Clinical Misstagings and Risk Factors of Occult Nodal Disease in Non-Small Cell Lung Cancer

Our objective was to compare the clinical to the pathologic stage in patients with non-small cell lung cancer (NSCLC). A prospective database from 1 surgeon was reviewed. Patients had NSCLC, chest tomography (CT), and most had positron emission tomography (PET). Those with suggested N1, N2, central tumors, or tumors larger than 5 cm underwent mediastinoscopy or endobronchial ultrasound, or both, and if N2 negative, underwent resection with complete thoracic lymphadenectomy. Between January 2006 and December 2016, there were 1,444 consecutive patients. The sensitivity and specificity for CT was 76% and 79% for pathologic stage I, 48% and 89% for stage II, and 58% and 88% for stage III. The sensitivity and specificity for PET was 77% and 70% for pathologic stage I, 43% and 88% for stage II, and 46% and 93% for stage III. Pathologic N1 disease was proven in 7% of patients and missed in 4% by CT, 5% by PET, and 3% by both. Pathologic N2 disease was proven in 20% of patients and missed in 9% by CT, 10% by PET, and 8% by both. Occult N2 disease was present in 10% of clinically stage I patients and in 21% of clinically stage II patients. Independent predictors of occult N1 disease included high maximum standardized uptake value (p = 0.034) and predictors of N2 disease included African American race (p = 0.020) and large tumor size (p = 0.047). Despite advancements in CT, PET, and minimally invasive nodal biopsy, there remains significant NSCLC misstaging, especially for N2 disease. Improved, targeted N2 lymph node biopsy may improve preresection staging.