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Original Research: Lung Cancer |

A Proposal for Combination of Total Number and Anatomical Location of Involved Lymph Nodes for Nodal Classification in Non-small Cell Lung CancerNew Lymph Node Classification

Hisashi Saji, MD, PhD; Masahiro Tsuboi, MD, PhD; Yoshihisa Shimada, MD, PhD; Yasufumi Kato, MD, PhD; Koichi Yoshida, MD, PhD; Masaharu Nomura, MD, PhD; Jun Matsubayashi, MD, PhD; Toshitaka Nagao, MD, PhD; Masatoshi Kakihana, MD, PhD; Jitsuo Usuda, MD, PhD; Naohiro Kajiwara, MD, PhD; Tatsuo Ohira, MD, PhD; Norihiko Ikeda, MD, PhD
Author and Funding Information

From the Division of Thoracic Surgery, Department of Surgery (Drs Saji, Tsuboi, Shimada, Kato, Yoshida, Kakihana, Usuda, Kajiwara, Ohira, and Ikeda), and Department of Anatomic Pathology (Drs Nomura, Matsubayashi, and Nagao), Tokyo Medical University, Tokyo, Japan.

Correspondence to: Hisashi Saji, MD, PhD, Division of Thoracic Surgery, Department of Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan; e-mail: saji-q@ya2.so-net.ne.jp


Funding/Support: This study was supported by grants from the Ministry of Education, Culture, Sports, Science and Technology [21791332] and the Ministry of Health, Labour and Welfare [22101601].

For editorial comment see page 1527

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(6):1618-1625. doi:10.1378/chest.12-0750
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Background:  We previously reported the prognostic impact of the number of involved lymph nodes (LNs) on survival in non-small cell lung cancer (NSCLC). However, it remains unknown whether the total number or anatomic location of involved LNs is a superior prognostic factor.

Methods:  A total of 689 patients with NSCLC who underwent complete resection involving dissection of the hilar and mediastinal LNs with curative intent of ≥ 10 LNs were enrolled. The association between the total number of LNs (nN) involved and survival was assessed by comparison with the anatomic location of LN involvement (pathologic lymph node [pN]), the present nodal category.

Results:  We classified the patients into five categories according to the combined pN and nN status as follows: pN0-nN0, pN1-nN1-3, pN1-nN4−, pN2-nN1-3, and pN2-nN4. Although there was no statistically significant difference between the pN1-nN4− and pN2-nN1-3 categories, pN2-nN1-3 had better prognoses than pN1-nN4−. On multivariate analysis, the nN category was an independent prognostic factor for overall survival and disease-free survival (vs nN4−; the hazard ratios of nN0 and nN1-3 for overall survival were 0.223 and 0.369, respectively, P < .0001 for all), similar to the pN category. We propose a new classification based on a combination of the pN and nN categories: namely, N0 becomes pN0-nN0, the N1 category becomes pN1-nN1-3, the N2a category becomes pN2-nN1-3 + pN1-nN4−, and the N2b category becomes pN2-nN4. Each survival curve was proportional and was well distributed among the curves.

Conclusions:  A combined anatomically based pN stage classification and numerically based nN stage classification is a more accurate prognostic determinant in patients with NSCLC, especially in the prognostically heterogeneous pN1 and pN2 cases. Further large-scale international cohort validation analyses are warranted.

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