Prognostic classifications of lymph node involvement in lung cancer and current International Association for the Study of Lung Cancer descriptive classification in zones

Prognostic significance of 4R lymph node dissection in patients with right primary non-small cell lung cancer

Background

To investigate the prognostic significance of station 4R lymph node (LN) dissection in patients who underwent operations for right primary non-small cell lung cancer (NSCLC).

Methods

We performed a retrospective study involving patients with right primary NSCLC who received lobotomy or pneumonectomy with mediastinal LN dissection between January 2011 and December 2017. Propensity score matching was performed. Disease-free survival (DFS) and overall survival (OS) were compared between patients with and without station 4R dissection.

Results

Our study included 2070 patients, with 207 patients having no station 4R dissection (S4RD− group) and 1863 patients having station 4R dissection (S4RD+ group). The 4R LN metastasis rate was 13.4% (142/1748), higher than that for other mediastinal LN metastases. Compared with the S4RD− group, the S4RD+ group had higher 5-year DFS (48.1% vs. 39.1%, P = 0.009) and OS (54.4% vs. 42.8%, P = 0.025). Station 4R dissection was an independent risk factor for DFS (odds ratio, OR, 1.28, 95% confidence interval, CI, 1.08–1.64, P = 0.007) and OS (OR 1.31, 95% CI 1.04–1.63, P = 0.018). Patients with adjuvant chemotherapy had a better prognosis after station 4R dissection than those without adjuvant chemotherapy (57.4% vs. 52.3%, P = 0.006). The 5-year OS in the station 4R metastasis group was lower than that in the station 4R non-metastasis group (26.9% vs. 44.3%, P = 0.006) among N2 patients. The 5-year OS of the single-station 4R metastasis group was lower than that of the single-station 7 metastasis group (15.7% vs. 51.6%, P = 0.002).

Conclusions

Station 4R metastasis was the highest among all the mediastinal station metastases in right primary NSCLC patients. Station 4R dissection can improve the prognosis and should be recommended as a routine procedure for these patients.

Management of Early-Stage Resected Non-Small Cell Lung Cancer: Consensus Statement of the Lung cancer Consortium

BACKGROUND

Management of early-stage non-small cell lung cancer (ES-NSCLC) has evolved over the last few years especially in terms of work-up and the use of systemic therapy. This consensus statement was developed to present updated guidelines for the management of this disease.

METHODS

Multidisciplinary team (MDT) of lung cancer experts convened to discuss a set of pertinent questions with importance relevance to the management of ES-NSCLC. ES-NSCLC includes stages I, II and resected stage III. The experts included consultants in chest imaging, thoracic surgery, radiation oncology, and medical oncology. Questions were discussed in virtual meetings and then a written manuscript with supporting evidence was drafted, reviewed, and approved by the team members.

RESULTS

The Consensus Statement included 9 questions addressing work-up and management of ES-NSCLC. Background information and literature review were presented for each question followed by specific recommendations to address the questions by oncology providers. The Statement was endorsed by various oncology societies in the Gulf region.

CONCLUSION

The Consensus Statement serves as a guide for thoracic MDT members in the management of ES-NSCLC. Adaptation of these to the local setting is dictated usually by available resources and expertise, however, all efforts should be excreted to provide the optimal care to all patients whenever possible.

Lobe-specific lymph node dissection in stage IA non-small-cell lung cancer: a retrospective cohort study

OBJECTIVES

To investigate lymph node (LN) metastasis according to tumour location and assess the impact of lobe-specific LN dissection on survival in stage IA non-small-cell lung cancer (NSCLC).

METHODS

We retrospectively analysed the data of patients with clinical stage IA NSCLC treated with lobectomy and systematic LN dissection at Asan Medical Center (Seoul, Korea) between June 2005 and April 2017. Patients who received neoadjuvant therapy had multiple primary tumours or missed the follow-up during the first postoperative year were excluded. The patients were divided into five groups according to involved lung lobes: right upper lobe (RUL), right middle lobe (RML), right lower lobe (RLL), left upper lobe (LUL) and left lower lobe (LLL), which were further divided into subgroups according to LN station metastasis. Overall survival (OS) and the incidence of metastasis were calculated for each subgroup. Efficacy indices (EIs) were calculated to determine the correlation between each lung lobe and LN station, and the impact of the dissection of these stations on survival.

RESULTS

A total of 1202 patients were analysed. The 5-year OS in the RUL, RML, RLL, LUL and LLL groups was 74%, 88%, 78%, 80% and 75%, respectively. The incidence of single LN station metastasis was 11%, 10%, 10%, 16% and 14%, respectively. The lobe-specific LNs for RUL, RML, RLL, LUL and LLL were stations 2/3/4, 4/7, 2/4/7, 4/5/6 and 6/7/9, respectively. Moreover, the LN stations with high EIs for RUL, RML, RLL, LUL and LLL were 4, 7, 7, 5 and 7, respectively. In the RUL group, the incidence of metastasis to stations 2, 3 and 4 was 2.3%, 0.5% and 7.6%, and the EI was 0.8, 0.3 and 4.3, respectively. In RML, the incidence of metastasis to stations 4 and 7 was 4% and 6%, and the EI was 1.3 and 2.4, respectively. In RLL, the incidence of metastasis to stations 2, 4 and 7 was 4.4%, 5.6% and 8.3%, and the EI was 1.3, 1.4 and 3.3, respectively. In LUL, the incidence of metastasis to stations 4, 5 and 6 was 1.4%, 11.8% and 2.5%, and the EI was 0.4, 7.1 and 0.5, respectively. In LLL, the incidence of metastasis to stations 6, 7 and 9 was 1.1%, 5.7% and 1.7%, and the EI was 0.6, 2.3 and 0.5, respectively. Furthermore, the OS of patients with lobe-specific LN metastasis was statistically significantly different from that of the non-lobe-specific LN metastasis group with P-values of <0.001 for RUL, 0.002 for RML, 0.002 for RLL, 0.001 for LUL and 0.003 for LLL.

CONCLUSIONS

Our findings support the use of lobe-specific LN dissection in stage IA NSCLC. When LN stations with high EI were negative, LN metastasis in other stations was unlikely. The incidence of LN metastasis beyond lobe-specific LN stations was ∼1% in all subgroups. Dissection of non-lobe-specific LNs may not improve the OS; however, prospective randomized controlled trials are needed to modify the standard approach.

Risk factors of lobar lymph node metastases in non-primary tumor-bearing lobes among the patients of non-small-cell lung cancer

Purpose

Lobar lymph node metastases in non-primary tumor-bearing lobes (NTBL) are rarely reported. This study examined the risk factors of lobar lymph node metastasis in NTBL.

Methods

We retrospectively studied 301 patients with non-small-cell lung cancer (NSCLC) who underwent surgical pulmonary resection with systematic lymph node dissection plus extended lobar lymph node dissection of NTBL. Patients were classified into positive and negative NTBL groups. Unconditional logistic regression was used to identify the risk factors for lobar lymph node metastasis in NTBL.

Results

NTBL lobar lymph nodes were identified in 38 patients (12.6%). A higher proportion of adenocarcinomas occurred in the positive NTBL group compared to the negative NTBL group (73.7% vs. 46.4%, P = 0.01). Risk of NTBL lobar lymph node metastases was significantly elevated in the lower lobe of primary site compared to the upper lobe (OR = 2.61, 95% CI = 1.26–5.75, P = 0.01), and with adenocarcinomas compared to squamous cell carcinomas (OR = 2.75, 95% CI = 1.09–7.65, P = 0.04). No differences were observed when comparing left and right lobes. NTBL lobar lymph node metastasis was most often observed among patients with larger tumor size, N1/N2 nodal involvement, with lymph vascular invasion (LVI), and visceral pleural invasion (VPI).

Conclusion

NTBL lobar lymph node metastases occurred more often in patients with a primary NSCLC tumor in the lower lobe, with adenocarcinomas, larger tumor size, N1/N2 nodal involvement, LVI or VPI. Extended lymphadenectomy including NTBL nodes may be clinically advantageous when these risk factors are present.

Segment Location and Ground Glass Opacity Ratio Reliably Predict Node-Negative Status in Lung Cancer

BACKGROUND

Although selective mediastinal lymph node dissection based on lobe-specific nodal metastasis has been proposed for non-small cell lung cancer, controversy remains over its validity. We hypothesized that different segments within the same lobe might have different patterns of lymph node metastasis.

METHODS

Data on 2749 invasive non-small cell lung cancer patients who underwent pulmonary resection with systematic lymph node dissection from April 2008 to December 2015 were retrospectively analyzed. The segment location and consolidation tumor ratio were identified using preoperative computed tomography scans.

RESULTS

None of the 151 tumors with consolidation tumor ratio ≤ 0.5 had lymph node involvement. None of the 333 tumors located in apical segments had inferior mediastinal lymph node metastasis. When the analysis was limited to patients without hilar nodes involvement, only 7 out of 740 (0.9%) peripheral upper lobe tumors had inferior mediastinal lymph node metastasis. Interestingly, all these 7 tumors showed visceral pleural invasion. If hilar nodes were negative, superior mediastinal lymph node metastasis was not present for lower lobe ground glass opacity lesions. Among patients with left lower lobe tumors, if hilar nodes were negative, station 4L lymph node metastasis was not found in superior-segment or basal-segment tumors, and station 5/6 lymph node involvement was always absent in basal-segment tumors.

CONCLUSIONS

Segment location, ground glass opacity proportion, and absence of hilar lymph nodes involvement are reliable predictors of node-negative status in specific mediastinal regions. Based on these findings, we propose a new selective mediastinal lymph node dissection strategy for non-small cell lung cancer.

Phase 1 study of the anti-vascular endothelial growth factor receptor 3 monoclonal antibody LY3022856/IMC-3C5 in patients with advanced and refractory solid tumors and advanced colorectal cancer

PURPOSE

Metastasis of solid tumors to regional lymph nodes is facilitated by tumor lymphangiogenesis, which is primarily mediated by the vascular endothelial growth factor receptor 3 (VEGFR-3). We conducted a phase 1 dose-escalation (part A) study of the VEGFR-3 human immunoglobulin G subclass 1 monoclonal antibody LY3022856 in advanced solid tumors, followed by a colorectal cancer (CRC) expansion (part B).

METHODS

Part A evaluated the safety profile and maximum tolerated dose (MTD) of LY3022856 in patients treated intravenously at doses of 5-30 mg/kg weekly (qwk). Part B further evaluated tolerability in CRC patients treated with 30 mg/kg. Secondary objectives were pharmacokinetics, anti-tumor activity, and pharmacodynamics (exploratory).

RESULTS

A total of 44 patients (23 in part A; 21 in part B) were treated; only one dose-limiting toxicity was observed at the lowest dose level. The MTD was not reached. Treatment-emergent adverse events (TEAEs) of any grade included in ≥15 % of all patients were: nausea (41 %), fatigue (32 %), vomiting (30 %), decreased appetite (27 %), pyrexia (25 %), peripheral edema (23 %), and urinary tract infection (UTI, 20 %). The most common grade 3/4 TEAEs included UTI and small intestinal obstruction (7 % each). No radiographic responses were noted. Median progression-free survival in part B was 6.3 weeks (95 % confidence interval: 5.1, 14.4), and a best overall response of stable disease was observed in 4 CRC patients (19.0 %).

CONCLUSIONS

LY3022856 was well tolerated up to a dose of 30 mg/kg qwk, but with minimal anti-tumor activity in CRC. CLINICALTRIALS.

GOV IDENTIFIER

NCT01288989.

Prognostic analysis of the bronchoplastic and broncho-arterioplastic lobectomy of non-small cell lung cancers-10-year experiences of 161 patients

BACKGROUND

Bronchoplastic and broncho-arterioplastic lobectomy is technically demanding. Present study performed a prognostic analysis of lobectomy patient based on 10-year data in a high-volume center.

METHODS

Overall, 161 non-small cell lung cancer (NSCLC) cases underwent bronchoplastic and broncho-arterioplastic lobectomy between January 2004 and November 2013. Follow-up information was obtained for 88.8% patients. Prognostic analysis was performed with the Cox proportional hazards model.

RESULTS

There were 133 bronchoplastic and 28 broncho-arterioplastic procedures. In detail, 97 sleeve and 64 wedge broncho-resection and reconstructions were conducted; pulmonary artery sleeve reconstructions were performed in 26 cases and tangential resection in 135 cases. 90-day post-operative mortality was 3.1% (5/161), and 24.8% (40/161) patients had post-operative complications. 5-year overall survival was 53.4% and 5-year disease-free survival (DFS) was 48.2% for the entire case series; these survival rates were 67.7% and 55.7% for stage I (n=31), 64.4% and 58.9% for stage II (n=62), and 36.9% and 31.9% for stage III disease, respectively. Univariate analysis revealed that age >65 and higher grade of pN were associated with worse overall survival while right side tumor, non-squamous histology type, and higher grade of pT and pN were associated with worse DFS. Multivariate analysis revealed that pN is the only independent factor of worse outcome.

CONCLUSIONS

Bronchoplastic and broncho-arterioplastic lobectomy are safe procedures for indicated NSCLC patients associated with a low rate of post-operative complications but favorable long-term survival. Recognition of prognostic factors helps improve outcomes for these patients.

The impact of positive nodal chain ratio on individualized multimodality therapy in non-small-cell lung cancer

This study aimed to analyze the prognostic significance of the positive nodal chain ratio (NCR) in non-small-cell lung cancer (NSCLC). A total of 208 pIIIa-N2 NSCLC patients who underwent complete surgical resections with a systematic nodal dissection were enrolled. The median values of NCR and the positive lymph node ratio (LNR) were used to grouping patients. The differences of overall survival (OS) and disease-free survival (DFS) between the different groups were compared. The median values of NCR and LNR were 0.31 and 0.45, respectively. The patients were separated into group A (NCR ≤0.45 and LNR ≤0.31; 91 cases), group B (NCR ≤0.45 and LNR >0.31 or NCR >0.45 and LNR ≤0.31; 51 cases), and group C (NCR >0.45 and LNR >0.31; 66 cases) according to their combined LCR and LNR values. Groups A, B, and C exhibited significantly different prognoses (5-year OS: 43.7, 25.2, and 12.3 %, respectively, p < 0.0001; 5-year DFS: 30.4, 23.3, and 8.6 %, respectively, p < 0.0001). Multivariate analyses revealed that this novel grouping method based on the combination of NCR and LNR was an independent prognostic factor for 5-year OS and 5-year DFS in pIIIa-N2 NSCLC. In group C, patients who received no postoperative treatment, adjuvant chemotherapy alone, or chemoradiotherapy exhibited different 5-year OS rates (0.0, 11.6, and 37.5 %, respectively, p = 0.003) and 5-year DFS rates (0.0, 7.5, and 25.0 %, respectively, p = 0.009). Therefore, postoperative chemoradiotherapy may significantly improve the prognosis of patients displaying NCR >0.45 and LNR >0.31. NCR combined with LNR may be more effective to guide individualized multimodality therapy including postoperative chemoradiotherapy for pIIIa-N2 NSCLC.

Prognostic role of station 3A mediastinal nodes for non-small-cell lung cancers

OBJECTIVES

Station 3A nodes have been commonly neglected in surgical practice. This retrospective study collected information on the incidence and risk factors of Station 3A node to ascertain the prognostic role of 3A nodal involvement.

METHODS

A total of 180 consecutive pN2 (stage IIIa) non-small-cell lung cancer (NSCLC) cases who underwent systemic lymphadenectomy and contained Station 3A nodes were enrolled. Survival rates were calculated according to the final pathology of Station 3A lymph node: Station 3A node (+) and Station 3A node (-). Statistical analysis was conducted using Kaplan-Meier and Cox regression models.

RESULTS

Station 3A nodal metastasis was validated in 32 cases, and the incidence of Station 3A node involvement was 17.8%. Station 3A nodes involvement was strongly associated with the metastatic status of Station 4R nodes and histological nature of pulmonary cancer. The overall 3-year survival was 53% and median survival time was 40.6 months. The 3-year survival difference was significant between Station 3A node (-) and Station 3A node (+) (63 vs 22%, χ(2) = 16.426, P < 0.001). Moreover, the overall 3-year survival was closely related with the number of involved nodal zones (χ(2) = 31.156, P < 0.001). Multivariate analysis showed two statistically significant risk factors for survival including metastasis of Station 3A node and the number of positive nodal zones (hazard ratios [HR]: 2.702; 95% confidence intervals [CI]: 1.008-7.242; P = 0.027; and HR: 7.404; 95% CI: 3.263-16.936, P < 0.001, respectively).

CONCLUSIONS

The involvement of Station 3A lymph nodes predicts poor prognosis of right-sided stage pIIIa-N2 NSCLC patients. Therefore, systemic lymphadenectomy for right-sided cancers should include Station 3A nodes when ascertaining a complete resection.

[Anatomy, micro-anatomy and physiology of the lymphatics of the lungs and chest wall]

The thoracic lymphatic vessels are pulsating channels which drain actively the fluid of lung parenchyma interstitium and pleural cavities. Their unidirectional valves that avoid reflux of contents, direct the current of fluid to the connection of thoracic duct to subclavian vein or to the thoracic duct itself by these pulsations. The ascending parietal and visceral currents have anastomoses between them. The parietal currents (internal thoracic anteriorly, external axillaries in lateral and paravertebral in posterior) drain the lymph of thoracic wall. Pleural cavities and the visceral currents, drain that of lungs and mediastinal organs. The thoracic duct goes upward in the posterior mediastinum and usually connects to the venous confluent of the left subclavian vein. It receives a part of thoracic lymph and also drains the lymph of trunk and inferior limbs. About a half or two thirds of thoracic duct lymph is originated from liver and intestines. The intestines have the lymph of digestion with the fatty elements, i.e., the chyle.

[Primitive thoracic lymphatic disease in adults]

Primary thoracic lymphatic diseases are both infrequent and probably under diagnosed. Current classification distinguishes lymphangioma (solitary tumor), lymphangiectasies (dilatation), lymphangiomatosis (proliferation) and lymphatic dysplasia syndrome (dysplasia). Classifications' efforts and radiologic progress may lead to an improvement in the management of these patients.

[Role of imaging techniques in the TNM classification of non-small cell bronchogenic carcinoma]

The Seventh Edition of the TNM Classification for non-small cell bronchogenic carcinomas include a series of changes in the T and M descriptor, in particular a re-classification of malignant pleural and pericardial effusions and of separated tumour nodes, new tumour size cut-off values and sub-divisions of the T1-T2 and M1 categories. We review these corrections that led to the changes in the staging system that affects stages II-III. Furthermore, we describe and illustrate the role of the different imaging techniques in tumour staging (CT, PET, PET-CT and MRI), highlighting their respective indications, advantages and disadvantages, as well their complementary function.

[Indications for surgery in non-small cell lung cancer with lymph node invasion]

Surgery is indicated for N1 non-small cell lung cancer and performed, with good results in some patients, when N2 disease is not diagnosed preoperatively "minimal N2". Following the publication of the "EORTC 08941" and "Intergroup 0139" trials, it remains debatable for patients with proven N2 disease. Good prognostic factors before treatment or post-induction favour surgery, which seems superior to radiochemotherapy if the operative risk is low (lobectomies, and some pneumonectomies). N3 status is a contraindication to surgery, except in some rare cases with a strong response to induction treatment.

Re-appraisal of N2 disease by lymphatic drainage pattern for non-small-cell lung cancers: by terms of nodal stations, zones, chains, and a composite

PURPOSE

N2 non-small-cell lung cancer (NSCLC) is a heterogeneous disease with an extremely wide range of 5-year survival rates. A composite method of sub-classification for N2 is likely to provide a more accurate method to more finely differentiate prognosis of N2 disease.

METHODS

A total of 720 pN2 (T1-4N2M0) NSCLC cases were enrolled in our retrospective analysis of the proposed composite method. Survival rates were respectively calculated according to the N2 stratification methods: singly by "nodal stations", "nodal zones", or "nodal chains", or by combination of all three. Statistical analysis was carried out by Kaplan-Meier and Cox regression models.

RESULTS

A total of 10,199 lymph nodes (8059 mediastinal; 2140 hilar and intra-lobar) were removed. By nodal station, there were 173 cases of single-station involvement and 547 multi-stations. By nodal zone, there were 413 single-zone involvement and 307 with multiple zones. By nodal chain, there were 311 cases with single-chain and 409 multi-chain involvements. The overall 5-year survival was 20% and median survival time was 27.52 months. The 5-year survival was significantly better for cases of single-zone involvement, as compared to multi-zones (29% vs. 6%, p<0.0001). The 5-year survival rates of single- and multi-chains involvement were 36% and 8%, respectively (p<0.0001). When taking all of the above grouping methods into consideration, the N2 disease state could be further sub-classified into two subgroups with respective survival rates of 36% and 7% (p<0.0001). Subgroup I was composed of individuals with single-chain involvement and having either one or two station metastasis; individuals with any other metastasis combinations formed Subgroup II. Multivariate analysis revealed that the composite sub-classification method, number of positive lymph nodes, ratio of nodal metastasis, and pT information were the most important risk factors of 5-year survival.

CONCLUSIONS

By combining the three N2 stratification methods based on "stations", "zones", and "chains" into one composite method, prognosis prediction was more accurate for N2 NSCLC disease. Single nodal chain involvement, which may be either one or two nodal stations metastasis, is associated with best outcome for pN2 patients.