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Regional lymph node stations for LLD-NSCLC. ( A ) Squares indicate mediastinal lymph node stations and circles indicate hilar, interlobar and lobar lymph node stations. The regional lymph node stations are indicated by grey squares and circles. A selective MLND includes #5, #10, #11 and #12u stations, and a complete MLND includes all node stations shown in Fig. 4A. ( B ) Validating process for regional lymph node stations of LLD-NSCLC. LLD-NSCLC: left lingular division non-small-cell lung cancer; MLND: mediastinal lymph node dissection.
Source publication
The purpose of this study is to assess the clinicopathological characteristics of non-small-cell lung cancer (NSCLC) occurring in the left lingular division (LLD) in association with a proposal of the LLD-specific regional lymph node stations.
Medical records of patients, who underwent complete tumour resection with mediastinal lymph node dissectio...
Contexts in source publication
Context 1
... the frequent metastatic lymph node stations were #12u lobar node, #5 subaortic node and #11 interlobar node in order, and because these three stations were also single metastatic sites in some patients, we assigned these lymph node stations as LLD-specific regional node stations for LLD-NSCLC (shown in grey in Fig. 4A). We then investigated whether an intraoperative patho- logical examination of these selected regional node stations would accurately diagnose the metastasis status, and appropriately lead to a selective or complete MLND [7]. Here, the selective MLND includes the regional node stations (#5, #11, #12u) and #10, and the complete MLND ...
Context 2
... whether an intraoperative patho- logical examination of these selected regional node stations would accurately diagnose the metastasis status, and appropriately lead to a selective or complete MLND [7]. Here, the selective MLND includes the regional node stations (#5, #11, #12u) and #10, and the complete MLND includes all node stations shown in Fig. 4A (#4L to #7, and #10 to #12u). A total of 160 LLD-NSCLC patients with c-T2N1M0 or less extensive disease were studied for validation of regional node stations (Fig. 4B). If the regional node stations for LLD-NSCLC had been examined in a pathological manner during surgery, 125 p-N0 and 5 p-N1 patients ( patient no. 1-5 in Fig. 5A), ...
Context 3
... to a selective or complete MLND [7]. Here, the selective MLND includes the regional node stations (#5, #11, #12u) and #10, and the complete MLND includes all node stations shown in Fig. 4A (#4L to #7, and #10 to #12u). A total of 160 LLD-NSCLC patients with c-T2N1M0 or less extensive disease were studied for validation of regional node stations (Fig. 4B). If the regional node stations for LLD-NSCLC had been examined in a pathological manner during surgery, 125 p-N0 and 5 p-N1 patients ( patient no. 1-5 in Fig. 5A), diagnosed as having no metastasis, would have been subjected to selective MLND. The metastatic node stations of those 5 p-N1 patients were #10 in 1 patient, #13/14 in 3 ...
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Citations
... In the past 30 years, several retrospective studies have validated the lobe-specific lymph metastatic pattern. [79][80][81][82][83][84] But there still were several limitations. In the study of Okada et al. 78 there are only 141 N2 cases of 760 patients. ...
... Often, station 4L is not routinely sampled or dissected during lung cancer resection out of concern for recurrent laryngeal nerve, thoracic duct, and aortic arch injury because of its anatomic location (4). Previous studies have shown that station 4L lymph nodes play a crucial role in the left bronchial-recurrent lymph node (LN) chain, an essential lymphatic pathway of the left lung (5,6). Recently, some studies have assessed the clinical significance of 4L lymph node dissection (4L LND) in left lung cancer and found that station 4L metastasis was not rare and that 4L LND may provide survival benefits (7)(8)(9)(10)(11)(12). ...
Background:
Whether 4L lymph node dissection (LND) should be performed remains unclear and controversial. Prior studies have found that station 4L metastasis was not rare and that 4L LND may provide survival benefits. The objective of this study was to analyze the clinicopathological and survival outcomes of 4L LND from the perspective of histology.
Methods:
This retrospective study included 74 patients with squamous cell carcinoma (SCC) and 84 patients diagnosed with lung adenocarcinoma (ADC) between January 2008 and October 2020. All patients underwent pulmonary resection with station 4L LND and were staged as T1-4N0-2M0. Clinicopathological features and survival outcomes were investigated based on histology. The study endpoints were disease-free survival (DFS) and overall survival (OS).
Results:
The incidence rate of station 4L metastasis was 17.1% (27/158) in the entire cohort, with 8.1% in the SCC group, and 25.0% in the ADC group. No statistical differences in the 5-year DFS rates (67.1% vs. 61.7%, P=0.812) and 5-year OS rates (68.6% vs. 59.3%, P=0.100) were observed between the ADC group and the SCC group. Multivariate logistic analysis revealed that histology (SCC vs. ADC: OR, 0.185; 95% CI, 0.049-0.706; P=0.013) was independently associated with 4L metastasis. Multivariate survival analysis showed that the status of 4L metastasis was an independent factor for DFS (HR, 2.563; 95% CI, 1.282-5.123; P=0.008) but not for OS (HR, 1.597; 95% CI, 0.749-3.402; P=0.225).
Conclusion:
Station 4L metastasis is not rare in left lung cancer. Patients with ADC have a greater predilection for station 4L metastasis and may benefit more from performing 4L LND.
... Adjuvant chemotherapy was shown to offer substantial improvement in the management of resectable stage IIIA NSCLC (56). If the tumor presents an EGFR mutation, targeted adjuvant therapy with EGFR tyrosine kinase inhibitors (TKIs) (33,35). CPET, cardiopulmonary exercise testing; DLCO, diffusion capacity of the lung for carbon monoxide; FEV1, maximum expiratory volume in the first second of forced expiration; VO 2 max, maximum oxygen consumption. ...
Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC.
... The discrete data between the LUD and LLD is reasonable from the view of more finely classifying and evaluating anatomical and functional division. However, there are few articles that paid attention to the LLD (20). In our previous study, 69 pN1-2 LLD-NSCLC cases metastasized to #10, #11, and #12u, which accounted for 15.4%, 53.8%, and 42.3% in N1, respectively, and the LPT#4L, AN#5+6, and SC#7, which accounted for 19.5%, 44.5%, and 3.9% in N2, respectively, and our retrospective study has reported that the incidence of subcarinal zone (#7) metastasis was 6.9-fold higher in the LUD than in the LLD (11). ...
... In our previous study, 69 pN1-2 LLD-NSCLC cases metastasized to #10, #11, and #12u, which accounted for 15.4%, 53.8%, and 42.3% in N1, respectively, and the LPT#4L, AN#5+6, and SC#7, which accounted for 19.5%, 44.5%, and 3.9% in N2, respectively, and our retrospective study has reported that the incidence of subcarinal zone (#7) metastasis was 6.9-fold higher in the LUD than in the LLD (11). In 2005, Shien et al. have revealed that the top three metastasis node stations were #12u, #11, and #5 in pN1-2 LLD-NSCLC and were decided as the regional node stations (20). Their lymphatic behavior is consistent with our results. ...
... Several retrospective studies (16)(17)(18)(19)(20)(21) have revealed the rules of lobe-specific lymphatic drainage pattern. Meanwhile, some authors have put forward a concept of regional lymph nodes (22)(23)(24)(25), which is similar to the idea of sentinel lymph nodes. They supposed that if regional lymph nodes are proved tumor-free, the rest should be preserved. ...
... They supposed that if regional lymph nodes are proved tumor-free, the rest should be preserved. On the basis of such findings (16)(17)(18)(19)(20)(21)(22)(23)(24)(25), SLND may be applicable for early-stage NSCLC patients to minimize surgical trauma and provide clinical benefits. ...
Background:
The proper extent of lymph node dissection is still controversial. Hence, we compared the clinical efficacy between two strategies of lymph node dissection [selective lymph node dissection (SLND) and systematic lymph node dissection (LND)] for clinical N2-negative non-small cell lung cancer (NSCLC) patients.
Methods:
After searching five databases, six cohort studies were eligible for this meta-analysis and the primary endpoint was overall survival (OS). In order to provide a comprehensive perspective, we estimated some perioperative outcomes as well. Either fixed effect or random effects model were properly selected to evaluate the data according to the heterogeneity of included studies.
Results:
A total of 7,333 patients with clinical N2-negative NSCLC patients were analyzed for OS. The pooled results demonstrated that LND did not improve survival in OS [hazard ratio (HR) =1.05, 95% confidence interval (CI): 0.82-1.34, P=0.69] compared with SLND. In accordance with OS, there is no significant difference in DFS between LND and SLND (HR =0.98, 95% CI: 0.78-1.23, P=0.87). Moreover, SLND could significantly reduce the operative time [mean difference (MD) =-21.45, 95% CI: -29.53 to -13.36, P<0.001] and blood loss (MD =-28.88, 95% CI: -44.38 to -13.39, P<0.001). Both postoperative morbidity and recurrence showed no significant between two groups.
Conclusions:
SLND is an alternative to LND for clinical N2-negative NSCLC patients, which may even provide clinical benefits. However, more randomized controlled trials (RCTs) are expected to determine whether SLND is valid and practical to become a standard procedure of surgical treatment for early-stage NSCLC patients.
... It has also been reported that lymph node metastasis was a predictor for poor prognosis in patients with NSCLC, which can be mainly characterized by the status of the intrapulmonary, hilar, and mediastinal lymph nodes [11,30]. Consistent with our results, previous data also suggested that lymph node metastasis and TNM stage in NSCLC were independent risk factors for prognosis [31,32]. According to Agarwal et al. [28], age, sex, type of surgery, and especially tumor size can be prognostic predictors in patients with early-stage (I and II) NSCLC after surgical resection. ...
Background:
This study investigated the relationship between contrast-enhanced computed tomography (CECT) and clinicopathological characteristics and prognosis of non-small cell lung cancer (NSCLC).
Methods:
A total of 198 NSCLC patients admitted to Enze Hospital from February 2009 to July 2012 underwent pre-surgical CECT to investigate parameters such as tumor size, CECT enhancement, lymph node enlargement, and lymph node size. Chi-square and log-rank tests were used to analyze associations between CECT parameters and pathological features as well as correlations of CECT parameters with prognosis. A Cox proportional hazard model and logistic regression analysis were applied to identify independent risk factors for prognosis.
Results:
Tumor size, CECT enhancement, and lymph node enlargement and size were related to degree of differentiation, TNM stage, and lymph node metastasis. Tumor size, lymph node enlargement and metastasis, lymph node size, and CECT enhancement were independent risk factors for NSCLC prognosis. Large tumors and lymph nodes, tumor enhancement, and enlarged and metastatic lymph nodes indicated a poor prognosis.
Conclusion:
Our study indicates that CECT features can be associated with clinicopathological characteristics and can predict the prognosis of patients with NSCLC.
... Based on their findings, the existence of pathological-N2 metastasis can be accurately predicted by intraoperative pathological examination and SLND or LND would be properly adopted in LLD-NSCLC patients with clinical-T2N1M0 or earlier stage (30). It is worth mentioning that only a few teams investigate in this area, and the reliability of RMLN should be further confirmed. ...
Lymph node dissection is a vital part of surgical treatment in early-stage non-small cell lung cancer (NSCLC). Removal of metastatic lymph nodes while preservation of intact lymph nodes are equally important. For hospitalized early-stage patients with limited lymph node metastasis, the operation treatment should be made according to some rules such as lobe-specific lymph node drainage pattern. In order to prevent unnecessary surgical trauma in early-stage patients, a minimally invasive approach with selective lymph node excision is preferred for more clinical benefits. This review summarizes the existing findings on lobe-specific lymph node drainage pattern and we hope to provide guidance for selective lymph node dissection (SLND). Furthermore, we include information on histologic views, a tumor marker and protocols of SLND, with hope to inspire creative research and clinical trials in this field.
... REFERENCES [1] ...
... We read with great interest the article by Shien et al. [1] on a series of 184 patients with non-small-cell lung cancer (NSCLC) occurring in the left lingular division. In this study, the Authors reported their findings regarding the intraoperative pathological examination of the regional lymph node stations and proposed selective mediastinal ...
Since Cahan proposed "radical lobectomy" in 1960, lobectomy or larger lung resection with regional hilar and mediastinal lymph node dissection has been globally recognized as a standard mode of surgery for non-small cell lung cancer (NSCLC). Systematic nodal dissection (SND), which involves the removal of mediastinal nodes from the superior to the inferior mediastinum compartmented by anatomical landmarks, has remained a standard mode mediastinal nodal dissection, irrespective of the tumor location. However, since the late 1990s, with the elucidation of the nodal spread pattern, we have included lobe-specific nodal dissection (LND) in our clinical practice. The indications for LND vary depending on institutions; however, the LND is currently a major mode of dissection, especially in Japan. An prospective trial is currently underway to evaluate the validity and clinical benefit of LND in comparison to SND. Recently, limited lung resection without lymph node dissection is indicated, especially for early lung adenocarcinoma with ground glass attenuation-dominant nodules. The improvement of imaging modalities and new technologies, including radiomics and deep learning will enable us to precisely predict the nodal status before surgery. In the near future, lymph node dissection will be more sophisticated and personalized than ever before. This review article outlines the clinical benefit, history, and future perspectives of lymph node dissection for operable NSCLC.
Background
Lobectomy with systematic lymph node dissection (SND) remains the standard procedure for resectable non–small-cell lung cancer (NSCLC), whereas lobe-specific lymph node dissection (LSND) was reported to have more advantages in perioperative recovery and complication reduction in treating early-stage diseases. Survival outcomes after LSND remains controversial compared with SND.
Patients and Methods
From 2014 to 2017, data of 546 patients with clinical stage IA solid-dominant NSCLC and who underwent curative lobectomies with LSND (n = 100) or SND (n = 446) at our institution were collected. Propensity score matching was conducted to eliminate the biases. Five-year disease-free survival and overall survival were compared between the groups. Perioperative parameters and postoperative complications were also analyzed.
Results
Lobectomies with LSND or SND were performed in 100 patients and 446 patients, respectively. After matching, there were 100 patients in each group and no significant differences in 5-year overall survival (P = .473) and disease-free survival (P = .789) were found between the groups. Recurrence patterns were also similar (P = .733). Perioperative parameters were similar, whereas the incidence of postoperative complications in the SND group was found to be significantly higher than that in the LSND group (P = .003).
Conclusions
Our study demonstrated that LSND has similar efficiency to SND in terms of survival, recurrence, lymph node dissection, and perioperative recovery of patients with clinical stage IA solid-dominant NSCLC, as well as significant advantages in reducing postoperative complications. Therefore, curative lobectomies with LSND may be more suitable and practical for clinical stage IA solid-dominant patients with NSCLC.
