American College of Surgeons Commission on Cancer Standard for Curative Intent Pulmonary Resection

Money Matters: The Effect of Income on Postsurgical Outcomes in Stage IA Non-small Cell Lung Cancer

BACKGROUND

Treatment of non-small cell lung cancer (NSCLC) remains challenging; 5-year survival is as low as 24% for resectable disease. However, the outlook for stage IA NSCLC is favorable, with 5-year survival exceeding 74% and with surgery often being curative. Despite this positive prognosis, low socioeconomic status has been shown to correlate with nonstandard treatment and worse overall survival specifically in stage IA. This study sought to examine income-based disparities in postsurgical survival which has yet to be discussed in the current literature.

METHODS

The National Cancer Database was retrospectively queried from 2004 to 2017 to identify patients with pathological stage IA NSCLC following surgical resection; survival/patient characteristics were analyzed by income quartiles and eras (2004-2007, 2008-2012, and 2013-2017). Kaplan-Meier methods and multivariable Cox hazard modeling were used to estimate survival and construct hazard ratios, respectively.

RESULTS

Inclusion criteria identified 138,219 patients. Overall, a stepwise decrease in 5-year survival was observed as income quartile decreased (Q4: 72.0%; Q3: 67.8%; Q2: 66.1%; Q1: 64.2%). Hazard modeling implicated income level as an independent predictor of mortality; patients of the lowest income quartile exhibited a hazard ratio of 1.26 (95% confidence interval 1.21-1.31; p < 0.001) relative to the highest. Although overall survival increased within each income quartile over consecutive eras, income-based survival disparities continued to be observed.

CONCLUSIONS

Lower-income patients with stage IA NSCLC display elevated mortality risk over 5 years than higher-income patients despite receiving potentially curative surgery, with income being an independent risk-factor. This difference may also be attributed to stacked risk-factors in lower-income patients.

The Impact of Preoperative Invasive Nodal Staging on Unexpected Mediastinal Upstaging in Early-Stage Non-small Cell Lung Cancer

INTRODUCTION

Preoperative invasive nodal staging is standard of care for early-stage non-small cell lung cancer (NSCLC). Complications and delays in care are not negligible and diagnostic accuracy varies. In our system, invasive nodal staging is performed for clear radiographic indications (node > 1.0 cm short axis or standardized uptake value > 3.0, tumor > 4.0 cm). This study assessed whether unexpected mediastinal upstaging was less common in patients receiving preoperative invasive nodal staging.

METHODS

This retrospective study evaluated nodal upstaging, defined as pathological N2 or IIIA+ disease, based on receipt or non-receipt of invasive nodal staging. Clinical stage I-II NSCLC patients who underwent resection (2009-2019) were identified from our cancer registry. Stage and preoperative nodal staging information were confirmed through chart review. Associations between patient characteristics, invasive nodal staging receipt, and clinical to pathological stage changes were analyzed.

RESULTS

Among 2576 patients, 18.7% (n = 481) underwent invasive nodal staging. After resection, 6.2% of all patients had nodal upstaging and 24.9% had TNM upstaging. Only 0.3% (n = 9) were upstaged to N2 and 0.5% (n = 13) were upstaged to IIIA+. Lack of preoperative nodal sampling was not associated with N2 or IIIA+ upstaging. Findings were consistent in subanalyses of patients with surgical specimens meeting Commission on Cancer nodal sampling criteria and with clinical IB+ disease.

CONCLUSIONS

Although most patients did not undergo invasive nodal staging, <1% had unexpected N2 on surgical pathology. There was no association between lack of preoperative invasive nodal sampling and N2 nodal upstaging. Preoperative invasive nodal staging did not increase pathologic N2 nodal upstaging in early-stage NSCLC patients in our integrated health system.

Is Sublobar Resection Feasible for High-Risk Pathologic Stage I Non-small Cell Lung Cancer?

BACKGROUND

Sublobar resection is the standard procedure for cT1N0 stage I non-small cell lung cancer (NSCLC) size ≤2 cm. However, its efficacy for high-risk pathologic stage I cases with a preoperative diagnosis of cT1N0 stage I NSCLC size ≤2 cm remains unclear. This study compared the outcomes of sublobar resection with those of lobectomy from a pathologic perspective.

METHODS

A multicenter retrospective analysis of patients with pathologic stage I NSCLC was performed following the eighth edition of tumor-node-metastasis (TNM) classification. The study enrolled patients with completely resected clinical stage I NSCLC and a tumor size of ≤2 cm determined by computed tomography. High-risk pathologic feature was defined as evidence of pleural invasion, lymphovascular invasion, or invasive component (>2 cm). Survival rates were compared between the patients who underwent sublobar resection and those who underwent lobectomy.

RESULTS

The study enrolled 875 patients (715 [81.7%] low-risk and 160 [18.3%] high-risk NSCLC patients). The high-risk patients in the lobectomy group had significantly better 5-year recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) rates than those in the sublobar resection group (RFS: 80.5% vs 44.3% [P < 0.001], OS: 84.9% vs 54.6% [P = 0.001], CSS: 91.6% vs 72.4% [P = 0.019]). In the low-risk group, lobectomy and sublobar resection resulted in equivalent 5-year RFS, OS, and CSS (RFS: 92.8% vs 88.6% [P = 0.13], OS: 93.8% vs 91.7% [P = 0.26], CSS: 98.9% vs 98.4% [P = 0.67]). Multivariate analysis indicated that sublobar resection was independently associated with poor RFS, OS, and CSS for the high-risk patients.

CONCLUSIONS

Sublobar resection is feasible for low-risk pathologic stage I NSCLC, whereas lobectomy may have a prognostic benefit for high-risk NSCLC.

Lymph node sampling and survival in non-small-cell lung cancer: a 10-year Danish cohort study†

OBJECTIVES

To investigate patterns of lymph node sampling and the potential impact on overall survival regarding adherence to selected intraoperative lymph node sampling guidelines. Additionally, we aimed to identify variables associated with guideline adherence and nodal upstaging.

METHODS

A retrospective cohort study was conducted of patients undergoing anatomical lung resection for non-small cell lung cancer (clinical T1-4, N0 disease) from 2012 to 2021 identified through the Danish Lung Cancer Registry. Intraoperative lymph node sampling guidelines according to The National Comprehensive Cancer Network (NCCN) were selected. Missing data were imputed and propensity-score-matched by guideline adherence. Survival outcomes were analysed using Kaplan-Meier curves and log-rank test. Logistic and Cox regression assessed factors associated with survival, guideline adherence and nodal upstaging.

RESULTS

A total of 6615 patients were included, 5670 remained after propensity-score-matched. Adherence to the NCCN guidelines did not impact overall survival (log-rank P-value = 0.31) or nodal upstaging (P-value = 0.26). No patient or tumour characteristics were significantly associated with guideline compliance. Factors associated with higher likelihood of upstaging included higher clinical T stage, histopathology, younger age, open surgery and type of resection.

CONCLUSIONS

In this cohort, intraoperative lymph node sampling in adherence with the selected NCCN guidelines did not impact survival or nodal upstaging rates.

Provider and procedural factors associated with guideline-concordant lymph node sampling in lung cancer resection

OBJECTIVE

The American College of Surgeons Commission on Cancer Standard 5.8 requires sampling of 3 mediastinal and 1 hilar lymph node stations during lung cancer resection. This study explores provider and procedural factors associated with guideline-concordant lymph node sampling during lung cancer resection.

METHODS

Prospectively collected statewide quality collaborative data were queried for adult patients undergoing lung cancer resection between July 1, 2021, and June 30, 2024. Guideline concordance was defined per American College of Surgeons Commission on Cancer Standard 5.8. Multivariable logistic regression was used to assess the likelihood of guideline-concordant sampling across surgeon volume, practice distribution, resection type, and procedural approach. Rates of nodal upstaging and postoperative complications were compared between guideline-concordant and nonconcordant sampling cohorts.

RESULTS

A total of 3031 patients were analyzed. Of 43 surgeons, 26 were general thoracic surgeons and 17 were mixed-practice cardiothoracic surgeons. 77.8% of cases demonstrated guideline-concordant sampling. Patients treated by highest-volume surgeons were more likely to receive concordant sampling than patients treated by lowest-volume surgeons (odds ratio, 2.27 [1.03-5.01], P = .042) with no significant difference between general thoracic surgeons and cardiothoracic surgeons. Patients undergoing wedge resection were less likely to receive concordant sampling (odds ratio, 0.17 [0.13-0.23], P < .001), as were patients undergoing open (odds ratio, 0.46 [0.33-0.66], P < .001) or video-assisted thoracic surgery (odds ratio, 0.35 [0.25-0.48], P < .001) resection compared with robotic resection. No differences in nodal upstaging or complications were found between the guideline-concordant and nonconcordant cohorts.

CONCLUSIONS

Guideline-concordant lymph node sampling is associated with surgeon volume, resection type, and operative approach. These findings inform initiatives to improve performance in lymph node sampling during lung cancer resection.

Early compliance with lung cancer lymph node standard 5.8: An analysis of 2022 and 2023 Commission on Cancer site reviews

OBJECTIVE

To address variability in nodal staging during curative-intent lung cancer resections, the Commission on Cancer implemented Standard 5.8 in 2021, requiring lymph nodes be sampled from ≥3 mediastinal stations and ≥1 hilar station and documented in a synoptic pathology report. We assessed compliance data from recent site reviews to evaluate the early implementation of Standard 5.8 through a federally funded collaborative.

METHODS

Hospital compliance rates with Standard 5.8 were extracted from a repository of site reviewers' documentation of Commission on Cancer site visits performed during 2022 and 2023. Each review included up to 7 randomly selected pathology reports eligible for the standard. For a site to be compliant, 5 of 7 pathology reports reviewed in 2022 must have met Standard 5.8, which increased to 6 of 7 reports in 2023 and beyond.

RESULTS

Overall, 652 site visits occurred in 2022 and 2023. Sites without eligible cases (n = 148 [23%]) were excluded. Among 504 eligible sites, 272 (54%) were found compliant, and 232 (46%) were found noncompliant. Of noncompliant sites, the median percentage of pathology reports meeting the standard was 29%. From 2022 to 2023, the median percentage of adherent pathology reports increased; however, overall compliance rates dipped in 2023 as the threshold needed for site compliance rose.

CONCLUSIONS

With almost half of Commission on Cancer-accredited sites noncompliant, there is a real opportunity to improve the quality of surgical lymph node evaluations. This aligns with growing efforts to support hospitals and surgeons with quality improvement tools and resources for Standard 5.8.

Increased Systemic Immune-Inflammatory Index and Association with Occult Nodal Disease in Non-Small Cell Lung Cancer

BACKGROUND

It has been proposed that more aggressive tumors trigger a stronger inflammatory response than less aggressive types. We hypothesize that systemic immune-inflammatory index (SII) is associated with occult nodal disease (OND) in clinically node-negative patients undergoing lung resection for non-small cell lung cancer (NSCLC).

STUDY DESIGN

The study included patients who underwent lung resection with nodal dissection, according to current guidelines, at a single center between 2010 and 2021 for NSCLC. Preoperative SII within 3 weeks of surgery was calculated. OND was defined as a clinically node-negative patient found to be pathologically node-positive. Cut-point analysis for SII was performed to identify the level most strongly associated with OND. Univariable and multivariable logistic regressions were used to examine the association between SII, clinical factors, and OND.

RESULTS

A total of 199 patients met inclusion criteria, of whom 51% (102 of 199) were women. The median number of nodes and nodal stations examined was 13 (interquartile range 9 to 17) and 6 (interquartile range 5 to 6), respectively. The cut point was determined to be SII 112 or more. On univariable analysis, high SII was associated with OND (odds ratio 15.75, 95% CI 2.09 to 118.73, p = 0.007). On multivariable analysis, after controlling for age, BMI, approach, sex, smoking history (pack-years), forced expiratory volume in 1 second, performance status, comorbidity, histology, lymphovascular invasion, tumor differentiation, and tumor size, high SII was associated with OND (odds ratio 34.59, 95% CI 2.69 to 444.88, p = 0.007).

CONCLUSIONS

Increased SII is associated with OND in patients undergoing lung resection for NSCLC.

Extent of resection in surgically resected stage IV non-small cell lung cancer: Results from two tertiary referral centers

OBJECTIVE

The benefits of pulmonary resection as local consolidative therapy for stage IV non-small cell lung cancer (NSCLC) have been clearly demonstrated in appropriate patients. For early-stage disease, debate continues regarding the role of anatomic versus parenchymal-sparing resection. We explored the impact of resection extent on outcomes for stage IV NSCLC.

METHODS

Patients were identified from 2 thoracic surgery departments. Included patients underwent pulmonary resection for stage IV NSCLC between 1996 and 2023. Resection extent was categorized as sublobar, lobar, or greater than lobar. The primary outcome was development of locoregional recurrence (adjacent to the surgical margin, ipsilateral hemithorax, or regional lymph nodes). A multivariable binomial logistic regression was performed for locoregional recurrence. Kaplan-Meier analyses evaluated survival outcomes.

RESULTS

In total, 179 patients were included, with mean age of 58.8 years (interquartile range, 51.8-66.5 years). The mean number of metastases was 1.68 (interquartile range, 1.0-2.0). A total of 116 (64.8%) patients received neoadjuvant treatment, with 22 (12.3%) achieving complete response, and 31 (17.3%) patients underwent sublobar resection, 130 (72.6%) lobectomy, and 18 (10.1%) more extensive resections. Locoregional recurrence occurred in 24 (13.4%) patients, including 2 (6.4%) in the sublobar group, 20 (15.4%) lobectomy group, and 2 (11.1%) greater-than-lobectomy group. Extent of resection did not independently predict locoregional recurrence (sublobar resection odds ratio, 0.44, P = .30; greater than lobar odds ratio, 0.48, P = .51). Overall (P = .14) and progression-free survival (P = .35) were similar between groups.

CONCLUSIONS

Resection extent in stage IV NSCLC does not impact subsequent locoregional recurrence, highlighting the importance of identifying relevant guidelines for optimal oncologic outcomes in patients undergoing surgery for metastatic disease.

Correlation Between the Extent of N1 Lymph Node Station Examination and Prognosis in Stage I Non-small Cell Lung Cancer Patients: One Station is Insufficient

BACKGROUND

Examination standards for hilar and intrapulmonary (N1) lymph nodes (LNs) have been debated. The objective of this study was to assess the prognostic significance of the extent of examination for N1 LN stations in patients with pathological stage I non-small cell lung cancer (NSCLC).

METHODS

A total of 1868 patients were identified and divided into 3 groups on the basis of the number of N1 stations examined: group A (≥3 stations), group B (2 stations) and group C (1 station). Moreover, we investigated the prognostic significance of each individual N1 station examined. The primary outcome was 5-year disease-free survival (DFS).

RESULTS

Overall, 1062, 607, and 199 patients were in groups A, B, and C, respectively. The baseline demographic and clinical characteristics were similar among the groups, except for the tumor side. The 5-year DFS rates were comparable between groups A and B (85.1% vs. 82.7%, P = .3), both of which were significantly greater than that of group C (74.4%) (P < .01). Similar results were observed for the corresponding 5-year overall survival rates. The number of N1 stations examined was an independent predictor in multiple analyses. Additionally, the examination of stations 10 and 13 were independent favorable predictors for 5-year DFS.

CONCLUSION

For patients with pathological stage I NSCLC, examination of only 1 N1 station is insufficient. Examinations of a minimum of two N1 stations, including stations 10 and 13, is recommended to obtain the optimal survival benefit.

Commission on Cancer Standards for Lymph Node Sampling and Oncologic Outcomes After Lung Resection

BACKGROUND

The newest Commission on Cancer standards recommend sampling 3 mediastinal and 1 hilar lymph node stations, 3 (N2) 1 (N1), for lung cancer resections. However, the relationship between the Commission on Cancer standards and outcomes has not been thoroughly investigated.

METHODS

A prospective institutional database was queried for clinical stage I-III lung resections before the implementation of the new standards. The relationship between the 3 (N2) 1 (N1) standard ("guideline concordant") and outcomes (upstaging, complications, receipt of adjuvant therapy, locoregional/distant recurrence, and survival) was assessed with multivariable models and stratified by stage.

RESULTS

Of 9289 pulmonary resections, 3048 (33%) were guideline concordant and 6241 (67%) were not. Compared with nonconcordant, those that were guideline concordant had higher rates of nodal upstaging (21% vs 13%; odds ratio [OR], 1.32 [95% CI, 1.14-1.51]; P < .001) and in-hospital complications (34% vs 27%; OR, 1.17 [95% CI, 1.05-1.30]; P = .004) but similar adjuvant systemic therapy administration (19% vs 13%; OR, 1.09 [95% CI, 0.95-1.24]; P = .2; 98% chemotherapy). Locoregional and distant recurrences were not significantly improved with guideline concordance across clinical stage I, II, and III subsets. Overall survival was similar in clinical stages I and II, but improved survival was observed for guideline concordant clinical stage III patients (hazard ratio, 0.85 [95% CI, 0.74-0.97]; P = .02).

CONCLUSIONS

Sampling 3 (N2) 1 (N1) was associated with increased upstaging and complications but not with decreased recurrence or mortality in clinical stage I or II patients. Survival was improved for concordant, clinical stage III patients. Further study is indicated to determine the ideal lymph node sampling strategy across heterogeneous lung cancer patients.

State of Lung Cancer in Egypt: Moving Towards Improved Guidelines for Prevention, Screening, Treatment, and Clinical Care Programs

Lung cancer remains a leading cause of cancer-related mortality globally and presents significant challenges in Egypt. In 2023, the first annual meeting of the Thoracic Oncology Multidisciplinary Faculty, organized by the Egyptian Cancer Research Network and the Egyptian Society of Respiratory Neoplasms, was held in Cairo, Egypt. The meeting aimed to address gaps in lung cancer management across Egypt and the broader Middle East and North Africa region. The discussions focused on the challenges posed by NSCLC and SCLC and emphasized the need for enhanced prevention, early detection, and treatment strategies. Key areas of concern include limited access to advanced diagnostics, such as comprehensive genomic profiling, and the underutilization of targeted therapies and immunotherapies, mainly owing to financial barriers. The meeting highlighted the importance of strengthening lung cancer screening programs, improving smoking cessation efforts, and addressing environmental risk factors like air pollution. Furthermore, the event underscored the need for greater research and collaboration, particularly in areas like precision oncology. The conference concluded with strategic recommendations to improve lung cancer prevention, screening, and treatment, aligning Egypt's lung cancer care with global advancements and ensuring equitable access to cutting-edge therapies.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Promoting guideline-concordant lung cancer staging

Accurate staging improves lung cancer survival by increasing the chances of delivering stage-appropriate therapy. However, there is underutilization of, and variability in, the use of guideline-recommended diagnostic tests used to stage lung cancer. Consequently, the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT) convened the Triage for Appropriate Treatment Task Group-a multidisciplinary expert and stakeholder panel-to identify knowledge and/or resource gaps contributing to guideline-discordant staging and make recommendations to overcome these gaps. The task group determined the following: Gap 1: facilitators of and barriers to guideline-concordant staging are incompletely understood; Recommendation 1: identify facilitators of and barriers to guideline-concordant lung cancer staging; Gap 2: the level of evidence supporting staging algorithms is low-to-moderate; Recommendation 2: prioritize comparative-effectiveness studies evaluating lung cancer staging; Gap 3: guideline recommendations vary across professional societies; Recommendation 3: harmonize guideline recommendations across professional societies; Gap 4: existing databases do not contain sufficient information to measure guideline-concordant staging; Recommendation 4: augment existing databases with the information required to measure guideline-concordant staging; Gap 5: health systems do not have a performance feedback mechanism for lung cancer staging; Recommendation 5: develop and implement a performance feedback mechanism for lung cancer staging; Gap 6: patients rarely self-advocate for guideline-concordant staging; Recommendation 6: increase opportunities for patient self-advocacy for guideline-concordant staging; and Gap 7: current health policies do not motivate guideline-concordant lung cancer staging; Recommendation 7: organize a representative working group under the ACS NLCRT that promotes policies that motivate guideline-concordant lung cancer staging. PLAIN LANGUAGE SUMMARY: Staging-determining the degree of cancer spread-is important because it helps clinicians choose the best cancer treatment. Receiving the best cancer treatment leads to the best possible patient outcomes. Practice guidelines are intended to help clinicians stage patients with lung cancer. However, lung cancer staging in the United States often varies from practice guideline recommendations. This report identifies seven opportunities to improve lung cancer staging.

Correlation Between the Number of Pathological Risk Factors and Postoperative Prognosis in Patients with Stage I Lung Adenocarcinoma

BACKGROUND

Although visceral pleural invasion, lymphovascular invasion, tumor spread through air spaces, and poor differentiation are pathological risk factors associated with unfavorable prognosis in patients with lung adenocarcinoma, the cumulative impact of these factors on prognosis remains unclear.

METHODS

We enrolled 1532 patients with stage I lung adenocarcinoma. Patients were divided according to the number of risk factors as follows: Group A (without risk factors), Group B (one risk factor), and Group C (multiple risk factors). Moreover, we stratified patients into two subgroups based on tumor size (≤ 3 cm, 3-4 cm). Kaplan-Meier analysis was used to evaluate 5-year disease-free survival (DFS) and overall survival (OS).

RESULTS

Overall, 949, 404, and 179 patients were included in Groups A, B, and C, respectively. Group C had a larger tumor size and more cases of extrathoracic recurrence than the other groups. The 5-year DFS and OS gradually decreased across Groups A to C (DFS: 94.3%, 80.6%, and 64.3%, respectively, p < 0.001; OS: 97.2%, 92.7%, and 77%, respectively, p < 0.001). A similar trend was observed for tumors ≤ 3 cm in size (DFS: 95.2%, 83.2%, and 68.5%, respectively, p < 0.001; OS: 97.6%, 94.1%, and 79.6%, respectively, p < 0.001), but a less pronounced trend was observed for tumors between 3 and 4 cm in size (DFS: 72.1, 60.8, and 43.3%, respectively, p = 0.054; OS: 85.7, 82.1, and 64.7%, respectively, p = 0.16).

CONCLUSIONS

Postoperative survival worsened with increasing pathological risk factors in patients with stage I lung adenocarcinoma, especially those with tumor size ≤ 3 cm.

Lymphatic vascular invasion: Diagnostic variability and overall survival impact on patients undergoing surgical resection

Objective

The diagnostic criteria of lymphatic vascular invasion have not been standardized. Our investigation assesses the factors associated with lymphatic vascular invasion positive tumors and the impact of lymphatic vascular invasion on overall survival for patients with non-small cell lung cancer undergoing (bi)lobectomy with an adequate node dissection.

Methods

The National Cancer Database was queried from the years 2010 to 2015 to find surgical patients who underwent lobectomy with at least 10 lymph nodes examined (adequate node dissection) and with known lymphatic vascular invasion status. Paired t tests were used to distinguish differences between the patients with and without lymphatic vascular invasion in their specimen. Multivariable analysis was used to determine factors associated with overall survival. Propensity score matching adjusting for overall survival factors was used to determine the lymphatic vascular invasion's overall survival impact by grade, histology, p-T/N/overall stage, and tumor size.

Results

Lymphatic vascular invasion status was reported in 91.6% and positive in 23.4% of 28,842 eligible patients. Academic medical centers, institutions with populations more than 1,000,000, and the mid-Atlantic region reported higher rates of lymphatic vascular invasion positive tumors as well as overall survival compared with other cancer centers. Lymphatic vascular invasion was independently associated with a significant decrement in overall survival as per multivariable analysis and propensity score matching. Propensity score matching demonstrated that lymphatic vascular invasion was associated with a significant decrement in overall survival for all histologies, tumor grades, tumor sizes, and stages, except for more advanced pathologic stages T3/III/N2 and larger tumors greater than 4 cm for which overall survival was trending worse with lymphatic vascular invasion positive.

Conclusions

Lymphatic vascular invasion positive varies based on hospital location/type and population, but it was associated with a decrement in overall survival that was independent of pathologic T/N/overall stage, histology, and tumor grade. Lymphatic vascular invasion must be standardized and considered as a staging variable and should be considered as a sole determinant for prognosis, especially for those with earlier-stage and smaller tumors.

The Surgical Renaissance: Advancements in Video-Assisted Thoracoscopic Surgery and Robotic-Assisted Thoracic Surgery and Their Impact on Patient Outcomes

Minimally invasive thoracic surgery has advanced the treatment of lung cancer since its introduction in the 1990s. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) offer the advantage of smaller incisions without compromising patient outcomes. These techniques have been shown to be safe and effective in standard pulmonary resections (lobectomy and sub-lobar resection) and in complex pulmonary resections (sleeve resection and pneumonectomy). Furthermore, several studies show these techniques enhance patient outcomes from early recovery to improved quality of life (QoL) and excellent oncologic results. The rise of RATS has yielded further operative benefits compared to thoracoscopic surgery. The wristed instruments, neutralization of tremor, dexterity, and magnification allow for more precise and delicate dissection of tissues and vessels. This review summarizes of the advancements in minimally invasive thoracic surgery and the positive impact on patient outcomes.

Improving care in lung cancer surgery: a review of quality measures and evolving standards

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines.

RECENT FINDINGS

Over the past 18 months, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection.

SUMMARY

Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers.

Impact of number of dissected lymph nodes on recurrence and survival following thoracoscopic segmentectomy for clinical stage I non-small cell lung cancer

OBJECTIVE

This study aimed to identify the impact of number of dissected lymph nodes during thoracoscopic segmentectomy on recurrence and survival of clinical stage I non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

We retrospectively analysed data from prospectively collected consecutive thoracoscopic segmentectomies conducted between June 2008 and September 2023 at a single institution. Kaplan-Meier analysis with log-rank test assessed OS. Fine-Gray's test assessed specific death in a competing risk model. The logistic regression model was utilized to predict recurrence, while the Cox regression model was employed to analyse overall survival (OS). Subgroup and sensitivity analyses were performed.

RESULTS

A total of 227 patients were included in the final analyses. The mean follow-up was 38.4 months (standard deviation 35.8). Among all patients, 37 patients (16.3 %) experienced recurrence and 51 (22.5 %) deceased during the follow-up period. The median number of dissected lymph nodes was 9 (interquartile range (IQR) 6-12). No statistical difference in recurrence rate and 5-year OS was observed between cases with dissected lymph nodes > 9 and ≤ 9 (14.6 % vs. 17.6 %, p = 0.549; 75.5 % vs. 69.5 %, p = 0.760). On multivariable analysis, body mass index (odds ratio [OR] 1.15, p = 0.002), Charlson Comorbidity index (OR 1.28, p = 0.002), synchronous pulmonary cancer (OR 3.05, p = 0.019), and tumour size (OR 1.04, p = 0.044) increased of the recurrence rate, while percentage of predicted forced expiratory volume in 1 s (hazard ratio (HR) 1.09, p = 0.048), history of smoking (HR 1.02, p = 0.009), and solid nodule (HR 1.56, p = 0.010) was related to poorer survival.

CONCLUSIONS

In this study, number of dissected lymph nodes did not impact recurrence rate or overall survival after thoracoscopic segmentectomy for clinical stage I NSCLC.

Surgeon experience does not influence nodal upstaging during vats lobectomy: Results from a large prospective national database

BACKGROUND

Despite recent improvement in preoperative staging, nodal and mediastinal upstaging occur in about 5% to 15% of cN0 patients. Different clinical and tumor characteristics are associated with upstaging, whereas the role of the surgeon's experience is not well evaluated. This study aimed to investigate if operator experience might influence nodal upstaging during video-assisted thoracic surgery anatomical lung resection.

METHODS

Clinical and pathological data from the prospective video-assisted thoracic surgery Italian nationwide registry were reviewed and analyzed. Patients with incomplete data about tumor and surgical characteristics, ground glass opacities tumors, cN2 to 3, and M+ were excluded. Clinical data, tumor characteristics, and surgeon experience were correlated to nodal and mediastinal (N2) upstaging using Pearson's χ2 statistic or Fisher exact test for categorical variables and Mann-Whitney U and t tests for quantitative variables. A multivariable model was built using logistic regression analysis. Surgeon experience was categorized considering the number of video-assisted thoracic surgery major anatomical resections and years after residency.

RESULTS

Final analysis was conducted on 3,319 cN0 patients for nodal upstaging and 3,471 cN0N1 patients for N2 upstaging. Clinical tumor-nodes-metastasis stage was stage I in 2,846 (81.9%) patients, stage II in 533 (15.3%), and stage III (cT3N1) in 92 (2.8%). Nodal upstaging occurred in 489 (13.1%) patients, whereas N2 upstaging occurred in 229 (6.1%) patients. Years after residency (P = .60 for nodal, P = .13 for N2 upstaging) and a number of video-assisted thoracic surgery procedures(P = .49 for nodal, P = .72 for nodal upstaging) did not correlate with upstaging. Multivariable analysis confirmed cT-dimension (P = .001), solid nodules (P < .001), clinical tumor-nodes-metastasis (P < .001) and maximum standardized uptake values (P < .001) as factors independently correlated to nodal upstaging, whereas cT-dimension (P = .005), clinical tumor-nodes-metastasis (P < .001) and maximum standardized uptake values (P = .028) resulted independently correlated to N2 upstaging.

CONCLUSION

Our study showed that surgeon experience did not influence nodal and mediastinal upstaging during -assisted thoracic surgery anatomical resection, whereas cT-dimension, clinical tumor-nodes-metastasis, and maximum standardized uptake values resulted independently correlated to nodal and mediastinal upstaging.

Quality improvement mechanisms to improve lymph node staging for lung cancer: Trends from a statewide database

OBJECTIVE

Our statewide thoracic quality collaborative has implemented multiple quality improvement initiatives to improve lung cancer nodal staging. We subsequently implemented a value-based reimbursement initiative to further incentivize quality improvement. We compare the impact of these programs to steer future quality improvement initiatives.

METHODS

Since 2016, our collaborative focused on improving lymph node staging for lung cancer by leveraging unblinded, hospital-level metrics and collaborative feedback. In 2021, a value-based reimbursement initiative was implemented with statewide yearly benchmark rates for (1) preoperative mediastinal staging for ≥T2N0 lung cancer, and (2) sampling ≥5 lymph node stations. Participating surgeons would receive additional reimbursement if either benchmark was met. We reviewed patients from January 2015 to March 2023 at the 21 participating hospitals to determine the differential effects on quality improvement.

RESULTS

We analyzed 6228 patients. In 2015, 212 (39%) patients had ≥5 nodal stations sampled, and 99 (51%) patients had appropriate preoperative mediastinal staging. During 2016 to 2020, this increased to 2253 (62%) patients and 739 (56%) patients, respectively. After 2020, 1602 (77%) patients had ≥5 nodal stations sampled, and 403 (73%) patients had appropriate preoperative mediastinal staging. Interrupted time-series analysis demonstrated significant increases in adequate nodal sampling and mediastinal staging before value-based reimbursement. Afterward, preoperative mediastinal staging rates briefly dropped but significantly increased while nodal sampling did not change.

CONCLUSIONS

Collaborative quality improvement made significant progress before value-based reimbursement, which reinforces the effectiveness of leveraging unblinded data to a collaborative group of thoracic surgeons. Value-based reimbursement may still play a role within a quality collaborative to maintain infrastructure and incentivize participation.

Precision Oncology in Lung Cancer Surgery

Precision in lung cancer surgery is our ability to use the most cutting edge and up to date information to provide personalized and targeted surgical care to our patients. It aims to tailor patient care to patient and tumor characteristics and susceptibilities as well as to optimize the ways treatments are administered. This may include specific perioperative medical treatment, changing operative techniques to more minimally invasive ones if the situation permits, performing sub-anatomical surgeries when possible, and using innovative tumor visualization methods to enhance detection of previously occult disease to ultimately decrease the extent of the planned resection.

Surgeon experience influence lymphadenectomy during VATS lobectomy: National VATS database results

OBJECTIVES

Aim of this study is to identify the factors that may influence the lymphadenectomy during VATS anatomical lung resection with particular interest on operator experience.

MATERIALS AND METHODS

Clinical and pathological data from the prospective VATS Italian nationwide registry were reviewed and analysed. Patients with incomplete data regarding tumor and surgical characteristics, GGO, or with distant metastases were excluded. Patients clinical data, tumor characteristics, operation information and surgeon experience were collected and compared to resected lymph nodes number (#RN), resected N2 nodes number (#N2RN) and resected N2 stations number. A multivariable model was built using logistic regression analysis. Surgeon experience was categorized considering the number of VATS major anatomical resection and years after residency.

RESULTS

The final analysis was conducted on 3727 patients. The median #RN and #N2RN were 11 (1-51) and 5 (0-41). Regarding the analysed outcomes, #N2RN > 6 resulted in 1812 (48.8%)cases, #RN > 10 in 2124 (57.0%)cases and more than 3 N2 stations were harvested in 1447 (38.8%)patients. First operator experience with number of VATS lobectomies>50 (p < 0.001), operator seniority after residency5-10years (p < 0.001), cTNM II/III(p = 0.017), lobectomy/bilobectomy vs segmentectomy (p < 0.001), and upper/middle lobe tumor location (p < 0.005)resulted significantly associated to #N2RN > 6 at the multivariable analysis. First operator experience with number of VATS lobectomies>50 (p < 0.001), operator seniority after residency5-10years (p < 0.001) and lobectomy/bilobectomy (p < 0.001) resulted significantly associated to #RN > 10 at the multivariable analysis.

CONCLUSIONS

Our study showed that lymphadenectomy during VATS lobectomy is influenced by tumor factors such as cTstage and tumor location but also by operator experience, with a higher number of resected lymph nodes in surgeons with a high number of VATS procedures and years after residency compared to surgeons with less experience.

Lobe-specific lymph node sampling is associated with lower risk of cancer recurrence

Objective

Adequate intraoperative lymph node (LN) assessment is a critical component of early-stage non-small cell lung cancer (NSCLC) resection. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer (CoC) recommend station-based sampling minimums agnostic to tumor location. Other institutions advocate for lobe-specific LN sampling strategies that consider the anatomic likelihood of LN metastases. We examined the relationship between lobe-specific LN assessment and long-term outcomes using a robust, highly curated cohort of stage I NSCLC patients.

Methods

We performed a cohort study using a uniquely compiled dataset from the Veterans Health Administration and manually abstracted data from operative and pathology reports for patients with clinical stage I NSCLC (2006-2016). For simplicity in comparison, we included patients who had right upper lobe (RUL) or left upper lobe (LUL) tumors. Based on modified European Society of Thoracic Surgeons guidelines, lobe-specific sampling was defined for RUL tumors (stations 2, 4, 7, and 10 or 11) and LUL tumors (stations 5 or 6, 7, and 10 or 11). Our primary outcome was the risk of cancer recurrence, as assessed by Fine and Gray competing risks modeling. Secondary outcomes included overall survival (OS) and pathologic upstaging. Analyses were adjusted for relevant patient, disease, and treatment variables.

Results

Our study included 3534 patients with RUL tumors and 2667 patients with LUL tumors. Of these, 277 patients (7.8%) with RUL tumors and 621 patients (23.2%) with LUL tumors met lobe-specific assessment criteria. Comparatively, 34.7% of patients met the criteria for count-based assessment, and 25.8% met the criteria for station-based sampling (ie, any 3 N2 stations and 1 N1 station). Adherence to lobe-specific assessment was associated with lower cumulative incidence of recurrence (adjusted hazard ratio [aHR], 0.83; 95% confidence interval [CI], 0.70-0.98) and a higher likelihood of pathologic upstaging (aHR, 1.49; 95% CI, 1.20-1.86). Lobe-specific assessment was not associated with OS.

Conclusions

Adherence to intraoperative LN sampling guidelines is low. Lobe-specific assessment is associated with superior outcomes in early-stage NSCLC. Quality metrics that assess adherence to intraoperative LN sampling, such as the CoC Operative Standards manual, also should consider lobe-specific criteria.

Systematic mediastinal staging in non-small cell lung cancer: Filling in the guideline evidence gap

See related article

Lymph Node Yield in Lung Cancer Resection is Associated With Demographic and Institutional Factors

INTRODUCTION

Lymphadenectomy is routinely performed during surgical resection of nonsmall cell lung cancer (NSCLC). Lymph node yield and number of nodal stations sampled are important prognostic markers viewed as surrogates of surgical quality. The purpose of this study was to identify factors associated with these quality metrics after resection of NSCLC.

MATERIALS AND METHODS

We identified NSCLC patients undergoing resection at a single institution from 2010 to 2021. Cases were matched to detailed pathologist reports, which included lymph node yield and number of stations sampled. Demographic and clinical characteristics were analyzed individually using unadjusted linear regression to identify factors associated with lymph node yield and number of stations sampled. Multivariable linear regression analyses were performed to evaluate the same end points, using covariates determined through stepwise-backwards selection.

RESULTS

The study cohort included 836 patients. Multivariable regression demonstrated that male sex, history of cardiothoracic surgery, and individual pathologist were independently associated with lymph node yield. Among 18 pathologists, interpathologist coefficients with respect to lymph node yield varied from -5.61 to 11.25. Multivariable regression demonstrated White race and history of cardiothoracic surgery to be independently associated with number of nodal stations sampled, as well as individual surgeon and pathologist.

CONCLUSIONS

Lymph node yield and number of nodal stations sampled after NSCLC resection may vary based on patient demographic and clinical characteristics, as well as institutional factors. These factors should be accounted for when using these metrics as markers of surgical quality and prognosis of NSCLC.

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

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

The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Staging and multidisciplinary management of patients with early-stage non-small cell lung cancer

Novel targeted therapy and immunotherapy drugs have recently been approved for use in patients with surgically resectable lung cancer. Accurate staging, early molecular testing, and knowledge of recent trials are critical to optimize oncologic outcomes in these patients.

Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resection

Objectives

Although sublobar resections have gained traction, wedge resections vary widely in quality. We seek to characterize the demographic and facility-level variables associated with high-quality wedge resections.

Methods

The National Cancer Database was queried from 2010 to 2018. Patients with T1/T2 N0 M0 non-small cell lung cancer 2 cm or less who underwent wedge resection without neoadjuvant therapy were included. A wedge resection with no nodes sampled or with positive margins was categorized as a low-quality wedge. A wedge resection with 4 or more nodes sampled and negative margins was categorized as a high-quality wedge. Facility-specific variables were investigated via quartile analysis based on the overall volume and proportion of high-quality wedge or low-quality wedge resections performed.

Results

A total of 21,742 patients met inclusion criteria, 6390 (29.4%) of whom received a high-quality wedge resection. Factors associated with high-quality wedge resection included treatment at an academic center (3005 [47.0%] vs low-quality wedge 6279 [40.9%]; P < .001). The 30- and 90-day survivals were similar, but patients who received a high-quality wedge resection had improved 5-year survival (4902 [76.7%] vs 10,548 [68.7%]; P < .001). Facilities in the top quartile by volume of high-quality wedge resections performed 69% (4409) of all high-quality wedge resections, and facilities in the top quartile for low-quality wedge resections performed 67.6% (10,378) of all low-quality wedge resections. A total of 113 facilities were in the top quartile by volume for both high-quality wedge and low-quality wedge resections.

Conclusions

High-quality wedge resections are associated with improved 5-year survival when compared with low-quality wedge resections. By volume, high-quality wedge and low-quality wedge resections cluster to a minority of facilities, many of which overlap. There is discordance between best practice guidelines and current practice patterns that warrants additional study.

A Systematic Review of Short-Term Outcomes of Minimally Invasive Thoracoscopic Surgery for Lung Cancer after Neoadjuvant Systemic Therapy

BACKGROUND

Minimally invasive surgeries for non-small cell lung cancers (NSCLCs) such as video-assisted thoracoscopic surgeries (VATSs) and robotic-assisted thoracoscopic surgeries (RATSs) have become standard of care for patients needing surgical resection in early stages. The role for neoadjuvant systemic therapy has increased with patients receiving neoadjuvant systemic chemotherapy and immunotherapy. However, there has been some equipoise over the intraoperative and overall outcomes for these patients. Here, we review the current data regarding outcomes of patients undergoing minimally invasive thoracic surgical resection after systemic chemotherapy, immunotherapy, or both.

METHODS

A systematic literature review of randomized controlled trials and observational studies presenting data on patients with NSCLC that underwent neoadjuvant systemic therapy followed by minimally invasive surgery was performed assessing complications, conversion rates, and lymph node yield.

RESULTS

Our search strategy and review of references resulted in 239 publications to screen with 88 full texts assessed and 21 studies included in our final review. VATS had a statistically significant higher lymph node yield in five studies. The reported conversion rates ranged from 0 to 54%. Dense adhesions, bleeding, and difficult anatomy were the most common reported reasons for conversion to open surgeries. The most common complications between both groups were prolonged air leak, arrythmia, and pneumonia. VATS was found to have significantly fewer complications in three papers.

CONCLUSIONS

The current literature supports VATS as safe and feasible for patients with NSCLC after neoadjuvant systemic treatment. Surgeons should remain prepared to convert to open surgeries in those patients with dense adhesions and bleeding risk.

Meeting the New Commission on Cancer Operative Standards: Where Do We Stand Now?

INTRODUCTION

The 2020 Commission on Cancer accreditation standards 5.7 and 5.8 address total mesorectal excision for rectal cancer and lymph node sampling for lung cancer. The purpose of this review was to assess our institution's compliance with these operative standards, which will be required in 2022 and 2023, and provide recommendations to other military training facilities seeking to comply with these standards.

MATERIALS AND METHODS

A 2018-2020 single institution chart review was performed of operative and pathology reports. Identified deficits were addressed in meetings with colorectal and thoracic surgery leadership, and cases were followed to reassess compliance.

RESULTS

A total of 12 rectal and 48 lung cancer cases met the inclusion criteria and were examined. Pre-intervention compliance for standards 5.7 and 5.8 was 58% and 35%, respectively, because of inadequate synoptic reporting and lymph node sampling. After intervention, compliance was 100%.

CONCLUSIONS

Our institution requires changes to comply with new standards, including in areas of documentation and systematic pulmonary lymph node sampling. We provide lessons learned from our own institutional experience, including practical tips and recommendations to achieve compliance. All military training facilities performing lung and rectal oncologic resections should conduct an internal review of applicable cases in preparation for upcoming American College of Surgeons Commission on Cancer site visits.

Association Between Surgical Quality Metric Adherence and Overall Survival Among US Veterans With Early-Stage Non-Small Cell Lung Cancer

Importance

Surgical resection remains the preferred treatment for functionally fit patients diagnosed with early-stage non-small cell lung cancer (NSCLC). Process-based intraoperative quality metrics (QMs) are important for optimizing long-term outcomes following curative-intent resection.

Objective

To develop a practical surgical quality score for patients diagnosed with clinical stage I NSCLC who received definitive surgical treatment.

Design, Setting, and Participants

This retrospective cohort study used a uniquely compiled data set of US veterans diagnosed with clinical stage I NSCLC who received definitive surgical treatment from October 2006 through September 2016. The data were analyzed from April 1 to September 1, 2022. Based on contemporary treatment guidelines, 5 surgical QMs were defined: timely surgery, minimally invasive approach, anatomic resection, adequate lymph node sampling, and negative surgical margin. The study developed a surgical quality score reflecting the association between these QMs and overall survival (OS), which was further validated in a cohort of patients using data from the National Cancer Database (NCDB). The study also examined the association between the surgical quality score and recurrence-free survival (RFS).

Exposures

Surgical treatment of early-stage NSCLC.

Main Outcomes and Measures

Overall survival and RFS.

Results

The study included 9628 veterans who underwent surgical treatment between 2006 and 2016. The cohort consisted of 1446 patients who had a mean (SD) age of 67.6 (7.9) years and included 9278 males (96.4%) and 350 females (3.6%). Among the cohort, 5627 individuals (58.4%) identified as being smokers at the time of surgical treatment. The QMs were met as follows: timely surgery (6633 [68.9%]), minimally invasive approach (3986 [41.4%]), lobectomy (6843 [71.1%]) or segmentectomy (532 [5.5%]), adequate lymph node sampling (3278 [34.0%]), and negative surgical margin (9312 [96.7%]). The median (IQR) follow-up time was 6.2 (2.5-11.4) years. An integer-based score (termed the Veterans Affairs Lung Cancer Operative quality [VALCAN-O] score) from 0 (no QMs met) to 13 (all QMs met) was constructed, with higher scores reflecting progressively better risk-adjusted OS. The median (IQR) OS differed substantially between the score categories (score of 0-5 points, 2.6 [1.0-5.7] years of OS; 6-8 points, 4.3 [1.7-8.6] years; 9-11 points, 6.3 [2.6-11.4] years; and 12-13 points, 7.0 [3.0-12.5] years; P < .001). In addition, risk-adjusted RFS improved in a stepwise manner between the score categories (6-8 vs 0-5 points, multivariable-adjusted hazard ratio [aHR], 0.62; 95% CI, 0.48-0.79; P < .001; 12-13 vs 0-5 points, aHR, 0.39; 95% CI, 0.31-0.49; P < .001). In the validation cohort, which included 107 674 nonveteran patients, the score remained associated with OS.

Conclusions and Relevance

The findings of this study suggest that adherence to intraoperative QMs may be associated with improved OS and RFS. Efforts to improve adherence to surgical QMs may improve patient outcomes following curative-intent resection of early-stage lung cancer.

Assessment of Updated Commission on Cancer Guidelines for Intraoperative Lymph Node Sampling in Early Stage NSCLC

INTRODUCTION

The American College of Surgeons Commission on Cancer recently updated its sampling recommendations for early stage NSCLC from at least 10 lymph nodes to at least one N1 (hilar) and three N2 (mediastinal) lymph node stations. Nevertheless, intraoperative lymph node sampling minimums remain subject to debate. We sought to evaluate these guidelines in patients with early stage NSCLC.

METHODS

We performed a cohort study using a uniquely compiled data set from the Veterans Health Administration. We manually abstracted data from operative notes and pathology reports of patients with clinical stage I NSCLC receiving surgery (2006-2016). Adequacy of lymph node sampling was defined using count-based (≥10 lymph nodes) and station-based (≥three N2 and one N1 nodal stations) minimums. Our primary outcome was recurrence-free survival. Secondary outcomes were overall survival and pathologic upstaging.

RESULTS

The study included 9749 patients. Count-based and station-based sampling guidelines were achieved in 3302 (33.9%) and 2559 patients (26.3%), respectively, with adherence to either sampling guideline increasing over time from 35.6% (2006) to 49.1% (2016). Adherence to station-based sampling was associated with improved recurrence-free survival (multivariable-adjusted hazard ratio = 0.815, 95% confidence interval: 0.667-0.994, p = 0.04), whereas adherence to count-based sampling was not (adjusted hazard ratio = 0.904, 95% confidence interval: 0.757-1.078, p = 0.26). Adherence to either station-based or count-based guidelines was associated with improved overall survival and higher likelihood of pathologic upstaging.

CONCLUSIONS

Our study supports station-based sampling minimums (≥three N2 and one N1 nodal stations) for early stage NSCLC; however, the marginal benefit compared with count-based guidelines is minimal. Further efforts to promote widespread adherence to intraoperative lymph node sampling minimums are critical for improving patient outcomes after curative-intent lung cancer resection.