#25, S2 Redefining Lymph Node Evaluation in Lung Cancer Surgery

Sure.

Um, so taking out lymph nodes is important.

Um, [chuckles] we-- Yeah, that's I think the, uh, you know, kind of one of the, the, the biggest things here and, um, and y- and, and I think we'll see that recurring theme throughout all three of these papers that, that we discussed today.

Um, and you know, as we in the thorac-- in the Society of Thoracic Surgeons', uh, general thoracic surgery databases, we look at various metrics.

Um, lymph node assessment is, uh, one that, you know, we've, we've talked about, that we've considered.

Um, however, at, you know, at the current time, the Commission on, on Cancer has done an excellent job with the three plus one standard and, um, you know, we don't necessarily-- uh, we have not yet, um, or do we necessarily intend to, uh, you know, create a lymph node, uh, standard, uh, based on the current data that we have.

I think those are great points.

It-- This was really a powerful study, Seth, because it, it's really showing that the gui- the guidelines matter, that this is working.

And I was curious, Seth, for you, was there anything surprising that you found as you were doing this analysis?

I was a little-- Yeah, that's a great point, Jeff.

I was a little surprised at actually the low level of adherence to start even within the STS database.

We, you know, have looked at other-- in other studies, and it's frequently commented on that the STS database is not-- It's representative of a large group of general thoracic surgeons, but it's often board-certified people who focus in general thoracic and, and sort of inherent in that is somewhat the implication that the outcome should be better, that it's a higher quality or standard compared to a regular nat- n- you know, nationwide patient sample.

And so to see 19% adherence to a, what, what I think is a relatively easy standard to meet, three plus one, right? And then 40% by the end surprised me, um, that, that that was lower.

Now again, we included lobe segment and wedge, and we started in 2021, and so part of the wedge resections into the segmentectomies were in an-- or before the publication of CLAGB and JCO study.

So some of those were probably being done in patients who are not quite medically as fit.

How that affects the lymphadenectomy, we don't quite know, right? It may be different to look at it in an era purely when patients are get-- well, patients who are getting those operations, it may be not because they're compromised physiologically because of less aggressive tumors.

Um, and so I think that was a surprising thing.

The one thing I'll note is that this was, I won't say in collaboration necessarily with the COC, but, but you know, they have a committee, I serve on that committee investigating standards.

So I think we're gonna see from the study that Alex is gonna discuss and where Chris is gonna go, this is a standard.

It's good to have a standard.

The COC themselves is not-- I don't speak for them, but any standard is not wedded to.

Part of the process is an iterative process to find out what this, is this-- what's the goal of the standard? Is it working? And so I, I think that, you know, all of these papers are a step towards that direction in saying we need a standard, right? But we need to con-continually evaluate how they're working and be iterative to get to the right standard and evolve that in, uh, over time if, if we get the, as the data evolves.

I think, I think that's a really great point, Seth.

Um, you know, and, and I-- the STS, as we had mentioned, has been traditionally this, um, short-term database, one that, uh, we look at primarily 30-day morbidity and mortality.

Um, well, as most people know, over the course of the last couple years, we've been incorporating long-term outcomes.