Zhou Yingjun, Xiao Pan, Li Yunhua, Liu Haibo, Jiang Dengke, Shuai Zhifeng
Department of Radiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, China.
Graguate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Xiangtan, Hunan, 421000, China.
Cancer Radiother. 2025 Apr;29(2):104611. doi: 10.1016/j.canrad.2025.104611. Epub 2025 Apr 17.
The traditional N staging system fails to adequately stratify the prognostic heterogeneity in patients with resectable node-positive, stage III, non-small cell lung cancer, particularly in those undergoing postoperative radiotherapy. The purpose of this study was to determine the optimal nodal status classification strategy: the traditional N classification, the positive lymph nodes-based classification, or the lymph node ratio-based classification. Furthermore, we aimed to identify the population that would benefit the most from postoperative radiotherapy using the best classification strategy.
We analysed data from 5028 patients with resectable node-positive, stage III, non-small cell lung cancer sourced from the Surveillance, Epidemiology, and End Results (SEER) database. Various lymph node staging systems, including traditional N staging, classification based on the number of positive lymph nodes, and classification based on the lymph node ratio, were incorporated into the prognostic prediction model. Survival outcomes were evaluated using lung cancer-specific survival and Kaplan-Meier analysis.
The lymph node ratio classification model demonstrated the highest prognostic prediction performance, with the highest C-index, area under the curve, and the lowest Akaike information criterion, followed by the positive lymph nodes classification model and the traditional N staging model. Prognostic stratification analysis based on different lymph node staging systems indicated that a lymph node ratio greater than 0.28 and more than three positive lymph nodes were associated with a high-risk prognosis. Furthermore, postoperative radiotherapy significantly improved lung cancer-specific survival in overall resectable node-positive, stage III, non-small cell lung cancer (P<0.05). Notably, survival curve analysis revealed the most pronounced differences in lung cancer-specific survival between the groups receiving postoperative radiotherapy or not in the high-risk prognosis group, particularly among those with a lymph node ratio greater than 0.28, and more than three positive lymph nodes, and lastly the traditional N staging model.
In patients with resectable node-positive, stage III, non-small cell lung cancer, classification according to the lymph node ratio, followed by the positive lymph nodes, may offer superior prognostic prediction capabilities compared to the traditional N staging in addressing prognostic heterogeneity. Additionally, identifying a high-risk prognosis with a lymph node ratio greater than 0.28 appears to be the most effective criterion for selecting candidates who would benefit from postoperative radiotherapy.
传统的N分期系统未能充分区分可切除的淋巴结阳性Ⅲ期非小细胞肺癌患者的预后异质性，尤其是那些接受术后放疗的患者。本研究的目的是确定最佳的淋巴结状态分类策略：传统的N分类、基于阳性淋巴结的分类或基于淋巴结比率的分类。此外，我们旨在使用最佳分类策略确定从术后放疗中获益最大的人群。
我们分析了来自监测、流行病学和最终结果（SEER）数据库的5028例可切除的淋巴结阳性Ⅲ期非小细胞肺癌患者的数据。各种淋巴结分期系统，包括传统的N分期、基于阳性淋巴结数量的分类和基于淋巴结比率的分类，被纳入预后预测模型。使用肺癌特异性生存率和Kaplan-Meier分析评估生存结果。
淋巴结比率分类模型显示出最高的预后预测性能，C指数、曲线下面积最高，赤池信息准则最低，其次是阳性淋巴结分类模型和传统N分期模型。基于不同淋巴结分期系统的预后分层分析表明，淋巴结比率大于0.28和三个以上阳性淋巴结与高风险预后相关。此外，术后放疗显著改善了总体可切除的淋巴结阳性Ⅲ期非小细胞肺癌患者的肺癌特异性生存率（P<0.05）。值得注意的是，生存曲线分析显示，在高风险预后组中，接受或未接受术后放疗的组之间肺癌特异性生存率的差异最为明显，特别是在淋巴结比率大于0.28、三个以上阳性淋巴结的患者中，最后是传统N分期模型。
在可切除的淋巴结阳性Ⅲ期非小细胞肺癌患者中，与传统N分期相比，根据淋巴结比率分类，其次是阳性淋巴结分类，在解决预后异质性方面可能具有更好的预后预测能力。此外，确定淋巴结比率大于0.28的高风险预后似乎是选择从术后放疗中获益的患者的最有效标准。
