A National Study of Nodal Upstaging After Thoracoscopic Versus Open Lobectomy for Clinical Stage I Lung Cancer

doi:10.1016/j.athoracsur.2013.04.011

The Annals of Thoracic Surgery

Volume 96, Issue 3, September 2013, Pages 943-950

Presented at the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013.

https://doi.org/10.1016/j.athoracsur.2013.04.011 Get rights and content

Background

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) occurs when unsuspected lymph node metastases are found during the final evaluation of surgical specimens. Recent data from The Society of Thoracic Surgery (STS) database demonstrated significantly lower nodal upstaging after thoracoscopic (VATS) lobectomy than after thoracotomy. STS data, however, may be biased from voluntary reporting, and survival was not investigated. We used a complete national registry to compare nodal upstaging and survival after lobectomy by VATS or thoracotomy.

Methods

The Danish Lung Cancer Registry was used to identify patients who underwent lobectomy for clinical stage I NSCLC from 2007 to 2011. Patient demographics, comorbidity, preoperative staging, surgical approach, number of lymph nodes harvested, final pathology, and survival were evaluated. Nodal upstaging was identified by comparing cT N M with pT N M.

Results

Lobectomy for clinical stage I NSCLC was performed in 1,513 patients: 717 (47%) by VATS and 796 (53%) by thoracotomy. Nodal upstaging occurred in 281 patients (18.6%) and was significantly higher after thoracotomy for N1 upstaging (13.1% vs 8.1%; p < 0.001) and N2 upstaging (11.5% vs 3.8%; p < 0.001). Overall unadjusted survival was significantly higher after VATS, but after adjusting for differences in sex, age, comorbidity, and pT N M by Cox regression analysis, we found no difference between VATS and thoracotomy (hazard ratio, 0.98; 95% confidence interval, 0.80 to 1.22, p = 0.88).

Conclusions

National data confirm that nodal upstaging was lower after VATS than after open lobectomy for clinical stage I NSCLC. Multivariate survival analysis, however, showed no difference in survival, indicating that differences in nodal upstaging result from patient selection for reasons not captured in our registry.

Section snippets

Patients and Methods

In accordance with Danish law, the National Ethics Committee waives review and consent requirements for follow-up studies based on registry data. The DLCR was established in 2000. Every patient diagnosed and treated with lung cancer in Denmark is reported to the DLCR, and reporting is not voluntary [7]. Completeness of data registration is validated by cross-linkage with other national registries such as the National Pathology Registry, the National Cancer Registry, and the National Diagnosis

Results

During the 5-year period, 1,513 patients, comprising 742 men (49%) and 771 women (51%), underwent standard anatomic lobectomy for clinical stage I NSCLC. VATS was used in 717 (47%) and thoracotomy in 796 (53%). Patients' ages were not significantly different between the two groups (p = 0.64). Thoracotomy was more frequent than VATS in men (57% vs 43%) compared with women (48% vs 52%), and this difference was statistically significant (p = 0.001). Clinical T1 tumors were resected more frequently

Comment

Hundreds of articles have been published on VATS lobectomy during the past 2 decades. VATS is generally assumed to be less traumatic than thoracotomy, with reduced postoperative pain, better pulmonary function, and shorter hospital stay, but the level of evidence for its superiority is low. With the exception of four small randomized trials, the literature is limited to case-series or case-control studies from single institutions 8, 9, and a significant amount of VATS data is published by

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The objective of this study is to evaluate the trends of and outcomes associated with the use of minimally invasive lobectomy for stage I and II non-small cell lung cancer (NSCLC) in the United States.
The use of and outcomes associated with open and minimally invasive lobectomy for clinical stage I and stage II NSCLC from 2010 to 2017 in the National Cancer Database were assessed by multivariable logistic regression and propensity score matching.
From 2010 to 2017, use of minimally invasive lobectomies increased for stage I NSCLC (multivariable-adjusted odds ratio [aOR] 4.52; 95% CI, 3.95-5.18; P < .001) and stage II NSCLC (aOR 4.38; 95% CI, 3.38-5.68; P < .001). In 2015, for the first time, more lobectomies for stage I NSCLC were performed by minimally invasive techniques (52.2%, n = 5647) than by thoracotomy (47.8%, n = 5164); and in 2017, more lobectomies for stage II NSCLC were performed by minimally invasive techniques (54.7%, n = 1620) than by thoracotomy (45.3%, n = 1,342). From 2010 to 2017, the conversion rates from minimally invasive to open lobectomy for stage I NSCLC decreased from 19.6% (n = 466) to 7.2% (n = 521; aOR 0.32; 95% CI, 0.23-0.43; P < .001). Similarly, from 2010 to 2017, the conversion rates from minimally invasive to open lobectomy for stage II NSCLC decreased from 20% (n = 114) to 11.5% (n = 186; aOR 0.39; 95% CI, 0.21-0.72; P = .002).
In the United States, for stage I and stage II NSCLC from 2010 to 2017, the use of minimally invasive lobectomy significantly increased while the conversion rate significantly decreased. By 2017, the minimally invasive approach had become the predominant approach for both stage I and stage II NSCLC.
Adequate lung cancer surgery lymphadenectomy within a statewide quality collaborative: Quality improvement in action
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In January 2016, our statewide quality improvement collaborative focused on 3 metrics of adequate lymph node harvest during lung cancer surgery: (1) rates of pathologic examination of 10 lymph nodes or more; (2) sampling 5 or more lymph node stations or more within the hilum or mediastinum; and (3) pathologic nodal upstaging (pathologic nodal stage higher than clinical nodal stage). Unblinded, hospital-level outcomes were presented at biannual meetings, and opportunities for education or improvement were discussed. We set out to describe this quality improvement initiative and the subsequent impact on surgical lymphadenectomies statewide.
We retrospectively reviewed patients undergoing lobectomy for stage IA to IIIA non–small-cell lung cancer from July 2015 to December 2020 at the 16 participating centers.
The study cohort included 3753 patients. The rates of examining 10 lymph nodes or more statewide increased from 215 lobectomies (44.0%) in 2015 to 522 lobectomies (78.9%) in 2020 (P < .001). Similar trends were noted statewide for 5 lymph node stations or more, which increased from 193 lobectomies (39.6%) to 531 lobectomies (80.3%) in 2020 (P < .001). The overall rate of nodal upstaging was more variable year to year and generally declined over time (P = .004).
Our statewide quality improvement initiative improved rates of appropriate lymph node staging for surgically treated non–small cell lung cancer compared with national rates. This work demonstrates the power that a “community of practice” philosophy can have on surgical treatment of lung cancer. Quality improvement interventions including transparent data-driven discussions and collaboration can help guide future quality improvement initiatives and should be readily transferrable to other clinical domains.
Advances in Surgical Techniques for Lung Cancer
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The Role of Lung Cancer Surgical Technique on Lymph Node Sampling and Pathologic Nodal Upstaging
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The role of operative approach in surgical lymphadenectomies and pathologic nodal upstaging for lung cancer remains unclear.
This study retrospectively reviewed patients who underwent lobectomy for non-small cell lung cancer from January 2015 to December 2020 at 16 centers within a statewide quality improvement collaborative in Michigan. Patients were stratified by operative approach, and our primary end points were number of LN recovered, number of LN stations sampled, and rates of nodal upstaging with nodal upstaging defined as a higher final pathologic nodal stage compared with preoperative clinical nodal staging.
A total of 3036 patients were included: 608 (20.0%) with open lobectomies, 1362 (41.3%) with video-assisted thoracoscopic surgery (VATS), and 1233 (37.4%) with robot-assisted thoracoscopic surgery (RATS) lobectomies. Using multivariable logistic regression, study investigators found that VATS was associated with lower rates of nodal upstaging (odds ratio [OR], 0.71; 95% CI, 0.54-0.94; P = .015) and harvesting ≥10 LNs (OR, 0.40; 95% CI, 0.31-0.50; P < .001) as compared with open surgery, whereas no significant difference was found between RATS and open techniques. Compared with open surgery, VATS had lower rates of sampling at ≥5 nodal stations (OR, 0.66; 95% CI, 0.53-0.84; P = .001), whereas RATS rates were higher (OR, 2.38; 95% CI, 1.85-3.06; P < .001).
VATS lobectomies were associated with lower rates of harvesting ≥10 LNs, sampling ≥5 LN stations, and pathologic nodal upstaging compared with open and RATS lobectomies. Compared with open procedures, RATS lobectomies were associated with higher rates of sampling ≥5 LN stations, but there was no significant difference between open and RATS approaches in rates of nodal upstaging or harvesting ≥10 LNs.
Preoperative PET-SUVmax and volume based PET parameters of the primary tumor fail to predict nodal upstaging in early-stage lung cancer
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Accurate nodal staging is of utmost importance in patients with lung cancer. FDG-PET/CT imaging is now part of the routine staging. Despite thorough preoperative staging nodal upstaging still occurs in early-stage lung cancer. However, the predictive value of preoperative PET metrics of the primary tumor on nodal upstaging remains to be unexplored. Our aim was to assess the association of these preoperative PET-parameters with nodal upstaging in histologically confirmed lung adenocarcinoma and squamous cell carcinoma.
From January 2016 to November 2018, 500 patients with pT1-T2/cN0 lung cancer received an anatomical resection with curative intent. 171 patients with adenocarcinoma and squamous cell carcinoma and available PET-CTs were retrospectively included. We analyzed the the association of nodal upstaging with preoperative PET-SUVmax and metabolic PET metrics including total lesion glycolysis (TLG) and metabolic tumor volume (MTV) with different defined thresholds.
High values of preoperative PET-SUVmax of the primary tumor were associated with squamous cell carcinoma (p < 0.0001) and with larger tumors (p < 0.0001). Increased preoperative C-reactive protein levels (<1mg/dL) correlated significantly with high preoperative PET-SUVmax values (p < 0.0001). No significant relationship between PET-SUVmax and lactate dehydrogenase activity (p = 0.6818), white blood cell count (p = 0.7681), gender (p = 0.1115) or age (p = 0.9284) was observed. Nodal upstaging rate was 14.0 % with 8.8 % N1 and 5.3 % N2 upstaging. Tumor size (p = 0.0468) and number of removed lymph nodes (p = 0.0461) were significant predictors of nodal upstaging but no significant association was found with histology or PET parameters. Of note, increased MTV – regardless of the threshold – tended to associate with nodal upstaging.
Early-stage lung cancer patients with squamous histology and T2 tumors presented increased preoperative PET-SUVmax values. Nevertheless, beyond tumor size and number of removed lymph nodes neither SUVmax nor metabolic PET parameters MTV and TLG were significant predictors of nodal upstaging.

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Original articleGeneral thoracicA National Study of Nodal Upstaging After Thoracoscopic Versus Open Lobectomy for Clinical Stage I Lung Cancer

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Lung Cancer

Original article
General thoracic
A National Study of Nodal Upstaging After Thoracoscopic Versus Open Lobectomy for Clinical Stage I Lung Cancer