Numbers and Stations: Impact of Examined Lymph Node on Precise Staging and Survival of Radiologically Pure-Solid NSCLC: A Multi-Institutional Study

OBJECTIVES: To determine the optimal number of examined lymph nodes (ELNs) and examined node stations (ENSs) in patients with radiologically pure-solid NSCLC and to investigate the impact of ELNs and ENSs on accurate staging and long-term survival. METHODS: Data from six institutions in the People’s Republic of China on resected c-stage Ⅰ to Ⅱ NSCLCs presenting as pure-solid tumors were analyzed for the impact of ELNs and ENSs on nodal upstaging, stage migration, recurrence-free survival, and overall survival by using multivariate models. The correlations between different end points and ELNs or ENSs were fitted with a smoother (using Locally Weighted Scatterplot Smoothing tool), and the structural break points were determined by the Chow test. RESULTS: Both ELNs and ENSs were identified as prognostic factors for overall survival (ENS: hazard ratio [HR], 0.697; 95% confidence interval [CI]: 0.590–0.824; p < 0.001; ELN: HR, 0.945; 95% CI: 0.909–0.983; p = 0.005) and recurrence-free survival (ENS: HR, 0.863; 95% CI: 0.791–0.941; p = 0.001; ELN: HR, 0.960; 95% CI: 0.938–0.981; p < 0.001). Intraoperative ELNs and ENSs were found to be associated with postoperative nodal upstaging. Cut point analysis revealed an optimal cutoff of 16 LNs and five node stations for patients with c-stage Ⅰ to Ⅱ pure-solid NSCLCs, which were examined in our multi-institutional cohort. CONCLUSIONS: Both ELNs and ENSs are associated with more accurate node staging and better long-term survival. We recommend 16 LNs and five stations as the cut point for evaluating the quality of LN examination for c-stage Ⅰ to Ⅱ patients with radiologically pure-solid NSCLCs.