Fixing A Problem That May Not Exist: 3N2 + 1N1 Mandate Prioritizes Compliance Over Safety

In 2020, the American College of Surgeons introduced Operative Standard 5.8 mandating that lymph nodes be sampled from 1 hilar (N1) station and 3 separate mediastinal (N2) stations for all lung resections with curative intent. Though lymph node assessment is necessary for staging, there is limited data to define the number of lymph nodes or the extent of dissection. We seek to clarify modern trends in mediastinal lymph node sampling.

The SEER database was queried for patients who underwent surgery, 18 years and older, between 2018 and 2020 with non-small cell lung cancer. Demographics, stage, histology, and cause-of-death were compared.

Of 17927 NSCLC patients, 16 431 (91.7%) underwent MLNS. Percentages increased over time 91% (2018), 92% (2019), and 93% (2020). MLNS was associated with more average harvested nodes (13.5 vs. 8.2), although the number of positive lymph nodes was similar. Death from any cause and lung cancer-specific death was higher in patients that did not receive MLNS (12.2% vs 9.1% and 7.8% vs 5.3%).

MLNS is performed in more than 91% of anatomic resections. It is not known if each satisfied the 3N2 + 1N1 threshold with evidence strong enough to demand it. Operative Standard 5.8 mandates a solution for a problem that may not exist. Threatening hospitals with loss of accreditation distracts the surgeon agency with non-clinical considerations and compromises safe choices.