Guideline-based lymph node sampling is not associated with increased postoperative complications in lung cancer

1. Lymph node sampling with the 3 + 1 rule was not associated with increased postoperative complications after lung cancer resection.

Evidence Rating Level: 2 (Good)

Non–small cell lung cancer (NSCLC) is the most common type of lung cancer, accounting for about 80-85% of all lung cancers. Surgical removal of the tumor with lymph node sampling (LNS) is the standard of care for patients with early-stage NSCLC. Current guidelines recommend LNS with the 3 + 1 rule, which involves station-based sampling with at least 3 N2 (mediastinal) and 1 N1 (hilar) nodal stations. However, the potential negative impacts of this method on surgical outcomes remain unclear. This study thus evaluated whether satisfying the 3 + 1 rule is associated with increased postoperative complications. This retrospective cohort study used the Society of Thoracic Surgeons General Thoracic Database. Patients with clinical stage T1 to T3, N0, M0 NSCLC who underwent surgical resection with known LNS between July 1, 2021, and January 1, 2023 were included. Patients were propensity-matched to compare postoperative complication rates by 3 + 1 LNS status. The primary outcomes were postoperative complications. Of the 28,439 patients in the study cohort (median [IQR] age, 69 [66-75] years; 4,791 [59.5%] female), 18,939 patients (66.6%) satisfied the 3 + 1 rule. In the unadjusted analyses, patients who underwent 3 + 1 LNS had longer median (IQR) operating room duration (224 [178-281] vs 210 [161-273] minutes, P < .001) and rates of pathologic upstaging (2,520 [13.3%] vs 922 [9.7%], P < .001) compared to those who did not. In the propensity-matched cohort, these associations were no longer significant. Overall, this study found that the 3 + 1 rule was not associated with increased postoperative complications in patients with early-stage NSCLC who underwent lung resection, supporting its continued use. 

Click here to read this study in JAMA Network Open

Image: PD

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