Is lobe specific lymph node dissection adequate for cN0-1 non-small cell lung cancer?

Canadian Consensus Recommendations for the Management of Operable Stage II/III Non-Small-Cell Lung Cancer: Results of a Modified Delphi Process

The treatment paradigm for patients with stage II/III non-small-cell lung cancer (NSCLC) is rapidly evolving. We performed a modified Delphi process culminating at the Early-stage Lung cancer International eXpert Retreat (ELIXR23) meeting held in Montreal, Canada, in June 2023. Participants included medical and radiation oncologists, thoracic surgeons and pathologists from across Quebec. Statements relating to diagnosis and treatment paradigms in the preoperative, operative and postoperative time periods were generated and modified until all held a high level of consensus. These statements are aimed to help guide clinicians involved in the treatment of patients with stage II/III NSCLC.

[Risk Factors and Sampling Range Evaluation of Lymph node Metastasis for Non-small Cell Lung Cancer with Diameter ≤2 cm]

BACKGROUND

More early-stage non-small cell lung cancer (NSCLC) are diagnosed in time and treated surgically, but systematic lymph node dissection can not bring enough survival benefits for them, and even increase the probability of postoperative complications. This study aims to analyze the risk factors and evaluate mediastinal lymph node metastasis sites in different lung lobes for NSCLC with diameter ≤2 cm, so as to provide reference for surgery.

METHODS

We collected 1051 patients with pulmonary nodule diameter ≤2 cm who were treated by pulmonary lobectomy with lymph node sampling/dissection in Department of Thoracic Surgery of the First Affiliated Hospital with Nanjing Medical University from December 2009 to December 2019. SPSS 26.0 statistical software was used for statistical analysis, to explore the risk factors and evaluate mediastinal lymph node metastasis sites in different lung lobes.

RESULTS

95 of 1051 (9.04%) patients presented lymph node metastasis. Male, pathological non-adenocarcinoma, 1 cm0.05). Lymph nodes in group N1 were significantly correlated with lymph node metastasis in groups #2R, #4R, #5, #6, #7 and #9 (P<0.01).

CONCLUSIONS

Lobe-specific lymph node dissection (LSND) can be performed for early-stage NSCLC. Male, pathological non-adenocarcinoma, 1 cm Collapse

Key Words

• Lobe-specific lymph node sampling
• Lung neoplasms
• Lymph node metastasis
• Risk factors

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MESH Headings

• Humans
• Male
• Carcinoma, Non-Small-Cell Lung/surgery
• Lymphatic Metastasis
• Lung Neoplasms/surgery
• Adenocarcinoma
• Small Cell Lung Carcinoma

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Grants Collapse

Affiliation(s)

Tianyu JIN
Zhicheng HE
Zhihua LI
Jianwei TANG
Jing XU
Weibing WU
Liang CHEN 陈亮，E-mail:

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Non-Lobe Specific Metastases in Occult N2 after Lobectomy for Clinical N0 Non-Small Cell Lung Cancer

OBJECTIVES

Non-small cell lung cancer can spread into lobe specific stations and non-lobe-specific mediastinal lymph nodes. We evaluated frequency and features of non-lobe specific nodal metastases, focusing especially on the prognostic value of only non-lobe specific N2-metastases after lobectomy.

METHODS

We performed a retrospective review of 550 patients with non-small cell lung cancer with clinical N0, undergoing lobectomy and systematic or lobe specific node dissection. We evaluated disease free and overall survival rates using Kaplan-Meier method and significance was tested by log-rank test.

RESULT

Occult N2 disease was detected in 68 patients (8.1%), 26 of them (38.2%) had metastases in non-lobe specific stations. Comparing patients with lobe and non-lobe specific lymph node metastases, 3-years DFS rate was 44.4% vs. 20.0% (p-value = 0.009), while 3-years OS rate was 87.3% vs. 26.7% (p-value <0.001). Among patients with non-lobe specific metastases 16 of them (61.5%) had only non-lobe specific metastases, the remaining 10 patients (38.5%) had metastatic lymph node at the same time in non-lobe specific station but also in lobe-specific stations. Comparing post-operative survival between patients with only non-lobe specific metastases and synchronous lobe and non-lobe specific metastases, 3-years DFS rate was 12.5% vs. 41.3% respectively (p-value = 0.03), and 3-years OS rate was 12.5% vs 76.7% (p-value = 0.002).

CONCLUSION

In patients with occult N2 disease, the finding of a metastatic lymph node in a non-lobe specific station relates with significant lower survival rate. The subset of patients who presented only non-lobe specific node metastases showed a significant lower survival rate compared to the remaining occult N2.

Lymph node micrometastasis in non-small cell lung cancer

Lung cancer has some of the highest morbidity and mortality rates of all cancers, and an important risk factor for mortality in patients with lung cancer is tumor metastasis. Even if a tumor is completely removed at an early stage of the disease, quite a number of patients still have the risk of recurrence. With the advent of molecular diagnostic and therapeutics, more and more studies have found that a poor prognosis may be related to lymph node micrometastasis. However, clinicians still find that predicting the prognosis and choosing the type of surgery and postoperative adjuvant chemotherapy are still challenging. Thus, this article reviews the current research status of lymph node micrometastasis in non-small cell lung cancer, envision to provide some updates and insights in this area.

Imbalanced Data Correction Based PET/CT Radiomics Model for Predicting Lymph Node Metastasis in Clinical Stage T1 Lung Adenocarcinoma

OBJECTIVES

To develop and validate the imbalanced data correction based PET/CT radiomics model for predicting lymph node metastasis (LNM) in clinical stage T1 lung adenocarcinoma (LUAD).

METHODS

A total of 183 patients (148/35 non-metastasis/LNM) with pathologically confirmed LUAD were retrospectively included. The cohorts were divided into training vs. validation cohort in a ratio of 7:3. A total of 487 radiomics features were extracted from PET and CT components separately for radiomics model construction. Four clinical features and seven PET/CT radiological features were extracted for traditional model construction. To balance the distribution of majority (non-metastasis) class and minority (LNM) class, the imbalance-adjustment strategies using ten data re-sampling methods were adopted. Three multivariate models (denoted as Traditional, Radiomics, and Combined) were constructed using multivariable logistic regression analysis, where the combined model incorporated all of the significant clinical, radiological, and radiomics features. One hundred times repeated Monte Carlo cross-validation was used to assess the application order of feature selection and imbalance-adjustment strategies in the machine learning pipeline. Prediction performance of each model was evaluated using the area under the receiver operating characteristic curve (AUC) and Geometric mean score (G-mean).

RESULTS

A total of 2 clinical parameters, 2 radiological features, 3 PET, and 5 CT radiomics features were significantly associated with LNM. The combined model with Edited Nearest Neighbors (ENN) re-sampling methods showed strong prediction performance than traditional model or radiomics model with the AUC of 0.94 (95%CI = 0.86-0.97) vs. 0.89 (95%CI = 0.79-0.93), 0.92 (95%CI = 0.85-0.97), and G-mean of 0.88 vs. 0.82, 0.80 in the training cohort, and the AUC of 0.75 (95%CI = 0.57-0.91) vs. 0.68 (95%CI = 0.36-0.83), 0.71 (95%CI = 0.48-0.83) and G-mean of 0.76 vs. 0.64, 0.51 in the validation cohort. The combination of performing feature selection before data re-sampling obtains a better result than the reverse combination (AUC 0.76 ± 0.06 vs. 0.70 ± 0.07, p<0.001).

CONCLUSIONS

The combined model (consisting of age, histological type, C/T ratio, MATV, and radiomics signature) integrated with ENN re-sampling methods had strong lymph node metastasis prediction performance for imbalance cohorts in clinical stage T1 LUAD. Radiomics signatures extracted from PET/CT images could provide complementary prediction information compared with traditional model.

Permissible Outcomes of Lobe-Specific Lymph Node Dissection for Elevated Carcinoembryonic Antigen in Non-Small Cell Lung Cancer

Background and Objectives: Lobe-specific nodal dissection (L-SND) is currently acceptable for the dissection of early-stage non-small cell lung cancer (NSCLC) but not for cancers of more advanced clinical stages. We aimed to assess the efficacy of L-SND, compared to systemic nodal dissection (SND). Materials and Methods: We retrospectively collected the clinical data of patients with carcinoembryonic antigen (CEA) abnormality who underwent complete resection of NSCLC via lobectomy or more in addition to either SND or L-SND at two cancer-specific institutions from January 2006 to December 2017. Results: A total of 799 patients, including 265 patients who underwent SND and 534 patients who underwent L-SND, were included. On multivariate analysis, thoracotomy, more than lobectomy, cN1-2, advanced pathological stage, adjuvant treatment, and EGFR or ALK were strongly associated with SND. No significant differences were found in overall survival, disease-free survival, and overtime survival after propensity adjustment (p = 0.09, p = 0.11, and p = 0.50, respectively). There were no significant differences in local (p = 0.16), regional (p = 0.72), or distant (p = 0.39) tumor recurrence between the two groups. Conclusions: SND did not improve the prognosis of NSCLC patients with CEA abnormality. Complete pulmonary resection via L-SND seems useful for NSCLC patients with CEA abnormality.

Video-assisted versus open thoracotomy lobectomy: comparison on lymphadenectomy and survival in early stage of lung cancer

Background

Video-assisted thoracic surgery (VATS) is increasingly used in the surgical treatment of early lung cancer, but the oncological benefits are still controversial. We aimed to compare video-assisted lobectomy and open thoracotomy lobectomy in terms of lymphadenectomy and long-term survival depending on the location of lobectomy.

Methods

A retrospective, multicenter study was based on the Polish Lung Cancer Study Group and included patients with stage I lung cancer who were surgically treated between 2007 and 2015. We included 1410 patients after video-assisted lobectomy and 4,855 after open thoracotomy.

Results

The average number of lymph nodes removed in video-assisted lobectomy was 10.9 and in open thoracotomy lobectomy was 12.9 (P<0.001). The 5-year survival was better in the video-assisted lobectomy group (78.6%) compared to open thoracotomy (73.8%) (P=0.002). Significant differences were found in the case of left lower lobe and left upper lobe lobectomies. Multivariable analysis showed that the prognostic factors for open thoracotomy relative to video-assisted lobectomy are: age over 60 [HR (95% CI): 1.55 (1.17-2.05), P=0.002], female [HR (95% CI): 1.57 (1.07-2.29), P=0.02], squamous cell carcinoma [HR (95% CI): 1.63 (1.12-2.37), P=0.011], left lower lobe [HR (95% CI): 2.69 (1.37-5.27), P=0.004] and left upper lobe [HR (95% CI): 1.53 (1.01-2.33), P=0.047].

Conclusions

The study showed that the number of lymph nodes removed during video-assisted lobectomy is significantly lower than in the open thoracotomy group. The long-term video-assisted lobectomy results were significantly better compared to open thoracotomy. Better long-term results were achieved on the left side of lobectomy.

New N1/N2 classification and lobe specific lymphatic drainage: Impact on survival in patients with non-small cell lung cancer treated with surgery

OBJECTIVE

to validate the proposed N descriptor revision on a large cohort of patients and assess the impact of tumour location on the distribution pattern of lymph node metastases for patients with NSCLC.

METHODS

This is a retrospective review of a consecutive series of patients who had anatomical lung resections. Systematic lymph node dissection was done for all patients.

RESULTS

Between January 2009 and December 2019 2566 patients had surgical resection for NSCLC. 448 patients (17.5%) had histologically confirmed lymph node metastases: 257 (57.4 %) had pN1 and 191 pN2. Median age of the study population was 69.1 years. Overall survival (OS) for study population was 37.3 months with 5-year survival rate of 35.7 %. The survival analysis of the N subgroups showed the pN2 patients had a median OS of 27.9 months vs. 41.7 months for pN1 patients (p = 0.013). Analysis as per the new proposal of the N subgroups N1a vs N1b vs N2a1 vs N2a2 vs N2b showed that median survival OS was 41.7 vs. 39.2 mo vs. 33.3 mo vs. 28.9 mo vs. 24.6 mo (p = 0.099). There was statistically significant difference in survival between N2 patients with skip metastasis and N2 patients without skip metastases: OS 32.2 (95 % CI: 16.8-47.6) months vs. 24.2 months (p = 0.024). On multivariate analysis only pathological N (p = 0.011) and the new proposed N classification (p = 0.006) were independent prognostic factors for survival.

CONCLUSIONS

N1 and N2 disease are heterogeneous groups and require further stratification. The number of N2 lymph node stations involved and the presence or not of N1 disease translated to significant differences in survival and therefore have to be included in N staging.

How we assess the perioperative anxiety of surgical patients with pulmonary nodules: the revision of state-trait anxiety inventory

PURPOSE

The aim of the study was to develop a short form of State-Trait Anxiety Inventory (STAI) and calculate the norms for the assessment of anxiety in surgical patients in mainland China.

METHODS

Patients who were scheduled to carry out pulmonary surgery in our department were included. The sinicized 40-item STAI Form-Y was used to assess the anxiety on the surgery eve. Then the coefficient of variation, coefficient of correlation, stepwise regression analysis, principal component analysis, and structural equation model were successively to filter the items. The reliability and validity of the revised STAI was estimated and the norms were computed.

RESULTS

445 intact replies were collected. A 13-item STAI with 6 items in state subscale and 7 items in trait subscale produced similar scores with the full version of STAI. The Cronbach alpha coefficients for the state and trait subscales were 0.924 and 0.936, respectively. The determinant coefficients were 0.781 and 0.822, respectively. Moreover, the norms of both state subscale and trait subscale are provided according to the age and gender.

CONCLUSIONS

The revised short form of STAI has good reliability and validity. It is likely to be more acceptable by reducing the fatigue effects, and is suitable for follow-up study on the assessment and intervention of perioperative anxiety of surgical patients with pulmonary nodules.