Heiden Brendan T, Eaton Daniel B, Chang Su-Hsin, Yan Yan, Schoen Martin W, Patel Mayank R, Kreisel Daniel, Nava Ruben G, Meyers Bryan F, Kozower Benjamin D, Puri Varun
Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
VA St. Louis Health Care System, St. Louis, Missouri.
J Thorac Oncol. 2022 Nov;17(11):1287-1296. doi: 10.1016/j.jtho.2022.08.009. Epub 2022 Aug 30.
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.
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.
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.
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.
美国外科医师学会癌症委员会最近将其对早期非小细胞肺癌的采样建议从至少10个淋巴结更新为至少一个N1（肺门）和三个N2（纵隔）淋巴结站。然而，术中淋巴结采样的最低标准仍存在争议。我们试图在早期非小细胞肺癌患者中评估这些指南。
我们使用退伍军人健康管理局独特汇编的数据集进行了一项队列研究。我们手动提取了接受手术的临床I期非小细胞肺癌患者（2006 - 2016年）手术记录和病理报告中的数据。淋巴结采样的充分性根据基于计数（≥10个淋巴结）和基于站数（≥三个N2和一个N1淋巴结站）的最低标准来定义。我们的主要结局是无复发生存期。次要结局是总生存期和病理分期上调。
该研究纳入了9749例患者。分别有3302例（33.9%）和2559例患者（26.3%）达到了基于计数和基于站数的采样指南，随着时间推移，遵循任何一种采样指南的比例从2006年的35.6%增至2016年的49.1%。遵循基于站数的采样与改善无复发生存期相关（多变量调整风险比 = 0.815，95%置信区间：0.667 - 0.994，p = 0.04），而遵循基于计数的采样则不然（调整风险比 = 0.904，95%置信区间：0.757 - 1.078，p = 0.26）。遵循基于站数或基于计数的指南均与改善总生存期和更高的病理分期上调可能性相关。
我们的研究支持对早期非小细胞肺癌采用基于站数的采样最低标准（≥三个N2和一个N1淋巴结站）；然而，与基于计数的指南相比，其边际效益极小。进一步努力促进广泛遵循术中淋巴结采样最低标准对于改善根治性肺癌切除术后患者的结局至关重要。
