Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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Prognostic Implications of Selective Dissection of Left Lower Paratracheal Lymph Nodes in Patients with Left-Sided Non-Small Cell Lung Cancer

  • Hyo Kyen Park (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Yelee Kwon (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Geun Dong Lee (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Sehoon Choi (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Hyeong Ryul Kim (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Yong-Hee Kim (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Dong Kwan Kim (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Seung-Il Park (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Jae Kwang Yun (Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine)
  • Received : 2024.03.04
  • Accepted : 2024.06.13
  • Published : 2024.09.05
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Abstract

Background: This study aimed to examine the clinical implications of selective station 4L lymph node dissection (S4L-LND) on survival in non-small cell lung cancer (NSCLC) and to evaluate its potential advantages. Methods: We enrolled patients with primary left-sided NSCLC who underwent upfront video-assisted thoracoscopic surgery with R0 resection including lobectomy and segmentectomy, with or without S4L-LND, at our institution between January 2007 and December 2021. Following 1:1 propensity score matching (PSM), we compared overall survival (OS) and recurrence-free survival (RFS) between patients with and without S4L-LND. Results: The study included 2,601 patients, of whom 1,126 underwent S4L-LND and 1,475 did not. PSM yielded 1,036 patient pairs. Among those who underwent S4L-LND, 87 (7.7%) exhibited S4L-LN involvement. Neither OS (p=0.12) nor RFS (p=0.24) differed significantly between matched patients with and without S4L-LND. In patients with S4L-LN involvement, metastases were more common in the left upper lobe (LUL) than in the left lower lobe (LLL) (3.6% vs. 2.0%, p=0.061). Metastasis became significantly more frequent with more advanced clinical N (cN) stage (cN0, 2.3%; cN1, 5.8%; cN2, 32.6%; p<0.001). Multivariate logistic regression analysis revealed that cN stage and tumor location were independently associated with S4L-LN involvement (p<0.001 for both). Conclusion: OS and RFS did not differ significantly between matched patients with and without S4L-LND. Among participants with S4L-LN involvement, metastases occurred more frequently in the LUL than the LLL, and their incidence increased significantly with more advanced cN stage. Thus, patients with LUL or advanced cN lung cancers may benefit from S4L-LND.

Keywords

Acknowledgement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.

References

  1. Takenaka T, Katsura M, Shikada Y, Takeo S. Outcome of surgical resection as a first line therapy in T3 non-small cell lung cancer patients. World J Surg 2013;37:2574-80. https://doi.org/10.1007/s00268-013-2174-7
  2. Whitson BA, Groth SS, Maddaus MA. Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer. Ann Thorac Surg 2007;84:1059-65. https://doi.org/10.1016/j.athoracsur.2007.04.032
  3. Watanabe S, Asamura H. Lymph node dissection for lung cancer: significance, strategy, and technique. J Thorac Oncol 2009;4:652-7. https://doi.org/10.1097/jto.0b013e31819cce50
  4. Darling GE, Allen MS, Decker PA, et al. Number of lymph nodes harvested from a mediastinal lymphadenectomy: results of the randomized, prospective American College of Surgeons Oncology Group Z0030 trial. Chest 2011;139:1124-9. https://doi.org/10.1378/chest.10-0859
  5. Darling GE, Allen MS, Decker PA, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg 2011;141:662-70. https://doi.org/10.1016/j.jtcvs.2010.11.008
  6. Wu Yl, Huang ZF, Wang SY, Yang XN, Ou W. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 2002;36:1-6. https://doi.org/10.1016/s0169-5002(01)00445-7
  7. Lardinois D, Suter H, Hakki H, Rousson V, Betticher D, Ris HB. Morbidity, survival, and site of recurrence after mediastinal lymphnode dissection versus systematic sampling after complete resection for non-small cell lung cancer. Ann Thorac Surg 2005;80:268-74. https://doi.org/10.1016/j.athoracsur.2005.02.005
  8. Lardinois D, De Leyn P, Van Schil P, et al. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Eur J Cardiothorac Surg 2006;30:787-92. https://doi.org/10.1016/j.ejcts.2006.08.008
  9. Rami-Porta R, Wittekind C, Goldstraw P; International Association for the Study of Lung Cancer (IASLC) Staging Committee. Complete resection in lung cancer surgery: proposed definition. Lung Cancer 2005;49:25-33. https://doi.org/10.1016/j.lungcan.2005.01.001
  10. Deng HY, Li D, Qiu XM, Zhu DX, Tang X, Zhou Q. Dissection of 4L lymph node for left-sided non-small cell lung cancer: a meta-analysis. ANZ J Surg 2021;91:E696-702. https://doi.org/10.1111/ans.17131
  11. Yun JK, Bok JS, Lee GD, et al. Long-term outcomes of upfront surgery in patients with resectable pathological N2 non-small-cell lung cancer. Eur J Cardiothorac Surg 2020;58:59-69. https://doi.org/10.1093/ejcts/ezaa042
  12. Yun JK, Kim YH. ASO author reflections: could VAMLA be a therapeutic strategy in selected patients with left-sided NSCLC? Ann Surg Oncol 2022;29:2840-1. https://doi.org/10.1245/s10434-021-11232-2
  13. D'Agostino RB. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998;17:2265-81. https://doi.org/10.1002/(sici)1097-0258(19981015)17:19%3C2265::aid-sim918%3E3.0.co;2-b
  14. Wang YN, Yao S, Wang CL, et al. Clinical significance of 4L lymph node dissection in left lung cancer. J Clin Oncol 2018;36:2935-42. https://doi.org/10.1200/jco.2018.78.7101
  15. Zhao K, Wei S, Mei J, et al. Survival benefit of left lower paratracheal (4L) lymph node dissection for patients with left-sided non-small cell lung cancer: once neglected but of great importance. Ann Surg Oncol 2019;26:2044-52. https://doi.org/10.1245/s10434-019-07368-x
  16. Gryszko GM, Cackowski MM, Zbytniewski M, et al. The impact of left lower paratracheal (4L) lymph node dissection on survival in patients with surgically treated left-sided NSCLC. Eur J Cardiothorac Surg 2021;60:1201-9. https://doi.org/10.1093/ejcts/ezab294
  17. Liang W, He J, Shen Y, et al. Impact of examined lymph node count on precise staging and long-term survival of resected non-small-cell lung cancer: a population study of the US SEER Database and a Chinese multi-institutional registry. J Clin Oncol 2017;35:1162-70. https://doi.org/10.1200/jco.2016.67.5140
  18. Watanabe Y, Shimizu J, Oda M, et al. Improved survival in left nonsmall-cell N2 lung cancer after more extensive operative procedure. Thorac Cardiovasc Surg 1991;39:89-94. https://doi.org/10.1055/s-2007-1013939
  19. Kuroda H, Sakao Y, Mun M, et al. Lymph node metastases and prognosis in left upper division non-small cell lung cancers: the impact of interlobar lymph node metastasis. PLoS One 2015;10:e0134674. https://doi.org/10.1371/journal.pone.0134674
  20. Yang MZ, Hou X, Li JB, et al. Impact of L4 lymph node dissection on long-term survival in left-side operable non-small-cell lung cancer: a propensity score matching study. Eur J Cardiothorac Surg 2020;57:1181-8. https://doi.org/10.1093/ejcts/ezaa008
  21. Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e211S-e250S. https://doi.org/10.1378/chest.12-2355
  22. Lin J, Fernandez F. Indications for invasive mediastinal staging for non-small cell lung cancer. J Thorac Cardiovasc Surg 2018;156:2319-24. https://doi.org/10.1016/j.jtcvs.2018.07.027