Subramanian Melanie P, Eaton Daniel B, Heiden Brendan T, Brandt Whitney S, Labilles Ulysses L, Chang Su-Hsin, Yan Yan, Schoen Martin W, Patel Mayank R, Kreisel Daniel, Nava Ruben G, Thomas Theodore, Meyers Bryan F, Kozower Benjamin D, Puri Varun
Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
Veterans Affairs St Louis Health Care System, St Louis, Mo.
JTCVS Open. 2023 Nov 23;17:271-283. doi: 10.1016/j.xjon.2023.11.009. eCollection 2024 Feb.
Adequate intraoperative lymph node (LN) assessment is a critical component of early-stage non-small cell lung cancer (NSCLC) resection. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer (CoC) recommend station-based sampling minimums agnostic to tumor location. Other institutions advocate for lobe-specific LN sampling strategies that consider the anatomic likelihood of LN metastases. We examined the relationship between lobe-specific LN assessment and long-term outcomes using a robust, highly curated cohort of stage I NSCLC patients.
We performed a cohort study using a uniquely compiled dataset from the Veterans Health Administration and manually abstracted data from operative and pathology reports for patients with clinical stage I NSCLC (2006-2016). For simplicity in comparison, we included patients who had right upper lobe (RUL) or left upper lobe (LUL) tumors. Based on modified European Society of Thoracic Surgeons guidelines, lobe-specific sampling was defined for RUL tumors (stations 2, 4, 7, and 10 or 11) and LUL tumors (stations 5 or 6, 7, and 10 or 11). Our primary outcome was the risk of cancer recurrence, as assessed by Fine and Gray competing risks modeling. Secondary outcomes included overall survival (OS) and pathologic upstaging. Analyses were adjusted for relevant patient, disease, and treatment variables.
Our study included 3534 patients with RUL tumors and 2667 patients with LUL tumors. Of these, 277 patients (7.8%) with RUL tumors and 621 patients (23.2%) with LUL tumors met lobe-specific assessment criteria. Comparatively, 34.7% of patients met the criteria for count-based assessment, and 25.8% met the criteria for station-based sampling (ie, any 3 N2 stations and 1 N1 station). Adherence to lobe-specific assessment was associated with lower cumulative incidence of recurrence (adjusted hazard ratio [aHR], 0.83; 95% confidence interval [CI], 0.70-0.98) and a higher likelihood of pathologic upstaging (aHR, 1.49; 95% CI, 1.20-1.86). Lobe-specific assessment was not associated with OS.
Adherence to intraoperative LN sampling guidelines is low. Lobe-specific assessment is associated with superior outcomes in early-stage NSCLC. Quality metrics that assess adherence to intraoperative LN sampling, such as the CoC Operative Standards manual, also should consider lobe-specific criteria.
充分的术中淋巴结（LN）评估是早期非小细胞肺癌（NSCLC）切除术的关键组成部分。美国国立综合癌症网络和美国外科医师学会癌症委员会（CoC）推荐基于站的采样最小值，而不考虑肿瘤位置。其他机构主张采用考虑LN转移解剖学可能性的叶特异性LN采样策略。我们使用一组强大的、经过高度整理的I期NSCLC患者队列，研究了叶特异性LN评估与长期预后之间的关系。
我们进行了一项队列研究，使用了退伍军人健康管理局独特汇编的数据集，并手动提取了临床I期NSCLC患者（2006 - 2016年）手术和病理报告中的数据。为了便于比较，我们纳入了右上叶（RUL）或左上叶（LUL）肿瘤患者。根据修改后的欧洲胸外科医师协会指南，RUL肿瘤（第2、4、7和10或11站）和LUL肿瘤（第5或6、7和10或11站）定义了叶特异性采样。我们的主要结局是癌症复发风险，通过Fine和Gray竞争风险模型进行评估。次要结局包括总生存期（OS）和病理分期上调。分析对相关的患者、疾病和治疗变量进行了调整。
我们的研究纳入了3534例RUL肿瘤患者和2667例LUL肿瘤患者。其中，277例（7.8%）RUL肿瘤患者和621例（23.2%）LUL肿瘤患者符合叶特异性评估标准。相比之下，34.7%的患者符合基于计数的评估标准，25.8%的患者符合基于站的采样标准（即任何3个N2站和1个N1站）。坚持叶特异性评估与较低的复发累积发生率相关（调整后风险比[aHR]，0.83；95%置信区间[CI]，0.70 - 0.98），且病理分期上调的可能性更高（aHR，1.49；95%CI，1.20 - 1.86）。叶特异性评估与OS无关。
术中LN采样指南的依从性较低。叶特异性评估与早期NSCLC的更好结局相关。评估术中LN采样依从性的质量指标，如CoC手术标准手册，也应考虑叶特异性标准。
