Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Data Sciences, Dana Farber Cancer Institute, Boston, Massachusetts.
Semin Thorac Cardiovasc Surg. 2021 Autumn;33(3):834-845. doi: 10.1053/j.semtcvs.2020.11.007. Epub 2020 Nov 9.
Analyze "number of nodes" as an integer-valued variable to identify possible minimum lymph node (LN) number to sample during lung cancer resection. The National Cancer Database (NCDB) queried 2004-14 for surgically treated clinical stage I/II non-small-cell lung cancer (NSCLC). Overall survival (OS) by number of LN sampled was examined for the complete dataset, by adenocarcinoma, and by degree of resection using number of sampled LN both as integer-valued (0-30 nodes) variable and collapsed into classes. A total of 102,225 patients were analyzed. Median sampled LNs were 7. Median overall survival was 59 months if no LNs were sampled (95% confidence interval [CI]: 57.0-62.4), 74.7 months for 1 sampled LN (95% CI: 69.6-78.1), 80.2 (95% CI: 74.2-85.6) for 2 sampled LN, up to 81.5 mos. for 29 sampled LN. A Cox regression model using "0 LN" as baseline level, showed association with increased overall survival starting at 1 LN (hazard ratio [HR] 0.81, 95% CI 0.76-0.87; P <0.001). A "moving baseline" Cox regression model, showed no additional benefit when sampling additional nodes. We noticed a decreasing, linear association between OS and a number of 0-5 sampled LNs, most pronounced between 0 and 1 LN sampled, using a martingale residual plot from a null Cox model; no association was observed for more sampled LNs. For patients undergoing lobectomy, difference in OS was noted between 0 and 1LN sampled but not between 2 and 30 LN. These differences were not statistically significant until the number of 4 removed LN (respectively 3 for wedge-resections). For segmentectomies, median survival was not statistically associated with number of LN sampled. Based on NCDB data, LN sampling for lung cancer resections is recommended. Lobectomy survival is positively associated with 4 LN sampled, but ideal sampling may lie at 5LN in most cases. NCDB data does not seem to justify the quality metric of minimum 10 LNs.
分析“淋巴结数量”作为一个整数值变量，以确定在肺癌切除术中可能需要采样的最小淋巴结数量。国家癌症数据库（NCDB）在 2004 年至 2014 年期间对接受手术治疗的临床 I/II 期非小细胞肺癌（NSCLC）患者进行了调查。对完整数据集、腺癌和切除程度分别按淋巴结采样数量进行了检查，采用了淋巴结采样数量作为整数值（0-30 个淋巴结）变量和分类变量。共分析了 102225 例患者。中位淋巴结采样数为 7 个。如果不采样淋巴结，中位总生存期为 59 个月（95%置信区间[CI]：57.0-62.4），1 个淋巴结采样的总生存期为 74.7 个月（95%CI：69.6-78.1），2 个淋巴结采样的总生存期为 80.2 个月（95%CI：74.2-85.6），而 29 个淋巴结采样的总生存期高达 81.5 个月。以“无淋巴结”为基线水平的 Cox 回归模型显示，从 1 个淋巴结开始，与总生存时间延长相关（危险比[HR]0.81，95%CI0.76-0.87；P<0.001）。一个“移动基线”Cox 回归模型显示，当采样更多淋巴结时，没有额外的获益。从 Cox 模型的 martingale 残差图中可以看出，我们注意到 OS 与 0-5 个采样淋巴结的数量之间存在下降的线性关系，在采样 0-1 个淋巴结时最为明显，而对于更多的采样淋巴结则没有观察到这种关系。对于接受肺叶切除术的患者，观察到 0 个和 1 个淋巴结采样之间的 OS 差异，但 2 个和 30 个淋巴结之间没有差异。直到切除 4 个淋巴结（楔形切除术为 3 个）时，这些差异才具有统计学意义。对于节段切除术，中位生存时间与淋巴结采样数量无统计学相关性。基于 NCDB 数据，建议对肺癌切除术进行淋巴结采样。肺叶切除术的生存与 4 个淋巴结采样呈正相关，但在大多数情况下，理想的采样可能为 5 个淋巴结。NCDB 数据似乎不能证明最低 10 个淋巴结的质量指标是合理的。
