN and an 87.5% increased probability for achieving downstaging (OR 8; 95%CI: 2.34-27.32; P = 0.001).

CONCLUSION

We found significant benefits in RR and PHR by adding RT to Ch as NT. A longer follow-up is necessary to assess the impact on clinical outcomes.

Future Perspectives on the TNM Staging for Lung Cancer

Since its conception by Pierre Denoix in the mid-20th century, the tumor, node, and metastasis (TNM) classification has undergone seven revisions. The North American database managed by Clifton Mountain was used to inform the 2nd to the 6th editions, and an international database collected by the International Association for the Study of Lung Cancer, promoted by Peter Goldstraw, was used to inform the 7th and the 8th editions. In these two latest editions, it was evident that the impact of tumor size was much greater than it was suggested in previous editions; that the amount of nodal disease had prognostic relevance; and that the number and location of the distant metastases had prognostic implications. However, the TNM classification is not the only prognostic factor. Data are being collected now to inform the 9th edition of the TNM classification, scheduled for publication in 2024. Patient-, environment-, and tumor-related factors, including biomarkers (genetic biomarkers, copy number alterations, and protein alterations) are being collected to combine them in prognostic groups to enhance the prognosis provided by the mere anatomic extent of the tumor, and to offer a more personalized prognosis to an individual patient. International collaboration is essential to build a large and detailed database to achieve these objectives.