Study Shows Mediastinal LND Not Recommended in GGO-Dominant Lung Cancer

A clinical study examining determined that systemical mediastinal lymph node dissection (LND) should no longer be recommended in stage T1 ground-glass (GGO)-dominant invasive lung adenocarcinoma..¹

The phase 3 study, ECTOP-1009 (NCT04527419),² was a randomized controlled trial with 302 patients. The primary end point was 3-year disease-free survival (DFS). Interim analysis revealed no lymph node metastasis in either study arm of the patients. The no LND arm had reduced surgery duration, with a mean of 74 minutes vs 109 minutes, P <.001. There was also a significant reduction in blood loss (mean, 44 mL vs 82 mL; P =.033) and postoperative hospital stay (mean, 3.9 days vs 4.5 days; P =.002). Complications in the systematic LND arm included chylothorax in 1 patient (0.7%) and intraoperative massive bleeding because of superior vena cava injury in 1 patient (0.7%).¹

“This [randomized clinical trial (RCT)] should be terminated in accordance with the principle of nonmaleficence in medical ethics. Given the current evidence and the recognized risks associated with LND, continuing with an RCT that involves LND in patients who are not at risk for lymph node metastasis may no longer be appropriate,” said the authors of the study.¹ “We plan to seek approval from our institutional review board to terminate this trial. Moving forward, guidelines for LND should adopt a more precise approach, incorporating the concept of selective LND. Metastatic lymph nodes should be removed, while nonmetastatic lymph nodes that can be predicted preoperatively or intraoperatively should be preserved, not only to minimize surgical complications but also to protect the body's immune function.”

What Were the Patient Characteristics?

The interim analysis ran from February 2022 to January 2025 and included 151 patients randomly assigned to systematic mediastinal LND and the other half randomly assigned to no mediastinal LND. Majority of the patients were female, with 62.9% in the no LND arm group and 60.3% in the systematic LND arm group. Majority of patients overall underwent segmentectomy, with 75.5% in the systematic LND arm group and 69.5% in the no LND arm group. The median number of resected lymph nodes was 10 (IQR, 8–15) in the systematic LND arm and 3 (IQR, 1–6) in the no mediastinal LND arm (P <.001).¹

What Were the Results of the Trial?

There was a significant reduction in duration of surgery (mean, 74 minutes for no LND vs 109 minutes for systematic LND; P < .001), blood loss (mean, 44 mL for no LND v 82 mL for systematic LND; P = .033), chest tube duration (mean, 2.7 days for no LND vs 3.0 days for systematic LND; P =.037), and length of postoperative stay (mean, 3.9 days for no LND vs 4.5 days for systematic LND; P .002) in the no LND arm compared with the systematic LND arm.¹

As of the data cutoff of in April 2025, no events of disease recurrence or death were observed in either arm. Between the no LND and systematic LND arms there was no significant difference in DFS or overall survival.¹

“In conclusion, this study provides evidence for omitting mediastinal LND in GGO-dominant invasive lung adenocarcinoma,” said the authors of the study. “The current clinical practice of routine systematic LND or sampling should be changed for patients with negative mediastinal lymph nodes, which can be predicted preoperatively or intraoperatively. Nonmetastatic mediastinal lymph nodes should not be resected.”¹

REFERENCES:

1. Zhang Y, Qian B, Song Q, et al. Phase III Study of Mediastinal Lymph Node Dissection for Ground Glass Opacity-Dominant Lung Adenocarcinoma. J Clin Oncol. 43, 3081-3089(2025). doi:10.1200/JCO-25-00610

2. SLND or Not in cT1 GGO Invasive Lung Adenocarcinoma (ECTOP-1009). ClinicalTrials.gov. Updated August 26, 2025. Accessed October 8, 2025. https://www.clinicaltrials.gov/study/NCT04527419