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Lymph node ratio as a prognostic factor in elderly patients with pathological N1 non-small cell lung cancer
  1. Juan P Wisnivesky1,2,
  2. Jacqueline Arciniega1,
  3. Grace Mhango1,
  4. John Mandeli3,
  5. Ethan A Halm4
  1. 1Divisions of General Internal Medicine, Mount Sinai School of Medicine, New York, New York, USA
  2. 2Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai School of Medicine, New York, New York, USA
  3. 3Department of Preventive Medicine, Mount Sinai School of Medicine, New York, New York, USA
  4. 4Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
  1. Correspondence to Juan P Wisnivesky, Department of Medicine, Mount Sinai School of Medicine, One Gustave L Levy Place, Box 1087, New York, NY 10029, USA; juan.wisnivesky{at}


Background Lymph node (LN) metastasis is an important predictor of survival for patients with non-small cell lung cancer (NSCLC). However, the prognostic significance of the extent of LN involvement among patients with N1 disease remains unknown. A study was undertaken to evaluate whether involvement of a higher number of N1 LNs is associated with worse survival independent of known prognostic factors.

Methods Using the Surveillance, Epidemiology and End Results-Medicare database, 1682 resected patients with N1 NSCLC diagnosed between 1992 and 2005 were identified. As the number of positive LNs is confounded by the total number of LNs sampled, the cases were classified into three groups according to the ratio of positive to total number of LNs removed (LN ratio (LNR)): ≤0.15, 0.16–0.5 and >0.5. Lung cancer-specific and overall survival was compared between these groups using Kaplan–Meier curves. Stratified and Cox regression analyses were used to evaluate the relationship between the LNR and survival after adjusting for potential confounders.

Results Lung cancer-specific and overall survival was lower among patients with a high LNR (p<0.0001 for both comparisons). Median lung cancer-specific survival was 47 months, 37 months and 21 months for patients in the ≤0.15, 0.16–0.5 and >0.5 LNR groups, respectively. In stratified and adjusted analyses, a higher LNR was also associated with worse lung cancer-specific and overall survival.

Conclusions The extent of LN involvement provides independent prognostic information in patients with N1 NSCLC. This information may be used to identify patients at high risk of recurrence who may benefit from aggressive postoperative therapy.

  • Lymph node ratio
  • lung cancer
  • prognosis
  • stage

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  • See Editorial, p 271

  • Linked articles 155010.

  • Funding This study was supported by the National Cancer Institute (5R01CA131348-02).

  • Competing interests JPW is a member of the research board of EHE International and has received a grant from Glaxo Smith Kline for a COPD study and lecture fees from Novartis Pharmaceuticals.

  • Ethics approval The study was classified exempt by Mount Sinai's Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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