Adequate staging is essential for delivering appropriate treatment to patients with lung cancer. However, limited access to genomic profiling and new therapies can hinder the availability of innovative treatments in the early-stage setting, such as immunotherapies and targeted therapies.
During the 2024 Latin America Conference on Lung Cancer (LALCA), Stella Martinez, MD, delivered a presentation on thoracic surgery in the region. She emphasized the significance of surgical intervention for treating non-small cell lung cancer (NSCLC) and highlighted both the challenges and opportunities for surgical research in Latin America.
“Surgery is an important tool in the treatment of NSCLC, even in advanced stages,” said Dr. Martinez. “In cases of locally advanced, resectable NSCLC, recent advancements in neoadjuvant therapies have changed the outcomes.”
Dr. Martinez also presented findings from a study that evaluated the relationship between nodal upstaging and risk factors in stage IA adenocarcinoma.
“The study aimed to identify the rates and trends in nodal upstaging, as well as to determine risk factors, evaluate the predictive model, and assess the impact of sub-lobar resection on nodal evaluation,” she said.
A total of 626 patients with clinical stage IA adenocarcinoma were enrolled, of whom 35 (5.6%) experienced nodal upstaging. Participants underwent clinical staging using CT and/or 18-FDG-PET/CT. Additionally, they were required to have had prior surgery with curative intention. Exclusion criteria included patients with other histologies, those without preoperative PET scans, and those who had undergone surgery more extensive than a lobectomy (such as bilobectomy or pneumonectomy).
Among preoperative factors, researchers found a significant difference in nodal upstaging based on PET SUVmax levels—2.4% for lower values (less than three) and 9.4% for higher values (more than three). Additionally, there were differences observed in nodal upstaging by tumor stage—5.5% for T1a, 3.8% for T1b, and 8.1% for T1c.
The results also indicated differences in nodal upstaging by the type of surgery: 16.1% in patients who underwent open surgery, compared with 5.1% for video-assisted thoracoscopic surgery (VATS) and 4.9% for robotic surgery.
The type of lung resection performed also influenced outcomes, with nodal upstaging rates of 2.7% for sub-lobar resections and 9.6% in lobectomies. Furthermore, differences were observed in the number of lymph nodes resected—4.4% for three to five, 5.4% for six to 10, and 9.9% for more than 10—and the number of nodal stations assessed—4.5% for two to three, 7% for four to five, and 8.3% for more than five.
The pathological analysis identified significant associations between nodal upstaging and visceral pleural invasion (VPI) and lymphovascular invasion (LVI): 18.9% for VPI; 28.8% for LVI. Additionally, variations were observed in adenocarcinoma subtypes, with micropapillary and solid adenocarcinomas associated with a higher likelihood of nodal upstaging: 12.6%.
While the pathological factors identified are important in predicting a higher risk of nodal upstaging, surgeons may not always be able to adjust their surgical plan beforehand based on these factors alone.
The problem is that certain factors have minimal impact on surgical decision-making, as some can’t be confirmed until after the surgery, Dr. Martinez noted. “While we can re-operate on patients [if nodal upstaging is discovered after], I don’t think we have enough evidence to decide [to perform additional surgeries], especially since we have alternative treatments [such as chemotherapy, radiation],” she said.
The findings indicate that VPI and LVI are strongly associated with nodal upstaging. Sub-lobar resections are associated with lower rates of upstaging, which is possibly because they are associated with less extensive lymph node dissection. However, more information is needed to evaluate sub-lobar resection and its impact on nodal evaluation.
“Nodal upstaging remains a concern in clinical stage IA adenocarcinoma, despite modern clinical staging modalities,” Dr. Martinez said. “The use of sub-lobar pulmonary resections in the presence of identified risk factors deserves continued evaluation.”
