Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Institute of Thoracic Oncology, Fudan University, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.
Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Institute of Thoracic Oncology, Fudan University, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.
Lung Cancer. 2022 Aug;170:141-147. doi: 10.1016/j.lungcan.2022.06.018. Epub 2022 Jun 29.
OBJECTIVE: The optimal extent of lymph node dissection (LND) remains controversial. We aimed to investigate whether the addition of station 4L lymph node dissection (S4L-LND) was beneficial for non-small cell lung cancer (NSCLC). METHODS: Data on 1040 left-sided NSCLC patients undergoing rigorous systematic LND were retrospectively reviewed. Multivariate logistic regression analysis determined risk factors of station 4L (S4L) nodal involvement to facilitate risk stratified analysis of the significance of S4L-LND. Propensity score matching (PSM) was conducted to reduce disparities of baseline characteristics between S4L-LND group and no-S4L-LND group. Recurrence-free survival (RFS), overall survival (OS), and postoperative complications were compared. RESULTS: S4L-LND was performed in 586 (56.3%) patients. The S4L nodal involvement rate was 15.5% (91/586). Aortopulmonary zone nodes involvement (P < 0.001), N1 nodes involvement (P < 0.001), and advanced T stage (P = 0.015) were independent risk factors of S4L nodal involvement. Patients with ≥ 2 risk factors of S4L nodal involvement were classified as high risk group, and the others were classified as low risk group. Among patients with negative aortopulmonary zone nodes and inferior mediastinal nodes (n = 425), only 28 (6.6%) patients had S4L involvement. After PSM, a total of 416 pairs were well matched. There was no significant survival difference between S4L-LND group and no-S4L-LND group (OS, P = 0.247; RFS, P = 0.569). When stratified by risk subgroup, S4L-LND group did not demonstrate superior survival than no-S4L-LND group in the high risk group (OS, P = 0.273; RFS, P = 0.754) or the low risk group (OS, P = 0.558; RFS, P = 0.319). S4L-LND group demonstrated significantly greater risk of postoperative complications than no-S4L-LND group (9.6% vs. 5.8%; P = 0.037). CONCLUSIONS: S4L involvement was not rare and usually occurred with multiple nodal stations involvement. Routine dissection of aortopulmonary zone and inferior mediastinal nodes was sufficient to ensure staging accuracy. The addition of S4L-LND did not improve survival, but might increase the risk of postoperative complications.
目的：淋巴结清扫术（LND）的最佳范围仍存在争议。本研究旨在探讨是否需要进行第 4L 站淋巴结清扫术（S4L-LND）。
方法：回顾性分析了 1040 例接受严格系统 LND 的左侧非小细胞肺癌（NSCLC）患者的数据。多因素 logistic 回归分析确定了 S4L 淋巴结受累的危险因素，以利于 S4L-LND 意义的风险分层分析。采用倾向评分匹配（PSM）来减少 S4L-LND 组和非 S4L-LND 组之间基线特征的差异。比较无复发生存期（RFS）、总生存期（OS）和术后并发症。
结果：586 例（56.3%）患者行 S4L-LND。S4L 淋巴结受累率为 15.5%（91/586）。主动脉肺动脉区淋巴结受累（P<0.001）、N1 淋巴结受累（P<0.001）和 T 分期较晚（P=0.015）是 S4L 淋巴结受累的独立危险因素。有≥2 个 S4L 淋巴结受累危险因素的患者被分为高危组，其余为低危组。在阴性主动脉肺动脉区和下纵隔淋巴结的患者（n=425）中，仅 28 例（6.6%）患者有 S4L 受累。PSM 后，共配对 416 对。S4L-LND 组与无 S4L-LND 组的 OS （P=0.247）和 RFS （P=0.569）差异无统计学意义。按风险亚组分层后，高危组 S4L-LND 组的 OS （P=0.273）和 RFS （P=0.754）或低危组 OS （P=0.558）和 RFS （P=0.319）均未显示出优于无 S4L-LND 组的生存优势。S4L-LND 组术后并发症的风险明显高于无 S4L-LND 组（9.6% vs. 5.8%；P=0.037）。
结论：S4L 受累并不少见，通常与多个淋巴结站受累有关。常规清扫主动脉肺动脉区和下纵隔淋巴结足以确保分期准确性。增加 S4L-LND 并不能提高生存率，但可能增加术后并发症的风险。
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