Survival Implications of Variation in the Thoroughness of Pathologic Lymph Node Examination in American College of Surgeons Oncology Group Z0030 (Alliance)

Propensity score matched comparison of lymph node upstaging in early-stage lung cancer: open versus minimally invasive surgery with standardized lymphadenectomy

BACKGROUND

Lymph node upstaging represents a quality criterion for standardized lymphadenectomy in lung cancer surgery. The aim of the study was to compare whether the quality of standardized lymphadenectomy in lung cancer surgery is comparable in minimally invasive (video-assisted thoracoscopic surgery) and the open approach (thoracotomy). Furthermore, factors associated with lymph node upstaging were assessed, as was its impact on overall survival and progression-free survival.

METHODS

This retrospective study reviewed data of all patients undergoing lobectomy at the Lung Tumor Center Munich between 2011 and 2020. Inclusion factors were non-small cell lung cancer without nodal involvement (N0) or metastasis (M0) and standardized lymphadenectomy. A propensity score matched analyses was performed. Frequency of categorical outcomes was compared with Chi [2]-test, mean values with t-test. We used logistic and Cox regression models to assess factors associated with upstaging, overall survival and progression-free survival, restrictively.

RESULTS

Of 1691 patients undergoing lobectomy, 637 met our inclusion criteria. After propensity score matching 198 patients remained in each group. Univariate analysis showed no significant difference in lymph node upstaging between the two groups. (p = 0.12). Overall affected lymph nodes (p = 0.45) and overall affected lymph node stations (p = 0.26) were not significantly different. Multivariate Cox regression analysis showed that overall survival and progression free survival were also independent of the surgical approach. L1 status was the only factor associated with progression-free survival.

CONCLUSION

Minimally invasive approaches achieves comparable lymph node upstaging in patients undergone standardized lymphadenectomy.

Conditional Survival of Patients With Early-Stage Non-Small Cell Lung Cancer Who Undergo Lobectomy, Segmentectomy, or Wedge Resection Using the NCDB

BACKGROUND AND OBJECTIVES

Randomized clinical trials have shown that sub-lobar resection for clinical stage (cStage) IA non-small cell lung cancer (NSCLC) is non-inferior to lobar resection. We evaluated traditional and conditional survival differences between lobectomy, wedge resection, and segmentectomy in patients with cStage IA NSCLC.

METHODS

The National Cancer Database (2004-2019) was queried for patients with cStage IA (≤ 2 cm) NSCLC who underwent upfront lobectomy, segmentectomy, or wedge resection. Patients were stratified by extent of resection. Propensity-matched traditional (TSA) and conditional (CSA) survival analyses were performed. Propensity score included age, gender, histology, tumor grade, and Charlson-Deyo score. Number of lymph nodes (LN) harvested was also compared between groups.

RESULTS

There were 46 395 patients who met the inclusion criteria, of whom 32 599 (70.3%) received lobectomy, 11 181 (24.1%) wedge resection, and 2615 (5.6%) segmentectomy. Following propensity matching, all groups contained 2615 patients. In the TSA, segmentectomy (hazard ratio [HR]: 1.19, 95% confidence interval [CI]: 1.08-1.32) and wedge resection (HR: 1.41, CI: 1.28-1.56) were associated with worse 5-year survival. This remained significant in CSA at 3- and 5-years post-resection in patients who underwent segmentectomy (HR: 1.24, CI: 1.08-1.43 and HR: 1.23, CI: 1.02-1.49, respectively) and wedge resection (HR: 1.42, CI: 1.24-1.63 and HR: 1.33, CI: 1.11-1.59, respectively). Wedge resection and segmentectomy were associated with a lower number of harvested LN (median = 4 and 6, respectively) compared to lobectomy (8, p < 0.001).

CONCLUSION

Analysis of real-world data suggests that lobectomy is associated with improved traditional and conditional 5-year survival as well as LN harvest.

Role of Pathologic Single-Nodal and Multiple-Nodal Descriptors in Resected Non-Small Cell Lung Cancer

BACKGROUND

The eighth edition of lung cancer nodal staging assignment includes the location of lymph node metastasis, but does not include single-nodal and multiple-nodal descriptors.

RESEARCH QUESTION

Do the single-nodal and multiple-nodal statuses stratify the prognosis of patients with non-small cell lung cancer (NSCLC)?

STUDY DESIGN AND METHODS

Using the National Cancer Database, we analyzed patients with pathologically staged N1 and N2 NSCLC. Nodal descriptors were classified into pathological single N1 (pSingle-N1), pathological multiple N1 (pMulti-N1), pathological single N2 (pSingle-N2), and pathological multiple N2 (pMulti-N2). Survival analysis was performed using the Kaplan-Meier method and multivariable Cox regression models.

RESULTS

In the general analysis cohort, 24,531, 22,256, 8,528, and 21,949 patients with NSCLC demonstrated pSingle-N1, pMulti-N1, pSingle-N2, and pMulti-N2 disease, respectively. Patients with pMulti-N1 and pMulti-N2 disease showed a shorter survival than those with pSingle-N1 and pSingle-N2 disease, respectively (hazard ratio, 1.22 [P < .0001] for N1 and 1.39 [P < .0001] for N2). After adjusting age, sex, and histologic findings, the hazard ratio for pSingle-N2 compared with pMulti-N1 disease was 1.05 (P = .0031). Patients with pN1 disease were categorized by metastatic lymph node count (1, 2, 3, ≥ 4), showing significant prognostic differences among groups (P < .0001). In the sensitivity analysis cohort (limited to R0 resection, lobectomy, or more; survival ≥ 30 days; ≥ 10 examined lymph nodes; and without neoadjuvant therapy; n = 34,904) and the external validation cohort (n = 708), analyses supported these results.

INTERPRETATION

Patients with NSCLC with one metastatic lymph node, whether in N1 or N2 stations, showed better survival than those with more than one lymph node involved. Patients with NSCLC with a single-skip N2 lymph node metastasis showed survival similar to patients with multiple N1 lymph nodes, and the number of lymph nodes involved in N1 resections up to four or more was sequentially prognostic.

Different clinicopathological features between young and older patients with pulmonary adenocarcinoma and ground-glass opacity

After the recommendation of computed tomography as a routine procedure for lung cancer screening, an increasing number of young adults have been diagnosed with pulmonary ground-glass opacity (GGO). Up to 63% of pulmonary nodules with a GGO component can be malignant. Since young cancer patients have limited exposure to environmental mutagens, they have special characteristics and needs. This study sought to compare the clinicopathological characteristics of young and old patients with GGO-associated lung adenocarcinoma (GGO-LUAD). Clinicopathological data from 203 patients who underwent video-assisted thoracoscopic surgery between January 2018 and April 2020 for pulmonary GGO component nodules were reviewed. Lung nonmucinous adenocarcinoma patients younger than 40 years old and older than 40 years old were enrolled: 103 patients ≤ 40 years old and 100 patients > 40 years old. The relevant clinicopathological features, including sex, smoking status, tumor size, pathological characteristics, radiographic features and prognosis of pulmonary nodules, were evaluated. Univariate analyses were applied for comparisons between groups. The differences in baseline characteristics (sex, smoking status, tumor location) between the different age groups were not significant. Young patients were more likely to have tumors < 1 cm in size, while older patients predominantly had tumors > 2 cm in size. The mean percentage of invasive adenocarcinoma was greater in the elderly group. Young and older patients seemed to have similar subtypes of adenocarcinoma (p > 0.05) but had different degrees of differentiation (p < 0.001). The 3-year overall survival (OS) and recurrence-free survival (RFS) of the young group were 100% and 99.03%, respectively, while the 3-years OS and RFS of the older group were 99% and 98%, respectively. Our work revealed that young patients with malignant pulmonary nodules and GGOs have distinct pathological subtypes. Patients with GGOs of different ages have different clinicopathological characteristics. The 3-year prognosis of young patients with malignant pulmonary nodules with GGOs is satisfactory.

Two Interventions on Pathologic Nodal Staging in a Population-Based Lung Cancer Resection Cohort

BACKGROUND

Despite its prognostic importance, poor pathologic nodal staging of lung cancer prevails. We evaluated the impact of 2 interventions to improve pathologic nodal staging.

METHODS

We implemented a lymph node specimen collection kit to improve intraoperative lymph node collection (surgical intervention) and a novel gross dissection method for intrapulmonary node retrieval (pathology intervention) in nonrandomized stepped-wedge fashion, involving 12 hospitals and 7 pathology groups. We used standard statistical methods to compare surgical quality and survival of patients who had neither intervention (group 1), pathology intervention only (group 2), surgical intervention only (group 3), and both interventions (group 4).

RESULTS

Of 4019 patients from 2009 to 2021, 50%, 5%, 21%, and 24%, respectively, were in groups 1 to 4. Rates of nonexamination of lymph nodes were 11%, 9%, 0%, and 0% and rates of nonexamination of mediastinal lymph nodes were 29%, 35%, 2%, and 2%, respectively, in groups 1 to 4 (P < .0001). Rates of attainment of American College of Surgeons Operative Standard 5.8 were 22%, 29%, 72%, and 85%; and rates of International Association for the Study of Lung Cancer complete resection were 14%, 21%, 53%, and 61% (P < .0001). Compared with group 1, adjusted hazard ratios for death were as follows: group 2, 0.93 (95% CI, 0.76-1.15); group 3, 0.91 (0.78-1.03); and group 4, 0.75 (0.64-0.87). Compared with group 2, group 4 adjusted hazard ratio was 0.72 (0.57-0.91); compared with group 3, it was 0.83 (0.69-0.99). These relationships remained after exclusion of wedge resections.

CONCLUSIONS

Combining a lymph node collection kit with a novel gross dissection method significantly improved pathologic nodal evaluation and survival.

Extensive lymphadenectomy may improve survival in node negative oesophageal cancer

Lymph node metastases are a major prognostic factor in survival of patients with oesophageal cancer. The number of lymph nodes removed during oesophagectomy has been previously proven to be associated with improved survival. The aim of this study was to examine the effect of lymph node harvest on survival specifically in pathologically node negative (pN0) patients with oesophageal cancer. Data were extracted from a prospectively populated single-surgeon database of oesophageal resections for cancer. All consecutive patients with pN0 were included. Patient-specific risk adjusted analysis of overall and disease-free survival was performed to identify the number of lymph nodes associated with improved survival. Inclusion criteria were met by 137 patients (49 squamous cell carcinoma and 88 adenocarcinoma). Adjusted for cancer stage, tumour (histological type, degree of differentiation, lympho-vascular invasion, neo-adjuvant therapy) and patient related factors (age, sex), increased lymph node number was associated with significant improvement in overall (P = 0.045) and disease free (P = 0.030) survival. Lymph node count ≥ 17 was associated with improved overall and disease-free survival. In this cohort of patients with pathologically node-negative oesophageal cancer, lymph node count of 17 or above was associated with significantly improved survival.

A 3 M Evaluation Protocol for Examining Lymph Nodes in Cancer Patients: Multi-Modal, Multi-Omics, Multi-Stage Approach

Through meticulous examination of lymph nodes, the stage and severity of cancer can be determined. This information is invaluable for doctors to select the most appropriate treatment plan and predict patient prognosis; however, any oversight in the examination of lymph nodes may lead to cancer metastasis and poor prognosis. In this review, we summarize a significant number of articles supported by statistical data and clinical experience, proposing a standardized evaluation protocol for lymph nodes. This protocol begins with preoperative imaging to assess the presence of lymph node metastasis. Radiomics has replaced the single-modality approach, and deep learning models have been constructed to assist in image analysis with superior performance to that of the human eye. The focus of this review lies in intraoperative lymphadenectomy. Multiple international authorities have recommended specific numbers for lymphadenectomy in various cancers, providing surgeons with clear guidelines. These numbers are calculated by applying various statistical methods and real-world data. In the third chapter, we mention the growing concern about immune impairment caused by lymph node dissection, as the lack of CD8 memory T cells may have a negative impact on postoperative immunotherapy. Both excessive and less lymph node dissection have led to conflicting findings on postoperative immunotherapy. In conclusion, we propose a protocol that can be referenced by surgeons. With the systematic management of lymph nodes, we can control tumor progression with the greatest possible likelihood, optimize the preoperative examination process, reduce intraoperative risks, and improve postoperative quality of life.

Association between number of dissected lymph nodes and survival in patients undergoing resection for clinical stage IA pure solid lung adenocarcinoma: a retrospective analysis

BACKGROUND

Lymph node dissection is essential for staging of pure solid lung adenocarcinoma and selection of treatment after surgical resection, particularly for stage I disease since the rate of lymph node metastasis can vary from 0 to 23.7%.

METHODS

We retrospectively screened all adult patients (18 years of age or older) who underwent lobectomy for pure solid cT1N0M0 lung adenocarcinoma between January 2015 and December 2017 at our center. Cox proportional hazard regression was used to assess the association between the number of dissected lymph nodes and recurrence-free survival (RFS) and to determine the optimal number of dissected lymph nodes.

RESULTS

The final analysis included 458 patients (age: 60.26 ± 8.07 years; 241 women). RFS increased linearly with an increasing number of dissected lymph nodes at a range between 0 and 9. Kaplan-Meier analysis revealed significantly longer RFS in patients with ≥ 9 vs. <9 dissected lymph nodes. In subgroup analysis, ≥ 9 dissected lymph nodes was not only associated with longer RFS in patients without lymph node metastasis (n = 332) but also in patients with metastasis (n = 126). In multivariate Cox proportional hazard regression, ≥ 9 dissected lymph nodes was independently associated with longer RFS (hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.26 to 0.73; P = 0.002).

CONCLUSIONS

≥9 Dissected lymph nodes was associated with longer RFS; accordingly, we recommend dissecting 9 lymph nodes in patients undergoing lobectomy for stage IA pure solid lung adenocarcinoma.

Identification of Factors Related to the Quality of Lymphadenectomy for Lung Cancer: Secondary Analysis of Prospective Randomized Trial Data

The outcomes of non-small cell lung cancer surgery are influenced by the quality of lymphadenectomy. This study aimed to evaluate the impact of different energy devices on lymphadenectomy quality and identify additional influencing factors. This secondary analysis of the prospective randomized trial data (clinicaltrials.gov: NCT03125798) compared patients who underwent thoracoscopic lobectomy with the LigaSure device (study group, n = 96) and monopolar device (control group, n = 94). The primary endpoint was the lobe-specific mediastinal lymphadenectomy. Lobe-specific mediastinal lymphadenectomy criteria were met in 60.4% and 38.3% of patients in the study and control groups, respectively (p = 0.002). In addition, in the study group, the median number of mediastinal lymph node stations removed was higher (4 vs. 3, p = 0.017), and complete resection was more often achieved (91.7% vs. 80.9%, p = 0.030). Logistic regression analysis indicated that lymphadenectomy quality was positively associated with the use of the LigaSure device (OR, 2.729; 95% CI, 1.446 to 5.152; p = 0.002) and female sex (OR, 2.012; 95% CI, 1.058 to 3.829; p = 0.033), but negatively associated with a higher Charlson Comorbidity Index (OR, 0.781; 95% CI, 0.620 to 0.986; p = 0.037), left lower lobectomy (OR, 0.263; 95% CI, 0.096 to 0.726; p = 0.010) and middle lobectomy (OR, 0.136; 95% CI, 0.031 to 0.606, p = 0.009). This study found that using the LigaSure device can improve the quality of lymphadenectomy in lung cancer patients and also identified other factors that affect the quality of lymphadenectomy. These findings contribute to improving lung cancer surgical treatment outcomes and provide valuable insights for clinical practice.

Standard Lymphadenectomy for Esophageal and Lung Cancer: Variability in the Number of Examined Lymph Nodes Among Pathologists and Its Survival Implication

AIM

We compared variability in number of examined lymph nodes between pathologists and analyzed survival implications in lung and esophageal cancer after standardized lymphadenectomy.

METHODS

Outcomes of 294 N2 dissected lung cancer patients and 132 2-field dissected esophageal cancer patients were retrospectively examined. The primary outcome was difference in reported lymph node count among pathologists. Secondary outcomes were overall and disease-specific survival related to this count and survival related to the 50% probability cut-off value of detecting metastasis based on the number of examined lymph nodes.

RESULTS

The median number of examined lymph nodes in lung cancer was 13 (IQR 9-17) and in esophageal cancer it was 22 (18-29). The pathologist with the highest median number of examined nodes had > 50% higher lymph node yield compared with the pathologist with the lowest median number of nodes in lung (15 vs. 9.5, p = 0.003), and esophageal cancer (28 vs. 17, p = 0.003). Survival in patients stratified by median reported lymph node count in both lung (adjusted RMST ratio < 14 vs. ≥ 14 lymph nodes 0.99, 95% CI 0.88-1.10; p = 0.810) and esophageal cancer (adjusted RMST ratio < 25 vs. ≥ 25 lymph nodes 0.95, 95% CI 0.79-1.15, p = 0.612) was similar. The cut-off value for 50% probability of detecting metastasis by number of examined lymph nodes in lung cancer was 15.7 and in esophageal cancer 21.8. When stratified by this cut-off, no survival differences were seen.

CONCLUSION

The quality of lymphadenectomy based on lymph node yield is susceptible to error due to detected variability between pathologists in the number of examined lymph nodes. This variability in yield did not have any survival effect after standardized lymphadenectomy.

Three-dimensional computed tomography reconstruction in video-assisted thoracoscopic segmentectomy (DRIVATS): A prospective, multicenter randomized controlled trial

OBJECTIVE

Anatomical segmentectomy has been proven to be a viable surgical treatment for small-size peripheral lung nodules. Three-dimensional (3D) reconstruction computed tomography (CT) has been proposed as an effective approach to overcome the challenges of encountering pulmonary anatomical variations when performing segmentectomy. Therefore, to further investigate the usefulness of preoperative 3D reconstruction CT in segmentectomy, we will conduct this prospective, multicenter randomized controlled DRIVATS study to compare the use of 3D reconstruction CT with standard chest CT in video-assisted segmentectomy (ClinicalTrials.gov ID: NCT04004494).

METHODS

This study began in July 2019 and a total of 190 patients will be accrued from three clinical centers within 4 years. The main inclusion criteria are patients with a single peripheral nodule 0.8-2 cm with at least one of the following requirements: (i) histology of adenocarcinoma in situ; (ii) nodule has ≥50% ground-glass appearance on CT; (iii) radiologic surveillance confirms a long doubling time (≥400 days). Surgical procedures include segmental resection of the lesion and mediastinal lymph node sampling (subsegmental resection or combined subsegmental resection will not be included in this study). The primary endpoint is operative time. The secondary endpoints include incidence of change of surgical plan, intraoperative blood loss, conversion rate, operative accident event, incidence of postoperative complications, postoperative hospital stay, length of hospitalization, duration of chest tube placement, postoperative 30-day mortality, dissection of lymph nodes, overall survival, disease-free survival, preoperative lung function, and postoperative lung function.

DISCUSSION

This multicenter DRIVATS study aims to verify the usefulness of preoperative 3D reconstruction CT compared with standard chest CT in segmentectomy. If successfully completed, this multicenter prospective study will provide a higher level of evidence for the use of 3D reconstruction CT in segmentectomy.

Impact of Lymph Node Dissection on Survival and Tumor Recurrence for Patients with Resected cT1-2N0 Small Cell Lung Cancer

BACKGROUND

The role of lymph node (LN) dissection for early-stage small cell lung cancer (SCLC) remains unclear. Therefore, this study aimed to investigate the impact of LN dissection on patient survival and tumor recurrence for patients with cT1-2N0M0 SCLC.

METHODS

Patients with cT1-2N0M0 SCLC who underwent intent-to-cure surgery at our institution between 2011 and 2019 were retrospectively reviewed. The survival outcomes of patients with systematic LN dissection (n = 112) and LN sampling (n = 35) were compared before and after propensity score-matching (PSM), as were the outcomes for patients with (pN+) and without (pN0) pathologic nodal metastasis. The prognostic impact of LN dissection was evaluated through multivariable analysis.

RESULTS

The dissection group displayed significantly better overall survival (66.4% vs. 48.4%; P = 0.009) and recurrence-free survival (RFS) (63.5% vs. 37.6%;, P = 0.003) than the sampling group at 5 years. The rate of local recurrence was significantly lower in the dissection group than in the sampling group (11.6% vs. 42.9%; P < 0.001). After adjustment by multivariable analysis and PSM, LN dissection retained its independent favorable effects. The overall nodal upstaging rate was 37.6%, and the dissection group had a tendency of better RFS in both the pN0 (P = 0.05) and pN+ (P = 0.036) patients.

CONCLUSION

Systematic LN dissection is associated with improved survival of patients who undergo surgery for cT1-2N0 SCLC. Further studies are warranted to verify the necessity of LN dissection in the surgery for SCLC.

Prognostic Impact of Examined Mediastinal Lymph Node Count in Clinical N0 Non-Small Cell Lung Cancer

OBJECTIVES

The number of examined mediastinal lymph nodes (mLNs) could represent the quality of mediastinal lymphadenectomy for non-small cell lung cancer (NSCLC). This study aimed to evaluate the prognostic impact of the number of examined individual mLNs in patients with resectable NSCLC.

METHODS

We retrospectively evaluated 1,420 patients with clinical-stage IA-IIB, N0 NSCLC who underwent complete resection by lobectomy, which involved hilar and mLN dissection, between 2008 and 2016. We investigated the threshold number of examined mLNs that had prognostic significance and evaluated their effects on the risk of mLN recurrence.

RESULTS

In a respective multivariable analysis according to the number of examined mLNs, examining ≥3 mLNs (reference [ref.] mLNs ≤2) achieved statistical significance and had the best prognosis (hazard ratio [HR], 0.68; p = 0.013). In the multivariable analyses for each pathological N (pN) stage, ≥3 examined mLNs (ref. mLNs ≤2) was an independent prognostic factor in pN1 disease (HR, 0.32, p = 0.002), but not in pN0 or pN2 disease. The cumulative incidence of mLN recurrence was significantly lower in patients with ≥3 examined mLNs (ref. mLNs ≤2, HR, 0.27; p = 0.008) in pN1 disease. Patients with ≥3 examined mLNs had higher upstaging rates to pN2 than those with ≤2 examined mLNs.

CONCLUSIONS

Examining ≥3 mLNs contributed to a favorable prognosis and low mLN recurrence risk in patients with clinical stage I-II, N0 NSCLC. Our findings can serve as a benchmark for the number of required mLNs to be examined.

Resection of calcified lymph nodes confers clinical benefit in patients with non-small cell lung cancer

The aim of the present study was to compare the metastatic ratio between calcified lymph node stations (CLNS) and non-CLNS (NCLNS) and to explore the impact of CLNS on surgical outcomes. Consecutive patients with non-small cell lung cancer (NSCLC) scheduled to receive surgical treatment between June and December 2020 were included in the present study. Their clinical and radiological data were prospectively collected and analyzed. A total of 91 patients with NCLNS and 64 patients with CLNS were enrolled in the present study. Out of the 91 patients, 38 (24.516%) patients had 61/343 (17.784%) lymph node stations (LNS) that were metastasized. On a per-patient basis, the differences in the LNS metastatic ratio were not significant between the CLNS with NCLNS groups. However, on a per-nodal station basis, all differences in the LNS metastatic ratio between the groups were significant not only in the all-LNS group (P=0.004), but also in the LNS group which in patients with solely CLNS or NCLNS (P=0.009) and in the patients with CLNS (P=0.010). Pathology, T stage and calcification were independent predictive factors for LNS metastasis (P=0.002, P=0.021 and P=0.044, respectively). More patients with CLNS than patients with NCLNS received thoracotomy or conversion from video-assisted thoracoscopic surgery to thoracotomy (P=0.006). The operating time and blood loss were significantly higher in patients with CLNS than in those without (P<0.001 and P<0.001, respectively). Although CLNS are a risk reduction factor for metastasis and their dissection is time- and blood-consuming in patients with NSCLC, their thorough removal is advisable, since metastases were identified in ~15% of patients and 9% of CLNS.

Lymphangiosis carcinomatosa independently affects long-term survival of Non-Small Cell Lung Cancer patients

OBJECTIVE

The significance of postoperatively diagnosed Lymphangiosis Carcinomatosa (L1) as an independent risk factor for long-term survival in Non-Small Cell Lung Cancer (NSCLC) remains controversial. We analyzed the effect of L1 on postoperative survival in stage I, II and III NSCLC-patients.

METHODS

We investigated all consecutive patients with NSCLC between January 2012 and December 2019 who underwent an anatomical resection and radical lymphadenectomy at our institute. L1-were compared to L0-patients. All patients received adjuvant chemotherapy in accordance with European guidelines. 3- and 5- year survival rates and median-survival were assessed. To investigate whether L1 is an independent risk factor, we carried out a multivariate cox regression and a pair-match analysis looking at different properties such as TNM.

RESULTS

A total of 641 patients (L0: 74%; L1: 26%) were analyzed. Baseline characteristics were comparable between groups. The mean age was 65.3 ± 10.2 years and 64.9 ± 9.4 years in the L0 and L1-groups respectively (p-value = 0.703). 58.5% of L0-patients were male (L1: 62.7%; p-value = 0.351). Overall survival in the L1-group was significantly shorter compared to the L0-group (L1: 42.3 ± 2.8; L0: 67.6 ± 2.1 months; p-value<0.0001). We confirmed this finding in a pair-matched analysis (L0: 73.9 ± 4.7 months; L1: 42.2 ± 4.2; p-value = 0.009). 3- and 5-year survival were significantly shorter for L1-patients (3-year: L0: 65.9%; L1: 35.9%; p-value<0.0001) (5-year: L0: 34.9%; L1: 7.5%; p-value<0.0001).

CONCLUSION

L1 is an independent risk factor for long-term survival of patients with NSCLC. This cohort supports that the L0/L1 status should be included in pathological reports. We suggest to further include L0/L1-status in guideline recommendations for NSCLC patients.

The impact of an N1 lymph node examination in patients with early-stage non-small cell lung cancer: a retrospective cohort study

Background

The examination of lymph nodes (LNs) is critical for accurate node staging in patients with non-small cell lung cancer (NSCLC), but a consensus on the examinations of hilar and intrapulmonary (N1 station) LNs has not been reached. This study aimed to evaluate the role of LN dissection and pathological examination of N1 LN stations and their effects on survival in patients with stage IA-IIA NSCLC.

Methods

Data from patients pathologically staged as IA-IIA who underwent radical surgery and confirmed as lacking LN metastases from January 2008 to March 2018 were retrospectively reviewed. The Kaplan-Meier method was used to determine the overall survival (OS) and disease-free survival (DFS). After propensity score matching (PSM), a Cox model was used to determine the prognostic factors.

Results

Of the 1,935 patients investigated, the median number of N1 stations examined was 3. Patients with at least 2 N1 stations examined had apparently better OS (P=0.002) and DFS (P=0.001). All patients were divided into patients with 0–1 N1 station examined and patients with 2–5 N1 stations examined. After PSM, the number of N1 stations examined was an independent prognostic factor for DFS (P=0.004). Patients with 2–5 N1 stations examined experienced prolonged DFS (P=0.010). Patients in group 12 experienced prolonged OS (P=0.021) and DFS (P=0.026). Patients in group 13 or 14 experienced prolonged OS (P=0.028).

Conclusions

A larger extent of N1 station examination was associated with prolonged DFS in patients with stage IA-IIA NSCLC after lobectomy. The dissection and examination of at least 2 N1 stations included LNs from the lobar and segmental drainage fields.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

BACKGROUND

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.

RESEARCH QUESTION

How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival?

STUDY DESIGN AND METHODS

We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.

RESULTS

Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities.

INTERPRETATION

Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

A large real-world cohort study of examined lymph node standards for adequate nodal staging in early non-small cell lung cancer

BACKGROUND

The current National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer (NSCLC) recommend that surgeons sample is not clear. We aimed to define a minimal number of examined lymph nodes for removal or sampling for optimized nodal staging recommendation, with a focus on T1-3N0M0 patients.

METHODS

A total of 55,101 consecutive patients were selected, including 52,099 patients with US Surveillance, Epidemiology, and End Results (SEER) data and 3,002 patients in a Chinese multicenter database from 11 thoracic referral centers, who underwent complete resection plus lymph node dissection or sampling for stage T1-3N0M0 NSCLC. Propensity score-matching analysis was performed with R software, and a cut-off value was calculated using X-tile software. Survival was evaluated using the Kaplan-Meier method and Cox proportional hazard models.

RESULTS

Five-year survival rates with respect to total examined lymph nodes numbers (examined lymph nodes <10 vs. examined lymph nodes ≥10) were 69% and 64% (group A), 66% and 63% (group B), 62% and 58% (group C), 81% and 75% (group D). There were significant differences between examined lymph nodes <10 and examined lymph nodes >10 in each group (P<0.001).

CONCLUSIONS

A minimum of 10 examined lymph nodes would significantly improve T1-3N0M0 NSCLC prognosis and patients' survival rates if implemented as a minimum standard for lymphadenectomy. Therefore, we recommended a minimum of 10 examined lymph nodes for T1-3N0M0 patients.

Postoperative long-term survival of non-small cell lung cancer patients with skip-N2 metastases

OBJECTIVE

Radical lymphadenectomy is crucial in operations for non-small cell lung cancer (NSCLC). Usually pN1 and pN2 lymph nodes are affected consecutively (N1N2). Nevertheless, pN2 metastases may also occur in the absence of pN1 as skip-N2 metastases (N0N2). Here we compare the long-term survival of N1N2- and N0N2 patients.

MATERIALS AND METHODS

464 patients underwent surgery for NSCLC at our institution between 2012 and 2017. We retrospectively reviewed data of pN2 stage patients (n = 68). Patients with N1N2 (n = 39) were compared to N0N2 (n = 29) patients. 1-, 3-and 5-year survival rates were measured. Survival was assessed by Kaplan-Meier curves and the cox proportional hazards model was used to identify prognostic factors for overall survival. All patients received adjuvant chemoradiation therapy according to European guidelines.

RESULTS

The baseline characteristics did not differ between groups. We observed no differences in the histology, localization, or gender in our cohort. N0N2 patients showed significantly better 1- (N1N2: 82.4% vs. N0N2 100%; p = 0.001), 3- (14.7% vs. 63.6%; p=<0.001) and 5-year (9.4% vs. 43.8%; p = 0.001) survival rates. Tumor size (Hazard ratio (HR) 1.46, Confidence interval (CI 95%) 1.03-2.04; p = 0.03) and the occurrence of N1N2 (HR 4.26, CI 2.04-8.91; p < 0.0001) were independent prognostic factors for worse long-term survival. The Kaplan-Meier curves showed a reduced overall survival for N1N2 patients (log-rank N1N2, N0N2 p < 0.0001).

CONCLUSION

N1N2 patients have a significantly worse prognosis compared to N0N2 patients. This will aid to classify the heterogeneous pN2-NSCLC patient population more precisely. Further, multimodal therapy should be considered for N1N2 patients.

Significance of accurate hilar and intrapulmonary lymph node examination and prognostication in stage IA-IIA non-small cell lung cancer, a retrospective cohort study

Background

The examination of lymph nodes (LNs) plays an important role in the nodal staging of non-small cell lung cancer (NSCLC). For patients without LN metastasis, the main role of thorough LN examination is accurate staging, which weakens the effect of staging migration. To date, the role of hilar and intrapulmonary (N1) station LNs has not been fully appreciated. In this study, we aimed to confirm the significance of N1 LNs in long-term survival for stage IA–IIA NSCLC patients and to find the minimum number of LN to examine.

Methods

The data of patients who underwent radical lobectomy and were confirmed as having non-metastatic LNs from January 2008 to March 2018 were retrospectively screened. Pathology records were reviewed for the number of LNs examined. The Kaplan-Meier method and Cox regression model were used to identify survival and prognostic factors.

Results

The median number of resected N1 LNs was 8. The number of patients with 0–2 N1 LNs, 3–5 N1 LNs, 6–8 N1 LNs, 9–11 N1 LNs, and more than 11 N1 LNs examined was 181, 425, 477, 414, and 531, respectively. Sex (P = 0.004), age (P < 0.001), tumor size (P = 0.004), differentiation degree (P = 0.001), and number of N1 LNs examined (P = 0.008) were independent prognostic factors of overall survival. Gender (P = 0.006), age (P = 0.031), tumor size (P = 0.001), differentiation degree (P = 0.001), vascular invasion (P = 0.034), and number of N1 LNs examined (P = 0.007) were independent prognostic factors of disease-free survival. Compared with patients with 0–5 N1 LNs examined, patients with more than 5 N1 LNs examined had better OS (P = 0.015) and had better DFS (P = 0.015) if only a landmark 5-year follow-up was performed.

Conclusion

Increasing the number of N1 LN examination might improve the long-term survival of T1-2N0 NSCLC patients. These data indicate that at least 6 N1 nodes examined is an essential part in surgical and pathological management but cannot prove this. This finding should be confirmed in a large, prospective randomized clinical study.

Survival After Mediastinal Node Dissection, Systematic Sampling, or Neither for Early Stage NSCLC

INTRODUCTION

The American College of Surgeons Oncology Group Z0030 found no survival difference between patients with early stage NSCLC who had mediastinal nodal dissection or systematic sampling. However, a meta-analysis of 1980 patients in five randomized controlled trials from 1989 to 2007 associated better survival with nodal dissection. We tested the survival impact of the extent of nodal dissection in curative-intent resections for early stage NSCLC in a population-based observational cohort.

METHODS

Resections for clinical T1 or T2, N0 or nonhilar N1, M0 NSCLC in four contiguous United States Hospital Referral Regions from 2009 to 2019 were categorized into mediastinal nodal dissection, systematic sampling, and "neither" on the basis of of the evaluation of lymph node stations. We compared demographic and clinical characteristics, perioperative complication rates, and survival after assessing statistical interactions and confounding.

RESULTS

Of the 1942 eligible patients, 18% had nodal dissection, 6% had systematic sampling, and 75% had an intraoperative nodal evaluation that met neither standard. In teaching hospitals, nodal dissection was associated with a lower hazard of death than "neither" resections (0.57 [95% confidence interval: 0.41-0.79]) but not systematic sampling (0.74 [0.40-1.37]) after adjusting for multiple comparisons. There was no significant difference in hazard ratios at nonteaching institutions (p > 0.3 for all comparisons). Perioperative complication rates were not significantly worse after mediastinal nodal dissection or systematic sampling, compared with "neither," (p > 0.1 for all comparisons).

CONCLUSIONS

In teaching institutions, mediastinal nodal dissection was associated with superior survival over less-comprehensive pathologic nodal staging. There was no survival difference between teaching and nonteaching institutions, a finding that warrants further investigation.

Lymph node assessment in early stage non-small cell lung cancer lymph node dissection or sampling?

Lymph node assessment is an essential component of the treatment of lung cancer. Identification of the correct "N" stage is important for staging which in turn determines treatment. Assessment of lymph nodes may be accomplished using imaging with CT scan and PET-CT, invasive techniques such as mediastinoscopy, endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) or endoscopic ultrasound fine needle aspiration (EUS-FNA). Ultimately, regardless of any pre-resection assessment, lymph nodes must be assessed at the time of resection. The question to be addressed in this report is the role of mediastinal lymph node dissection versus lymph node sampling. However, the issues surrounding lymph node assessment in NSCLC are complex, depending on clinical stage, imaging and histology.

Numbers and Stations: Impact of Examined Lymph Node on Precise Staging and Survival of Radiologically Pure-Solid NSCLC: A Multi-Institutional Study

Objectives

To determine the optimal number of examined lymph nodes (ELNs) and examined node stations (ENSs) in patients with radiologically pure-solid NSCLC and to investigate the impact of ELNs and ENSs on accurate staging and long-term survival.

Methods

Data from six institutions in the People’s Republic of China on resected c-stage Ⅰ to Ⅱ NSCLCs presenting as pure-solid tumors were analyzed for the impact of ELNs and ENSs on nodal upstaging, stage migration, recurrence-free survival, and overall survival by using multivariate models. The correlations between different end points and ELNs or ENSs were fitted with a smoother (using Locally Weighted Scatterplot Smoothing tool), and the structural break points were determined by the Chow test.

Results

Both ELNs and ENSs were identified as prognostic factors for overall survival (ENS: hazard ratio [HR], 0.697; 95% confidence interval [CI]: 0.590–0.824; p < 0.001; ELN: HR, 0.945; 95% CI: 0.909–0.983; p = 0.005) and recurrence-free survival (ENS: HR, 0.863; 95% CI: 0.791–0.941; p = 0.001; ELN: HR, 0.960; 95% CI: 0.938–0.981; p < 0.001). Intraoperative ELNs and ENSs were found to be associated with postoperative nodal upstaging. Cut point analysis revealed an optimal cutoff of 16 LNs and five node stations for patients with c-stage Ⅰ to Ⅱ pure-solid NSCLCs, which were examined in our multi-institutional cohort.

Conclusions

Both ELNs and ENSs are associated with more accurate node staging and better long-term survival. We recommend 16 LNs and five stations as the cut point for evaluating the quality of LN examination for c-stage Ⅰ to Ⅱ patients with radiologically pure-solid NSCLCs.

Resection of Early-Stage Second Primary Non-small Cell Lung Cancer After Small Cell Lung Cancer: A Population-Based Study

Introduction: A certain number of small cell lung cancer (SCLC) patients become long-term survivors after treatment, and they are at high risk to develop a second primary malignancy, including non-small cell lung cancer. However, the optimal management of early-stage second primary non-small cell lung cancer (SPLC) after SCLC remains unknown. This study aims to evaluate the survival benefits of surgery in these patients.

Methods: Patients with early-stage SPLC after SCLC were identified from the Surveillance, Epidemiology, and End Results database. Patients were balanced with propensity score matching (PSM). Overall survival (OS) and lung cancer-specific survival (CSS) were compared between non-surgery group and surgery group with the Kaplan–Meier method and Cox multivariate regressions.

Results: A total of 228 patients with early-stage SPLC after SCLC were identified. Surgery was associated with significantly improved OS and CSS in the multivariate Cox regression analysis (OS, 5-year survival: 41.2 vs. 11.6%, HR: 0.42, 95% CI: 0.31–0.59, P < 0.01; CSS, 5-year survival: 46.8 vs. 24.3%, HR: 0.53, 95% CI: 0.37–0.75, P < 0.01). However, no statistically significant survival difference was found between sublobar resection and lobectomy (OS, 5-year survival: 41.0 vs. 45.3%, P = 0.73; CSS, 5-year survival: 43.5 vs. 54.1%, P = 0.49). After 1:1 PSM, 162 patients were selected for further analysis, and surgery continued to demonstrate superior survival (OS, 5-year survival: 44.2 vs. 7.2%, HR: 0.48, 95% CI: 0.33–0.70, P < 0.01; CSS, 5-year survival: 48.0 vs. 20.6%, HR: 0.44, 95% CI: 0.42–0.97, P = 0.03).

Conclusion: The resection of early-stage SPLC after SCLC led to significantly improved OS and CSS and therefore should be considered whenever possible. Nevertheless, further randomized controlled trials are warranted to investigate the safety and effect of surgery in these patients.

Different prognostic significance of examined lymph node count for patients with non-small-cell lung cancer ≤1 cm or >1-2 cm: a population-based study

Aim: This study aimed to investigate the impact of examined lymph node (ELN) count on survival of resected pT1a-1bN0M0 non-small-cell lung cancer (NSCLC). Materials & methods: Data were extracted from the US Surveillance, Epidemiology and End Results database. The association between ELN count and overall survival (OS) or lung cancer-specific survival (LCSS) was investigated. Results: A total of 9603 patients were enrolled. For the first through the fourth quartiles of pT1aN0M0 group, the 5-year OS and LCSS rates were of no statistical difference. While in pT1bN0M0 group, they were 68.7, 73.8, 76.6 and 77.8% (p < 0.001) and 80.7, 84.1, 85.9 and 87.1% (p < 0.001), respectively. X-Tile analysis showed that 4 is the optimal cutoff value for ELN count in pT1bN0M0 patients for both OS and LCSS. Conclusion: These findings indicated that greater number of ELNs is associated with better survival of resected pT1bN0M0 NSCLC. But a greater number of ELNs is worth to discuss for pT1aN0M0 NSCLC during surgery.

Association of Pathologic Nodal Staging Quality With Survival Among Patients With Non-Small Cell Lung Cancer After Resection With Curative Intent

Importance

Pathologic nodal stage is the most significant prognostic factor in resectable non-small cell lung cancer (NSCLC). The International Association for the Study of Lung Cancer NSCLC staging project revealed intercontinental differences in N category-stratified survival. These differences may indicate differences not only in cancer biology but also in the thoroughness of the nodal examination.

Objective

To determine whether survival was affected by sequentially more stringent definitions of pN staging quality in a cohort of patients with NSCLC after resection with curative intent.

Design

This observational study used the Mid-South Quality of Surgical Resection cohort, a population-based database of lung cancer resections with curative intent. A total of 2047 consecutive patients who underwent surgical resection at 11 hospitals with at least 5 annual lung cancer resections in 4 contiguous US Dartmouth hospital referral regions in northern Mississippi, eastern Arkansas, and western Tennessee (>90% of the eligible population) were included. Resections were performed from January 1, 2009, through January 25, 2016. Survival was evaluated with the Kaplan-Meier method and Cox proportional hazards models.

Exposures

Eight sequentially more stringent pN staging quality strata included the following: all patients (group 1); those with complete resections only (group 2); those with examination of at least 1 mediastinal lymph node (group 3); those with examination of at least 10 lymph nodes (group 4); those with examination of at least 3 hilar or intrapulmonary and at least 3 mediastinal lymph nodes (group 5); those with examination of at least 10 lymph nodes, including at least 1 mediastinal lymph node (group 6); those with examination of at least 1 hilar or intrapulmonary and at least 3 mediastinal nodal stations (group 7); and those with examination of at least 1 hilar or intrapulmonary lymph node, at least 10 total lymph nodes, and at least 3 mediastinal nodal stations (group 8).

Main Outcomes and Measures

N category-stratified overall survival.

Results

Of the total 2047 patients (1046 men [51.1%] and 1001 women [48.9%]; mean [SD] age, 67.0 [9.6] years) included in the analysis, the eligible analysis population ranged from 541 to 2047, depending on stringency. Sequential improvement in the N category-stratified 5-year survival of pN0 and pN1 tumors was found from the least stringent group (0.63 [95% CI, 0.59-0.66] for pN0 vs 0.46 [95% CI, 0.38-0.54] for pN1) to the most stringent group (0.71 [95% CI, 0.60-0.79] for pN0 vs 0.60 [95% CI, 0.43-0.73] for pN1). The pN1 cohorts with 3 or more mediastinal nodal stations examined had the most striking survival improvements. More stringently defined mediastinal nodal examination was associated with better separation in survival curves between patients with pN1 and pN2 tumors.

Conclusions and Relevance

The prognostic value of pN stratification depends on the thoroughness of examination. Differences in thoroughness of nodal staging may explain a large proportion of intercontinental survival differences. More thorough nodal examination practice must be disseminated to improve the prognostic value of the TNM staging system. Future updates of the TNM staging system should incorporate more quality restraints.

Influence of Extent of Lymph Node Evaluation on Survival for Pathologically Lymph Node Negative Non-Small Cell Lung Cancer

OBJECTIVES

Despite previous retrospective reports that the number of lymph nodes resected at curative intent surgery for lung cancer correlates with overall survival (OS), no consensus exists regarding the minimal nor optimal number of lymph nodes to resect at curative lung cancer surgery.

METHODS

We studied subjects in the Surveillance Epidemiology and End Results Database (SEER) diagnosed with non-small cell lung cancer between 2000 and 2011 who underwent either lobectomy or pneumonectomy and had pathologic negative nodal evaluation. We excluded patients with sublobar resection and/or no lymph node evaluation. We examined associations between number of lymph nodes evaluated and OS/lung cancer-specific survival by multivariable Cox regression; and predictors of evaluation of more lymph nodes.

RESULTS

Among the 33,463 patients in our sample, a median of 7 lymph nodes were evaluated. We found that lung cancer-specific survival and OS improved with increasing lymph node evaluation up to 16 to 18 lymph nodes (hazard ratio, 0.77 [95% confidence interval, 0.70-0.85] and 0.78 [95% confidence interval, 0.72-0.86], respectively). There was little additional improvement in outcomes with evaluation of >16 to 18 lymph nodes. Blacks, Hispanics, females, and patients from distinct geographical regions were less likely to have 16 or more lymph nodes evaluated.

CONCLUSIONS

There was a consistently increasing survival benefit associated with a more extensive lymph node evaluation at lung cancer resection, up to 16 to 18 lymph nodes removed. The median number of nodes evaluated was, however, only 7, suggesting that setting a goal of ≥16 examined lymph nodes may lead to improved survival outcomes, and reduce disparities in care.

Clinical characteristics and prognosis of ground-glass opacity nodules in young patients

Background

The detection rate of ground-glass opacity (GGO) in young patients has increased year by year with the increasingly widespread use of high-resolution computed tomography (HRCT) and the increased resolution of HRCT imaging. However, no scholars have reported the clinical characteristics and prognosis of GGO in young patients systematically. The purpose of this study is to investigate the clinical characteristics and prognosis presenting as GGO in young patients.

Methods

Clinical data of 127 young patients who were diagnosed as GGO and who underwent video-assisted thoracoscopic surgery (VATS) and had routine pathological examination were collected from January 2016 to January 2017. Nodules were classified according to benign and malignant: 26 benign nodules (Group A) and 115 malignant nodules (Group B). The pathological types, nodules size, surgical methods were analyzed, and the clinical characteristics and prognosis were evaluated.

Results

The results of pathological examination of 91 pure ground-glass opacities (pGGOs) revealed 16 adenocarcinoma in situs (AISs), 42 micro invasive adenocarcinomas (MIAs), 13 invasive adenocarcinomas (IAs), 8 atypical adenomatous hyperplasias (AAHs), 1 inflammatory granuloma, 2 pulmonary inflammatory pseudotumors (IPTs) and 9 other benign nodules. The results of pathological examination of 50 mixed ground-glass opacities (mGGOs) revealed 6 AISs, 29 MIAs, 9 IAs, 1 AAH, 2 inflammatory granulomas and 3 other benign nodules. All patients had no lymph nodes invasion. The rates of perioperative complications were 6.30%, compared to 7.63% for long-term complications. None of the patients with GGO experienced a recurrence and death [2-year recurrence-free survival (RFS), 100%; 2-year overall survival (OS), 100%].

Conclusions

The GGO in young patients that received VATS has a high proportion of malignant, its prognosis is satisfied.

Safe Introduction of Minimally Invasive Esophagectomy at a Medium Volume Center

BACKGROUND AND AIMS

Minimally invasive esophagectomy is a favored alternative in high-volume centers. We evaluated the introduction of, and transition to, minimally invasive esophagectomy at a medium volume tertiary referral center (10-20 esophagectomies annually) with focus on surgical results.

MATERIAL AND METHODS

Patients who underwent minimally invasive esophagectomy or open transthoracic surgery for carcinoma of the esophagus or gastroesophageal junction (Siewert I and II) during 2007-2016 were retrospectively studied. Sorted on surgical approach, perioperative data, surgical outcomes, and postoperative complications were analyzed and multivariate regression models were used to adjust for possible confounders.

RESULTS

One hundred and sixteen patients were included, 51 minimally invasive esophagectomy (21 hybrid and 30 totally minimally invasive) and 65 open resections. The groups were well matched. However, higher body mass index, neoadjuvant chemoradiotherapy, and cervical anastomosis were more frequent in the minimally invasive esophagectomy group. Minimally invasive esophagectomy was associated with less peroperative bleeding (384 vs 607 mL, p = 0.036) and reduced length of stay (14 vs 15 days, p = 0.042). Duration of surgery, radical resection rate, and postoperative complications did not differ between groups. Lymph node yield was higher in the minimally invasive esophagectomy group, 18 (13-23) vs 12 (8-16), p < 0.001, confirmed in a multivariate regression model (adjusted odds ratio 3.15, 95% class interval 1.11-8.98, p = 0.032).

CONCLUSION

The introduction of minimally invasive esophagectomy at a medium volume tertiary referral center resulted in superior lymph node yield, less peroperative blood loss and shorter length of stay, without compromising the rate of radical resection, or increasing the complication rate.

New revisions and current issues in the eighth edition of the TNM classification for non-small cell lung cancer

In the eighth edition of the TNM classification of lung cancer, the prognostic impact of tumor size is emphasized as a descriptor of all T categories. Especially in lung cancer where tumor size is 5 cm or less, the 1-cm cutoff point significantly differentiated the survival outcome. In addition, the new staging categories were assigned, namely, Tis (adenocarcinoma in situ) and T1mi (minimally invasive adenocarcinoma). Furthermore, the measurement of a radiological solid component size excluding the ground glass opacity component or pathological invasive size without a lepidic component was proposed for deciding the cT/pT categories for lung adenocarcinoma. The N descriptors were kept the same as in the eventh edition on the whole, however, quantification of nodal disease had a prognostic impact based on the number of nodal stations involved in the eighth edition, i.e. N1a as a single N1 station, N1b as a multiple N1 station, N2a1 as a single N2 station without N1 (skip metastasis), N2a2 as a single N2 station with N1 disease, and N2b as a multiple N2 station. In the M descriptors, subclassification was performed based on the location or numbers of distantly metastatic lesions, i.e. M1a as any intrathoracic metastases, M1b as a single distant metastatic lesion in one organ, and M1c as multiple distant metastases in either a single organ or multiple organs. Survival analysis of the eighth edition of the TNM classification clearly separated the distinct groups, however, unsolved issues still remain that should be discussed and further revised for the forthcoming TNM staging system.

Impact of visceral pleural invasion on the association of extent of lymphadenectomy and survival in stage I non-small cell lung cancer

Visceral pleural invasion (VPI) has been identified as an adverse prognostic factor for non‐small cell lung cancer (NSCLC). Accurate nodal staging for NSCLC correlates with improved survival, but it is unclear whether tumors with VPI require a more extensive lymph nodes (LNs) dissection to optimize survival. We aimed to evaluate the impact of VPI status on the optimal extent of LNs dissection in stage I NSCLC, using the Surveillance, Epidemiology, and End Results (SEER) database. We identified 9297 surgically treated T1‐2aN0M0 NSCLC patients with at least one examined LNs. Propensity score matching was conducted to balance the baseline clinicopathologic characteristics between the VPI group and non‐VPI group. Log‐rank tests along with Cox proportional hazards regression methods were performed to evaluate the impact of extent of LNs dissection on survival. VPI was correlated with a significant worse survival, but there was no significant difference in survival rate between PL1 and PL2. Patients who underwent sublobectomy had slightly decreased survival than those who underwent lobectomy. Pathologic LNs examination was significantly correlated with survival. Examination of 7‐8 LNs and 14‐16 LNs conferred the lowest hazard ratio for T1‐sized/non‐VPI tumors (stage IA) and T1‐sized/VPI tumors (stage IB), respectively. The optimal extent of LNs dissection varied by VPI status, with T1‐sized/VPI tumors (stage IB) requiring a more extensive LNs dissection than T1‐sized/non‐VPI tumors (stage IA). These results might provide guidelines for surgical procedure in early stage NSCLC.

Trends in perioperative outcomes of hospitals performing major cancer surgery

BACKGROUND AND OBJECTIVES

Cancer surgery outcomes at National Cancer Institute-designated cancer centers (NCI-CCs) have been shown to vary, and have not been uniformly better than outcomes among non-NCI-CCs. We aimed to assess whether NCI-CCs have improved their short-term outcomes over time and whether variation across these centers has changed.

METHODS

Patients who underwent colectomy, esophagectomy, hepatectomy, pancreatectomy, and proctectomy for cancer were identified from the 2010 to 2016 American College of Surgeons' National Surgical Quality Improvement Program registry. Hospital trends in risk-adjusted, smoothed observed-to-expected ratios were assessed to evaluate improvement and variation in perioperative complications, stratified by NCI-CC status.

RESULTS

Complications occurred in 18.8% of 204 732 patients who underwent major cancer operations at 645 hospitals, and complications occurred in 19.9% of 60,903 patients at 54 NCI-CCs studied. More NCI-CCs than non-NCI-CCs improved over the period (85.2% vs 58.4%, P < 0.001; relative risk [RR] 1.46, 95% confidence interval [CI], 1.28-1.66); this remained significant after adjusting for years of participation (RR 1.33, 95% CI, 1.17-1.51). Variation in performance remained unchanged over time.

CONCLUSION

NCI-CCs were detected to have improved over a contemporary seven-year period and to have improved more than non-NCI-CCs. However, NCI-CCs do not uniformly outperform non-NCI-CCs, and variation in perioperative outcomes remains, warranting continued quality improvement efforts targeting cancer-specific operations.

Novel perspective to evaluate the safety of segmentectomy: clinical significance of lobar and segmental lymph node metastasis in cT1N0M0 lung adenocarcinoma

OBJECTIVES

The regularity of intrapulmonary lobar and segmental lymph node (LSN) metastasis in cT1N0M0 stage lung adenocarcinoma remains unclear. Thus, segmentectomy with uncertain LSN metastatic status remains a potential oncological risk. We aimed to facilitate more accurate determination of N staging and filter more suitable cases for segmentectomy.

METHODS

A prospective study was performed from March 2014 to September 2016. A total of 196 patients diagnosed with cT1N0M0 stage lung adenocarcinoma were enrolled and received lobectomy together with mediastinal lymph node dissection. The intrapulmonary LSNs were dissected and classified as adjacent LSN or isolated LSN. The metastatic status of the LSNs together with the TNM staging were analysed. A comparison of the metastatic probability of isolated LSN was carried out considering the metastatic status of adjacent LSN, imaging features, smoking history, pathological subtypes, size of the lesions and serum level of tumour markers (carcinoembryonic antigen and Cyfra21-1).

RESULTS

Among the 196 cases enrolled, 152 were confirmed as pN0, 36 as pN1, 6 as pN1 + N2 and 2 as skip pN2. When the LSNs had not been dissected, the false-negative rate for N staging was 9.0% (15 of 167). Patients with adjacent LSN metastasis (P < 0.001), solid nodule (P = 0.001), non-lepidic predominant invasive adenocarcinoma (P < 0.001), nodules with maximum diameter larger than 2 cm (P < 0.001) and those with elevated serum carcinoembryonic antigen level (>5 ng/ml) (P = 0.005) had a higher isolated LSN metastasis rate. No significant difference in isolated LSN metastasis rate was found between groups with or without smoking history (P = 0.90) and with different serum Cyfra21-1 levels (P = 0.14).

CONCLUSIONS

Dissection of intrapulmonary LSNs reduces the false-negative rate of lymph node metastasis. Solid nodule, non-lepidic predominant invasive adenocarcinoma, lung adenocarcinoma larger than 2 cm in maximum diameter or with elevated serum carcinoembryonic antigen level (>5 ng/ml) might not be suitable for segmentectomy. The lymph node sampling area during segmentectomy should include adjacent LSNs of the target segment. When metastasis to the adjacent LSNs is confirmed by fast-frozen pathology, segmentectomy would not be suitable.

Effectiveness of Implemented Interventions on Pathologic Nodal Staging of Non-Small Cell Lung Cancer

BACKGROUND

Accurate pathologic nodal staging improves early stage non-small cell lung cancer survival. In an ongoing implementation study, we measured the impact of a surgical lymph node specimen collection kit and a more thorough pathologic gross dissection method on attainment of guideline-recommended pathologic nodal staging quality.

METHODS

We prospectively collected data on curative intent non-small cell lung cancer resections from 2009 to 2016 from 11 hospitals in four contiguous Dartmouth Hospital referral regions. We categorized patients into four groups based on exposure to the two interventions in our staggered implementation study design. We used χ² tests to examine the differences in demographic and disease characteristics and surgical quality criteria across implementation groups.

RESULTS

Of 2,469 patients, 1,615 (65%) received neither intervention; 167 (7%) received only the pathology intervention; 264 (11%) received only the surgery intervention; and 423 (17%) had both. Rates of nonexamination of lymph nodes reduced sequentially in the order of no intervention, novel dissection, kit, and combined interventions, including nonexamination of any lymph nodes and hilar/intrapulmonary and mediastinal nodes (p < 0.001 for all comparisons). The rates of attainment of National Comprehensive Cancer Network, Commission on Cancer, American Joint Committee on Cancer, and American College of Surgeons Oncology Group guidelines increased significantly in the same sequential order (p < 0.001 for all comparisons).

CONCLUSIONS

The combined effect of two interventions to improve pathologic lymph node examination has a greater effect on attainment of a range of surgical quality criteria than either intervention alone.

Adjuvant chemotherapy may improve outcome of patients with non-small-cell lung cancer with metastasis of intrapulmonary lymph nodes after systematic dissection of N1 nodes

Objective

Survival benefit of adjuvant chemotherapy (AC) of patients with intrapulmonary lymph node (IPLN) metastasis (level 12−14) needs investigation. We evaluated the impact of AC on patients whose metastatic nodes were limited to intrapulmonary levels after systematic dissection of N1 nodes.

Methods

First, 155 consective cases of lung cancer confirmed as pathologic N1 were collected and evaluated. Patients received systematic dissection of N2 and N1 nodes. For patients with IPLN metastasis, survival outcomes were compared between those receiving AC and those not receiving AC.

Results

In this group, 112 cases (72.3%) had IPLN metastasis and 55 cases (35.5%) had N1 involvement limited to level 13−14 without further disease spread to higher levels. Patients with IPLN involvement had a better prognosis than that of patients with hilar-interlobar involvement. For the intrapulmonary N1 group (level 12−14-positive, level 10−11-negative or unknown, n=112), no survival benefit was found between the AC group and non-AC group [5-year overall survival (OS): 54.6±1.6vs. 50.4±2.4 months, P=0.177]. However, 76 of 112 cases for whom harvesting of level-10 and level-11 nodes was done did not show cancer involvement in pathology reports (level 12−14-positive, level 10−11 both negative), oncologic outcome was better for patients receiving AC than those not receiving AC in this subgroup (5-year OS: 57.3±1.5vs. 47.1±3.2 months, P=0.002).

Conclusions

Oncologic outcome may be improved by AC for patients with involvement of N1 nodes limited to intrapulmonary levels after complete examination of N1 nodes.

Identifying the factors influencing practice variation in thrombosis medicine: A qualitative content analysis of published practice-pattern surveys

Practice variation, the differences in clinical management between physicians, is one reason why patient outcomes may differ. Identifying factors that contribute to practice variation in areas of clinical uncertainty or equipoise may have implications for understanding and improving patient care. To discern what factors may influence practice variation, we completed a qualitative content analysis of all practice-pattern surveys in thrombosis medicine in the last 10years. Out of 2117 articles screened using a systematic search strategy, 33 practice-pattern surveys met eligibility criteria. Themes were identified using constant comparative analysis of qualitative data. Practice variation was noted in all 33 practice-pattern surveys. Contributing factors to variation included lack of available evidence, lack of clear and specific guideline recommendations, past experience, patient context, institutional culture and the perceived risk and benefit of a particular treatment. Additional themes highlight the value placed on expertise in challenging clinical scenarios, the complexity of practice variation and the value placed on minimizing practice variation.

Can mathematics replace anatomy to establish recommendations in lung cancer surgery?

The greater the number of lymph node (LN) sampled (NLNsS) during lung cancer surgery, the lower the risk of underestimating the pN-status and the better the outcome of the pN0-patients due to stage-migration. Thus, regarding LN sampling "to be or not to be", number is the question. Recent studies advocate removing 10 LNs. The most suitable NLNsS is unfortunately impossible to establish by mathematics. A too high NLNsS variability exists, based on anatomy, surgery and pathology. The methodology may vary according to Inter-institutional differences in the surgical approach regarding LN inspection and number sampling. The NLNsS increases with the type of resection: sublobar, lobectomy or pneumonectomy. Concerning pathology, one LN may be divided into several pieces, leading to number overestimation. The pathological examination is limited by the number of slices analyzed by LN. The examined LNs can arbitrarily depend on the probability of detecting nodal metastasis. In fact, the only way to ensure the best NLNsS and the best pN-staging is to remove all LNs from the ipsilateral mediastinal and hilar LN-stations as they are discovered by thoroughly dissecting their anatomical locations. In doing so, a deliberate lack of harvest of LNs is unlikely, number turns out not to be the question anymore and a low NLNsS no longer means incomplete surgery. This prevents from judging as incomplete a complete LN dissection in a patient with a small NLNsS and from considering as complete a true incomplete one in a patient with a great NLNsS. Precise information describing the course of the operation and furnished in the surgeon's reports is also advisable to further improve the quality of LN-dissection, which ultimately might be beneficial in the long-term to patients. However, that procedure is of limited interest in pN-staging if LNs are not thoroughly examined and also described by the pathologist.

Noteworthy Literature Published in 2016 for Thoracic Surgery

The past year has produced several important articles in the field of thoracic surgery, spanning many different diseases. Thoracic surgeons continue to investigate methods to perform complex operations and procedures less invasively, with the least possible morbidity to our patients. We also continue to critically evaluate new technology and procedures to ensure that they meet our rigorous standards for oncologic efficacy and for management of benign disease. Importantly, as we continue to evolve, thoracic surgeons have remained focused on optimizing processes of care, both inside and outside the operating room. The purpose of this review is to highlight the major advances in thoracic surgical disease in the year 2016.