Prognostic significance of main bronchial lymph nodes involvement in non-small cell lung carcinoma: N1 or N2?

Surgical outcomes of one-stage resection for synchronous multiple primary lung adenocarcinomas with no less than three lesions

Background

More and more synchronous multiple primary lung adenocarcinomas (SMPLA) have been diagnosed and surgical treatment has become the mainstay of treatment for them, but there are few reports on the surgical outcome of patients with ≥ 3 lesions who underwent surgical resection. Therefore, we summarized and analyzed the clinical characteristics and surgical outcomes of these patients, hoping to provide some experience in the diagnosis and treatment.

Methods

Clinical characteristics and treatment outcomes of patients with ≥ 3 lesions who have been diagnosed as SMPLA and underwent surgical resection in our hospital from March 2015 to July 2019 were retrospectively reviewed.

Results

Twenty-eight patients, 20 females and 8 males, with a mean age of 57.7 ± 5.69 (45–76) years, were finally included. A total of 95 lesions, 86.4% were ground-glass opacity (GGO) lesions (pure-GGO,45.3%; mixed-GGO,41.1%); 51 lesions had EGFR mutations and the mutation rate of invasive adenocarcinoma was significantly higher than that of other pathological subtypes (P < 0.001); the mutation rate of mGGO was also significantly higher than that of pGGO and solid nodule (SN) (P < 0.05). Four and 24 patients respectively underwent bilateral and unilateral surgical resection. The surgical procedure was mainly sublobar resection, and no severe postoperative complications or deaths occurred. After a median follow-up time of 32.2 months, the rates of overall survival and disease-free survival at 3 years were 94.7% and 88.9%, respectively.

Conclusions

For SMPLA with ≥ 3 lesions, one-stage resection may be safe and feasible, and surgical procedure was mainly sublobar resection as far as possible, which can yield satisfactory prognosis. EGFR mutation testing should be used routinely in the diagnosis and treatment of patients with SMPLA, especially in the presence of mGGO and invasive adenocarcinoma.

The importance of anatomical localization of non-small cell lung carcinoma in predicting mediastinal lymph node metastasis

Bronchopulmonary segmental location of non-small lung carcinomas is closely related to metastatic lymph node foci in the mediastinum. Our aim was to investigate the relationship between the anatomical locations of pulmonary masses on the bronchopulmonary segmental base and metastatic lymph node regions in non-small cell lung cancer using preoperative 18F-FDG PET/CT images. Ninety patients newly diagnosed with non-small cell lung carcinoma and referred to PET/CT imaging for staging were included in the study. Tumoral masses that could be evaluated visually and mediastinal node metastases were identified in 18F-FDG PET/CT images, then the relationship between them was investigated statistically. The diagnostic power of 18F-FDG PET/CT of mediastinal nodes was also revealed. Seventy-four males (82.2%) and sixteen females (17.8%) were enrolled in the study. Half of the patients were diagnosed as adenocarcinoma (50%). Investigation of the tumor location and mediastinal metastatic nodes revealed a statistically significant relationship between the apicoposterior segment of the left superior lobe and the left upper and lower paratracheal, subaortic, paraaortic, and left hilar regions according to the IASLC map. The sensitivity, specificity and accuracy of 18F-FDG PET/CT in the mediastinal nodes were 69.2%, 66.6%, and 68%, respectively. There was no statistically significant relationship between tumor location and 8th TNM Stage. Anatomical locations of non-small cell lung carcinomas can affect the disease stage and prognosis because of their tendency to metastasize to some mediastinal regions. However, this relationship needs to be investigated in larger study groups.

Validation of the Proposed cN2 Subclassification in the Eighth Edition of the IASLC Staging System: A Prospective Phase II Multicenter Study

Introduction

Surgery for N2 stage IIIA NSCLC is not recommended in major guidelines. Nevertheless, it has been noted that single-station N2 may have a better prognosis than multistation N2 and that surgery can be performed as the main therapeutic option.

Methods

We conducted a prospective phase II study for single-station clinical N2 (cN2) NSCLC to evaluate the efficacy and safety of surgical resection without induction therapy. Complete resection with lobectomy, bilobectomy, or pneumonectomy followed by ipsilateral mediastinal lymphadenectomy was performed in 32 of 34 enrolled patients, whereas the remaining two patients underwent incomplete resection. Three-quarters of the patients underwent subsequent adjuvant chemotherapy.

Results

The 5-year overall survival rate was 58.5% (95% confidence interval: 41.9–75.4) for all 34 patients, and eight patients (23.5%) with pN0 or pN1 seemed to have been enrolled. The 5-year overall survival rates for single-station cN2 without and with hilar node enlargement were 81.3% and 37.5%, respectively (p = 0.025). Surgical mortality was 0% for all, and no considerable perioperative complications were noted; however, two patients died of interstitial pneumonia and unknown cause within 3 months after surgical resection.

Conclusions

This is the very first prospective study on the surgical approach for cN2 NSCLC, and our result partially validated the proposed classification of the N descriptor in the new staging system. The treatment for single-station cN2 without hilar node enlargement would better if it were similar to that for cN1 disease. Induction chemotherapy or chemoradiotherapy may not be needed for such an entity.

Boundary between N1 and N2 Lymph Node Descriptors in the Subcarinal Zone in Lower Lobe Lung Cancer: A Brief Report

INTRODUCTION

In the International Association for the Study of Lung Cancer (IASLC) lymph node (LN) map, some LNs in the subcarinal space defined as #10 (N1) in the Naruke map were changed to #7 (N2). We aimed to validate the boundary between N1 and N2 in the subcarinal zone.

METHODS

We reviewed the records of 399 consecutive patients who had undergone complete resection for lower lobe non-small cell lung cancer. Involved lymph node stations were classified as N1 by both maps (N1 group), N1 by the Naruke map but reclassified as N2 by the IASLC map (#10 [subcarinal] group), and N2 by both maps (N2 group). The survival rates among these groups were compared using Kaplan-Meier and log-rank analyses.

RESULTS

LNs were classified as N0, N1, and N2 in 268, 67, and 64 patients, respectively, on the IASLC map and as N1 and N2 in 82 and 49 patients, respectively, on the Naruke map. The 5-year disease-free survival rates were 81.7% for N0, 50.9% for N1, 33.3% for the #10 (subcarinal) group, and 24.4% for N2. The rates of the N1 and #10 (subcarinal) groups were significantly different (p = 0.027), but those of the N2 and #10 (subcarinal) groups were not (p = 0.78). On multivariate analysis, metastatic disease in the LNs of #10 in the subcarinal space was an independent prognostic factor for patients classified as N1 on the Naruke map (hazard ratio = 2.47, 95% confidence interval: 1.17-4.85, p = 0.019).

CONCLUSION

All lymph nodes in the subcarinal space should be defined as #7 (N2) for prognosis.

[Lymphatic spread of lung cancer: anatomical lymph node chains unchained in zones]

Lung cancer is characterized by its lymphophilia. Its metastatic spread mainly occurs by tumor cells lymphatic drainage into the blood circulation. Initially, the lymph node TNM classification was based on clinical and therapeutic considerations, particularly concerning N2 involvement. The goals were to avoid futile exploratory thoracotomies without lung resection, to provide more accurate data from mediastinoscopy, and to take into account the radiation therapy fields. Since 1997, the international lymph node classification was more used to analyse the disparities within N1 and N2 groups. However, this attempt did not succeed in clarifying the lymphatic metastazing process, and was not progressing any more. Anatomy not being considered, it did not permit to grasp the anatomical and physiological significances of N2 and N3 involvement. In effect, this classification is now confined in zones and is lacking the anatomical and physiological descriptions that characterise the lymphatic pathways draining the lungs and their tumoral pathology. The stations proposed in numbers in cartographies should have gained in accuracy and in prognostic value if they had been expressed in their anatomical counterparts.

High dose involved field radiation therapy as salvage for loco-regional recurrence of non-small cell lung cancer

PURPOSE

To determine the effectiveness of salvage radiation therapy (RT) in patients with loco-regional recurrences (LRR) following initial complete resection of non-small cell lung cancer (NSCLC) and assess prognostic factors affecting survivals.

MATERIALS AND METHODS

Between 1994 and 2007, 64 patients with LRR after surgery of NSCLC were treated with high dose RT alone (78.1%) or concurrent chemo-radiation therapy (CCRT, 21.9%) at Samsung Medical Center. Twenty-nine patients (45.3%) had local recurrence, 26 patients (40.6%) had regional recurrence and 9 patients (14.1%) had recurrence of both components. The median RT dose was 54 Gy (range, 44-66 Gy). The radiation target volume included the recurrent lesions only.

RESULTS

The median follow-up time from the start of RT in survivors was 32.0 months. The rates of in-field failure free survival, intra-thoracic failure free survival and extra-thoracic failure free survival at 2 years were 52.3%, 33.9% and 59.4%, respectively. The median survival after RT was 18.5 months, and 2-year overall survival (OS) rate was 47.9%. On both univariate and multivariate analysis, the interval from surgery till recurrence and CCRT were significant prognostic factors for OS.

CONCLUSION

The current study demonstrates that involved field salvage RT is effective for LRR of NSCLC following surgery.

N1 non-small-cell lung cancer. A 20-year surgical experience

N1 non-small-cell lung cancer has heterogeneous prognosis in relation to node descriptors. There is no agreement on the ideal type of resection. A new classification of N1 descriptors was proposed in the 7th edition of the TNM staging system. A retrospective study was conducted on 384 patients with T1-T3N1 non-small-cell lung cancer who underwent complete pulmonary resection. The prognostic role of N1 descriptors according to the current and new staging systems and type of resection was investigated. The 5-year survival rate was 46%. Involvement of hilar node stations, multiple stations, and multiple nodes were poor prognostic factors (5-year survival, 33%, 21%, and 30%, respectively), as well as involvement of the hilar zone and multiple zones (5-year survival, 27% and 23%, respectively). Pneumonectomy showed significantly better survival rates compared to lobectomy or bilobectomy (5-year survival, 60% vs. 29%). Multivariate analysis showed that the number of N1 zones and type of resection were independent prognostic factors. Patients with hilar nodal, multiple-level, or multiple-zone involvement had poor prognosis. Standard lobectomy remains the procedure of choice, but in cases of fixed nodes in the hilar zone, sleeve resection or even pneumonectomy should be considered.

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

The lymphatic drainage of solid organ tumors crosses through the lymph nodes (LNs) whose tumoral involvement may still be considered as local disease. Concerning lung cancer, LN involvement may be intrapulmonary (N1), and mediastinal and/or extra-thoracic. More than 30 years ago, mediastinal involved LNs were all considered as N2, and outside the scope of surgery. In 1978, Naruke presented an original article entitled 'Lymph node mapping and curability at various levels of metastasis in resected lung cancer', demonstrating that N2 was not a contraindication to surgery in all patients. The map permitted to localize the favorable N2 on the lung cancer ipsilateral side of the mediastinum. Several maps ensued aiming to discriminate between right and left involvement (1983), and to distinguish N2 (ipsilateral) and N3 (contralateral) mediastinal LN involvement (1983, 1986). The last map (1997 regional LN classification) was recently replaced by a descriptive classification in anatomical zones. This new LN map of the TNM classification for lung cancer is a step toward using anatomical view points which might be the best way to better understand lung cancer lymphatic spread. Nowadays, the LNs are easily identified by current radiological imaging, and their resectability may be anticipated. Each LN chain may be removed by en-bloc lymphadenectomy performed during radical lung resection, a safe procedure which seems to be more oncological based than sampling, and which avoids the source of discrepancies pointed out during the labeling of LN stations by surgeons.

Prognostic significance of surgical-pathologic N1 lymph node involvement in non-small cell lung cancer

BACKGROUND

Patients with N1 non-small cell lung cancer represent a heterogeneous population with varying long-term survival. To better define the importance of N1 disease and its subgroups in non-small cell lung cancer staging, we analyzed patients with N1 disease using the sixth edition and proposed seventh edition TNM classifications.

METHODS

From January 1995 to November 2006, 540 patients with N1 non-small cell lung cancer who had at least lobectomy with systematic mediastinal lymphadenectomy were analyzed retrospectively.

RESULTS

For completely resected patients, the median survival rate and 5-year survival rate were 63 months and 50.3%, respectively. The 5-year survival rates for patients with hilar N1 (station 10), interlobar (station 11), and peripheral N1 (stations 12 to 14) involvement were 39%, 51%, and 53%, respectively. Patients with hilar lymph node metastasis showed a shorter survival period than patients with peripheral lymph node involvement (p = 0.02). Patients with hilar zone N1 (stations 10 and 11) involvement tended to show poorer survival than patients with peripheral zone N1 (12 to 14) metastasis (p = 0.08). Multiple-station lymph node metastasis indicated a poorer prognosis than single-station involvement (5-year survival 39% versus 51%, respectively, p = 0.01). Patients with multiple-zone N1 involvement showed poorer survival than patients with single-zone N1 metastasis (p = 0.04). A significant survival difference was observed between N1 patients with T1a versus T1b tumors (p = 0.02). Multivariate analysis revealed that only multiple-station lymph node metastasis was predictive of poor prognosis (p = 0.05).

CONCLUSIONS

Multiple-station versus single-station N1 disease and multiple-zone versus single-zone N1 involvement indicate poorer survival rate. Patients with hilar lymph node involvement had lower survival rates than patients with peripheral N1. The impact of T factor seemed to be veiled by the heterogenous nature of N1 disease. Further studies of adjusted postoperative strategies for different N1 subgroups are warranted.

Prognostic Variability in Completely Resected pN1 Non-Small-Cell Lung Cancer

We used the Tuscan Cancer Registry archives to retrieve records of 2,896 patients with a histological diagnosis of lung tumor from January 1996 to December 2000. Of 2,410 patients with non-small-cell lung cancer, 767 (31.8%) underwent complete resection. The following variables were analyzed for their influence on survival in the 157 patients with pathologic N1 status: sex, age, cell type, pathologic tumor status, number and level of involved lymph nodes, tumor grade, and type of surgery. Overall 5-year survival rates were 43.9% for 417 patients with pN0 disease, 10.8% for 176 with pN2 disease, and 31.6% for those with pN1 disease. In pN1 disease, the overall 5-year survival rates for patients with hilar and non-hilar lymph node involvement were 27.4% and 39.6%, respectively. Univariate analysis demonstrated that pathological T status and level of N1 involvement weresignificant prognostic factors. Cox proportional hazards analysis indicated that hilar lymph node involvement was an independent prognostic factor. N1 lymph node status was identified as an independent prognostic factor in a combination of subgroups with different prognoses.

Significance of extranodal extension of regional lymph nodes in surgically resected non-small cell lung cancer

STUDY OBJECTIVES

Regional lymph node (LN) involvement affects the prognosis of patients with surgically resected non-small cell lung cancer (NSCLC). The significance of extranodal extension in these groups of patients was prospectively studied to determine its clinicopathologic relationships and its influence on patient survival.

METHODS

A total of 199 NSCLC patients who were proved to have regional LN involvement after resection were included. Histologic examinations including tumor cell type, grade of differentiation, vascular invasion, regional LN metastasis emphasizing the number and station of LN involvement, the presence or absence of extranodal extension, and the immunohistochemistry of p53 expression were obtained. The relationships between extranodal extension and histologic type, grade of differentiation, vascular invasion, tumor size, pathologic stage, p53 expression, or patient survival were analyzed.

RESULTS

Extranodal extension was significantly higher in women, adenocarcinoma, advanced stage, tumors with vascular invasion, or p53 overexpression. The total number and positive rate of resected LNs with extranodal extension were significantly correlated with advanced stage, tumors with vascular invasion, or p53 overexpression. By multivariate analysis of survival, the presence or total number of LNs with extranodal extension, tumor stage, and p53 expression were significant prognostic factors. The 5-year survival rate of stage IIIA patients without extranodal extension (30.4%) was significantly better than that of stage II patients with extranodal extension (16.8%). No survival difference between extranodal positive stage II and IIIA patients was noted.

CONCLUSIONS

Extranodal extension of regional LNs is an important prognostic factor in patients with surgically resected NSCLC.

Expression of macrophage-derived chemokine (MDC)/CCL22 in human lung cancer

BACKGROUND

Ligands for CXCR3 chemokines [IFN-gamma-inducible protein of 10 kD (IP-10/CXCL10), monokine induced by IFN-gamma (Mig/CXCL9), IFN-inducible T cell alpha chemoattractant (I-TAC/CXCL11)] and those for CCR4 [macrophage-derived chemokine (MDC/CCL22), thymus- and activation-regulated chemokine (TARC/CCL17)] have been shown to play the central roles for T helper-cell recruitment into the tissues. To examine the role of these chemokines in tumor progression of lung cancer, we investigated their expression in human lung cancer tissues to determine the possible relationship between their expression and the prognosis of patients.

METHODS

Total RNA was prepared from lung cancer tissues of 40 patients (24 adenocarcinoma and 16 squamous cell carcinoma). We measured gene expression levels of chemokines (IP-10, Mig, I-TAC, MDC and TARC) by real-time quantitative RT-PCR.

RESULTS

Higher gene expression of MDC in lung cancer was significantly correlated with longer disease-free survival time and lower risk of recurrence after tumor resection. We could not find any significant relationship of IP-10, Mig, I-TAC and TARC gene expression with disease-free survival or lower risk of recurrence after surgery.

CONCLUSIONS

These results suggest that increased gene expression of MDC in tumor tissues may be a predictive marker for improving the prognosis of lung cancer.

[Lung cancer and lymph drainage]

Lung cancer is lymphophile and may involve lymph nodes (LN) belonging to lung lymph drainage. LN metastases are figured within stations numbered 1 to 14. These stations are located along lymph vessels. The lymph vessels and the LN are forming together anatomical chains. Lymph vessels are valved and pulsatile and travel to the cervical venous confluence where they pour the lung lymph into the blood circulation. They may be totally or partly nodeless along their travel, anastomose with each other around the trachea, and connect with the thoracic duct within the mediastinum. Within the anatomical LN chains, LN are variable in number and in size from one individual to another. They may be absent from one or several stations of the international mapping. Stations are located along the anatomical chains: pulmonary ligament (9), tracheal bifurcation(8 and 7), right paratracheal (4R, 2R and 1), preaortic (5 and 6), left paratracheal (4L, 2L and 1). Station 3 is located on 2 differents chains (phrenic and right esophagotracheal). Station 10 are located at the beginning of the mediastinal lymph nodes chains. Each chain connects with the blood circulation, anastomoses with he neighbouring chains and behave as an own entity whatever the number of its LN. International station mapping misknowns this anatomy and occults the true pronostic value of lung lymph drainage.

Problems in pathologic staging of lung cancer

CONTEXT

Tumor stage is the most important prognostic and predictive factor for patients with lung cancer, the most lethal neoplasm in the United States. It is used by thoracic surgeons, radiation therapists, and oncologists to determine whether patients with these neoplasms will be treated surgically with curative intent or with palliative radiation therapy and/or chemotherapy.

OBJECTIVE

To review the variety of practical problems that can arise during the assessment of the pathologic stage and other prognostic/predictive factors included in the College of American Pathologist checklist for evaluation of resected lung neoplasms.

DATA SOURCES

Potential practical difficulties that can arise during the pathologic staging of lung cancer patients include the distinction between pT1, pT2, and pT3 lesions based on their location and the presence of visceral pleura and/or parietal pleura invasion; the differential diagnosis between multiple synchronous or metachronous primary lung neoplasms (pT1m) and intrapulmonary metastasis of non-small cell carcinoma of the lung (pT4 or pM1 according to their location); and the role of the recent American Joint Committee on Cancer terminology for the classification of lymph nodes (isolated tumor cells, micrometastases, and metastases).

CONCLUSIONS

The variety of practical problems that can arise during the assessment of important prognostic and predictive features such as resection margin status and evaluation of lymphovascular invasion are reviewed. A brief discussion of the assessment of the effects of neoadjuvant therapy on resected lung neoplasms is also included.

Prognostic variability among nonsmall cell lung cancer patients with pathologic N1 lymph node involvement

BACKGROUND

Patients who have nonsmall cell lung cancer with N1 lymph node status are an intermediate group of patients who have a variable prognosis. Differences in lymph node level (hilar or pulmonary lymph nodes) may influence patient survival. The authors retrospectively analyzed the factors that influenced prognosis, including the level of N1 lymph node involvement.

METHODS

The authors used the Tuscan Cancer Registry archives to retrieve records on 2523 patients who had lung tumors diagnosed during the period from 1996 and 1998 in the provinces of Florence and Prato, central Italy. To analyze the survival of patients according to the level of lymph node involvement, the prognoses of patients with nonsmall cell lung cancer who had N1 lymph node status were compared in a population-based case series. Among 112 patients with pathologic N1 status, the following variables were analyzed for their influence on postoperative survival: gender, age, cell type, pathologic tumor status, the number of metastatic lymph nodes, the level of metastatic lymph nodes (hilar or pulmonary), and the type of surgical resection.

RESULTS

The 5-year survival rates for patients who had involvement of pulmonary and hilar lymph nodes were 41.2% and 21.8%, respectively (P =.005). A Cox proportional hazards model analysis indicated that the presence of hilar lymph node involvement was an independent prognostic factor.

CONCLUSIONS

N1 pathologic lymph node status was identified in a combination of subgroups with different prognoses, and the presence of hilar lymph node disease had prognostic significance. This difference in survival may lead to the use of different therapies for these subgroups of patients with pathologic N1 non-small cell lung cancer.

Prognostic factors in non-small cell lung cancer surgery

AIMS

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

METHODS

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

RESULTS

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

CONCLUSIONS

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.