Does This Lymph Node Look Bulky to You? What Should We Do About It? A Survey of Thoracic Surgeons.

K. Xue. Huang¹, A. Fox¹, S. Hardin¹, K. Engelhardt¹, F. Farjah², G. Silvestri¹, I. Bostock^1
1Medical University of South Carolina, Charleston, South Carolina ²University of Washington, Division of Cardiothoracic Surgery, Seattle, Washington

Purpose: Clinical staging plays an integral role in determining surgical candidacy for patients with non-small cell lung cancer (NSCLC) 1, 2, 3. In locoregionally advanced NSCLC, the specific characteristics of mediastinal/hilar lymph nodes (LN) can lead to a wide variation in treatment strategies. However, these characteristics are not standardized.

Methods: A 24-item survey was distributed to attending surgeons who were members of The Society of Thoracic Surgeons email list on 3 separate occasions over a 6-week period. The aim was to ascertain the frequency of acceptance of varying definitions for what constitutes bulky mediastinal/hilar LN by size as well as other LN characteristics, treatment trends, demographics, surgical volume, and experience level.

Results: The survey was sent to 1336 individual email addresses of cardiothoracic surgeons, opened by 48.9%, with a 5.87% click rate and 165 unique responses. Most respondents were general thoracic surgeons (N=161, 98.2%), white (N=121, 83.4%), and male (N=127, 80.9%). Approximately half had been in practice >15 years (N=80, 48.8%) and most performed >5 lung resections for cancer per month (N=134, 81.2%). The majority classified an enlarged LN on CT scan as >1 cm (N=149, 90.3%), but the definition of bulky LN showed wide variation with 2 cm being used by 39% (N=64), 3 cm by 24% (N=40), and 32% (N=53) not using size criteria alone. Most respondents considered two or more mediastinal LN stations as multi-station disease (N=147, 89.1%) but there was more variation on the definition of bulky multi-station disease (Table 1). The majority employed neo-adjuvant chemo-immunotherapy (N=157, 95.2%) and adjuvant targeted therapy (N=109, 66.1%) for resectable locoregionally advanced NSCLC. LN staging appeared to be a substantial factor in deciding which locoregionally advanced NSCLC patients are surgical candidates as patients with N2 disease were less likely to be considered (Figure 1).

Conclusion: LN burden is an important factor for deciding surgical candidacy for locoregionally advanced NSCLC. However, our study shows that there is wide variation in LN assessment and subsequent treatment strategies being offered. This further highlights the need for a standardized LN assessment process in order to accurately benchmark outcomes.

Identify the source of the funding for this research project: None