A.F. Landreneau1, Y. Suzuki1, R. Levy1, A. Pennathur1, J.D. Luketich1, S. Mazur1, R. Landreneau1, E. Alicuben1, M.J. Schuchert1 1University Of Pittsburgh Medical Center, Cardiothoracic Surgery, Pittsburgh, PA, USA
Introduction:
Despite detailed preoperative staging, nearly one-third of patients with completely resected (R0) clinical stage I non-small cell lung cancer (NSCLC) are upstaged on final pathological assessment, and 20-30% of patients with pathological Stage I NSCLC recur. Beyond TNM status, several pathological variables have been associated with increased risk of recurrence: angiolymphatic invasion (ALI), visceral pleural invasion (VPI), and tumor size. There is little data regarding the importance of tumor location (central vs peripheral) on surgical outcomes. This study aims to analyze the impact tumor location has on clinical staging and prognosis for early-stage NSCLC.
Methods:
We performed a single-institution retrospective study for patients with clinical Stage IA (T1a-T1cN0) NSCLC who underwent lobectomy from 2013 to 2022. The primary tumor location was analyzed for each case using chest computed tomography (CT) scans immediately before surgery. As defined by RTOG 0813, central tumors were those located within 2 cm of the proximal bronchial tree (carina, main bronchi, intermediate bronchus, and lobar bronchi until bifurcation). Tumors outside this zone were classified as peripheral. Pathological upstaging frequency and long-term prognosis were analyzed by tumor location.
Results:
During the study period, 794 patients with Stage IA NSCLC underwent lobectomy at our institution. Eighty-five (10.7%) central and 709 (89.3%) peripheral tumors were observed. PET/CT scans were performed on 67 (79%) central and 532 (75%) peripheral cases. Nodal upstaging differed significantly by tumor location (Central (C)=24% vs Peripheral (P)=13%; p=0.007). For central tumors, 15 pN1 (17.6%; p=0.004) and 5 pN2 (5.9%; p=0.66) cases were identified, while peripheral tumors had 51 pN1 (8.0%) and 34 pN2 (4.8%) patients. There was a significant difference in recurrence rate (C=26% vs P=15%; p=0.007), due to higher locoregional recurrence in central tumors (C=11.8%, P=3.8%; p=0.001). There was no difference in overall survival (Median: C=98.1 vs P=118.1 months; p=0.7) or in recurrence-free survival (Median: C=79.1 vs P=104.4 months; p=0.1). There was no significant difference in ALI (C=48.3% vs P=42.2%; p=0.29) or VPI (C=17.7% vs P=24.5%; p=0.16).
Conclusion:
Tumor location was predictive of locoregional recurrence and pathological nodal upstaging. There was no significant difference in overall survival. Central tumors were more likely to present occult nodal disease than peripheral cases, especially N1. This shortcoming of clinical staging, identified only through surgical resection, makes a strong case for the continued use of surgery with detailed nodal staging to treat early-stage NSCLC in good-risk patients in lieu of ablative strategies.