Predictors and survival impact of station 4L metastasis in left non-small cell lung cancer

  • Likui Fang
  • Luming Wang
  • Yiqing Wang
  • Yihe Wu
  • Peng Ye
  • Wang Lv
  • Jian HuEmail author
Original Article – Clinical Oncology



It remains unclear about the predictors and survival impact of station 4L metastasis in left-sided non-small cell lung cancer (NSCLC). This study aims to investigate these issues to explore the significance of station 4L lymph-node dissection (LND).


We retrospectively enrolled 405 patients with station 4L LND, and divided them into the positive station 4L metastasis group and the negative station 4L metastasis group. The logistic regression was performed to identify the predictors of station 4L metastasis. The survival outcomes including disease-free survival (DFS) and overall survival (OS) were analyzed in pN2 patients to explore the prognostic effect of station 4L metastasis.


There were 48 (11.9%) patients in the positive station 4L metastasis group and 357 (88.1%) patients in the negative station 4L metastasis group. Station 5 metastasis (P = 0.008, OR 7.578, 95% CI 1.710–33.589), station 10 metastasis (P = 0.004, OR 7.133, 95% CI 1.904–26.717), and cN2 (P = 0.010, OR 5.062, 95% CI 1.473–17.392) were independent risk factors of station 4L metastasis. In pN2 patients, the positive station 4L metastasis group had inferior DFS (P = 0.019) and OS (P = 0.006) compared with the negative station 4L metastasis group, and station 4L metastasis was the independent risk factor for poor prognosis.


It is of great necessity to perform station 4L LND in left NSCLC, because station 4L metastasis is not rare and has an unfavorable prognosis.


Non-small cell lung cancer Station 4L metastasis Lymph-node dissection Prognosis 


Author contributions

Drs. JH and LF contributed to the conception and design of the work. Dr. LF and contributed to conception, design, data analysis, and editing the manuscript. Drs. LF, LW, YW, and YW contributed to data acquisition, statistical analysis, and interpretation of the data. Drs. PY and WL contributed to the revision of the manuscript.


This study was funded by Major Science and Technology Projects of Zhejiang Province (2014C03032), Key Disciplines of Traditional Chinese Medicine in Zhejiang Province (2017-XK-A33), National Key R&D Program of China (2017YFC0113500), and National Natural Science Foundation of China (31700690). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest regarding the publication of this paper.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. Adachi H, Sakamaki K, Nishii T et al (2017) Lobe-specific lymph node dissection as a standard procedure in surgery for non-small cell lung cancer: a propensity score matching study. J Thorac Oncol 12(1):85–93CrossRefGoogle Scholar
  2. Billiet C, De Ruysscher D, Peeters S et al (2016) Patterns of locoregional relapses in patients with contemporarily staged stage III-N2 NSCLC treated with induction chemotherapy and resection: implications for postoperative radiotherapy target volumes. J Thorac Oncol 11(9):1538–1549CrossRefGoogle Scholar
  3. Bray F, Ferlay J, Soerjomataram I et al (2018) Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 68(6):394–424CrossRefGoogle Scholar
  4. Clement-Duchene C, Luc A, Casse JM et al (2018) Survival impact of stations of pathological lymph nodes in N2 non-small cell lung cancer in a French Hospital. Ann Surg Oncol 25(5):1262–1268CrossRefGoogle Scholar
  5. Darling GE, Allen MS, Decker PA et al (2011) Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg 141(3):662–670CrossRefGoogle Scholar
  6. Feng W, Fu XL, Cai XW et al (2014) Patterns of local-regional failure in completely resected stage IIIA(N2) non-small cell lung cancer cases: implications for postoperative radiation therapy clinical target volume design. Int J Radiat Oncol Biol Phys 88(5):1100–1107CrossRefGoogle Scholar
  7. Han H, Chen H (2017) Selective lymph node dissection in early-stage non-small cell lung cancer. J Thorac Dis 9(7):2102–2107CrossRefGoogle Scholar
  8. Howington JA, Blum MG, Chang AC et al (2013) Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 143(5 Suppl):e278S–e313SCrossRefGoogle Scholar
  9. Johnson DH, Schiller JH, Bunn PA Jr (2014) Recent clinical advances in lung cancer management. J Clin Oncol 32(10):973–982CrossRefGoogle Scholar
  10. Kim HJ, Kim YH, Choi SH et al (2016) Video-assisted mediastinoscopic lymphadenectomy combined with minimally invasive pulmonary resection for left-sided lung cancer: feasibility and clinical impacts on surgical outcomesdagger. Eur J Cardiothorac Surg 49(1):308–313CrossRefGoogle Scholar
  11. Kuroda H, Sakao Y, Mun M et al (2015) Lymph node metastases and prognosis in left upper division non-small cell lung cancers: the impact of interlobar lymph node metastasis. PLoS One 10(8):e0134674CrossRefGoogle Scholar
  12. Liang RB, Yang J, Zeng TS et al (2018) Incidence and distribution of lobe-specific mediastinal lymph node metastasis in non-small cell lung cancer: data from 4511 resected cases. Ann Surg Oncol 24:3300–3307CrossRefGoogle Scholar
  13. Nagashima T (2016) Thoracoscopic left mediastinal lymph node dissection. Ann Transl Med 4(1):10Google Scholar
  14. Postmus PE, Kerr KM, Oudkerk M et al (2017) Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 28(suppl 4):iv1–iv21CrossRefGoogle Scholar
  15. Rami-Porta R, Wittekind C, Goldstraw P et al (2005) Complete resection in lung cancer surgery: proposed definition. Lung Cancer 49(1):25–33CrossRefGoogle Scholar
  16. Rami-Porta R, Asamura H, Travis WD et al (2017) Lung cancer—major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 67(2):138–155CrossRefGoogle Scholar
  17. Reck M, Heigener DF, Mok T et al (2013) Management of non-small-cell lung cancer: recent developments. Lancet 382(9893):709–719CrossRefGoogle Scholar
  18. Rusch VW, Asamura H, Watanabe H et al (2009) The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 4(5):568–577CrossRefGoogle Scholar
  19. Sakao Y, Miyamoto H, Yamazaki A et al (2006) The spread of metastatic lymph nodes to the mediastinum from left upper lobe cancer: results of superior mediastinal nodal dissection through a median sternotomy. Eur J Cardiothorac Surg 30(3):543–547CrossRefGoogle Scholar
  20. Sayar A, Citak N, Buyukkale S et al (2016) The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging. Acta Chir Belg 116(1):23–29CrossRefGoogle Scholar
  21. Siegel RL, Miller KD, Jemal A (2018) Cancer statistics, 2018. CA Cancer J Clin 68(1):7–30CrossRefGoogle Scholar
  22. Takenaka T, Katsura M, Shikada Y et al (2013) Outcome of surgical resection as a first line therapy in T3 non-small cell lung cancer patients. World J Surg 37(11):2574–2580CrossRefGoogle Scholar
  23. Trujillo-Reyes JC, Martínez-Téllez E, Rami-Porta R et al (2018) Combination video-assisted mediastinoscopic lymphadenectomy and transcervical thoracoscopy. Multimed Man Cardiothorac Surg. Google Scholar
  24. Wang YN, Yao S, Wang CL et al (2018) Clinical significance of 4L lymph node dissection in left lung cancer. J Clin Oncol 36(29):2935–2942CrossRefGoogle Scholar
  25. Watanabe S, Asamura H (2009) Lymph node dissection for lung cancer: significance, strategy, and technique. J Thorac Oncol 4(5):652–657CrossRefGoogle Scholar
  26. Whitson BA, Groth SS, Maddaus MA (2007) Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer. Ann Thorac Surg 84(3):1059–1065CrossRefGoogle Scholar
  27. Yoo DG, Kim YH, Kim DK et al (2011) Clinical feasibility and surgical benefits of video-assisted mediastinoscopic lymphadenectomy in the treatment of resectable lung cancer. Eur J Cardiothorac Surg 40(6):1483–1486Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Thoracic Surgery, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina

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