Skip metastasis in mediastinal lymph node is a favorable prognostic factor in N2 lung cancer patients: a meta-analysis

Clinical characteristics and prognostic impact of direct distant organ metastasis in colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third most common type of cancer worldwide, and distant metastasis is frequently noted at diagnosis or follow-up. Notably, some patients with CRC can present with distant organ metastasis without any nodal involvement, which was defined as direct distant organ metastasis (DDOM). In this study, we evaluated the prognostic significance of DDOM for patients with CRC.

METHODS

This study included 325 patients who had undergone primary colorectal cancer resection between August 2008 and December 2021. The patients with and without DDOM were compared (Kaplan-Meier analysis) in terms of overall survival (OS) and time to recurrence. Furthermore, the patients' clinicopathological risk factors and protective factors were analyzed (multivariate Cox proportional hazards model).

RESULTS

Of the 325 patients, 65 (20%) had DDOM (Direct+ group) and 260 (80%) did not (Direct- group). The Kaplan-Meier analysis revealed that OS was significantly better in the Direct+ group than in the Direct- group (p < 0.01). A subgroup analysis by CRC stage was performed; for the patients with non-stage-IV CRC, the rate of OS was significantly higher in the Direct+ group than in the Direct- group (p = 0.02). However, DDOM did not affect the OS of the patients with stage IV CRC. The multivariate analysis indicated DDOM, left colon tumor location, and postoperative adjuvant chemotherapy were significant protective factors for disease-related mortality in the patients with non-stage-IV CRC; by contrast, body mass index, curative resection, and postoperative adjuvant chemotherapy were identified to be significant protective factors in the patients with stage IV CRC.

CONCLUSIONS

DDOM appears to be significantly associated with improved OS in patients with non-stage-IV CRC but not in those with stage IV CRC. Furthermore, the time to cancer recurrence may not vary significantly between patients with DDOM and those without it.

The Negative Prognostic Impact of Lymph Node Skip Metastasis in Stage III Colon Cancer With pN1 Disease: A Single-Center and Retrospective Cohort Study

BACKGROUND

Lymph node skip metastasis is a subgroup of lymph node metastatic patterns with low incidence in node-positive colon cancer. Its clinical significance is still unclear.

OBJECTIVE

This study aimed to investigate the prognostic impact of lymph node skip metastasis in stage III colon cancer.

DESIGN

This is a retrospective observational analysis.

SETTINGS

The study was conducted at the Taipei Veterans General Hospital.

PATIENTS

This study included patients with stage III colon cancer who underwent D3 lymphadenectomy between 2006 and 2015.

MAIN OUTCOME MEASURES

The patients were divided into a lymph node skip metastasis-positive group and a negative group. Recurrence-free survival and overall survival were compared using Kaplan-Meier curves and log-rank test. Cox regression was applied to identify related risk factors influencing survival.

RESULTS

A total of 461 patients were reviewed, and lymph node skip metastasis-positive patients represented 13.2% of our sample. Patients with lymph node skip metastasis tended to present with a higher proportion of right-sided cancer, lower positive lymph nodes, lower lymph node ratio, and higher mean BMI. Liver recurrence was more prevalent in the lymph node skip metastasis group ( p = 0.028) than in the negative group. The presence of lymph node skip metastasis was a negative prognostic factor for 5-year recurrence-free survival (51.4% vs 68.7%; p = 0.002) and 5-year overall survival (66.4% vs 80.4%; p = 0.024) in Kaplan-Meier curves and multivariate Cox regression. Subgroup analysis revealed the survival significance of recurrence-free survival ( p = 0.001) and overall survival ( p = 0.011) in lymph node skip metastasis with pN1 disease.

LIMITATIONS

This study was limited by its retrospective design, single-center nature, and sampling error.

CONCLUSIONS

Lymph node skip metastasis is an independent negative prognostic factor in stage III colon cancer with pN1 disease. More intensive surveillance may be necessary for patients of this subgroup. See Video Abstract at https://links.lww.com/DCR/C60 .

IMPACTO PRONSTICO NEGATIVO DE LAS METSTASIS DISCONTNUAS GANGLIONARES LINFTICAS EN CASOS DE CNCER DE COLON ESTADIO III CON ENFERMEDAD PN ESTUDIO DE COHORTES RETROSPECTIVO MONOCENTRICO

ANTECEDENTES:Las metástasis discontínuas ganglionares linfáticas, son un subgrupo de patrones metastásicos en los ganglios linfáticos con baja incidencia en el cáncer de colon con nódulos positivos. Su significado clínico aún no está claro.OBJETIVO:Estudio que tiene por objetivo el investigar el impacto pronóstico de las metástasis discontínuas de los ganglios linfáticos en el cáncer de colon de estadio III.DISEÑO:Análisis observacional retrospectivo.AJUSTES:El estudio se realizó en el Hospital General de Veteranos de Taipei.PACIENTES:Pacientes con cáncer de colon en estadio III que se sometieron a linfadenectomía D3 entre 2006 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en un grupo positivo de metástasis discontínuas en los ganglios linfáticos y un otro grupo negativo. La sobrevida libre de recidiva y la sobrevida global, fueron comparadas mediante las curvas de Kaplan-Meier y la prueba de rango logarítmico. Se aplicó la regresión de Cox para identificar los factores de riesgo relacionados que influyeron en la sobrevida.RESULTADOS:Se revisaron un total de 461 casos, donde los pacientes positivos con metástasis en los ganglios linfáticos representaron el 13,2% de nuestra muestra. Los pacientes con metástasis discontínuas ganglionares linfáticas tendían a presentar una mayor proporción de cáncer localizado en el lado derecho del colon, presentar un menor numéro de ganglios linfáticos positivos y una proporción menor de ganglios linfáticos con un IMC promedio más alto. Las recidivas hepáticas fueron más prevalentes en el grupo de metástasis discontínuas ganglionares linfáticas ( p = 0,028) que en el grupo negativo. La presencia de metástasis discontínuas ganglionares linfáticas fué un factor de pronóstico negativo en la sobrevida libre de recidiva a 5 años (51,4% frente a 68,7%, p = 0,002) y la sobrevida general a 5 años (66,4% frente a 80,4%, p = 0,024) evaluada por las curvas de Kaplan-Meier y la regresión multivariada de Cox. El análisis de subgrupos reveló la importancia de la sobrevida libre de recidiva ( p = 0,001) y la sobrevida general ( p = 0,011) en los casos con metástasis discontínuas ganglionares linfáticas con enfermedad pN1.LIMITACIONES:Diseño retrospectivo, naturaleza de centro único y error de muestreo.CONCLUSIONES:Las metástasis discontínuas ganglionares linfáticas son un factor pronóstico negativo independiente en los casos de cáncer de colon estadio III con enfermedad pN1. Tal vez sea necesaria una mayor vigilancia de los pacientes en este subgrupo.Consulte Video Resumen en https://links.lww.com/DCR/C60 . (Traducción-Dr. Xavier Delgadillo ).

Role of skip N2 lymph node metastasis for patients with the stage III-N2 lung adenocarcinoma: a propensity score matching analysis

PURPOSE

Recent studies have indicated some differences in the prognosis of patients with stage III-N2 lung adenocarcinoma, and the prognosis of patients with skip N2 lymph node metastasis (SKN2) is good. This study grouped patients with stage III-N2 lung adenocarcinoma by propensity score matching (PSM) to evaluate the impact of SKN2 on the prognosis of these patients.

METHODS

The clinical data for patients who underwent radical lobectomy and had a postoperative pathological diagnosis of stage III-N2 lung adenocarcinoma at our centre from 2016 to 2018 were collected, and PSM was performed at a ratio of 1:1.

RESULTS

A total of 456 patients were enrolled in this study. After PSM, 112 patients were included in the SKN2 group, and 112 patients were included in the non-SKN2 group. When comparing the SKN2 group with the non-SKN2 group, the 3-year OS rate was (71.4% vs. 12.5%, p < 0.001), and the 3-year DFS rate was (35.7% vs. 5.4%, p < 0.001). It is further divided into four groups:single-station SKN2 (N2a1),Multi-station SKN2 (N2a2),single-station non-SKN2 (N2b1) and Multi-station non-SKN2 (N2b2).The 3-year OS and DFS rates of skip lymph node metastasis were better than those of non-skip lymph node metastasis(OS:N2a1 vs. N2b1 68.4% vs. 23.5%,p < 0.001;N2a2 vs. N2b2 73.0% vs. 7.7%,p < 0.001)(DFS:N2a1 vs. N2b1 68.4% vs. 5.9%,p < 0.001;N2a2 vs. N2b2 62.2% vs. 5.1%,p < 0.001), regardless of the number of N2 station(OS:N2a1 vs. N2a2 68.4% vs. 73.0%,p = 0.584;N2b1 vs. N2b2 23.5% vs. 7.7%,p = 0.051). On multivariate analysis, sex (p = 0.008) ,Vascular tumour thrombus(p = 0.047),size(p = 0.002)and SKN2 (p < 0.001) were independent predictors of OS.

CONCLUSION

For patients with stage III-N2 lung adenocarcinoma, the prognosis of SKN2 patients is better than non-SKN2 patients', and SKN2 may be used as an important factor in the N2 subgroup classification in future TNM staging.

Portrayal of video-assisted mediastinoscopic lymphadenectomy's range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

BACKGROUND

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious - at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 - to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure.

CASE PRESENTATION

We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up.

CONCLUSION

Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA's important role as a diagnostic and therapeutic tool.

Lymph node sampling-what are the numbers?

Lung cancer is a deadly disease. Lymph node staging is the most important prognostic factor, and lymphatic drainage of the lung is complex. Major advances have been made in this field over the last several decades, but there is much left to understand and improve upon. Herein, we review the history of the lymphatic system and the creation of lymph node maps, the evolution of tumor, node, and metastasis lung cancer classification, the importance of lung cancer staging, techniques for lymph node dissection, and our recommendations regarding a minimum number of nodes to sample during pulmonary resection.

[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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Slug and Vimentin downregulation at the metastatic site is associated with Skip-N2 metastasis of lung adenocarcinoma

OBJECTIVE

Lung cancer displays heterogeneity both in the tumor itself and in its metastatic regions. One interesting behavior of the tumor is known as Skip N2 metastasis, which N2 lymph nodes contain tumor cells while N1 are clean. In this study, mRNA levels of epithelial mesenchymal transition (EMT) related genes in skip N2 and normal N2 involvements of non-small cell lung cancer tissues were investigated to evaluate the possible molecular background that may contribute to the pathogenesis of Skip N2 metastasis.

MATERIALS AND METHODS

Eighty-three surgically resected and paraffin embedded lymph node samples of lung cancer patients were analyzed in this study, which 40 of them were Skip N2. N2 tissues were sampled from 50% tumor containing areas and total RNA was extracted. mRNA levels for 18S, E-cadherin, Vimentin, ZEB1 and SLUG were analyzed via qPCR and E-cadherin and vimentin protein levels via immunohistochemistry (IHC). Bioinformatic analysis were adopted using online datasets to evaluate significantly co-expressed genes with SLUG in lung cancer tissue samples.

RESULTS

Skip-N2 patients who had adenocarcinoma subtype had better survival rates. Comparative analysis of PCR results indicated that Skip N2 tumor tissues had increased E-Cadherin/Vimentin ratio and ZEB1 mRNA expression, and significantly decreased levels of SLUG. E-cadherin IHC staining were higher in Skip N2 and Vimentin were in Non-Skip N2. TP63 had a strong correlation with SLUG expression in the bioinformatics analyses.

CONCLUSION

The results indicate that, at molecular level, Skip N2 pathogenesis has different molecular background and regulation of SLUG expression may orchestrate the process.