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Surgical Outcomes of Non-Small Cell Lung Cancer in Single-Zone N2 in the Aortopulmonary Zone
Objectives We evaluate the surgical outcome of clinically single-zone N2 lung cancer limited to aortopulmonary zone (AP zone; lymph node #5 or #6).
Patients and Methods We performed a retrospective analysis of patients with non-small cell lung cancer, in whom mediastinal lymph node metastasis was confined to AP zone.
Results A total of 84 patients who underwent upfront surgery were included in final analysis. Among these patients, pathological nodal outcomes were pN0–1 in 27 patients (32.1%), pN2a in 31 (36.9%), and pN2b in 26 (31.0%). In multivariate analysis, adenocarcinoma (p = 0.005) and staging workup without endobronchial ultrasound-transbronchial needle aspiration (p = 0.002) were independent risk factors for unexpected pN2b. The 5-year overall survival (OS) and disease-free survival (DFS) were 55.9 and 54.4%, respectively. There was no survival difference among patients with pN0–1, pN2a, and pN2b (p = 0.717). In survival analysis, there were no significant risk factors for OS. However, female sex and the ratio of positive lymph nodes to removed lymph nodes were significant risk factors for DFS in multivariate analysis (p = 0.032 and p = 0.009).
Conclusion In this study, cN2a in the AP zone with current diagnostic tool exhibited a relatively high false-positive rate (cN2/pN0–1; 32.1%). However, despite the possibility of pN2b, there were no significant differences in survival outcome according to the pathologic nodal stage.
Kanghoon Lee: Conceptualization, methodology, formal analysis, and writing—original draft preparation. Yong Ho Jeong: Investigation and data curation. Jin-Sook Ryu and Yong-Il Kim: Data curation, verification, and resources. Hyeong Ryul Kim: Methodology, supervision, resources, and writing—review and editing. Seung-Il Park, Dong Kwan Kim, Yong-Hee Kim, and Se Hoon Choi: Resources.
Received: 22 September 2020
Accepted: 25 January 2021
21 April 2021 (online)
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- 1 Asamura H, Chansky K, Crowley J. et al; International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee, Advisory Board Members, and Participating Institutions. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: proposals for the revision of the N descriptors in the forthcoming 8th edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2015; 10 (12) 1675-1684
- 2 Riquet M, Manac'h D, Dupont P, Dujon A, Hidden G, Debesse B. Anatomic basis of lymphatic spread of lung carcinoma to the mediastinum: anatomo-clinical correlations. Surg Radiol Anat 1994; 16 (03) 229-238
- 3 Patterson GA, Piazza D, Pearson FG. et al. Significance of metastatic disease in subaortic lymph nodes. Ann Thorac Surg 1987; 43 (02) 155-159
- 4 Keller SM, Vangel MG, Wagner H. et al; Eastern Cooperative Oncology Group. Prolonged survival in patients with resected non-small cell lung cancer and single-level N2 disease. J Thorac Cardiovasc Surg 2004; 128 (01) 130-137
- 5 Cerfolio RJ, Bryant AS, Eloubeidi MA. Accessing the aortopulmonary window (#5) and the paraaortic (#6) lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg 2007; 84 (03) 940-945
- 6 Rusch VW, Asamura H, Watanabe H, Giroux DJ, Rami-Porta R, Goldstraw P. Members of IASLC Staging Committee. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 2009; 4 (05) 568-577
- 7 Goldstraw P, Chansky K, Crowley J. et al; International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee, Advisory Boards, and Participating Institutions, International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee Advisory Boards and Participating Institutions. The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2016; 11 (01) 39-51
- 8 Nwogu CE, Groman A, Fahey D. et al. Number of lymph nodes and metastatic lymph node ratio are associated with survival in lung cancer. Ann Thorac Surg 2012; 93 (05) 1614-1619 , discussion 1619–1620
- 9 Saji H, Tsuboi M, Yoshida K. et al. Prognostic impact of number of resected and involved lymph nodes at complete resection on survival in non-small cell lung cancer. J Thorac Oncol 2011; 6 (11) 1865-1871
- 10 Saji H, Tsuboi M, Shimada Y. et al. A proposal for combination of total number and anatomical location of involved lymph nodes for nodal classification in non-small cell lung cancer. Chest 2013; 143 (06) 1618-1625
- 11 Kim HK, Choi YS, Kim J, Shim YM, Kim K. Outcomes of unexpected pathologic N1 and N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2010; 140 (06) 1288-1293
- 12 Bille A, Woo KM, Ahmad U, Rizk NP, Jones DR. Incidence of occult pN2 disease following resection and mediastinal lymph node dissection in clinical stage I lung cancer patients. Eur J Cardiothorac Surg 2017; 51 (04) 674-679
- 13 Kawano R, Hata E, Ikeda S, Yokota T. Lobe-specific skip nodal metastasis in non-small cell lung cancer patients. Ann Thorac Cardiovasc Surg 2008; 14 (01) 9-14
- 14 Riquet M, Assouad J, Bagan P. et al. Skip mediastinal lymph node metastasis and lung cancer: a particular N2 subgroup with a better prognosis. Ann Thorac Surg 2005; 79 (01) 225-233
- 15 Rosell R, Gómez-Codina J, Camps C. et al. A randomized trial comparing preoperative chemotherapy plus surgery with surgery alone in patients with non-small-cell lung cancer. N Engl J Med 1994; 330 (03) 153-158
- 16 Roth JA, Fossella F, Komaki R. et al. A randomized trial comparing perioperative chemotherapy and surgery with surgery alone in resectable stage IIIA non-small-cell lung cancer. J Natl Cancer Inst 1994; 86 (09) 673-680
- 17 Bezjak A, de Perrot M. Trimodality approach to stage IIIA-N2 NSCLC: as good as it gets?. J Thorac Oncol 2016; 11 (11) 1817-1818
- 18 McElnay PJ, Choong A, Jordan E, Song F, Lim E. Outcome of surgery versus radiotherapy after induction treatment in patients with N2 disease: systematic review and meta-analysis of randomised trials. Thorax 2015; 70 (08) 764-768
- 19 Yoshino I, Yoshida S, Miyaoka E. et al; Japanese Joint Committee of Lung Cancer Registration. Surgical outcome of stage IIIA- cN2/pN2 non-small-cell lung cancer patients in Japanese lung cancer registry study in 2004. J Thorac Oncol 2012; 7 (05) 850-855
- 20 Tsitsias T, Boulemden A, Ang K, Nakas A, Waller DA. The N2 paradox: similar outcomes of pre- and postoperatively identified single-zone N2a positive non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45 (05) 882-887
- 21 Vinod SK. Decision making in lung cancer – how applicable are the guidelines?. Clin Oncol (R Coll Radiol) 2015; 27 (02) 125-131
- 22 Sher DJ, Liptay MJ, Fidler MJ. Prevalence and predictors of neoadjuvant therapy for stage IIIA non-small cell lung cancer in the National Cancer Database: importance of socioeconomic status and treating institution. Int J Radiat Oncol Biol Phys 2014; 89 (02) 303-312
- 23 Boffa DJ, Hancock JG, Yao X. et al. Now or later: evaluating the importance of chemotherapy timing in resectable stage III (N2) lung cancer in the National Cancer Database. Ann Thorac Surg 2015; 99 (01) 200-208