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

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.

Lobectomy vs Sublobar Resection in The Society of Thoracic Surgeons Database: Importance of Patient Factors and Lymph Node Evaluation

BACKGROUND

Prospective randomized trials have demonstrated noninferior survival between sublobar resection and lobectomy in healthy patients with non-small cell lung cancer with tumors ≤2 cm. However, some patient attributes are not well represented in randomized trials, and uncertainty remains in the widespread applicability of randomized trial nodal dissection protocols.

METHODS

Patients with ≤2 cm, node-negative non-small cell lung cancer (cT1 N0) in The Society of Thoracic Surgeons prospective database were linked to Medicare survival data by using a probabilistic matching algorithm. Survival was assessed by propensity score-weighted Kaplan-Meier analysis.

RESULTS

Overall, 20,031 patients were identified, including 11,976 patients who underwent lobectomy, 2586 who underwent segmentectomy, and 5469 who underwent wedge resection. Fewer lymph nodes were sampled in the sublobar resection group (mean, 5.5 vs 12.8), and pathologic upstaging was less common (7.1% vs 14.2%). Overall survival after sublobar and lobar resection was similar within groups understudied in recent trials, including age ≥75 years (P = .07), forced expiratory volume in 1 second of 10% to 59% (P = .14), and Zubrod performance status 2 to 3 (P = .23). When sublobar resection was performed with inadequate nodal evaluation (<2 nodes removed), survival was inferior to survival after lobectomy (P < .001). Among patients with nodal upstaging, lobectomy was not associated with improved survival over sublobar resection (P = .42).

CONCLUSIONS

The clinical trial finding that sublobar resections achieve survival similar to that seen with lobectomy in early-stage lung cancer appears to apply to older, less healthy patients in a real-world setting, provided adequate lymph node resection is performed. Performing a lobectomy in the setting of nodal upstaging does not obviously improve survival. Further study is warranted to clarify the role of sublobar resection in the general population.

Kirsten Rat Sarcoma Virus Mutations Effect On Tumor Doubling Time And Prognosis Of Solid Dominant Stage I Lung Adenocarcinoma

INTRODUCTION

To analyze the impact of Kirsten-Rat-Sarcoma Virus (KRAS) mutations on tumor-growth as estimated by tumor-doubling-time (TDT) among solid-dominant clinical-stage I lung adenocarcinoma. Moreover, to evaluate the prognostic role of KRAS mutations, TDT and their combination in completely-resected pathologic-stage I adenocarcinomas.

METHODS

In this single-center retrospective analysis, completely resected clinical-stage I adenocarcinomas presenting as solid-dominant nodules (consolidation-to-tumor ratio > 0.5) in at least 2 preoperative computed-tomography scans were enrolled. Nodules' growth was scored as fast (TDT < 400 days) or slow (TDT > 400 days). KRAS-mutated adenocarcinomas were identified with next-generation sequencing. Logistic- and Cox-regressions were used to identify predictors of fast-growth and disease-free survival (DFS), respectively.

RESULTS

Among 151 patients, 83 (55%) had fast-growing nodules and 64 (42.4%) were KRAS-mutated. Fast-growing nodules outnumbered in the KRAS-mutated group (n = 45; 70.3%), median TDT 95-days (interquartile range, IQR 43.5-151.5) compared to the KRAS wild-type group (38, 43.7%), median TDT 138-days (IQR 70.3-278.5). KRAS-mutations predicted faster-growth at multivariable analysis (P = .009). In a subgroup analysis including 108 pathologic-stage I adenocarcinomas, neither KRAS-mutations (P = .081) nor fast-growing pattern (P = .146) affected DFS. Nevertheless, the association of KRAS-mutations and fast-growing pattern identified a subgroup of patients with worse DFS (P = .02). The combination of fast-growing and KRAS-mutations (hazard-ratio 2.97 [95%CI 1.22-7.25]; P = .017) and average nodule diameter at diagnosis (hazard-ratio 1.08 [95%CI 1.03-1.14]; P = .004) were independent predictors of worse DFS.

CONCLUSION

KRAS mutations are associated to faster growth, in clinical-stage I adenocarcinoma presenting at diagnosis as solid-dominant nodules undergoing complete resection. Moreover, faster-growth identifies a subgroup of pathologic-stage I KRAS-mutated adenocarcinomas with higher recurrences.

Computer Assisted Nodule Analysis and Risk Yield is Associated With Occult Lymph Node Status in Clinical Stage I-IIA Lung Adenocarcinoma Undergoing Resection

BACKGROUND

Current staging work-up does not capture all occult lymph node (OLN) disease. We sought to determine if Computer Assisted Nodule Analysis and Risk Yield (CANARY) analysis could help distinguish OLN status in early-stage lung adenocarcinoma.

METHODS

Retrospective review of resected lung cancer patients from 2016 to 2021 was performed. Patients with surgically resected clinical stage I-IIA lung adenocarcinoma were included. Preoperative imaging was entered into the CANARY software, and each lesion was categorized into good, intermediate, and poor risk. OLN status was determined per pathology results. Pearson's Chi-square correlation, univariate and multivariate logistic regression models were used to assess OLN metastases as a function of CANARY risk profile, with statistical significance at α=0.05.

RESULTS

In total, the study cohort included 228 patients with median age of 70. By clinical stage, 195 (85.5%), 24 (10.5%), and 9 (3.9%) patients were determined to be in IA, IB, and IIA, respectively. 28 (12.3%) patients were found to have OLN metastases. Among them, 1 (3.6%), 3 (10.7%), and 24 (85.7%) patients had a good, intermediate, and poor CANARY risk profile, respectively. CANARY risk profile was significantly associated with OLN metastases (χ2 = 9.9, P = .007). Relative to the good/intermediate group, patients with poor risk had a more-than 3-fold increase in likelihood of having OLN metastases (odd ratio [OR] = 3.3, 95% confidence interval [CI]:1.6-9.2, P = .007).

CONCLUSION

CANARY analysis was able to risk-stratify the likelihood of OLN metastases in early-stage lung adenocarcinoma. CANARY can provide an adjunctive non-invasive tool to aid in determining an appropriate individualized treatment plan.

Surveying surgeon practices and perspectives on extent of intraoperative nodal evaluation in non-small cell lung cancer

Objective

The National Comprehensive Cancer Network and Commission on Cancer guidelines encourage surgeons to obtain tissue from 1 or more N1 and 3 N2 nodal stations during resection for non-small cell lung cancer. We aimed to characterize surgeons' familiarity with and adherence to recommended guidelines and to elucidate factors influencing surgical practices globally.

Methods

A questionnaire was designed to assess surgeon behaviors regarding intraoperative nodal assessment decisions during lung cancer resection. Survey items included demographics, case-based scenarios, self-perceived behaviors regarding nodal decision-making, and knowledge-based questions regarding nodal assessment guidelines. The survey was distributed to the General Thoracic Surgical Club, European Society of Thoracic Surgeons, Canadian Association of Thoracic Surgeons, and Australian & New Zealand Society of Cardiac & Thoracic Surgeons.

Results

Altogether, 236 of 2396 surgeons (9.8%) from 46 countries responded. The majority were men (192/236) and general thoracic surgeons (204/236). Participants were subcategorized into North America (n = 96), Europe (n = 96), and All Other (n = 44). The importance of 4 variables that impact lymph node excision varied by region: length of procedure (P = .04), patient age (P = .0004), patient frailty (P = .0034), and institutional guidelines (P = .01). Surgeons stated that in patients who received neoadjuvant treatment, most would opt for a full lymphadenectomy. A total of 80.5% (n = 190) claimed familiarity with guidelines, yet only 56.4% (n = 133) could identify the guidelines.

Conclusions

The variables driving intraoperative decision-making for nodal dissection vary by region. Moreover, surgeons tend to overstate their knowledge of existing guidelines. To optimize cancer care around the world, education needs to be provided uniformly to drive positive patient outcomes.

Is segmentectomy potentially adequate for clinical stage IA3 non-small cell lung cancer

OBJECTIVES

This study aims to identify the feasibility of segmentectomy for clinical stage IA3 (cIA3) vs cIA1-2 non-small cell lung cancer (NSCLC).

METHODS

We retrospectively analysed data of consecutive patients with segmentectomy for cIA NSCLC across three centres between January 2017 and December 2022. The stabilized inverse probability of treatment-weighting (IPTW) was employed to minimize potential confounding in baseline characteristics. Recurrence-free survival (RFS) differences were examined using Kaplan-Meier estimator with the log-rank test. The Cox regression model was applied to assess the average treatment effect (ATE) between two groups in RFS. Subgroup and sensitivity analyses were performed.

RESULTS

Of a total of 589 patients who underwent segmentectomy, 478 presented with cIA1-2 NSCLC while 111 presented with cIA3 NSCLC. In comparison with cIA1-2 cases, the cIA3 cohort were significantly older with poorer lung function and more comorbidity. The cIA3 NSCLC presented significantly invasive characteristics, with extensive tissues dissected. After median follow-up of 24.0 (interquartile range 12.5-40.1) months, we did not observe significant difference in RFS (3-year 73.4% vs 78.5%, P = 0.490; ATE: 1.17) between the cIA3 vs cIA1-2 groups. These findings were corroborated following the stabilized IPTW. Preoperative characteristics in the cIA3 subgroup were not related to RFS. In the sensitivity analysis, no difference in RFS was found between the two groups stratified by peripheral and central localization.

CONCLUSIONS

In well-selected patients with cIA3 NSCLC, segmentectomy leads to no statistical difference in oncologic outcomes compared to those observed in earlier stages in a relatively short follow-up period.

Risk factors and clinical impact of prolonged air leak following video-assisted thoracoscopic surgery: a retrospective cohort study

Objective

This study aims to reveal the incidence and risk factors of prolonged air leak (PAL) following video-assisted thoracoscopic surgery (VATS) and to evaluate its impact on postoperative outcomes.

Methods

A retrospective analysis was performed on the clinical data of all pulmonary surgery patients who underwent VATS at the Department of Hospital Surgery No.2 at Sechenov University, from September 2023 to September 2024. Patients were categorized into two groups based on the presence of PAL (defined as prolonged air leak lasting ≥ 5 days): the PAL group and the non-PAL group. Risk factors for PAL and its effects on postoperative recovery were assessed.

Results

A total of 110 patients were included in the study, with an incidence of PAL of 26.3%. Multivariate analysis identified chronic obstructive pulmonary disease (COPD) (OR = 9.023, P = 0.003) and pleural adhesions (OR = 3.404, P = 0.013) as independent risk factors for the development of PAL. Significant differences were found between the PAL and non-PAL groups in terms of length of hospital stay (P < 0.001) and chest tube removal time (P < 0.001). The PAL group had a higher overall complication rate than the non-PAL group, with significantly more postoperative pneumonia (P = 0.003), postoperative empyema (P = 0.023), and postoperative wound infections (P = 0.005).

Conclusion

Chronic obstructive pulmonary disease and pleural adhesions were identified as independent risk factors for PAL after VATS. Patients with PAL experienced more postoperative complications and longer hospital stays.

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.

Microwave Ablation Combined with Flt3L Provokes Tumor-Specific Memory CD8+ T Cells-Mediated Antitumor Immunity in Response to PD-1 Blockade

For medically inoperable non-small cell lung cancer, microwave ablation (MWA) represents a super minimally invasive alternative treatment. However, tumor recurrence remains a concern. Here, it is demonstrated that the combination of MWA with Flt3L significantly inhibits tumor recurrence by CD8+ central memory T (TCM)-like cell-dependent antitumor immune responses within the tumor-draining lymph nodes (TdLN). TdLN-TCM-like cells encompassed both tumor-specific memory T (TTSM) and progenitor-exhausted T (TPEX) cells. The expansion of these cells markedly altered the differentiation of exhausted T cells within the tumor microenvironment (TME). TPEX predominantly differentiated into transitory effector-like exhausted T cells (TEX-int). The expansion of TTSM cells elicited by the combined therapy was reliant on conventional dendritic cells (cDCs) and was likely specifically dependent on the migratory cDC1s (Mig cDC1s) within the TdLN. The upregulation of ICOSL on migratory cDC1s was pivotal in initiating TTSM-like cell-mediated antitumor responses. Slc38a2 may be a critical gene responsible for the upregulation of ICOSL in Mig cDC1s following combined treatment. Finally, the combined treatment significantly enhanced the antitumor efficacy of immunotherapy based on PD-1 blockade. The research thereby afforded a novel strategic approach to forestall tumor recurrence after MWA therapy, while also providing the foundational proof-of-concept for impending clinical investigations.

A pilot quality improvement initiative for lymph node dissection during lung cancer surgery

OBJECTIVES

To evaluate the impact of a quality improvement initiative on intraoperative lymph node (LN) dissection adequacy.

METHODS

A single-centre cohort of 781 naïve patients who underwent resection of non-small cell lung cancer with pathological LN involvement and survived beyond 90 days was reviewed. LN dissection metrics were compared before and after the implementation of a quality improvement initiative. Quality metrics (QM) were: QM1 (≥10 LN examined), QM2 (≥3 intrapulmonary and hilar LN, ≥ 3 mediastinal stations, including station 7 in all cases), and QM3 (combination of QM1 and QM2).

RESULTS

The proportion of patients meeting QM1 did not differ significantly between the pre- (87.8%) and post-implementation (89.1%) periods. However, meeting QM2 and QM3 significantly improved from 79.5% to 88.6% (P = 0.001), and 76.2% to 84.4% (P = 0.007), respectively. Cox proportional hazard regression model for disease-free survival showed that patients operated on after the implementation of the quality improvement initiative exhibited better disease-free survival compared to those operated on before [adjusted hazard ratio (aHR): 0.73; 95% confidence interval (CI) 0.59-0.90; P = 0.003]. Nevertheless, none of these quality metrics influenced long-term outcomes. In contrast, adjuvant chemotherapy (aHR: 0.55; 95% CI 0.43-0.71; P < 0.001) was associated with improved disease-free survival. In case of metastatic progression, immunotherapy improved overall survival (hazard ratio: 0.54; 95% CI 0.37-0.77; P = 0.0003).

CONCLUSIONS

Utilizing transparent data and collaborative feedback were effective to enhance the quality of nodal assessment in lung cancer surgery. Overall, long-term outcomes for patients with lymph node involvement was primarily associated with disease burden, adjuvant chemotherapy, and rescue immunotherapy.

IRB APPROVAL NUMBER

CERC-SFCTCV-2024-04-30_34750 on 30 April 2024.

Should sampling of three N2 stations be a quality metric for curative resection of stage I lung cancer?

OBJECTIVE

In 2022, the American College of Surgeons Commission on Cancer issued standard 5.8 quality metric for curative lung cancer resections requiring nodal resection from 3 N2 stations. In this report, we compare oncologic outcomes after resection of 3 N2 stations versus 2 N2 stations in stage I non-small cell lung cancer.

METHODS

A retrospective review from a single institution database was conducted from 2011 to 2020 to identify patients with clinical stage I non-small cell lung cancer. Patients with a history of lung cancer, carcinoid tumors, and ground-glass lesions less than 50% solid component were excluded. The primary outcome was overall survival. Secondary outcomes included disease-free survival, recurrence patterns, and nodal upstaging.

RESULTS

A total of 581 patients were identified and divided into 2 groups based on the number of N2 stations examined: Group A had 2 N2 stations examined (364 patients), and group B had 3 or more N2 stations examined (217 patients). Baseline demographic and clinical characteristics were similar between groups. In group A, N1 and N2 positive nodal stations were present in 8.2% (30/364) and 5.2% (19/364) of patients versus 7.4% (16/217) and 5.5% (12/217), respectively, in group B. Five-year overall survival and disease-free survival were 89% and 74% in group A versus 88% and 78% in group B, respectively. Recurrence occurred in 56 patients (15.4%) in group A (6.6% local and 8.8% distant) and 29 patients (13.4%) in group B (5.1% local and 8.3% distant; P = .73).

CONCLUSIONS

There was no significant difference in oncological outcomes in stage I non-small cell lung cancer resections that included 2 N2 stations compared with at least 3 N2 stations examined.

Spatial immunogenomic patterns associated with lymph node metastasis in lung adenocarcinoma

BACKGROUND

Lung adenocarcinoma (LUAD) with lymph node (LN) metastasis is linked to poor prognosis, yet the underlying mechanisms remain largely undefined. This study aimed to elucidate the immunogenomic landscape associated with LN metastasis in LUAD.

METHODS

We employed broad-panel next-generation sequencing (NGS) on a cohort of 257 surgically treated LUAD patients to delineate the molecular landscape of primary tumors and identify actionable driver-gene alterations. Additionally, we used multiplex immunohistochemistry (mIHC) on a propensity score-matched cohort, which enabled us to profile the immune microenvironment of primary tumors in detail while preserving cellular metaclusters, interactions, and neighborhood functional units. By integrating data from NGS and mIHC, we successfully identified spatial immunogenomic patterns and developed a predictive model for LN metastasis, which was subsequently validated independently.

RESULTS

Our analysis revealed distinct immunogenomic alteration patterns associated with LN metastasis stages. Specifically, we observed increased mutation frequencies in genes such as PIK3CG and ATM in LN metastatic primary tumors. Moreover, LN positive primary tumors exhibited a higher presence of macrophage and regulatory T cell metaclusters, along with their enriched neighborhood units (p < 0.05), compared to LN negative tumors. Furthermore, we developed a novel predictive model for LN metastasis likelihood, designed to inform non-surgical treatment strategies, optimize personalized therapy plans, and potentially improve outcomes for patients who are ineligible for surgery.

CONCLUSIONS

This study offers a comprehensive analysis of the genetic and immune profiles in LUAD primary tumors with LN metastasis, identifying key immunogenomic patterns linked to metastatic progression. The predictive model derived from these insights marks a substantial advancement in personalized treatment, underscoring its potential to improve patient management.

Clinical utility of artificial intelligence-augmented endobronchial ultrasound elastography in lymph node staging for lung cancer

Objective

Endobronchial ultrasound elastography produces a color map of mediastinal lymph nodes, with the color blue (level 60) indicating stiffness. Our pilot study demonstrated that predominantly blue lymph nodes, with a stiffness area ratio greater than 0.496, are likely malignant. This large-scale study aims to validate this stiffness area ratio compared with pathology.

Methods

This is a single-center prospective clinical trial where B-mode ultrasound and endobronchial ultrasound elastography lymph node images were collected from patients undergoing endobronchial ultrasound transbronchial needle aspiration for suspected or diagnosed non-small cell lung cancer. Images were fed to a trained deep neural network algorithm (NeuralSeg), which segmented the lymph nodes, identified the percent of lymph node area above the color blue threshold of level 60, and assigned a malignant label to lymph nodes with a stiffness area ratio above 0.496. Diagnostic statistics and receiver operating characteristic analyses were conducted. NeuralSeg predictions were compared with pathology.

Results

B-mode ultrasound and endobronchial ultrasound elastography lymph node images (n = 210) were collected from 124 enrolled patients. Only lymph nodes with conclusive pathology results (n = 187) were analyzed. NeuralSeg was able to predict 98 of 143 true negatives and 34 of 44 true positives, resulting in an overall accuracy of 70.59% (95% CI, 63.50-77.01), sensitivity of 43.04% (95% CI, 31.94-54.67), specificity of 90.74% (95% CI, 83.63-95.47), positive predictive value of 77.27% (95% CI, 64.13-86.60), negative predictive value of 68.53% (95% CI, 64.05-72.70), and area under the curve of 0.820 (95% CI, 0.758-0.883).

Conclusions

NeuralSeg was able to predict nodal malignancy based on endobronchial ultrasound elastography lymph node images with high area under the receiver operating characteristic curve and specificity. This technology should be refined further by testing its validity and applicability through a larger dataset in a multicenter trial.

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.

Artificial Intelligence Algorithm Can Predict Lymph Node Malignancy from Endobronchial Ultrasound Transbronchial Needle Aspiration Images for Non-Small Cell Lung Cancer

INTRODUCTION

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for lung cancer staging is operator dependent, resulting in high rates of non-diagnostic lymph node (LN) samples. We hypothesized that an artificial intelligence (AI) algorithm can consistently and reliably predict nodal metastases from the ultrasound images of LNs when compared to pathology.

METHODS

In this analysis of prospectively recorded B-mode images of mediastinal LNs during EBUS-TBNA, we used transfer learning to build an end-to-end ensemble of three deep neural networks (ResNet152V2, InceptionV3, and DenseNet201). Model hyperparameters were tuned, and the optimal version(s) of each model was trained using 80% of the images. A learned ensemble (multi-layer perceptron) of the optimal versions was applied to the remaining 20% of the images (Test Set). All predictions were compared to the final pathology from nodal biopsies and/or surgical specimen.

RESULTS

A total of 2,569 LN images from 773 patients were used. The Training Set included 2,048 LNs, of which 70.02% were benign and 29.98% were malignant on pathology. The Testing Set included 521 LNs, of which 70.06% were benign and 29.94% were malignant on pathology. The final ensemble model had an overall accuracy of 80.63% (95% confidence interval [CI]: 76.93-83.97%), 43.23% sensitivity (95% CI: 35.30-51.41%), 96.91% specificity (95% CI: 94.54-98.45%), 85.90% positive predictive value (95% CI: 76.81-91.80%), 79.68% negative predictive value (95% CI: 77.34-81.83%), and AUC of 0.701 (95% CI: 0.646-0.755) for malignancy.

CONCLUSION

There now exists an AI algorithm which can identify nodal metastases based only on ultrasound images with good overall accuracy, specificity, and positive predictive value. Further optimization with larger sample sizes would be beneficial prior to clinical application.

Application of tissue pneumoperitoneum technique around lymph nodes in thoracoscopic lung cancer resection

Background

Thoracoscopic surgery is a primary treatment for lung cancer, with lobectomy and mediastinal lymph node dissection being the predominant surgical approaches for invasive lung cancer. While many thoracic surgeons can proficiently perform lobectomy, thorough and standardized lymph node dissection remains challenging. This study aimed to explore a safer and more efficient surgical method for mediastinal lymph node dissection in lung cancer.

Methods

A prospective randomized controlled study was conducted, involving 100 patients with right lung cancer who were admitted to our hospital from January 2021 to April 2024 and met the inclusion criteria. These patients were randomly divided into an observation group (tissue pneumoperitoneum technique around lymph nodes group) and a control group (conventional surgery group). Thoracoscopic lobectomy and mediastinal lymph node dissection were performed. Intraoperative and postoperative related indicators were observed to validate the effectiveness and safety of the tissue pneumoperitoneum technique around lymph nodes.

Results

The observation group showed a significantly shorter lymph node dissection surgery time compared to the control group, with a statistically significant difference (p < 0.05). The number of lymph nodes dissected in the observation group was significantly higher than that in the control group, with a statistically significant difference (p < 0.05). Although the observation group had slightly more mediastinal lymph node stations dissected than the control group, the difference was not statistically significant (p > 0.05). The total drainage volume within three days postoperatively was comparable between the two groups, with no statistically significant difference (p > 0.05). The observation group had shorter chest tube indwelling time and postoperative hospital stay than the control group, with statistically significant differences (p < 0.05). The incidence of surgical complications was similar between the two groups, and there were no perioperative deaths.

Conclusion

The tissue pneumoperitoneum technique around lymph nodes is a more efficient method for mediastinal lymph node dissection in lung cancer, demonstrating safety and feasibility, and is worthy of promotion.

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.

Modifications to the video-assisted thoracoscopic surgery technique reduce 1-year mortality and postoperative complications in intrathoracic tumors

OBJECTIVE

The purpose of the study is to analyze the immediate outcomes and results of video-assisted thoracoscopic lobectomy and lung resection performed in the surgical department of the AOC between 2014 and 2018.

METHODS

For the period from 2014 to 2018, 118 patients with peripheral lung cancer were operated on in the surgical department of the AOC. The following operations were performed: lobectomy in 92 cases (78%), of which: upper lobectomy, 44 (47.8%); average lobectomy, 13 (14.1%); lower lobectomy, 32 (35%); bilobectomy, 3 (3.3%). All patients underwent extensive lymphadenectomy on the side of the operation. In 22 patients, for various reasons, preservation of thoracotomy was performed.

RESULTS

The absence of N0 lymph node damage was observed in 82 patients (70%), the first-order lymph node damage N1 in 13 (11%), N2 in 13 (11%), N3 in 5 (4%), and NX in 5 (4%). Histological examination revealed: squamous cell carcinoma - 35.1%, adenocarcinoma - 28.5%, undifferentiated carcinoma - 8.3%, NSCLC - 5.6%, NEO - 4.6%, sarcoma - 1.8%. At the same time, in 12.7% of patients, mts was detected - lung damage, and in 3.4%, malignant cells were not detected. Most patients were activated on the first day after surgery.

CONCLUSION

An analysis of the direct results of the study allows us to conclude that video-assisted thoracoscopic surgery is a highly effective, minimally invasive, safe method for treating peripheral lung cancer, which allows us to recommend it for wider use in oncological practice.

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.

Microwave ablation for the treatment of peripheral ground-glass nodule-like lung cancer: Long-term results from a multi-center study

INTRODUCTION

Microwave ablation (MWA) is an effective and safe approach for the treatment of ground-glass nodule (GGN)-like lung cancer, but long-term follow-up is warranted. Therefore, this multi-center retrospective study aimed to evaluate the results of MWA for the treatment of peripheral GGN-like lung cancer with a long-term follow-up.

MATERIALS AND METHODS

From June 2013 to January 2018, a total of 87 patients (47 males and 40 females, mean age 64.6 ± 10.2 years) with 87 peripheral lung cancer lesions showing GGN (mean long axis diameter, 17 ± 5 mm) underwent computed tomography (CT)-guided percutaneous MWA. All GGN-like lung cancers were histologically verified. The primary endpoints were local progression-free survival (LPFS) and overall survival (OS). The secondary endpoints were cancer-specific survival (CSS) and complications.

RESULTS

During a median follow-up of 65 months, both the 3-year and 5-year LPFS rates were 96.6% and 96.6%. The OS rate was 94.3% at 3 years and 84.9% at 5 years, whereas the 3-year and 5-year CSS rates were 100% and 100%, respectively. No periprocedural deaths were observed. Complications were observed in 49 patients (51.6%). Grade 3 or higher complications included pneumothorax, pleural effusion, hemorrhage, and pulmonary infection, which were identified in ten (10.5%), two (2.1%), two (2.1%), and one (1.1%) patient, respectively.

CONCLUSIONS

CT-guided percutaneous MWA is an effective, safe, and potentially curative treatment regimen for GGN-like lung cancer.

Institution-Level Evolution of Lung Cancer Resection Quality With Implementation of a Lymph Node Specimen Collection Kit

INTRODUCTION

Lung cancer surgery with a lymph node kit improves patient-level outcomes, but institution-level impact is unproven.

METHODS

Using an institutional stepped-wedge implementation study design, we compared lung cancer resection quality between institutions in preimplementation and postimplementation phases of kit deployment and, within implementing institutions, resections without versus with the kit. Benchmarks included rates of nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and attainment of American College of Surgeons Operative Standard 5.8. We report institution-level adjusted ORs (aORs) for attaining quality benchmarks.

RESULTS

From 2009 to 2020, three preimplementing hospitals had 953 resections; 11 implementing hospitals had 4013 resections, 58% without and 42% with the kit. Quality was better in implementing institutions and with kit cases. Compared with preimplementing institutions, the aOR for nonexamination of lymph nodes was 0.62 (0.49-0.8, p = 0.002), nonexamination of mediastinal lymph nodes was 0.56 (0.47-0.68, p < 0.0001), and attainment of Operative Standard 5.8 was 7.3 (5.6-9.4, p < 0.0001); aORs for kit cases were 0.01 (0.001-0.06), 0.08 (0.06-0.11), and 11.6 (9.9-13.7), respectively (p < 0.0001 for all). Surgical quality was persistently poor in preimplementing institutions but sequentially improved in implementing institutions in parallel with kit adoption. In implementing institutions, resections with the kit had a uniformly high level of quality, whereas nonkit cases had a low level of quality, approximating that of preimplementing institutions. Within implementing institutions, 5-year overall survival was 61% versus 51% after surgery with versus without the kit (p < 0.001).

CONCLUSIONS

Surgery with a lymph node specimen collection kit improved institution-level quality of curative-intent lung cancer resection.

KRAS G12C mutation and risk of disease recurrence in stage I surgically resected lung adenocarcinoma

KRAS G12C mutations are found in about 12-13% of LUAD samples and it is unclear whether they are associated with worse survival outcomes in resected, stage I LUAD. We assessed whether KRAS-G12C mutated tumours had worse DFS when compared to KRAS-nonG12C mutated tumours and to KRAS wild-type tumours in a cohort of resected, stage I LUAD (IRE cohort). We then leveraged on publicly available datasets (TCGA-LUAD, MSK-LUAD⁶⁰⁴) to further test the hypothesis in external cohorts. In the stage I IRE cohort we found a significant association between the KRAS-G12C mutation and worse DFS in multivariable analysis (HR: 2.47). In the TCGA-LUAD stage I cohort we did not find statistically significant associations between the KRAS-G12C mutation and DFS. In the MSK-LUAD⁶⁰⁴ stage I cohort we found that KRAS-G12C mutated tumours had worse RFS when compared to KRAS-nonG12C mutated tumours in univariable analysis (HR 3.5). In the pooled stage I cohort we found that KRAS-G12C mutated tumours had worse DFS when compared to KRAS-nonG12C mutated tumours (HR 2.6), to KRAS wild-type tumours (HR 1.6) and to any other tumours (HR 1.8); in multivariable analysis, the KRAS-G12C mutation was associated with worse DFS (HR 1.61). Our results suggest that patients with resected, stage I LUAD with a KRAS-G12C mutation may have inferior survival outcomes..

The Uncomfortable Truth: Open Thoracotomy versus Minimally Invasive Surgery in Lung Cancer: A Systematic Review and Meta-Analysis

For decades, lung surgery in thoracic cancer has evolved in two ways: saving more parenchyma and being minimally invasive. Saving parenchyma is a fundamental principle of surgery. However, minimally invasive surgery (MIS) is a matter of approach, so it has to do with advances in surgical techniques and tools. For example, MIS has become possible with the introduction of VATS (video-assisted thoracic surgery), and the development of tools has extended the indication of MIS. Especially, RATS (robot-assisted thoracic surgery) improved the quality of life for patients and the ergonomics of doctors. However, the dichotomous idea that the MIS is new and right but the open thoracotomy is old and useless may be inappropriate. In fact, MIS is exactly the same as a classic thoracotomy in that it removes the mass/parenchyma containing cancer and mediastinal lymph nodes. Therefore, in this study, we compare randomized-controlled trials about open thoracotomy and MIS to find out which surgical method is more helpful.

ALK rearrangement is an independent predictive factor of unexpected nodal metastasis after surgery in early stage, clinical node negative lung adenocarcinoma

OBJECTIVES

Despite notable advances made in preoperative staging, unexpected nodal metastases after surgery are still significantly detected. Given the promising role of neoadjuvant targeted treatments, the definition of novel predictive factors of nodal metastases is an extremely important issue. In this study we aim to analyze the upstaging rate in patients with early stage NSCLC without evidence of nodal disease in the preoperative staging who underwent lobectomy and radical lymphadenectomy.

MATERIAL AND METHODS

Patients who underwent lobectomy and systematic lymphadenectomy for early stage LUAD without evidence of nodal disease at the preoperative staging using NGS analysis for actionable molecular targets evaluation after surgery were evaluated. Exclusion criteria included the neoadjuvant treatment, incomplete resection and no adherence to preoperative guidelines.

RESULTS

A total of 359 patients were included in the study. 172 patients were female, and the median age was 68 (61-72). The variables that showed a significant correlation with the upstaging rate at the univariate analysis were the ALK rearrangement, the number of resected lymph nodes and the diameter of the tumor. This result was confirmed in the multivariate analysis, with an OR of 8.052 (CI95% 3.123-20.763, p = 0.00001) for ALK rearrangement, 1.087 (CI95% 1.048-1.127, p = 0.00001) for the number of resected nodes and 1.817 (CI95% 1.214-2.719, p = 0.004) for cT status.

CONCLUSION

Our results showed that in a homogeneous cohort of patients with clinical node early stage LUAD the ALK rearrangement, the number of resected lymph nodes and the tumor diameter can significantly predict nodal metastasis.

Association between imaging surveillance frequency and outcomes following surgical treatment of early-stage lung cancer

BACKGROUND

Recent studies have suggested that more frequent postoperative surveillance imaging via computed tomography following lung cancer resection may not improve outcomes. We sought to validate these findings using a uniquely compiled dataset from the Veterans Health Administration, the largest integrated health-care system in the United States.

METHODS

We performed a retrospective cohort study of veterans with pathologic stage I non-small cell lung cancer receiving surgery (2006-2016). We assessed the relationship between surveillance frequency (chest computed tomography scans within 2 years after surgery) and recurrence-free survival and overall survival.

RESULTS

Among 6171 patients, 3047 (49.4%) and 3124 (50.6%) underwent low-frequency (<2 scans per year; every 6-12 months) and high-frequency (≥2 scans per year; every 3-6 months) surveillance, respectively. Factors associated with high-frequency surveillance included being a former smoker (vs current; adjusted odds ratio [aOR] = 1.18, 95% confidence interval [CI] = 1.05 to 1.33), receiving a wedge resection (vs lobectomy; aOR = 1.21, 95% CI = 1.05 to 1.39), and having follow-up with an oncologist (aOR = 1.58, 95% CI = 1.42 to 1.77), whereas African American race was associated with low-frequency surveillance (vs White race; aOR = 0.64, 95% CI = 0.54 to 0.75). With a median (interquartile range) follow-up of 7.3 (3.4-12.5) years, recurrence was detected in 1360 (22.0%) patients. High-frequency surveillance was not associated with longer recurrence-free survival (adjusted hazard ratio = 0.93, 95% CI = 0.83 to 1.04, P = .22) or overall survival (adjusted hazard ratio = 1.04, 95% CI = 0.96 to 1.12, P = .35).

CONCLUSIONS

We found that high-frequency surveillance does not improve outcomes in surgically treated stage I non-small cell lung cancer. Future lung cancer treatment guidelines should consider less frequent surveillance imaging in patients with stage I disease.

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.