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What affects adequate lymph node harvest in pulmonary resections?-assessment of compliance with a national quality
Eric Klipsch1, Joshua Braun2, Saylor Hardin1
1Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA.
Background:
The Commission on Cancer (CoC) quality standard 5.8 for lung cancer lymph node sampling requires sampling of at least one hilar lymph node and three mediastinal lymph nodes. We hypothesized there may be multifactorial reasons for non-compliance, and in this study, we sought to determine these factors in order to identify targets for local interventions.
Methods:
We built a conceptual model for compliance with standard 5.8, considering tumor, patient, provider, and structural factors. We performed a retrospective cohort study of all patients undergoing pulmonary resection for lung cancer at a single tertiary care center from 2022 to 2023 who met criteria to be considered for the CoC Standard 5.8. Resections that met the standard were compared to those that did not.
Results:
Out of 210 resections, 80.5% (n=169) were compliant, meeting the minimal institutional threshold set by the CoC. Most non-compliant cases were due to missing mediastinal stations whereas a minority (n=8, 3.8%) lacked a sampled hilar node. There was wide surgeon variability with compliance: 93%, 87.5%, and 70.9% (P=0.002). Resections done for adenocarcinoma were more likely to be compliant than other histology (86% for adenocarcinoma versus 75% for carcinoid and squamous; P=0.02). The overall number of lymph nodes sampled correlated with compliance (13.0±6.6 in non-compliant cases versus 17.5±9.6 in compliant cases; P<0.001). The following examined variables were not associated with compliance: previous autoimmune disorder, fungus/environmental exposure, previous cancers, clinical node status, calcified lymph nodes on imaging, pre-operative radiation to the chest/mediastinum, pre-operative chemotherapy, and pre-operative immunotherapy.
Conclusions:
In our single center, we found non-adenocarcinoma histology, overall fewer nodes sampled, and surgeon variability were associated with non-compliance with the quality standard. A multi-center study is needed to assess structural factors that may contribute to non-compliance.
