11ip lymph node may play as N2 stage in right middle NSCLC

11ip lymph node may play as N2 stage in right middle NSCLC | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article 11ip lymph node may play as N2 stage in right middle NSCLC Xu Han, Wenjing Zhang, Wenjun Jiang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3878368/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Right middle lobe NSCLC has a worse prognosis compared to other lobes possibly due to the lower number of lymph node dissections in surgery.So,we investigate the clinical significance of #11ip lymph node(LN) metastasis in right middle lobe NSCLC. Methods Symbolize the right lung #11 LN as superior 11(#11s), anterior 11(#11ia), and posterior 11(#11ip), based on their adjacency to the superior lobar bronchus, the middle lobar bronchus, and the region between right dorsal segmental bronchus and intermediate bronchus of right lung respectively in the view of single-port thoracoscopic surgery. The clinical data of mediastinal and #11 LN metastasis in 80 cases of right middle lobe NSCLC who were underwent surgical pulmonary resection from 2015–2022 were analyzed retrospectively and one case of #11ip LN metastasis retrogradely from #7 LN in bladder cancer was reported. Results None of 32 patients with pure ground-glass nodule (pGGN) were found to have lymph node metastasis (LNM). Out of the 48 patients with mixed ground-glass nodule (mGGN), no case with #11ip LNM was found in N1 cases(n = 6), but there was one case of #11ip LNM in N2 cases(n = 6).This tumor was in lateral segment and > 2 cm. #11ip LN resection with undifferentiated dorsal oblique fissure need more operative time than those with differentiated dorsal oblique fissure(149.32m to109.68m,p < 0.05) ,but postoperative drainage extubation time has no difference(5.22 days to 4 days,p = 0.116) and the postoperative drainage volume has no difference either (823.33ml to 607.14ml,p = 0.100). In addition, the survival period of N2 patient with #11ip LNM is 6 months. Conclusion To right middle lobe NSCLC with pGGN, #11ip LN dissection or biopsy is not necessary.Presenting as mGGN, #11ip LN should be dissected or biopsied particularly #4 or #7 LNM were found during surgery. #11ip LNM has a worse prognosis and may play as N2 stage in right middle lobe NSCLC. Biological sciences/Cancer/Lung cancer/Non small cell lung cancer Biological sciences/Cancer/Cancer imaging Biological sciences/Cancer/Cancer therapy Biological sciences/Cancer/Metastases Right middle lobe The lymphatic sump of Borrie 3-dimensional reconstruction 11ip lymphatic node Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Globally, lung cancer continues to be the leading cause of cancer-related mortality( 1 ).Lobectomy, along with systematic lymph node dissection, has been widely recognized as the standard surgical approach for NSCLC. Additionly,the concept of lobe-specific or selective lymph node dissection for lung cancer has gained acceptance among both domestic and foreign scholars( 2 – 6 ).However,a comprehensive lymph node dissection is crucial for achieving positive treatment outcomes especially for right middle lung lobe cancer. The worse effectiveness of surgical treatment for right lung middle lobe cancer is compromised due to the lower number of lymph node dissections compared to other lobes( 7 ). Recent studies have provided a more accurate categorization of bronchopulmonary lymph nodes, the lymphatic sump of Borrie( 8 , 9 )in right lung, which plays a crucial role in metastasis. We have divided the lymphatic sump of Borrie into three parts as superior 11(#11s), anterior 11(#11ia), and posterior 11(#11ip), based on their adjacency to the superior lobe bronchus, middle lobe bronchus, and the region between right dorsal segmental bronchus and intermediate bronchus of right lung respectively. Until now,there is no research on whether routine dissection or biopsy of #11ip LN is necessary for right middle lobe NSCLC.Hence, we conducted a retrospective study to investigate the occurrence and prognostic significance of #11ip LN metastasis in the right middle lobe NSCLC. Patients and methods This study is a retrospective study. Our Institutional Review Board waived the requirement to obtain patient informed consent and approved the study, as the patient identity was not revealed(the IRB number:EC-2023-KS-002).We confirm that all methods were performed in accordance with the relevant guidelines and regulations. From Jan 2015 to Dec 2022, 80 patients with primary right middle lung cancer were admitted to our hospital and underwent radical resection. Inclusion criteria were as follows:( 1 )The pathological result is non-small cell carcinoma of the lung (including adenocarcinoma and squamous cell carcinoma). ( 2 )Minimum three groups of mediastinal lymph nodes (2R, 4R, 7, 8, 9) are dissected or sampled. ( 3 )The medical history information is complete. Exclusion criteria were as follows: ( 1 ) The pathological results were benign tumors and small cell lung cancer ( 2 )Right middle lobe secondary malignant tumors ( 3 )The medical history data are missing. The patient records consisted of information such as age, gender, tumor consistency, tumor size, p-T stage, p-N stage, TNM stage,distribution of nodular (medial and lateral segments), histological diagnosis (Table 1). Table 1. Patient Characteristics Number Age(yr.) 32–83,median:63 Gender(male/female) 27/53 p-N(N0/N1/N2) 68/6/6 P-T(T1/T2/T3/T4) 64/12/2/2 M(M0/M1) 80/0 Tumor stage(I/II/III/IV) 66/5/9/0 Tumor consistency (pGGN/mGGN) 32/48 Tumor size(≤ 2 cm />2 cm) 52/28 Medial segment/Lateral segment/Uncertain 19/58/3 Histological diagnosis Adenocarcinoma/squamous cell carcinoma 79/1 To investigate the risk factors for lymph node metastasis in right middle lobe cancer, we categorized 80 patients into groups based on five different criteria. These criteria included gender (male and female),age (≤ 70 years old and > 70 years old) ,nodule nature (pGGN/mGGN) and size(≤ 2 cm and > 2 cm), and distribution of mGGN(Medial segment/Lateral segment/Uncertain) We reconstructed the #11 LNs in 3 Dimensions using authorized software DeepInSight (Internal Trial Version 1.0, Key Laboratory of Medical Imaging Intelligent Computer of Ministry of Education, Northeastern University). To investigate the impact of pulmonary dorsal fissure completeness on #11ip LN resection in surgery and postoperative recovery, we categorized patients into two groups: incomplete dorsal fissure and complete dorsal fissure. We conducted a comparison between the two groups in terms of operation time, drainage tube removal time, and postoperative drainage volume. To assess the prognosis of the patients, we conducted a follow-up study on 80 patients. We reviewed their chest CT scaned every 3–6 months after surgery, spanning from January 2015 to December 2022 or to the date of death of patients. Statistical analysis The statistical analysis was performed using IBM SPSS statistics 26.0. Chi-squared test or Fisher’s exact test was used to compare categorical data between groups. A two-sided P value less than 0.05 was considered statistically significant. Results 1.The risk factors for lymph node metastasis in right middle lobe cancer This subgroup included 26 men and 54 women, 68 cases ≤ 70 years and 12 cases > 70 years, Table 2 Influencing factors of lymph node metastasis: Univariate Analysis Variables N0 N1 N2 Total P Gender (Male/female) 20/48 4/2 2/4 26/54 0.251 Age (≤ 70/>70) 59/9 4/2 5/1 68/12 0.400 Tumor consistency(pGGN/mGGN) 32/36 0/6 0/6 32/48 0.008 Tumor size(≤ 2 cm />2 cm) 49/19 1/5 2/4 52/28 0.003 Distribution of GGN (Medial segment/Lateral segment/Uncertain) 18/49/1 0/4/2 1/5/0 19/58/3 0.042 P values in Table 2 are all derived using fisher’s exact test (median 61 years). None of 32 patients with pure ground-glass nodule (pGGN) were found to have lymph node metastasis.In 48 patients with mixed ground-glass nodule (mGGN), there were 6 N1 cases and 6 N2 cases.In 52 cases with ≤ 2 cm,there were 1 N1 case and 2 N2 cases.In 28 cases with > 2 cm,there were 5 N1 cases and 4 N2 cases. Among mGGN patients,4 N1 cases and 5 N2 cases appeared in lateral segment,only 1 N2 case appeared in medial segment. The statistical significance was primarily observed in the consistency of the nodules (P = 0.008),the size of the nodules (P = 0.003)and the nodule distribution(P = 0.042). However, age and gender did not show any statistical significance in relation to the metastasis of right middle lobe NSCLC(refer to Table 2 ). 2.Location of #11ia, #11ip, and #11s LN in enhanced CT and three-dimensional reconstruction image #11s LN is around the superior lobe bronchus,#11ia LN is around middle lobe bronchus, #11ip LN, is in the region between right dorsal segmental bronchus and intermediate bronchus of right lung.(Fig. 1 ) 3.Status of Lymph Node Metastases In 48 patients with mGGN, there were 6 N1 cases and 6 N2 cases. For the 6 patients with N1 stage, the probability of LNM was 1/2 in the #11ia LN, 0 in the #11ip LN, and 2/3 in the #12 LN. For the 6 patients with N2 stage, the probability of LNM was 5/6 in #4 LN, 2/3 in #7 LN, 1/2 in #11ia LN, and 1/6 in the #11ip LN.(Table 3 ) Table 3 Distribution of lymph node involvement N Stage of lung cancer Patient number Station of lymph node 2 4 7 9 10 11ia 11ip 11s 12 N1 1 - - - - - - - - + 2 - - - - - - - - + 3 - - - - + + - - - 4 - - - - - - - - + 5 - - - - - + - - - 6 - - - - - + - - + N2 7 - + + + + + - - + 8 - + - - - - - - - 9 - - + - - - - - - 10 + + + - + + - - + 11 + + - - - - - - + 12 - + + - - + + - + 4.The impact of the completeness of dorsal fissure on patients on #11ip LN resection during surgery and postoperative recovery (Table 4 ) Table 4 Impact of pulmonary dorsal fissure completeness on #11ip LN resection Variables Dorsal fissure completeness P Incomplete Complete Operation time(min) 149.32 109.68 0.001 Drainage tube removal time(h) 5.22 4 0.116 Postoperative drainage volume(ml) 823.33 607.14 0.100 P values in Table 4 are all derived using fisher’s exact test For incomplete dorsal fissure and complete dorsal fissure, the average operation time was 149.32 minutes and 109.68 minutes. The average drainage tube removal time was 5.22 days and 4 days. The average postoperative drainage volume was 823.33ml and 607.14ml. In cases who have incomplete dorsal fissure, it is frequently necessary to cut off the dorsal fissure during the operation to resect #11ip LN. Obviously, this situation can extend operation time (P = 0.001) and may also lead to various unexpected situations during the procedure,such as accidental bleeding. However, we did not observe any significant statistical difference in extubation time and postoperative drainage volume.(Table 4 ) 5.Postoperative follow-up Follow-up was conducted on the same 80 patients. Out of the 32 patients with pGGN, it was found that no one experienced metastasis. Out of 48 patients with mGGN, 15 lost patients were excluded from the follow-up analysis. Among the 5 patients with N2 stage, 2 experienced postoperative metastasis. Interestingly, 2 patients with stage N1 showed no signs of metastasis, while 2 of 32 patients with stage N0 had metastasis. We compared four patients with similar characteristics of the metastasis N0 stage patients, and observed that the metastasis of N0 stage patients might be associated with the incompleteness of dissection in the #11ip LN. The prognosis time of the six patients is depicted in the figure (Fig. 2 ). When reviewing the N2 stage patients with metastases, we observed that in one patient, the #4 and #11ip LN did not show any signs of metastasis before the operation. However, during the postoperative follow-up, we noticed that the lymph nodes of #4 and #11ip LN had enlarged and intrapulmonary metastasis had occurred 2 years late. The survival period of this patient is 28 months.(Fig. 3 ) 6.Retrograde metastasis of #11ip LN by #7 LN. #7 LN and #11ip LN were found to be abnormally enlarged in a bladder cancer woman who was a 80 years old. (Fig. 4 ) Discussion The occurrence of right middle lobe NSCLC is lower compared to other lobes. And it has a worse prognosis( 10 , 11 ), possibly due to the lower number of lymph node dissections in surgery( 7 ). Currently, there are no studies available reporting on the grouping of #11 LN in middle lobe lung cancer, especially #11ip LN. The NSCLC diagnosis and treatment guidelines issued by the NCCN( 12 ), the European Association of Thoracic Surgeons guidelines( 13 ), and the NSCLC diagnosis and treatment guidelines issued by the Chinese Medical Association( 14 ) do not provide clear instructions regarding the necessity of dissecting or sampling #11ip LN in right middle lobe NSCLC. Among the 80 patients who underwent surgery for right middle lobe NSCLC at our hospital, we observed a patient who had a poor prognosis due to the #11ip LNM. This finding caught our attention. We reconstructed the patient's #11s, #11ia, and #11ip LN using three-dimensional reconstruction techniques(DeepInSight), as depicted in the accompanying figure(Fig. 1 ). In addition, #11ip LN dissection is often hindered by the undifferentiated dorsal oblique fissure and the inferior trunk of the pulmonary artery. When the lung fissures are poor differentiated, incision of the dorsal oblique fissure is required, resulting in a significantly longer operation time(P 0.05). Therefore, in cases of Single-incision video-assisted thoracic right middle lobectomy, dissection of the 11ip lymph node does not lead to any related complications even when the dorsal oblique fissure is undifferentiated. Scholars generally believe that intrapulmonary lymph nodes serve as continuous sites for metastasis to interlobar lymph nodes, hilar lymph nodes, and mediastinal lymph nodes( 15 , 16 ).From the anatomical perspective, researchers have injected dye into the pleural lymphatic vessels of the right lung and observed that 87.5% of the lymph fluid in the middle lobe of the right lung drains into #7 LN. Also they found that a lymphatic chain between lateral segment and #7 LN. These lymph nodes then pass through various lymph node chains (such as the paraesophageal chain, right paratracheal chain, tracheoesophageal chain, and recurrent chain) before draining into different stations of lymph nodes in the lungs and systemic circulation( 17 – 19 ). As a result, #11 LN are considered to have the highest incidence of lymph node metastasis within the lung. However, there are opposing views among scholars regarding this perspective. Yukinori Sakao( 20 ) conducted a review of surgical records of 170 patients with right middle lobe NSCLC. His findings revealed that out of the 14 patients with N1 stage, the most common site of metastasis was the 12, which are located adjacent to the middle lobe bronchus. In contrast, there was only one case of metastasis in the interlobar lymph nodes of the #11s LN(superior interlobe lymph nodes), and no metastasis was observed in the #11i LN(inferior interlobe lymph nodes). Additionally, when tumor tissue invades the lymph nodes in #11s or #11i LN, eight out of nine cases or five out of five cases respectively are classified as N2 cases. At the same time, Hiroaki Kuroda( 21 ) discovered that the likelihood of lymph node involvement in the #11s and #11i LN for N1 stage lung cancer patients was 5.6% and 0% respectively. Additionally, lymph node metastasis in the #11i LN, as well as #2 and #4LN, were identified as significant factors contributing to a poor prognosis in patients with middle lobe lung cancer. However, these studies did not provide a clear distinction between the lymph nodes in the #11i LN, specifically the #11ia LN and the #11ip LN. In a study conducted by Il Kwon Ko( 22 ),55 patients with mediastinal metastasis of head and neck cancer were investigated. The findings revealed that head and neck cancer frequently spread to the upper mediastinal region (#2, #3, and #4 LN), hilar region, and interlobular region (#10 and #11 LN). Additionally, there were instances of metastatic cancer involving paratracheal lymph nodes( 23 , 24 ). Upon reviewing relevant cases in our hospital, we identified a patient with bladder cancer whose lymph nodes in #7 and #11ip LN of the right lung had metastasized(Fig. 4 ), and another case of postoperative recurrence and progression of lung cancer. Notably, the lymph nodes in #4 and# 11ip LN did not show any signs of metastasis prior to surgery. However, during the follow-up after surgery, these lymph nodes exhibited increased size and metastasis in 2 years(Fig. 3 ). All in all, we speculate that the metastasis of the #11ip LN may be caused by indirect metastasis of #4 and #7 LN(Fig. 1 ), rather than direct metastasis from the middle lobe. Therefore, it suggests that for patients with right middle lobe NSCLC, the #11ip LN may function as N2 stage lymph nodes. In the surgery for right middle lobe NSCLC, the necessity of lymph node dissection in #11 LN can be determined by the results of intraoperative frozen pathology in #4 and #7 LN. Hiroaki Kuroda( 21 ) found that in patients with N2 stage, the probability of lymph node involvement in #4 and #7 LN was 48.5% and 58.8% respectively, suggesting that these lymph nodes are the main metastatic sites of lung cancer. By performing intraoperative dissection of lymph nodes in #4 and #7 LN, patients can be accurately staged and the need for lymph node dissection in #11ip LN can be determined based on the results of intraoperative frozen pathology. If the pathology of lymph nodes in #4 and #7 LN is positive during surgery, the #11ip LN dissection must be performed. In the field of imaging, the density of nodules plays a crucial role in determining whether lymph node dissection is necessary. In a retrospective analysis conducted by Zhirong Zhang( 25 ),a total of 270 patients with NSCLC in each lobe were examined. These patients underwent systematic lymph node dissection, with a maximum nodule diameter of ≤ 3cm. The analysis revealed that patients with pGGN did not show any lymph node metastasis. However, those with mGGN exhibited partial LNM. In our study, we observed that out of 80 lung cancer patients, 32 patients with pGGN did not have LNM. Among the 48 patients with mGGN, there were 6 cases of metastasis in the #11ia LN and 1 case of LNM in the #11ip LN. Therefore, for patients with mGGN, if preoperative CT reveals enlarged #11ip LN, it is recommended to consider performing #11ip LN dissection. In conclusion,out of right middle lobe NSCLC,for pGGN patients, lymph node dissection or biopsy in the #11ip LN is not necessary. In mGGN patients, #11ip LN should be dissected when it showed enlargement in preoperative CT or particularly #4 and #7 LNM were found during surgery especially the tumor was in lateral segment. Right middle lobe NSCLC with #11ip LNM has a worse prognosis. Therefore, #11ip LN may play as N2 stage in right middle lobe NSCLC. Abbreviations inferior lobar bronchus(11ip), superior lobar bronchus(11s), anterior bronchus(11ia), non-small cell lung cancer(NSCLC), pure ground-glass nodule (pGGN), mixed ground-glass nodule (mGGN), lymphatic node(LN), lymphatic node metastasis(LNM). Declarations Ethics approval and consent to participate: This study is a retrospective study. Our Institutional Review Board waived the requirement to obtain patient informed consent and approved the study, as the patient identity was not revealed(the IRB number:EC-2023-KS-002). We confirm that all methods were performed in accordance with the relevant guidelines and regulations. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: Not applicable Authors' contributions: WJZ analyzed the data and wrote the manuscript; XH participated to write and revise the manuscript;WJJ designed and supervised for this research; All the authors participated in discussions during the research and manuscript preparation process. XH and WJZ contributed equally to this work. Acknowledgements: Not applicable Authors' information Institutional addresses: From the Department of Thoracic Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China. Address for reprints: Wenjun Jiang,MD,No 4 Chongshandong Rd, Huanggu District, Shenyang, Liaoning Province, China 110032 (E-mail: [email protected] ). Corresponding authors: Wenjun Jiang References Nasim F, Sabath BF, Eapen GA. Lung Cancer. Med Clin North Am. 2019;103(3):463–73. Ding N, Mao Y. [Advances in Lymph Node Metastasis and the Modes of Lymph Node Dissection in Early Stage Non-small Cell Lung Caner]. Zhongguo Fei Ai Za Zhi. 2016;19(6):359–63. Wang W, Shentu Y. [Progress of lymphadenectomy on lung cancer surgery]. Zhongguo Fei Ai Za Zhi. 2010;13(7):744–7. Chen J, Shen-Tu Y. [Research progress of lobe-specific lymphadenectomy on early stage lung cancer operation]. Zhongguo Fei Ai Za Zhi. 2011;14(1):63–8. 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[Exploration of lymph node metastasis and appropriate lymph node dissection modes in patients with clinical stage I non-small cell lung cancer]. Zhonghua Zhong Liu Za Zhi. 2014;36(7):536–40. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3878368","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":269759788,"identity":"344cf7cc-b43d-45d2-9634-bb244ab06008","order_by":0,"name":"Xu Han","email":"","orcid":"","institution":"The Fourth Affiliated Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Han","suffix":""},{"id":269759789,"identity":"249f1c84-df33-46d2-8a9d-145aee7ab2d3","order_by":1,"name":"Wenjing Zhang","email":"","orcid":"","institution":"The Fourth Affiliated Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenjing","middleName":"","lastName":"Zhang","suffix":""},{"id":269759790,"identity":"0ba674f3-9da5-4a07-b4c9-26e93c844190","order_by":2,"name":"Wenjun Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBACxmYYo4GB8QGEmUC8FmYDorQgAzYJorQwtzM/e/i1zSaPeUbusYqfOYcZ+NlzDBh+7sDnMDZzY9m2tGLGGXlpN3u3HWaQ7HljwNh7Bp8WBjNpyW2HExtn5JjdZgRqMbiRY8DM2IZPC/s3oJb/YC3FIC32hLXwmEl+3HYArIUZbIsEYS1l0oz/khMbe94YS/ZuS+eROPOs4GAvHi2G/ce3Sf44Y5e4sT3H8MPPbdZy/O3JGx/8xKelARjQPFAGCIDYDAdwa2BgkAc57geUMQpGwSgYBaMAKwAAiVFQcYGei4kAAAAASUVORK5CYII=","orcid":"","institution":"The Fourth Affiliated Hospital of China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Wenjun","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2024-01-19 10:02:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3878368/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3878368/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50382442,"identity":"76986a10-611f-4c2f-bbf1-cc60a35447a6","added_by":"auto","created_at":"2024-01-30 17:19:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":365518,"visible":true,"origin":"","legend":"\u003cp\u003eA. The #11ia,#11ip,#11s LN and bronchus of right lung reconstructed in 3 dimensions.The red dotted line represents the transfer of tumor from the middle lobe to #7 LN and then to #11ip LN. The bule line represents the transfer of tumor from the middle lobe to #4 LN and then to #11ip LN.B. #11ia LN in enhanced CT.C.#11ip LN in enhanced CT.D.#11s LN in enhanced CT.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3878368/v1/ecae5e9b9f4028495457ea14.png"},{"id":50382440,"identity":"aaa3867f-9fd0-4745-98d6-0572211734b2","added_by":"auto","created_at":"2024-01-30 17:19:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48618,"visible":true,"origin":"","legend":"\u003cp\u003eThe prognosis time of the six patients\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3878368/v1/f50d2de12ff03de3e029d68f.png"},{"id":50382441,"identity":"cbacede1-4cd7-4f36-991d-4ea1acbadc71","added_by":"auto","created_at":"2024-01-30 17:19:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":134891,"visible":true,"origin":"","legend":"\u003cp\u003eLymph node evolution in #4 and #11ipLN. A.#4 LN in enhance CT in 2015.B.#4 LN in enhance CT in 2017.C.#4 LN in enhance CT in 2018.D.#11ip LN in enhance CT in 2015.E.#11ip LN in enhance CT in 2017. F.#11ip LN in enhance CT in 2018.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3878368/v1/4e8b8e97b9f7d80608cad82a.png"},{"id":50382443,"identity":"8c1f8ba4-c75a-4dd2-af80-4569636d1afb","added_by":"auto","created_at":"2024-01-30 17:19:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":59331,"visible":true,"origin":"","legend":"\u003cp\u003eEnlarged #7 LN and #11ip LN of the bladder cancer patient in enhance CT.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3878368/v1/4a773c0bee858516460b06a1.png"},{"id":54340084,"identity":"03289cdb-8d03-4ff4-af21-9d924b7b97d4","added_by":"auto","created_at":"2024-04-09 04:52:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":801135,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3878368/v1/cd20070f-e8e9-4044-8467-99de0c7bd1f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"11ip lymph node may play as N2 stage in right middle NSCLC","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, lung cancer continues to be the leading cause of cancer-related mortality(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).Lobectomy, along with systematic lymph node dissection, has been widely recognized as the standard surgical approach for NSCLC. Additionly,the concept of lobe-specific or selective lymph node dissection for lung cancer has gained acceptance among both domestic and foreign scholars(\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).However,a comprehensive lymph node dissection is crucial for achieving positive treatment outcomes especially for right middle lung lobe cancer. The worse effectiveness of surgical treatment for right lung middle lobe cancer is compromised due to the lower number of lymph node dissections compared to other lobes(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Recent studies have provided a more accurate categorization of bronchopulmonary lymph nodes, the lymphatic sump of Borrie(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)in right lung, which plays a crucial role in metastasis. We have divided the lymphatic sump of Borrie into three parts as superior 11(#11s), anterior 11(#11ia), and posterior 11(#11ip), based on their adjacency to the superior lobe bronchus, middle lobe bronchus, and the region between right dorsal segmental bronchus and intermediate bronchus of right lung respectively. Until now,there is no research on whether routine dissection or biopsy of #11ip LN is necessary for right middle lobe NSCLC.Hence, we conducted a retrospective study to investigate the occurrence and prognostic significance of #11ip LN metastasis in the right middle lobe NSCLC.\u003c/p\u003e \u003cp\u003ePatients and methods\u003c/p\u003e \u003cp\u003eThis study is a retrospective study. Our Institutional Review Board waived the requirement to obtain patient informed consent and approved the study, as the patient identity was not revealed(the IRB number:EC-2023-KS-002).We confirm that all methods were performed in accordance with the relevant guidelines and regulations. From Jan 2015 to Dec 2022, 80 patients with primary right middle lung cancer were admitted to our hospital and underwent radical resection. Inclusion criteria were as follows:(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)The pathological result is non-small cell carcinoma of the lung (including adenocarcinoma and squamous cell carcinoma). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)Minimum three groups of mediastinal lymph nodes (2R, 4R, 7, 8, 9) are dissected or sampled. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)The medical history information is complete. Exclusion criteria were as follows: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) The pathological results were benign tumors and small cell lung cancer (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)Right middle lobe secondary malignant tumors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)The medical history data are missing. The patient records consisted of information such as age, gender, tumor consistency, tumor size, p-T stage, p-N stage, TNM stage,distribution of nodular (medial and lateral segments), histological diagnosis (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;1. Patient Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(yr.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u0026ndash;83,median:63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender(male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27/53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ep-N(N0/N1/N2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68/6/6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP-T(T1/T2/T3/T4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64/12/2/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM(M0/M1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor stage(I/II/III/IV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66/5/9/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor consistency (pGGN/mGGN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32/48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size(\u0026le;\u0026thinsp;2 cm /\u0026gt;2 cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52/28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial segment/Lateral segment/Uncertain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19/58/3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistological diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenocarcinoma/squamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79/1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo investigate the risk factors for lymph node metastasis in right middle lobe cancer, we categorized 80 patients into groups based on five different criteria. These criteria included gender (male and female),age (\u0026le;\u0026thinsp;70 years old and \u0026gt;\u0026thinsp;70 years old) ,nodule nature (pGGN/mGGN) and size(\u0026le;\u0026thinsp;2 cm and \u0026gt;\u0026thinsp;2 cm), and distribution of mGGN(Medial segment/Lateral segment/Uncertain)\u003c/p\u003e \u003cp\u003e We reconstructed the #11 LNs in 3 Dimensions using authorized software DeepInSight (Internal Trial Version 1.0, Key Laboratory of Medical Imaging Intelligent Computer of Ministry of Education, Northeastern University).\u003c/p\u003e \u003cp\u003eTo investigate the impact of pulmonary dorsal fissure completeness on #11ip LN resection in surgery and postoperative recovery, we categorized patients into two groups: incomplete dorsal fissure and complete dorsal fissure. We conducted a comparison between the two groups in terms of operation time, drainage tube removal time, and postoperative drainage volume.\u003c/p\u003e \u003cp\u003eTo assess the prognosis of the patients, we conducted a follow-up study on 80 patients. We reviewed their chest CT scaned every 3\u0026ndash;6 months after surgery, spanning from January 2015 to December 2022 or to the date of death of patients.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe statistical analysis was performed using IBM SPSS statistics 26.0. Chi-squared test or Fisher\u0026rsquo;s exact test was used to compare categorical data between groups. A two-sided P value less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e1.The risk factors for lymph node metastasis in right middle lobe cancer\u003c/p\u003e \u003cp\u003eThis subgroup included 26 men and 54 women, 68 cases\u0026thinsp;\u0026le;\u0026thinsp;70 years and 12 cases\u0026thinsp;\u0026gt;\u0026thinsp;70 years,\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInfluencing factors of lymph node metastasis: Univariate Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20/48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26/54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (\u0026le;\u0026thinsp;70/\u0026gt;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor consistency(pGGN/mGGN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32/36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32/48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size(\u0026le;\u0026thinsp;2 cm /\u0026gt;2 cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49/19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistribution of GGN (Medial segment/Lateral segment/Uncertain)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/49/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/4/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1/5/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19/58/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eP values in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e are all derived using fisher\u0026rsquo;s exact test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e(median 61 years). None of 32 patients with pure ground-glass nodule (pGGN) were found to have lymph node metastasis.In 48 patients with mixed ground-glass nodule (mGGN), there were 6 N1 cases and 6 N2 cases.In 52 cases with \u0026le;\u0026thinsp;2 cm,there were 1 N1 case and 2 N2 cases.In 28 cases with \u0026gt;\u0026thinsp;2 cm,there were 5 N1 cases and 4 N2 cases. Among mGGN patients,4 N1 cases and 5 N2 cases appeared in lateral segment,only 1 N2 case appeared in medial segment. The statistical significance was primarily observed in the consistency of the nodules (P\u0026thinsp;=\u0026thinsp;0.008),the size of the nodules (P\u0026thinsp;=\u0026thinsp;0.003)and the nodule distribution(P\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e \u003cp\u003eHowever, age and gender did not show any statistical significance in relation to the metastasis of right middle lobe NSCLC(refer to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e2.Location of #11ia, #11ip, and #11s LN in enhanced CT and three-dimensional reconstruction image\u003c/p\u003e \u003cp\u003e#11s LN is around the superior lobe bronchus,#11ia LN is around middle lobe bronchus, #11ip LN, is in the region between right dorsal segmental bronchus and intermediate bronchus of right lung.(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e3.Status of Lymph Node Metastases\u003c/p\u003e \u003cp\u003eIn 48 patients with mGGN, there were 6 N1 cases and 6 N2 cases. For the 6 patients with N1 stage, the probability of LNM was 1/2 in the #11ia LN, 0 in the #11ip LN, and 2/3 in the #12 LN. For the 6 patients with N2 stage, the probability of LNM was 5/6 in #4 LN, 2/3 in #7 LN, 1/2 in #11ia LN, and 1/6 in the #11ip LN.(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of lymph node involvement\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN Stage of lung cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePatient number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c11\" namest=\"c3\"\u003e \u003cp\u003eStation of lymph node\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11ia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11ip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e11s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e4.The impact of the completeness of dorsal fissure on patients on #11ip LN resection during surgery and postoperative recovery (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImpact of pulmonary dorsal fissure completeness on #11ip LN resection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDorsal fissure completeness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncomplete\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time(min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrainage tube removal time(h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative drainage volume(ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e823.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e607.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eP values in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e are all derived using fisher\u0026rsquo;s exact test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor incomplete dorsal fissure and complete dorsal fissure, the average operation time was 149.32 minutes and 109.68 minutes. The average drainage tube removal time was 5.22 days and 4 days. The average postoperative drainage volume was 823.33ml and 607.14ml.\u003c/p\u003e \u003cp\u003eIn cases who have incomplete dorsal fissure, it is frequently necessary to cut off the dorsal fissure during the operation to resect #11ip LN. Obviously, this situation can extend operation time (P\u0026thinsp;=\u0026thinsp;0.001) and may also lead to various unexpected situations during the procedure,such as accidental bleeding. However, we did not observe any significant statistical difference in extubation time and postoperative drainage volume.(Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e5.Postoperative follow-up\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFollow-up was conducted on the same 80 patients. Out of the 32 patients with pGGN, it was found that no one experienced metastasis. Out of 48 patients with mGGN, 15 lost patients were excluded from the follow-up analysis. Among the 5 patients with N2 stage, 2 experienced postoperative metastasis. Interestingly, 2 patients with stage N1 showed no signs of metastasis, while 2 of 32 patients with stage N0 had metastasis. We compared four patients with similar characteristics of the metastasis N0 stage patients, and observed that the metastasis of N0 stage patients might be associated with the incompleteness of dissection in the #11ip LN. The prognosis time of the six patients is depicted in the figure (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). When reviewing the N2 stage patients with metastases, we observed that in one patient, the #4 and #11ip LN did not show any signs of metastasis before the operation. However, during the postoperative follow-up, we noticed that the lymph nodes of #4 and #11ip LN had enlarged and intrapulmonary metastasis had occurred 2 years late. The survival period of this patient is 28 months.(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e6.Retrograde metastasis of #11ip LN by #7 LN.\u003c/p\u003e \u003cp\u003e#7 LN and #11ip LN were found to be abnormally enlarged in a bladder cancer woman who was a 80 years old. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe occurrence of right middle lobe NSCLC is lower compared to other lobes. And it has a worse prognosis(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), possibly due to the lower number of lymph node dissections in surgery(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Currently, there are no studies available reporting on the grouping of #11 LN in middle lobe lung cancer, especially #11ip LN. The NSCLC diagnosis and treatment guidelines issued by the NCCN(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), the European Association of Thoracic Surgeons guidelines(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and the NSCLC diagnosis and treatment guidelines issued by the Chinese Medical Association(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) do not provide clear instructions regarding the necessity of dissecting or sampling #11ip LN in right middle lobe NSCLC.\u003c/p\u003e \u003cp\u003eAmong the 80 patients who underwent surgery for right middle lobe NSCLC at our hospital, we observed a patient who had a poor prognosis due to the #11ip LNM. This finding caught our attention. We reconstructed the patient's #11s, #11ia, and #11ip LN using three-dimensional reconstruction techniques(DeepInSight), as depicted in the accompanying figure(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition, #11ip LN dissection is often hindered by the undifferentiated dorsal oblique fissure and the inferior trunk of the pulmonary artery. When the lung fissures are poor differentiated, incision of the dorsal oblique fissure is required, resulting in a significantly longer operation time(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there is no statistically significant difference in postoperative drainage volume and chest tube removal time(p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Therefore, in cases of Single-incision video-assisted thoracic right middle lobectomy, dissection of the 11ip lymph node does not lead to any related complications even when the dorsal oblique fissure is undifferentiated.\u003c/p\u003e \u003cp\u003eScholars generally believe that intrapulmonary lymph nodes serve as continuous sites for metastasis to interlobar lymph nodes, hilar lymph nodes, and mediastinal lymph nodes(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).From the anatomical perspective, researchers have injected dye into the pleural lymphatic vessels of the right lung and observed that 87.5% of the lymph fluid in the middle lobe of the right lung drains into #7 LN. Also they found that a lymphatic chain between lateral segment and #7 LN. These lymph nodes then pass through various lymph node chains (such as the paraesophageal chain, right paratracheal chain, tracheoesophageal chain, and recurrent chain) before draining into different stations of lymph nodes in the lungs and systemic circulation(\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). As a result, #11 LN are considered to have the highest incidence of lymph node metastasis within the lung.\u003c/p\u003e \u003cp\u003eHowever, there are opposing views among scholars regarding this perspective. Yukinori Sakao(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) conducted a review of surgical records of 170 patients with right middle lobe NSCLC. His findings revealed that out of the 14 patients with N1 stage, the most common site of metastasis was the 12, which are located adjacent to the middle lobe bronchus. In contrast, there was only one case of metastasis in the interlobar lymph nodes of the #11s LN(superior interlobe lymph nodes), and no metastasis was observed in the #11i LN(inferior interlobe lymph nodes). Additionally, when tumor tissue invades the lymph nodes in #11s or #11i LN, eight out of nine cases or five out of five cases respectively are classified as N2 cases. At the same time, Hiroaki Kuroda(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) discovered that the likelihood of lymph node involvement in the #11s and #11i LN for N1 stage lung cancer patients was 5.6% and 0% respectively. Additionally, lymph node metastasis in the #11i LN, as well as #2 and #4LN, were identified as significant factors contributing to a poor prognosis in patients with middle lobe lung cancer. However, these studies did not provide a clear distinction between the lymph nodes in the #11i LN, specifically the #11ia LN and the #11ip LN.\u003c/p\u003e \u003cp\u003eIn a study conducted by Il Kwon Ko(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e),55 patients with mediastinal metastasis of head and neck cancer were investigated. The findings revealed that head and neck cancer frequently spread to the upper mediastinal region (#2, #3, and #4 LN), hilar region, and interlobular region (#10 and #11 LN). Additionally, there were instances of metastatic cancer involving paratracheal lymph nodes(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Upon reviewing relevant cases in our hospital, we identified a patient with bladder cancer whose lymph nodes in #7 and #11ip LN of the right lung had metastasized(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), and another case of postoperative recurrence and progression of lung cancer. Notably, the lymph nodes in #4 and# 11ip LN did not show any signs of metastasis prior to surgery. However, during the follow-up after surgery, these lymph nodes exhibited increased size and metastasis in 2 years(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll in all, we speculate that the metastasis of the #11ip LN may be caused by indirect metastasis of #4 and #7 LN(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), rather than direct metastasis from the middle lobe. Therefore, it suggests that for patients with right middle lobe NSCLC, the #11ip LN may function as N2 stage lymph nodes.\u003c/p\u003e \u003cp\u003eIn the surgery for right middle lobe NSCLC, the necessity of lymph node dissection in #11 LN can be determined by the results of intraoperative frozen pathology in #4 and #7 LN. Hiroaki Kuroda(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) found that in patients with N2 stage, the probability of lymph node involvement in #4 and #7 LN was 48.5% and 58.8% respectively, suggesting that these lymph nodes are the main metastatic sites of lung cancer. By performing intraoperative dissection of lymph nodes in #4 and #7 LN, patients can be accurately staged and the need for lymph node dissection in #11ip LN can be determined based on the results of intraoperative frozen pathology. If the pathology of lymph nodes in #4 and #7 LN is positive during surgery, the #11ip LN dissection must be performed.\u003c/p\u003e \u003cp\u003eIn the field of imaging, the density of nodules plays a crucial role in determining whether lymph node dissection is necessary. In a retrospective analysis conducted by Zhirong Zhang(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e),a total of 270 patients with NSCLC in each lobe were examined. These patients underwent systematic lymph node dissection, with a maximum nodule diameter of \u0026le;\u0026thinsp;3cm. The analysis revealed that patients with pGGN did not show any lymph node metastasis. However, those with mGGN exhibited partial LNM. In our study, we observed that out of 80 lung cancer patients, 32 patients with pGGN did not have LNM. Among the 48 patients with mGGN, there were 6 cases of metastasis in the #11ia LN and 1 case of LNM in the #11ip LN. Therefore, for patients with mGGN, if preoperative CT reveals enlarged #11ip LN, it is recommended to consider performing #11ip LN dissection.\u003c/p\u003e \u003cp\u003eIn conclusion,out of right middle lobe NSCLC,for pGGN patients, lymph node dissection or biopsy in the #11ip LN is not necessary. In mGGN patients, #11ip LN should be dissected when it showed enlargement in preoperative CT or particularly #4 and #7 LNM were found during surgery especially the tumor was in lateral segment. Right middle lobe NSCLC with #11ip LNM has a worse prognosis. Therefore, #11ip LN may play as N2 stage in right middle lobe NSCLC.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003einferior lobar bronchus(11ip), superior lobar bronchus(11s), anterior bronchus(11ia), non-small cell lung cancer(NSCLC), pure ground-glass nodule (pGGN), mixed ground-glass nodule (mGGN), lymphatic node(LN), lymphatic node metastasis(LNM).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study is a retrospective study. Our Institutional Review Board waived the requirement to obtain patient informed consent and approved the study, as the patient identity was not revealed(the IRB number:EC-2023-KS-002).\u0026nbsp;We confirm that all methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthors' contributions: WJZ analyzed the data and wrote the manuscript; XH participated to write and revise the manuscript;WJJ designed and supervised for this research; All the authors participated in discussions during the research and manuscript preparation process. XH and WJZ contributed equally to this work.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthors' information\u003c/p\u003e\n\u003cp\u003eInstitutional addresses: From the Department of Thoracic Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China.\u003c/p\u003e\n\u003cp\u003eAddress for reprints: Wenjun Jiang,MD,No 4 Chongshandong Rd, Huanggu District, Shenyang, Liaoning Province, China 110032 (E-mail: [email protected]).\u003c/p\u003e\n\u003cp\u003eCorresponding authors: Wenjun Jiang\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNasim F, Sabath BF, Eapen GA. Lung Cancer. Med Clin North Am. 2019;103(3):463\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDing N, Mao Y. [Advances in Lymph Node Metastasis and the Modes of Lymph Node Dissection in Early Stage Non-small Cell Lung Caner]. 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Isolated mediastinal lymph node false positivity of [18F]-fluorodeoxyglucose-positron emission tomography/computed tomography in patients with cervical cancer. Int J Gynecol Cancer. 2013;23(2):337\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Z, Mao Y, He J, Gao S, Cheng G, Liu X, et al. [Exploration of lymph node metastasis and appropriate lymph node dissection modes in patients with clinical stage I non-small cell lung cancer]. Zhonghua Zhong Liu Za Zhi. 2014;36(7):536\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Right middle lobe, The lymphatic sump of Borrie, 3-dimensional reconstruction,11ip lymphatic node","lastPublishedDoi":"10.21203/rs.3.rs-3878368/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3878368/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRight middle lobe NSCLC has a worse prognosis compared to other lobes possibly due to the lower number of lymph node dissections in surgery.So,we investigate the clinical significance of #11ip lymph node(LN) metastasis in right middle lobe NSCLC.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSymbolize the right lung #11 LN as superior 11(#11s), anterior 11(#11ia), and posterior 11(#11ip), based on their adjacency to the superior lobar bronchus, the middle lobar bronchus, and the region between right dorsal segmental bronchus and intermediate bronchus of right lung respectively in the view of single-port thoracoscopic surgery. The clinical data of mediastinal and #11 LN metastasis in 80 cases of right middle lobe NSCLC who were underwent surgical pulmonary resection from 2015\u0026ndash;2022 were analyzed retrospectively and one case of #11ip LN metastasis retrogradely from #7 LN in bladder cancer was reported.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNone of 32 patients with pure ground-glass nodule (pGGN) were found to have lymph node metastasis (LNM). Out of the 48 patients with mixed ground-glass nodule (mGGN), no case with #11ip LNM was found in N1 cases(n\u0026thinsp;=\u0026thinsp;6), but there was one case of #11ip LNM in N2 cases(n\u0026thinsp;=\u0026thinsp;6).This tumor was in lateral segment and \u0026gt;\u0026thinsp;2 cm. #11ip LN resection with undifferentiated dorsal oblique fissure need more operative time than those with differentiated dorsal oblique fissure(149.32m to109.68m,p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) ,but postoperative drainage extubation time has no difference(5.22 days to 4 days,p\u0026thinsp;=\u0026thinsp;0.116) and the postoperative drainage volume has no difference either (823.33ml to 607.14ml,p\u0026thinsp;=\u0026thinsp;0.100). In addition, the survival period of N2 patient with #11ip LNM is 6 months.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo right middle lobe NSCLC with pGGN, #11ip LN dissection or biopsy is not necessary.Presenting as mGGN, #11ip LN should be dissected or biopsied particularly #4 or #7 LNM were found during surgery. #11ip LNM has a worse prognosis and may play as N2 stage in right middle lobe NSCLC.\u003c/p\u003e","manuscriptTitle":"11ip lymph node may play as N2 stage in right middle NSCLC","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-30 17:19:15","doi":"10.21203/rs.3.rs-3878368/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7e0907d-7e05-4080-b509-acbed08d8d9a","owner":[],"postedDate":"January 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28414309,"name":"Biological sciences/Cancer/Lung cancer/Non small cell lung cancer"},{"id":28414310,"name":"Biological sciences/Cancer/Cancer imaging"},{"id":28414311,"name":"Biological sciences/Cancer/Cancer therapy"},{"id":28414312,"name":"Biological sciences/Cancer/Metastases"}],"tags":[],"updatedAt":"2024-04-09T04:44:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-30 17:19:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3878368","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3878368","identity":"rs-3878368","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}