A national analysis of adherence to the American College of Surgeons Commission on Cancer (CoC) Standard 5.8 for lymph node dissection and assessment in non-small cell lung cancer (NSCLC) found that surgical practice patterns are improving, though significant room remains for better standardization.1 Additionally, greater adherence to the CoC standard was linked to increased pathologic nodal upstaging.
Standard 5.8 was implemented in 2021 and requires pathologic assessment of at least three mediastinal (N2) and one hilar (N1) lymph node during lung cancer resection with curative intent. The findings were reported at the 2026 Society of Thoracic Surgeons Annual Meeting.
The analysis showed a 2.1% absolute increase in pathologic nodal upstaging among patients meeting Standard 5.8 compared with those who did not (11.5% vs 9.4%) despite negative preoperative endobronchial ultrasound, with an adjusted odds ratio (aOR) of 1.14 (95% CI, 1.07-1. 22). There was no significant difference in 30-day major morbidity (aOR 0.93) or operative mortality (aOR 1.00) between the groups.
“With expanded node dissection, more patients whose cancer has spread will be identified and they will receive appropriate systemic treatments,” said investigator Christopher Seder, MD, Chief of Thoracic Surgery, Rush University Medical Center, who presented the data. “The onus here is not only on surgeons for them to dissect more lymph nodes but on pathologists to take the lung specimen we give them and do a very thorough evaluation of that lung specimen to get all the additional lymph nodes with cancer that are hiding in the specimen.”
The real-world impact of Standard 5.8 on patient survival and surgical workflow remains unclear, however.
“The standard is still relatively new, and surgeons are still struggling to incorporate it into their practice,” said Leah Backhus, MD, MPH, Thelma and Henry Doelger Professor of Cardiothoracic Surgery at Stanford University School of Medicine. “The standard concentrates on lymph nodes, not the extent of resection itself, but they go together somewhat because the lymph nodes that we need are pretty deep within the lung tissue and are almost always going to require more extensive lung resection to get to them.
“We have a couple of really good, large-scale randomized prospective trials that have demonstrated the benefits of, or at least the noninferiority of, sublobar resection and lung cancer survival. The pendulum has shifted away from doing lobectomy to doing smaller resections without any compromise of survival benefit.”
For the analysis, researchers identified 52,497 patients diagnosed with stage I to IIIA NSCLC who underwent wedge resection, segmentectomy, or lobectomy from the Society of Thoracic Surgeons General Thoracic Surgical Database (STS GTSD) between July 1, 2021, and December 31, 2024. All were clinically node negative. During the study period, 66.4% of patients met Standard 5.8, increasing from 54.3% in 2021 to 75.1% in 2024. According to the data, adherence improved across all three types of resections but was lower for wedge resections (44.7%) compared with segmentectomies (68.4%) and lobectomies (72.8%).
The percentages of surgeons and centers with ≥80% adherence increased from 19.3% and 23.2% to 43.5% and 44.2%, respectively, during the study period. Factors associated with adherence to the standard included patients who are Asian (aOR 1.26), current (aOR 1.19) or past smoking history (aOR 1.11), segmentectomy (aOR 2.78), and lobectomy (aOR 3.70). Patients who underwent right middle lobectomy were less likely to meet the standard (aOR 0.71).
Dr. Backhus noted that the data on Standard 5.8 adherence were abstracted from a limited cohort of STS-participating institutions with a larger number of thoracic surgeons. An earlier analysis of the larger CoC database, which included a more heterogeneous pool of thoracic and nonthoracic surgeons and institutions, showed 54% adherence to Standard 5.8.1 She said that while meeting Standard 5.8 requires minimal procedural adjustments for most thoracic surgeons, it could necessitate significant workflow changes for pathology departments and hospital operations.
References
1. Baskin AS, Funk EC, Francescatti AB, et al. Early compliance with lung cancer lymph node Standard 5.8: An analysis of 2022 and 2023 Commission on Cancer site reviews. J Thorac Cardiovasc Surg. 2025;170(4):926-932. doi:10.1016/j.jtcvs.2025.04.041
