Risk factors for recurrence after complete resection of pathological stage N2 non-small cell lung cancer

Prognostic Value of Preoperative N Subcategories in Patients with Stage IIIA N2 Non-Small Cell Lung Cancer

Purpose To evaluate the preoperative risk factors in patients with pathologic IIIA N2 non-small cell lung cancer (NSCLC) who underwent upfront surgery and to evaluate the prognostic value of new N subcategories. Materials and Methods Patients with pathologic stage IIIA N2 NSCLC who underwent upfront surgery in a single tertiary center from January 2015 to April 2021 were retrospectively reviewed. Each patient's clinical N (cN) was assigned to one of six subcategories (cN0, cN1a, cN1b, cN2a1, cN2a2, and cN2b) based on recently proposed N descriptors. Cox regression analysis was used to identify the significant prognostic factors for recurrence-free survival (RFS) and overall survival (OS). Results A total of 366 patients (mean age ± SD, 62.0 years ± 10.1; 202 male patients [55%]) were analyzed. The recurrence rate was 55% (203 of 366 patients) over a median follow-up of 37.3 months. Multivariable analysis demonstrated that cN (hazard ratios [HRs] for cN1 and cN2b compared with cN0, 1.66 [95% CI: 1.11, 2.48] and 2.11 [95% CI: 1.32, 3.38], respectively) and maximum lymph node (LN) size at N1 station (≥12 mm; HR, 1.62 [95% CI: 1.15, 2.29]), in addition to clinical T category (HR, 1.51 [95% CI: 1.14, 1.99]), were independent prognostic factors for RFS. For OS, clinical N subcategories (cN1, cN2a2, and cN2b vs cN0; HRs, 1.91 [95% CI: 1.11, 3.27], 1.89 [95% CI: 1.13, 2.18], and 2.02 [95% CI: 1.07, 3.80], respectively) and LN size at N1 station (HR, 1.75 [95% CI: 1.12, 2.71]) were independent prognostic factors. For clinical N1, OS was further stratified according to LN size (log-rank test, P < .001). Conclusion Assessing the proposed N subcategories by reporting single versus multistation involvement of N2 disease and maximum size of metastatic LN, reflecting metastatic burden, at preoperative CT may offer useful prognostic information for planning optimal treatment strategies. Keywords: CT, Lung, Staging, Non-Small Cell Lung Cancer Supplemental material is available for this article. ©RSNA, 2024.

Dynamic perioperative variation of neutrophil-to-lymphocyte ratio as an independent prognosis factor following lobectomy for NSCLC

Inflammation plays a key role in malignant tumor progression. The neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and, as such, high isolated pretreatment NLR has been shown to be associated with worse long-term outcomes. The aim of the present study is to evaluate the prognostic value of pre- and post-operative NLR in relation to mortality and recurrence rates in patients undergoing lung lobectomy for NSCLC. A single-center retrospective analysis of 534 lobectomies was performed between 2009 and 2018. NLR was measured in two opportunities: 1 month prior to surgery and 1-4 months after. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Secondary outcomes were variables associated with mortality and recurrence. The study sample included 264 lobectomies. Independent predictors of OS were ASA 3/4 (p = 0.041) and open surgical approach (p = 0.042). Adjuvant chemotherapy (p = 0.002) and pathological N 1/2-stage (p = 0.0015) were associated with RFS. Delta NLR correlated with OS (p = 0.042) and RFS (p < 0.001). Patients were divided into three delta NLR categories: delta NLR < 0, delta NLR 0-0.5 and delta NLR > 0.5. Increasing delta NLR was significantly associated with worse OS (p < 0.001) and RFS (p < 0.001). Dynamic behaviour of NLR assessed through delta NLR is a useful tool that potentially allows predicting mortality and recurrence outcomes in patients undergoing lung lobectomy for NSCLC and may be more informative than static baseline values.

Risk analyses of N2 lymph-node metastases in patients with T1 non-small cell lung cancer: a multi-center real-world observational study in China

PURPOSE

N2 lymph-node metastases occur in approximately 6-17% of the patients with T1-2 non-small cell lung cancer (NSCLC). However, the clinical characteristics of N2 patients are not fully understood.

METHODS

This retrospective, multi-center analysis included T1 NSCLC patients receiving surgical resection during a period from Jan 2nd, 2014 to Dec 27th, 2017. The diagnosis was pathologically verified in all cases. Univariate and multivariate logistic regression analyses were conducted to analyze the factors that are associated with pN2 lymph-node metastases.

RESULTS

A total of 10,885 patients (48.4% men; 84.7% adenocarcinoma) were included in the analysis. The mean age was 59.0 ± 9.9 years. The mean tumor size was 1.8 ± 0.8 cm. Of the patients, 3260 (29.9%) were smokers or ex-smokers. Lymph-node metastases were verified in 1808 (16.6%) patients, and 1167 (10.7%) patients had N2 lymph-node metastases. The multivariate analyses indicated that larger tumor size, lower differentiation, CEA level ≥ 5 ng/mL, vascular invasion (+), and pleural involvement (+) were associated with higher percentages of N2 lymph-node metastases (p < 0.001 for all).

CONCLUSIONS

This study demonstrated the significant association between N2 lymph-node metastases and tumor size and differentiation, CEA levels, and status of vascular invasion and pleural involvement.

Five-year survival analysis and prognostic factors in patients operated on for non-small cell lung cancer with N2 disease

Background

The aim of the study is to analyse 5-year survival and prognostic factors in patients operated due to lung cancer with postoperatively confirmed metastases to N2 group nodes.

Methods

In the years 2007-2015, 1,148 patients with lung cancer were treated surgically. A postoperative histopathological study confirmed N2 feature in 150 patients. One hundred and ten patients, in whom a 5-year survival analysis was possible to perform, were included in such analysis. The patients underwent the following procedures: pneumonectomy, 31 patients; lobectomy, 61; bilobectomy, 10; and wedge resection, 8. All patients were subjected to supplementary treatment after the surgery.

Results

Five-year survival was achieved in 23 patients (21%). The patients' survival did not depend on the type of surgery, type of tumour, its location or presence of metastases in N1 nodes (P=0.82, P=0.51, P=0.36 and P=0.23, respectively). A statistically significant correlation was observed (P=0.01) between the 5-year survival of a patient and the occurrence of metastases only in one group of lymph nodes of the N2 feature (22 patients, 20%). Involvement of three or more mediastinal nodal groups resulted in survival shorter than 5-year.

Conclusions

(I) In patients with the N2 feature, the type of performed surgery, type of tumour and the occurrence of metastases in the lymph nodes of the lung hilum do not affect 5-year survival; (II) involvement of only one nodal group allows to achieve 5-year survival in 20% of patients; (III) involvement of three and more nodal groups with the N2 feature results in decreased 5-year survival.

Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management

Background

Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients.

Methods

Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime.

Results

The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 vs. 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 vs. 31.8 months; P=0.137).

Conclusions

N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).

The Role of Race and Economic Characteristics in the Presentation and Survival of Patients With Surgically Resected Non-Small Cell Lung Cancer

Background

Little is understood regarding the inter-relation between economic, marital, and racial/ethnic differences in presentation and survival of surgically resected lung cancer patients. Our investigation will assess these differences in addition to known therapeutic, patient, and histopathologic factors.

Methods

A retrospective review of the Surveillance Epidemiology and End Reporting database was conducted through the years 2007–2012. The population was split into nine different ethnic groups. Population differences were assessed via chi-square testing. Multivariable analysis (MVA) were used to detect overall survival (OS) differences in the total surgical population (TS, N = 35,689) in an ear (T1–T2 < 4 cm N0) surgical population [early-stage resectable (ESR), N = 17,931]. Lung cancer-specific survival (LCSS) was assessed in the ESR.

Results

In the TS population, as compared to Whites, Blacks, and Hispanics presented with younger age, more adenocarcinomas, lower rates of marriage, lower rates of insurance, less stage I tumors, and had less nodes examined, but their type of surgical procedures and OS/LCSS were the same. MVA demonstrated that lower OS and LCSS were associated with males, single/divorced/widowed partnership, lower income (TS only), and Medicaid insurance. MVA also found that Blacks and Hispanics had a similar OS/LCSS to Whites and that all ethnic groups were associated with a similar or better outcomes. The 90-day mortality and positive nodes were correlated with not having insurance and not being married, but they were not associated with ethnicity.

Conclusion

In TS and ESR groups, OS was not different in the two largest ethnic groups (Black and Hispanic) as compared to Whites, but was related to single/widowed/divorced status, Medicaid insurance, and income (TS group only). Nodal positivity was associated with patients who did not have a married partner or insurance suggesting that these factors may impact disease biology. Economic and psychosocial variables may play a role in survival of ear lung cancer in addition to standard histopathologic and treatment variables.

C-reactive protein-albumin ratio is an independent prognostic predictor of tumor recurrence in stage IIIA-N2 lung adenocarcinoma patients

OBJECTIVE

To systematically evaluate the prognostic value of nutrition/inflammation-based markers for recurrence-free survival (RFS) in pN2-stage IIIA lung adenocarcinoma patients.

MATERIALS AND METHODS

Data from 156 patients who had pathologically confirmed pN2-stage IIIA primary lung adenocarcinoma and received complete surgical resection from 2010 to 2014 were retrospectively analyzed. The data for Glasgow prognostic score (GPS), modified GPS (mGPS), high-sensitivity mGPS, C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and prognostic nutritional index were analyzed. Univariate and multivariate Cox proportional-hazards regression analyses were used to identify the prognostic factors associated with RFS.

RESULTS

The optimal cutoff value for the CAR was set at 0.6. A significant correlation was found between the CAR and RFS (P=0.001) by univariate analysis. Multivariate analysis between RFS and the factors selected from univariate analysis showed that ECOG performance status, pneumonectomy, multi-level N2, and high CAR were independent predictors of RFS.

CONCLUSION

The CAR was the best prognostic marker to predict tumor recurrence in pN2-stage IIIA lung adenocarcinoma patients among the 7 nutrition/inflammation-based markers. The preoperative CAR may identify patients with a high risk of postoperative tumor recurrence.