Contemporary outcomes of en bloc stapling of the pulmonary artery, bronchus, and lymph nodes during lobectomy for non-small cell lung cancer: a retrospective study

Contemporary outcomes of en bloc stapling of the pulmonary artery, bronchus, and lymph nodes during lobectomy for non-small cell lung cancer: a retrospective study | 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 Research Article Contemporary outcomes of en bloc stapling of the pulmonary artery, bronchus, and lymph nodes during lobectomy for non-small cell lung cancer: a retrospective study Keiji Yamanashi, Ryo Miyata, Takeshi Kawaguchi, Masatsugu Hamaji This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8518736/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background This study investigates the safety and postoperative outcomes of en bloc stapling of the pulmonary artery branches, bronchial branches, and lymph nodes using an auto-stapler during lobectomy for non-small cell lung cancer. Methods A retrospective chart review was conducted to identify consecutive patients who underwent lobectomy for non-small cell lung cancer with en bloc stapling of the pulmonary artery branches, bronchial branches, and lymph nodes using an auto-stapler between 2019 and 2024. Patient characteristics, perioperative outcomes, and long-term survival rates were analyzed. Results Eighteen patients were included, with the median age of 76.5 years and the median follow-up of 35.1 months. Thirteen patients underwent complete resection, whereas five patients had incomplete resection due to adherent metastatic lymph nodes around the pulmonary artery and bronchus. The incidences of grade ≥ 3 intraoperative and postoperative complications were 0% and 11%, respectively, with no procedure-related events such as bronchovascular fistula. The five-year overall survival rates in patients who underwent complete and incomplete resections were 44.0% and 50.0%, respectively. Among patients with incomplete resection, four experienced disease progression, and two died of lung cancer. Two patients receiving targeted therapies remained alive at 31.4 and 73.8 months postoperatively, without any evidence of disease progression. Conclusions En bloc stapling of the pulmonary artery branches, bronchial branches, and lymph nodes using an auto-stapler during lobectomy for non-small cell lung cancer is feasible and safe. Even in cases involving lymph node metastases near the stapling site, multimodal therapy guided by genetic profiling of surgical specimens may contribute to acceptable long-term outcomes in carefully selected patients. Trial registration Not applicable. en bloc stapling pulmonary artery bronchus non-small cell lung cancer lobectomy Figures Figure 1 Figure 2 Figure 3 Background Thoracic surgeons occasionally encounter dense adhesions of non-metastatic lymph nodes (LNs) involving the pulmonary artery (PA) and bronchus during lung cancer surgery [ 1 , 2 ]. These adhesions potentially arise owing to dust-laden macrophages that promote inflammation and lead to disorganized fibrous tissue formation between the LNs and the surrounding lung structures, making dissection difficult [ 3 ]. Pulmonary arterioplasty and/or bronchoplasty are often required to achieve complete resection during the removal of adherent LNs [ 4 – 7 ]. However, these techniques can occasionally be challenging because of the anatomical location of the LNs and the primary tumor. Furthermore, if a patient is unable to tolerate PA clamping, pulmonary arterioplasty becomes technically demanding. In these scenarios, en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler has traditionally been employed [ 1 , 2 , 8 ]. However, to our knowledge, only one institution—University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ, USA—has reported on the safety and favorable long-term postoperative outcomes of this approach for early-stage non-small cell lung cancer (NSCLC), with most available data now considered outdated [ 8 – 10 ]. On the other hand, patients with NSCLC and hilar metastatic LNs also require LN dissection from the PA and bronchus to achieve complete resection. When such dissection is not feasible due to extensive metastatic nodal involvement—similar to cases involving non-metastatic LNs—pneumonectomy may be required despite its high morbidity and mortality rates [ 11 , 12 ]. This is because pulmonary arterioplasty and/or bronchoplasty for complete resection in cases of extensive metastatic nodal involvement are technically challenging with uncertain oncological outcomes, and these procedures have only been completed in a limited number of cases [ 4 , 5 , 13 ]. At our institution, lobectomy with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler followed by additional therapy, is occasionally performed in patients who are unable to tolerate pneumonectomy. This strategy appears to follow the international guidelines for managing R1–2 resections [ 14 , 15 ]. However, there has been a paucity of data upon this management. This study aimed to evaluate the safety and postoperative outcomes of en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler during lobectomy for NSCLC, in light of recent advancements in medical technology and lung cancer treatment. Methods Patients and data collection A retrospective chart review was conducted to identify all consecutive patients who underwent surgical resection for NSCLC at Nara Medical University Hospital between January 2019 and December 2024. Patients were eligible if they underwent lobectomy with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler. Clinical staging was based on radiological findings at initial presentation, typically assessed using whole-body contrast-enhanced computed tomography (CT), contrast-enhanced brain magnetic resonance imaging, and 18F-fluorodeoxyglucose positron emission tomography (PET). If mediastinal LNs exhibited a short-axis diameter > 1 cm on CT or 18F-fluorodeoxyglucose uptake on PET-CT, endobronchial ultrasound-guided transbronchial needle aspiration was the preferred method, with video-assisted mediastinoscopy as the second choice, following the European Society for Medical Oncology (ESMO) guidelines [ 15 ]. During surgery, lobe-specific mediastinal LN dissection or sampling was routinely performed. Pathological staging was based on the 9th edition of the TNM classification [ 16 ]. The following clinical data were collected: age, sex, performance status, smoking history, dust exposure history, body mass index, pulmonary function at the time of the initial pulmonary resection, Charlson comorbidity index [ 17 ], details of pulmonary resection, histological and pathological stage of lung cancer, treatment for recurrence, and follow-up information. Postoperative surveillance typically included chest CT every 3–6 months, with brain magnetic resonance imaging performed only in symptomatic patients, in line with the National Comprehensive Cancer Network and ESMO guidelines [ 14 , 15 ]. Patients who experienced recurrence and received treatment were followed up at similar 3–6-month intervals. The follow-up data were censored on December 10, 2025. This study was approved by the Nara Medical University Institutional Review Board (March 31, 2025; reference number: 3945). The requirement for informed consent was waived due to the retrospective design. The study was conducted in accordance with the Declaration of Helsinki and its amendments. Statistical analysis Descriptive statistics are presented as frequencies and percentages for categorical variables and as medians with interquartile ranges for continuous variables. Categorical variables were compared using Fisher’s exact test, whereas continuous variables were compared using the Mann–Whitney U test. The median follow-up time was calculated using the reverse Kaplan–Meier method for potential follow-up [ 18 ]. Overall survival (OS) was defined as the time from surgery to death from any cause or to the last known date the patient was alive. OS was estimated using the Kaplan–Meier method, and differences between survival curves were assessed using a two-tailed log-rank test. Data were analyzed using the R software (version 3.3.2; R Foundation for Statistical Computing, Vienna, Austria). All P -values are two-sided, with values < 0.05 considered statistically significant. Results Patient characteristics and survival outcomes In this study, 808 consecutive patients who underwent surgical resection for NSCLC were reviewed, and 18 (2.2%) who underwent lobectomy for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler were included in the analyses (Table 1 ). Additional details are provided in Supplementary Tables S1, S2, and S3. None of the patients received any neoadjuvant therapy. Of the 18 patients, 13 achieved R0 resection, one patient underwent lobectomy with R1 resection of metastatic LNs unexpectedly, and four patients underwent lobectomy with R2 resection due to invasive metastatic LNs involving the PA and bronchus. Among patients who underwent R2 resection, pneumonectomy was deemed unfeasible owing to the following reasons: low forced expiratory volume in 1 s (< 2.0 L) in two patients according to international guidelines [ 19 , 20 ], poor cardiac function in one patient, and multiple comorbidities in one patient. Four patients had driver gene alterations, including epidermal growth factor receptor ( EGFR ) exon 19 deletion ( n = 1) and EGFR L858R mutation ( n = 3). Among patients with pathological stage ≥ IIB, adjuvant therapy was administered to four; however, it was withheld in one patient owing to disease progression and in four patients following a comprehensive assessment of their condition, performance status, and social circumstances. Table 1 Patient characteristics. Variables n = 18 Age, years 76.5 (68.5–80.8) Sex (male/female) 14/4 Performance status (0/1/≥ 2) 16/2/0 Smoking history (never/former/current) 5/9/4 Pack-years of smoking 47.6 (4.5–58.1) Dust exposure (yes/no/unknown) 1/15/2 BMI, kg/m 2 (< 18.5 or ≥ 25) 3 VC, % predicted 98.1 (92.3–112.1) FEV 1 /FVC, % 68.4 (63.9–76.5) CCI (≥ 3) 7 Clinical T status (9th edition) (T1a/T1b/T1c/T2a/T2b/T3) 1/2/5/5/0/5 Clinical N status (9th edition) (0/1/≥ 2) 10/8/0 Clinical stage (9th edition) (IA1/IA2/IA3/IB/IIA/IIB/IIIA) 1/1/5/2/0/5/4 Site of tumor (LUL/LLL/RUL/RLL) 2/5/2/9 Attempted surgical approach (Thoracotomy/VATS) 0/18 Conversion to thoracotomy 4 Extent of pulmonary resection (lobectomy/bilobectomy) 17/1 R-status (0/1/2) 13/1/4 Pathological T status (9th edition) (Tis/T1a/T1b/T1c/T2a/T2b/T3/T4) 1/0/3/1/6/4/2/1 Pathological N status (9th edition) (0/1/2a) 12/4/2 Pathological stage (9th edition) (0/IA1/IA2/IA3/IB/IIA/IIB/IIIA) 1/0/2/1/4/1/7/2 Histology (Ad/Sq/others) 7/10/1 EGFR mutation (present/absent/unknown) 4/5/9 PD-L1 tumor proportion score (≥ 50/1–49/< 1/unknown) 5/5/3/5 Adjuvant therapy (radiotherapy/cytotoxic chemotherapy/cytotoxic chemotherapy followed by TKI/chemoradiotherapy) 1/1/1/1 Values are presented as numbers or medians (interquartile range). BMI, body mass index; VC, vital capacity; FEV 1 , forced expiratory volume in 1 s; FVC, forced vital capacity; CCI, Charlson comorbidity index; 9th, 9th edition of the tumor-node-metastasis classification of lung cancer; LUL, left upper lobe; LLL, left lower lobe; RUL, right upper lobe; RLL, right lower lobe; VATS, video-assisted thoracic surgery; Ad, adenocarcinoma; Sq, squamous cell carcinoma; EGFR, epidermal growth factor receptor; PD-L1, programmed death-ligand 1; TKI, tyrosine kinase inhibitor. Table 2 summarizes the clinicopathological characteristics of patients who underwent R0 resection and R1 or R2 resection. No significant difference in the detection of EGFR mutations was observed between the two groups ( P = 0.64). Programmed death-ligand 1 (PD-L1) expression was assessed in all patients who underwent R1 or R2 resection; however, this data was unavailable in five of the 13 patients in the R0 resection group. The incidences of grade ≥ 3 intraoperative and postoperative complications were 0% and 11%, respectively, with no procedure-related events such as bronchovascular fistula. The median follow-up period after surgery was 35.1 months, and the five-year OS rate for all patients was 44.7% (Fig. 1 a). The five-year OS rates of patients who underwent R0 resection and those who underwent R1 or R2 resection were 44.0 and 50.0%, respectively ( P = 0.67, log-rank test; Fig. 1 b). The clinical courses of patients who underwent R1 or R2 resection are shown in Fig. 2 . Among these patients, four experienced disease progression and two died of lung cancer. Two patients receiving osimertinib remained alive at 31.4 and 73.8 months postoperatively, without any cancer-related symptoms or evidence of disease progression. Table 2 Patient characteristics according to R-status. R0 resection ( n = 13) R1 or R2 resection ( n = 5) P -value Age, years 78 (73–84) 74 (66–74) 0.17 Sex (male/female) 11/2 3/2 0.53 Performance status (0/1/2) 12/1/0 4/1/0 0.49 Smoking history (never/former/current) 3/6/4 2/3/0 0.51 Pack-years of smoking 42.8 (18.0–57.0) 53.0 (0–58.5) 0.88 Dust exposure (yes/no/unknown) 1/11/1 0/4/1 0.65 BMI, kg/m 2 (< 18.5 or ≥ 25) 2 1 1.00 VC, % predicted 100.0 (92.5–111.5) 94.7 (92.2–112.3) 1.00 FEV 1 /FVC, % 69.6 (65.0–76.5) 64.2 (63.8–73.3) 0.63 CCI (≥ 3) 5 2 1.00 Clinical stage (9th edition) (IA1/IA2/IA3/IB/IIA/IIB/IIIA) 1/1/5/2/0/2/2 0/0/0/0/0/3/2 0.27 Site of tumor (LUL/LLL/RUL/RLL) 1/4/2/6 1/1/0/3 1.00 Surgical approach (Thoracotomy/VATS) 2/11 2/3 0.53 Extent of pulmonary resection (lobectomy/bilobectomy) 13/0 4/1 0.28 Pathological T status (9th edition) (Tis/T1a/T1b/T1c/T2a/T2b/T3/T4) 1/0/2/1/5/1/2/1 0/0/1/0/1/3/0/0 0.46 Pathological N status (9th edition) (0/1/2a) 12/1/0 0/3/2 0.001 Pathological stage (9th edition) (0/IA1/IA2/IA3/IB/IIA/IIB/IIIA) 1/0/2/1/4/1/3/1 0/0/0/0/0/0/4/1 0.36 Histology (Ad/Sq/others) 5/8/0 2/2/1 0.35 EGFR mutation (present/absent/unknown) 2/4/7 2/1/2 0.64 PD-L1 tumor proportion score (≥ 50/1–49/< 1/unknown) 2/5/1/5 3/0/2/0 0.046 Adjuvant therapy (radiotherapy/cytotoxic chemotherapy/cytotoxic chemotherapy followed by TKI/chemoradiotherapy) 0/0/0/0 1/1/1/1 NA Values are presented as numbers or medians (interquartile range). Categorical variables were compared using Fisher’s exact test, whereas continuous variables were compared using the Mann–Whitney U test. BMI, body mass index; VC, vital capacity; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; CCI, Charlson comorbidity index; 9th, 9th edition of the tumor-node-metastasis classification of lung cancer; LUL, left upper lobe; LLL, left lower lobe; RUL, right upper lobe; RLL, right lower lobe; VATS, video-assisted thoracic surgery; Ad, adenocarcinoma; Sq, squamous cell carcinoma; EGFR, epidermal growth factor receptor; PD-L1, programmed death-ligand 1; TKI, tyrosine kinase inhibitor; NA, not applicable. A representative case A 78-year-old woman was referred to our department after a chest CT scan incidentally revealed a 7-mm part-solid nodule in the left upper lobe. Over three years, the nodule size increased to 12 mm, with a consolidation-to-tumor ratio > 0.5 (Fig. 3 a). The patient declined PET-CT due to claustrophobia. Because the lesion was suspected to be a stage IA1 NSCLC, a left upper lobectomy was planned, considering the location of the nodule and the patient’s preoperative cardiopulmonary function assessment. A 4.5-cm incision was made in the fourth intercostal space, and two additional ports were placed in the seventh intercostal space. Intraoperatively, multiple adherent LNs were observed around the left upper division of the bronchus (B1–3) and the adjacent tissues. The left main PA was exposed after dissection of the superior pulmonary vein. The interlobar LNs were strongly adhered to the anterior PA to the upper lobe (A3), the first branch of the posterior PA (A1 + 2a + b), the second branch of the posterior PA (A1 + 2c), and B1–3. Owing to the high risk of vascular injury, a thoracotomy was performed, with the left main PA encircled as a precaution. The lingular PA and bronchus were safely dissected. However, when the left main PA was clamped to facilitate dissection of the LNs adhered to the PA branches, the patient’s systolic blood pressure abruptly decreased to approximately 50 mmHg. The blood pressure immediately recovered upon declamping the PA, indicating that the patient could not tolerate unilateral PA occlusion. Subsequently, the left upper division PA branches (A3, A1 + 2a + b, A1 + 2c), B1–3, and the adherent LNs were encircled and simultaneously stapled using ECHELON FLEX™ GST staplers (Ethicon, Inc.). The staple lines were intact and well formed, without any evidence of bleeding (Fig. 3 b). Subsequently, systematic mediastinal LN dissection was performed. Finally, the stump was covered with free pericardial fat pad. The operation lasted 3 h and 50 min, with an estimated blood loss of less than 10 mL. Histopathological examination revealed adenocarcinoma in situ without LN metastasis. The chest tube was removed on postoperative day 3, and the patient was discharged on postoperative day 6. No evidence of fistula formation between the PA and the bronchial stump was observed during the follow-up period. Although the bronchial stump remained stapled, the left upper divisions of the PA branches were separated from it at both the 6- and 12-month follow-ups (Figs. 3 c and 3 d). Discussion In this study, we assessed the surgical outcomes of patients who underwent lobectomy for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler. This technique was performed safely without procedure-related complications such as bronchovascular fistula. Although the complete resection of metastatic LNs adhered to the PA and bronchus is challenging, acceptable long-term outcomes may be achievable in selected patients with incomplete resection, guided by genetic profiling of the surgical specimen. In the late 1990s, Lewis et al. first reported the safety and long-term postoperative outcomes of lobectomies for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler [ 8 ]. They observed an OS rate of 83% in 177 patients with lung neoplasms during a mean follow-up period of 34 months. In our study, although the median follow-up period of 35.1 months was comparable with that in the study by Lewis et al., the five-year OS rate was 44.7% for all stages of NSCLC. However, meaningful comparisons are challenging because of the small sample size of our study, the heterogeneity of the patient population, and differences in baseline characteristics between the two cohorts. Since Lewis et al.’s report [ 8 ], to our knowledge, only two other case series have reported short-term outcomes of lobectomy for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs in a small number of patients [ 2 , 21 ]. Table 3 summarizes the findings of these studies, none of which reported procedure-related complications such as bronchovascular fistula. In a previous swine model study, the PA and bronchial stumps created by en bloc stapling were observed to separate six weeks after surgery [ 1 ]. Notably, while the bronchial stump remained stapled, the stapled tissue of the PA disappeared, and a new vascular stump was formed, which histologically resembled the PA stump after individual ligation [ 22 ]. This process may promote separation of the PA and bronchial stumps, potentially lowering the risk of bronchovascular fistula. In our representative case, this separation was confirmed by contrast-enhanced CT. As in previous studies [ 1 , 2 , 8 ], no patient in our study experienced procedure-related complications, suggesting that en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler may be safe in selected patients, likely because the PA and bronchial stumps separate during the postoperative healing process. Several international guidelines provide specific recommendations for managing R1–2 resections, suggesting reoperation if the residual disease is resectable, postoperative radiotherapy, or adjuvant chemotherapy/chemoradiotherapy regardless of nodal status [ 14 , 15 ]. In this study, four patients with metastatic hilar LNs were deemed unsuitable candidates for pneumonectomy and complete resection of these LNs was technically challenging. As a result, lobectomy with en bloc stapling of the PA branches, bronchial branches, and LNs was performed, followed by postoperative non-surgical treatment based on a comprehensive assessment of each patient’s clinical condition. This strategy appears to follow the international guidelines for managing incomplete resection [ 14 , 15 ]. Although the five-year OS rate of 50.0% observed in our cohort of patients with incomplete resection lacks sufficient statistical power to support definitive conclusions, it appears to be better than the rates reported in the National Cancer Database studies from the 2010s (28.8–33.8%) [ 23 , 24 ], presumably because of recent advances in medical technology and lung cancer management, particularly the introduction of tyrosine kinase inhibitors (TKIs) [ 25 ] and immune checkpoint inhibitors [ 26 ]. One potential benefit of R1–2 resection is the acquisition of sufficient histological material, which enables accurate genetic profiling to guide targeted therapy. Specifically, the adequacy of surgical specimens for assessing EGFR mutations, anaplastic lymphoma kinase rearrangement, ROS1 rearrangement, and PD-L1 expression (98.2%, 100%, 95.7%, and 97.8%, respectively) was higher than that of small biopsy specimens (87.5%, 94.7%, 81.8%, and 92.2%, respectively) [ 27 ]. Another possible benefit is tumor volume reduction (debulking surgery), which has long been the standard of care for selected patients with ovarian cancer [ 28 , 29 ], renal cell carcinoma [ 30 , 31 ], and thymic epithelial tumors [ 32 – 34 ]; however, only a few studies have shown promising outcomes in NSCLC [ 35 , 36 ]. Recently, a randomized phase III study was conducted to compare systemic therapy with and without debulking surgery (primary tumor resection) in patients with advanced NSCLC [ 37 ], and its long-term results are awaited. Although the small number of patients in this study precludes drawing definitive conclusions regarding lobectomy with incomplete resection of metastatic LNs around the PA and bronchus, two patients receiving multidisciplinary treatment, including EGFR-TKIs, are alive without signs of disease progression. These findings suggest that surgery may contribute to the management of NSCLC with adherent metastatic LNs in selected patients. This study has some limitations. First, the study design was retrospective and non-randomized. Second, we were unable to identify a control group, such as patients who underwent standard lobectomy, due to the heterogeneity among those who underwent lobectomy with en bloc stapling. In particular, five of the 18 patients in this group underwent incomplete resection. Third, the indications for en bloc stapling varied and were unclear in some cases because they occasionally depended on the individual surgeon’s skill and judgment. Despite these limitations, this study reports contemporary outcomes of en bloc stapling of the PA branches, bronchial branches, and LNs during lobectomy for NSCLC in a real-world setting, which may be difficult to obtain through clinical trials. Conclusions Our findings suggest that en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler during lobectomy for NSCLC is a feasible and safe approach, without procedure-related complications. Even in cases involving LN metastases near the stapling site, multimodal therapy guided by genetic profiling of surgical specimens may contribute to acceptable long-term outcomes in carefully selected patients. Abbreviations CT, computed tomography EGFR, epidermal growth factor receptor ESMO, European Society for Medical Oncology LN, lymph node NSCLC, non-small cell lung cancer OS, overall survival PA, pulmonary artery PD-L1, programmed death-ligand 1 PET, positron emission tomography TKI, tyrosine kinase inhibitor Declarations Ethics approval and consent to participate This study was approved by the Nara Medical University Institutional Review Board (March 31, 2025; reference number: 3945). The requirement for informed consent was waived due to the retrospective design. The study was conducted in accordance with the Declaration of Helsinki and its amendments. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding No external funding was received for this study. Author Contribution K.Y. designed the study, collected the data, performed the data analysis, and drafted the manuscript. 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Ann Thorac Surg. 1991;51:152–6. Hishida T, Masai K, Kaseda K, Asakura K, Asamura H. Debulking surgery for malignant tumors: the current status, evidence and future perspectives. Jpn J Clin Oncol. 2021;51:1349–62. Guisier F, Cousse S, Jeanvoine M, Thiberville L, Salaun M. A rationale for surgical debulking to improve anti-PD1 therapy outcome in non small cell lung cancer. Sci Rep. 2019;9:16902. Sekino Y, Hishida T, Yoshioka H, Wakabayashi M, Mitome N, Shiono S, et al. Protocol summary of a randomized phase III study: comparing systemic therapy with and without debulking surgery (primary tumour resection) for clinical stage IVA (cT1-2bN0-1M1a) non-small cell lung cancer with radiologically undetermined pleural dissemination JCOG2103 (DEBULK-LUNG). Jpn J Clin Oncol. 2025;55:176–82. Additional Declarations No competing interests reported. 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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-8518736","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587148758,"identity":"142b3cc1-0e3f-4570-9f4d-652f098530dd","order_by":0,"name":"Keiji Yamanashi","email":"data:image/png;base64,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","orcid":"","institution":"Nara Medical University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Keiji","middleName":"","lastName":"Yamanashi","suffix":""},{"id":587148759,"identity":"157e8579-5ae4-4172-9e6b-4b989def9688","order_by":1,"name":"Ryo Miyata","email":"","orcid":"","institution":"Nara Medical University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ryo","middleName":"","lastName":"Miyata","suffix":""},{"id":587148760,"identity":"3be09e9b-9efa-4e6c-b047-51d6512cb92b","order_by":2,"name":"Takeshi Kawaguchi","email":"","orcid":"","institution":"Nara Medical University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Takeshi","middleName":"","lastName":"Kawaguchi","suffix":""},{"id":587148764,"identity":"5d4dff14-dd42-47da-9459-77f572b058dd","order_by":3,"name":"Masatsugu Hamaji","email":"","orcid":"","institution":"Nara Medical University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Masatsugu","middleName":"","lastName":"Hamaji","suffix":""}],"badges":[],"createdAt":"2026-01-05 08:24:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8518736/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8518736/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102218459,"identity":"d27eab40-c8ad-4423-92cd-70c6af0dc960","added_by":"auto","created_at":"2026-02-09 13:23:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":351359,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves for OS in all patients (a) and by R-status (b)\u003c/p\u003e\n\u003cp\u003eOS, overall survival\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8518736/v1/80c96f683f27758b7e3204a9.jpg"},{"id":102218457,"identity":"3730327f-09d1-41e8-82fa-169e8c970b64","added_by":"auto","created_at":"2026-02-09 13:23:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":72497,"visible":true,"origin":"","legend":"\u003cp\u003eClinical courses of patients with R1 or R2 resection\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8518736/v1/d74e5a9ab8740a76758d0194.png"},{"id":102218461,"identity":"6635406c-4f54-4f6f-828b-82732ec8937b","added_by":"auto","created_at":"2026-02-09 13:23:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":699980,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT demonstrates a pulmonary lesion in the left upper lobe (a). The staple lines show no evidence of bleeding or bronchopleural fistula (b). Chest CT demonstrates no evidence of bronchovascular fistula at 6 months (c) and 12 months (d) after surgery\u003c/p\u003e\n\u003cp\u003eCT, computed tomography\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8518736/v1/03c47b56ac05734f46dca4f4.jpg"},{"id":102218862,"identity":"84475001-b1aa-4486-8c65-1dc1f43ff359","added_by":"auto","created_at":"2026-02-09 13:25:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1841677,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8518736/v1/c1219016-11b9-41bb-8ba1-ee01c33343c2.pdf"},{"id":102218620,"identity":"5b452ba9-9e72-4fe4-ac72-b8ebffb8a9c8","added_by":"auto","created_at":"2026-02-09 13:24:27","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":36473,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaltables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8518736/v1/b20390db2e8b2137486db10e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Contemporary outcomes of en bloc stapling of the pulmonary artery, bronchus, and lymph nodes during lobectomy for non-small cell lung cancer: a retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003eThoracic surgeons occasionally encounter dense adhesions of non-metastatic lymph nodes (LNs) involving the pulmonary artery (PA) and bronchus during lung cancer surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These adhesions potentially arise owing to dust-laden macrophages that promote inflammation and lead to disorganized fibrous tissue formation between the LNs and the surrounding lung structures, making dissection difficult [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePulmonary arterioplasty and/or bronchoplasty are often required to achieve complete resection during the removal of adherent LNs [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, these techniques can occasionally be challenging because of the anatomical location of the LNs and the primary tumor. Furthermore, if a patient is unable to tolerate PA clamping, pulmonary arterioplasty becomes technically demanding.\u003c/p\u003e \u003cp\u003eIn these scenarios, en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler has traditionally been employed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, to our knowledge, only one institution\u0026mdash;University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ, USA\u0026mdash;has reported on the safety and favorable long-term postoperative outcomes of this approach for early-stage non-small cell lung cancer (NSCLC), with most available data now considered outdated [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, patients with NSCLC and hilar metastatic LNs also require LN dissection from the PA and bronchus to achieve complete resection. When such dissection is not feasible due to extensive metastatic nodal involvement\u0026mdash;similar to cases involving non-metastatic LNs\u0026mdash;pneumonectomy may be required despite its high morbidity and mortality rates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This is because pulmonary arterioplasty and/or bronchoplasty for complete resection in cases of extensive metastatic nodal involvement are technically challenging with uncertain oncological outcomes, and these procedures have only been completed in a limited number of cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. At our institution, lobectomy with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler followed by additional therapy, is occasionally performed in patients who are unable to tolerate pneumonectomy. This strategy appears to follow the international guidelines for managing R1\u0026ndash;2 resections [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, there has been a paucity of data upon this management.\u003c/p\u003e \u003cp\u003eThis study aimed to evaluate the safety and postoperative outcomes of en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler during lobectomy for NSCLC, in light of recent advancements in medical technology and lung cancer treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and data collection\u003c/h2\u003e \u003cp\u003e A retrospective chart review was conducted to identify all consecutive patients who underwent surgical resection for NSCLC at Nara Medical University Hospital between January 2019 and December 2024. Patients were eligible if they underwent lobectomy with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler. Clinical staging was based on radiological findings at initial presentation, typically assessed using whole-body contrast-enhanced computed tomography (CT), contrast-enhanced brain magnetic resonance imaging, and 18F-fluorodeoxyglucose positron emission tomography (PET). If mediastinal LNs exhibited a short-axis diameter\u0026thinsp;\u0026gt;\u0026thinsp;1 cm on CT or 18F-fluorodeoxyglucose uptake on PET-CT, endobronchial ultrasound-guided transbronchial needle aspiration was the preferred method, with video-assisted mediastinoscopy as the second choice, following the European Society for Medical Oncology (ESMO) guidelines [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. During surgery, lobe-specific mediastinal LN dissection or sampling was routinely performed. Pathological staging was based on the 9th edition of the TNM classification [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe following clinical data were collected: age, sex, performance status, smoking history, dust exposure history, body mass index, pulmonary function at the time of the initial pulmonary resection, Charlson comorbidity index [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], details of pulmonary resection, histological and pathological stage of lung cancer, treatment for recurrence, and follow-up information. Postoperative surveillance typically included chest CT every 3\u0026ndash;6 months, with brain magnetic resonance imaging performed only in symptomatic patients, in line with the National Comprehensive Cancer Network and ESMO guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Patients who experienced recurrence and received treatment were followed up at similar 3\u0026ndash;6-month intervals. The follow-up data were censored on December 10, 2025.\u003c/p\u003e \u003cp\u003e This study was approved by the Nara Medical University Institutional Review Board (March 31, 2025; reference number: 3945). The requirement for informed consent was waived due to the retrospective design. The study was conducted in accordance with the Declaration of Helsinki and its amendments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics are presented as frequencies and percentages for categorical variables and as medians with interquartile ranges for continuous variables. Categorical variables were compared using Fisher\u0026rsquo;s exact test, whereas continuous variables were compared using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test. The median follow-up time was calculated using the reverse Kaplan\u0026ndash;Meier method for potential follow-up [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Overall survival (OS) was defined as the time from surgery to death from any cause or to the last known date the patient was alive. OS was estimated using the Kaplan\u0026ndash;Meier method, and differences between survival curves were assessed using a two-tailed log-rank test. Data were analyzed using the R software (version 3.3.2; R Foundation for Statistical Computing, Vienna, Austria). All \u003cem\u003eP\u003c/em\u003e-values are two-sided, with values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics and survival outcomes\u003c/h2\u003e \u003cp\u003eIn this study, 808 consecutive patients who underwent surgical resection for NSCLC were reviewed, and 18 (2.2%) who underwent lobectomy for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler were included in the analyses (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Additional details are provided in Supplementary Tables S1, S2, and S3. None of the patients received any neoadjuvant therapy. Of the 18 patients, 13 achieved R0 resection, one patient underwent lobectomy with R1 resection of metastatic LNs unexpectedly, and four patients underwent lobectomy with R2 resection due to invasive metastatic LNs involving the PA and bronchus. Among patients who underwent R2 resection, pneumonectomy was deemed unfeasible owing to the following reasons: low forced expiratory volume in 1 s (\u0026lt;\u0026thinsp;2.0 L) in two patients according to international guidelines [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], poor cardiac function in one patient, and multiple comorbidities in one patient. Four patients had driver gene alterations, including epidermal growth factor receptor (\u003cem\u003eEGFR\u003c/em\u003e) exon 19 deletion (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1) and \u003cem\u003eEGFR\u003c/em\u003e L858R mutation (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3). Among patients with pathological stage\u0026thinsp;\u0026ge;\u0026thinsp;IIB, adjuvant therapy was administered to four; however, it was withheld in one patient owing to disease progression and in four patients following a comprehensive assessment of their condition, performance status, and social circumstances.\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 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\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\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.5 (68.5\u0026ndash;80.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\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\u003e(male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance status\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\u003e(0/1/\u0026ge; 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/2/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\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\u003e(never/former/current)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/9/4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack-years of smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.6 (4.5\u0026ndash;58.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDust exposure\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\u003e(yes/no/unknown)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/15/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e (\u0026lt;\u0026thinsp;18.5 or \u0026ge;\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVC, % predicted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.1 (92.3\u0026ndash;112.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e/FVC, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.4 (63.9\u0026ndash;76.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI (\u0026ge;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical T status (9th edition)\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\u003e(T1a/T1b/T1c/T2a/T2b/T3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/2/5/5/0/5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical N status (9th edition)\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\u003e(0/1/\u0026ge; 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/8/0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage (9th edition)\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\u003e(IA1/IA2/IA3/IB/IIA/IIB/IIIA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/1/5/2/0/5/4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of tumor\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\u003e(LUL/LLL/RUL/RLL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/5/2/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttempted surgical approach\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\u003e(Thoracotomy/VATS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtent of pulmonary resection\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\u003e(lobectomy/bilobectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17/1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR-status\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\u003e(0/1/2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/1/4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological T status (9th edition)\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\u003e(Tis/T1a/T1b/T1c/T2a/T2b/T3/T4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/0/3/1/6/4/2/1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological N status (9th edition)\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\u003e(0/1/2a)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/4/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological stage (9th edition)\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\u003e(0/IA1/IA2/IA3/IB/IIA/IIB/IIIA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/0/2/1/4/1/7/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology\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\u003e(Ad/Sq/others)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/10/1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEGFR mutation\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\u003e(present/absent/unknown)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/5/9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD-L1 tumor proportion score\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\u003e(\u0026ge;\u0026thinsp;50/1\u0026ndash;49/\u0026lt; 1/unknown)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/5/3/5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant therapy\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\u003e(radiotherapy/cytotoxic chemotherapy/cytotoxic chemotherapy followed by TKI/chemoradiotherapy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/1/1/1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as numbers or medians (interquartile range).\u003c/p\u003e \u003cp\u003eBMI, body mass index; VC, vital capacity; FEV\u003csub\u003e1\u003c/sub\u003e, forced expiratory volume in 1 s; FVC, forced vital capacity; CCI, Charlson comorbidity index; 9th, 9th edition of the tumor-node-metastasis classification of lung cancer; LUL, left upper lobe; LLL, left lower lobe; RUL, right upper lobe; RLL, right lower lobe; VATS, video-assisted thoracic surgery; Ad, adenocarcinoma; Sq, squamous cell carcinoma; EGFR, epidermal growth factor receptor; PD-L1, programmed death-ligand 1; TKI, tyrosine kinase inhibitor.\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the clinicopathological characteristics of patients who underwent R0 resection and R1 or R2 resection. No significant difference in the detection of \u003cem\u003eEGFR\u003c/em\u003e mutations was observed between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.64). Programmed death-ligand 1 (PD-L1) expression was assessed in all patients who underwent R1 or R2 resection; however, this data was unavailable in five of the 13 patients in the R0 resection group.\u003c/p\u003e \u003cp\u003eThe incidences of grade\u0026thinsp;\u0026ge;\u0026thinsp;3 intraoperative and postoperative complications were 0% and 11%, respectively, with no procedure-related events such as bronchovascular fistula. The median follow-up period after surgery was 35.1 months, and the five-year OS rate for all patients was 44.7% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). The five-year OS rates of patients who underwent R0 resection and those who underwent R1 or R2 resection were 44.0 and 50.0%, respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.67, log-rank test; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe clinical courses of patients who underwent R1 or R2 resection are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Among these patients, four experienced disease progression and two died of lung cancer. Two patients receiving osimertinib remained alive at 31.4 and 73.8 months postoperatively, without any cancer-related symptoms or evidence of disease progression.\u003c/p\u003e \u003cp\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 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics according to R-status.\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\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR0 resection\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR1 or R2 resection\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (73\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (66\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(0/1/2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/1/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/1/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(never/former/current)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/6/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/3/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack-years of smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.8 (18.0\u0026ndash;57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.0 (0\u0026ndash;58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDust exposure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(yes/no/unknown)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/11/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/4/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e (\u0026lt;\u0026thinsp;18.5 or \u0026ge;\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVC, % predicted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.0 (92.5\u0026ndash;111.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.7 (92.2\u0026ndash;112.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFEV\u003csub\u003e1\u003c/sub\u003e/FVC, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.6 (65.0\u0026ndash;76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.2 (63.8\u0026ndash;73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI (\u0026ge;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage (9th edition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(IA1/IA2/IA3/IB/IIA/IIB/IIIA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/1/5/2/0/2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/0/0/0/0/3/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSite of tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(LUL/LLL/RUL/RLL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/4/2/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/1/0/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Thoracotomy/VATS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtent of pulmonary resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(lobectomy/bilobectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological T status (9th edition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Tis/T1a/T1b/T1c/T2a/T2b/T3/T4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/0/2/1/5/1/2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/0/1/0/1/3/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological N status (9th edition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(0/1/2a)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/1/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/3/2\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\u003ePathological stage (9th edition)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(0/IA1/IA2/IA3/IB/IIA/IIB/IIIA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/0/2/1/4/1/3/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/0/0/0/0/0/4/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Ad/Sq/others)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/8/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEGFR mutation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(present/absent/unknown)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/4/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD-L1 tumor proportion score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(\u0026ge;\u0026thinsp;50/1\u0026ndash;49/\u0026lt; 1/unknown)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/5/1/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/0/2/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(radiotherapy/cytotoxic chemotherapy/cytotoxic chemotherapy followed by TKI/chemoradiotherapy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/0/0/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/1/1/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as numbers or medians (interquartile range). Categorical variables were compared using Fisher\u0026rsquo;s exact test, whereas continuous variables were compared using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test.\u003c/p\u003e \u003cp\u003eBMI, body mass index; VC, vital capacity; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; CCI, Charlson comorbidity index; 9th, 9th edition of the tumor-node-metastasis classification of lung cancer; LUL, left upper lobe; LLL, left lower lobe; RUL, right upper lobe; RLL, right lower lobe; VATS, video-assisted thoracic surgery; Ad, adenocarcinoma; Sq, squamous cell carcinoma; EGFR, epidermal growth factor receptor; PD-L1, programmed death-ligand 1; TKI, tyrosine kinase inhibitor; NA, not applicable.\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 \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eA representative case\u003c/h3\u003e\n\u003cp\u003eA 78-year-old woman was referred to our department after a chest CT scan incidentally revealed a 7-mm part-solid nodule in the left upper lobe. Over three years, the nodule size increased to 12 mm, with a consolidation-to-tumor ratio\u0026thinsp;\u0026gt;\u0026thinsp;0.5 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). The patient declined PET-CT due to claustrophobia. Because the lesion was suspected to be a stage IA1 NSCLC, a left upper lobectomy was planned, considering the location of the nodule and the patient\u0026rsquo;s preoperative cardiopulmonary function assessment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA 4.5-cm incision was made in the fourth intercostal space, and two additional ports were placed in the seventh intercostal space. Intraoperatively, multiple adherent LNs were observed around the left upper division of the bronchus (B1\u0026ndash;3) and the adjacent tissues. The left main PA was exposed after dissection of the superior pulmonary vein. The interlobar LNs were strongly adhered to the anterior PA to the upper lobe (A3), the first branch of the posterior PA (A1\u0026thinsp;+\u0026thinsp;2a\u0026thinsp;+\u0026thinsp;b), the second branch of the posterior PA (A1\u0026thinsp;+\u0026thinsp;2c), and B1\u0026ndash;3. Owing to the high risk of vascular injury, a thoracotomy was performed, with the left main PA encircled as a precaution.\u003c/p\u003e \u003cp\u003eThe lingular PA and bronchus were safely dissected. However, when the left main PA was clamped to facilitate dissection of the LNs adhered to the PA branches, the patient\u0026rsquo;s systolic blood pressure abruptly decreased to approximately 50 mmHg. The blood pressure immediately recovered upon declamping the PA, indicating that the patient could not tolerate unilateral PA occlusion. Subsequently, the left upper division PA branches (A3, A1\u0026thinsp;+\u0026thinsp;2a\u0026thinsp;+\u0026thinsp;b, A1\u0026thinsp;+\u0026thinsp;2c), B1\u0026ndash;3, and the adherent LNs were encircled and simultaneously stapled using ECHELON FLEX\u0026trade; GST staplers (Ethicon, Inc.). The staple lines were intact and well formed, without any evidence of bleeding (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). Subsequently, systematic mediastinal LN dissection was performed. Finally, the stump was covered with free pericardial fat pad. The operation lasted 3 h and 50 min, with an estimated blood loss of less than 10 mL.\u003c/p\u003e \u003cp\u003eHistopathological examination revealed adenocarcinoma in situ without LN metastasis. The chest tube was removed on postoperative day 3, and the patient was discharged on postoperative day 6. No evidence of fistula formation between the PA and the bronchial stump was observed during the follow-up period. Although the bronchial stump remained stapled, the left upper divisions of the PA branches were separated from it at both the 6- and 12-month follow-ups (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we assessed the surgical outcomes of patients who underwent lobectomy for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler. This technique was performed safely without procedure-related complications such as bronchovascular fistula. Although the complete resection of metastatic LNs adhered to the PA and bronchus is challenging, acceptable long-term outcomes may be achievable in selected patients with incomplete resection, guided by genetic profiling of the surgical specimen.\u003c/p\u003e \u003cp\u003eIn the late 1990s, Lewis et al. first reported the safety and long-term postoperative outcomes of lobectomies for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. They observed an OS rate of 83% in 177 patients with lung neoplasms during a mean follow-up period of 34 months. In our study, although the median follow-up period of 35.1 months was comparable with that in the study by Lewis et al., the five-year OS rate was 44.7% for all stages of NSCLC. However, meaningful comparisons are challenging because of the small sample size of our study, the heterogeneity of the patient population, and differences in baseline characteristics between the two cohorts.\u003c/p\u003e \u003cp\u003eSince Lewis et al.\u0026rsquo;s report [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], to our knowledge, only two other case series have reported short-term outcomes of lobectomy for NSCLC with en bloc stapling of the PA branches, bronchial branches, and LNs in a small number of patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Table\u0026nbsp;3 summarizes the findings of these studies, none of which reported procedure-related complications such as bronchovascular fistula. In a previous swine model study, the PA and bronchial stumps created by en bloc stapling were observed to separate six weeks after surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Notably, while the bronchial stump remained stapled, the stapled tissue of the PA disappeared, and a new vascular stump was formed, which histologically resembled the PA stump after individual ligation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This process may promote separation of the PA and bronchial stumps, potentially lowering the risk of bronchovascular fistula. In our representative case, this separation was confirmed by contrast-enhanced CT. As in previous studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], no patient in our study experienced procedure-related complications, suggesting that en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler may be safe in selected patients, likely because the PA and bronchial stumps separate during the postoperative healing process.\u003c/p\u003e \u003cp\u003eSeveral international guidelines provide specific recommendations for managing R1\u0026ndash;2 resections, suggesting reoperation if the residual disease is resectable, postoperative radiotherapy, or adjuvant chemotherapy/chemoradiotherapy regardless of nodal status [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this study, four patients with metastatic hilar LNs were deemed unsuitable candidates for pneumonectomy and complete resection of these LNs was technically challenging. As a result, lobectomy with en bloc stapling of the PA branches, bronchial branches, and LNs was performed, followed by postoperative non-surgical treatment based on a comprehensive assessment of each patient\u0026rsquo;s clinical condition. This strategy appears to follow the international guidelines for managing incomplete resection [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although the five-year OS rate of 50.0% observed in our cohort of patients with incomplete resection lacks sufficient statistical power to support definitive conclusions, it appears to be better than the rates reported in the National Cancer Database studies from the 2010s (28.8\u0026ndash;33.8%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], presumably because of recent advances in medical technology and lung cancer management, particularly the introduction of tyrosine kinase inhibitors (TKIs) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and immune checkpoint inhibitors [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne potential benefit of R1\u0026ndash;2 resection is the acquisition of sufficient histological material, which enables accurate genetic profiling to guide targeted therapy. Specifically, the adequacy of surgical specimens for assessing \u003cem\u003eEGFR\u003c/em\u003e mutations, anaplastic lymphoma kinase rearrangement, \u003cem\u003eROS1\u003c/em\u003e rearrangement, and PD-L1 expression (98.2%, 100%, 95.7%, and 97.8%, respectively) was higher than that of small biopsy specimens (87.5%, 94.7%, 81.8%, and 92.2%, respectively) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Another possible benefit is tumor volume reduction (debulking surgery), which has long been the standard of care for selected patients with ovarian cancer [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], renal cell carcinoma [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and thymic epithelial tumors [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]; however, only a few studies have shown promising outcomes in NSCLC [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Recently, a randomized phase III study was conducted to compare systemic therapy with and without debulking surgery (primary tumor resection) in patients with advanced NSCLC [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and its long-term results are awaited. Although the small number of patients in this study precludes drawing definitive conclusions regarding lobectomy with incomplete resection of metastatic LNs around the PA and bronchus, two patients receiving multidisciplinary treatment, including EGFR-TKIs, are alive without signs of disease progression. These findings suggest that surgery may contribute to the management of NSCLC with adherent metastatic LNs in selected patients.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, the study design was retrospective and non-randomized. Second, we were unable to identify a control group, such as patients who underwent standard lobectomy, due to the heterogeneity among those who underwent lobectomy with en bloc stapling. In particular, five of the 18 patients in this group underwent incomplete resection. Third, the indications for en bloc stapling varied and were unclear in some cases because they occasionally depended on the individual surgeon\u0026rsquo;s skill and judgment. Despite these limitations, this study reports contemporary outcomes of en bloc stapling of the PA branches, bronchial branches, and LNs during lobectomy for NSCLC in a real-world setting, which may be difficult to obtain through clinical trials.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings suggest that en bloc stapling of the PA branches, bronchial branches, and LNs using an auto-stapler during lobectomy for NSCLC is a feasible and safe approach, without procedure-related complications. Even in cases involving LN metastases near the stapling site, multimodal therapy guided by genetic profiling of surgical specimens may contribute to acceptable long-term outcomes in carefully selected patients.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eCT, computed tomography\u003c/p\u003e \u003cp\u003eEGFR, epidermal growth factor receptor\u003c/p\u003e \u003cp\u003eESMO, European Society for Medical Oncology\u003c/p\u003e \u003cp\u003eLN, lymph node\u003c/p\u003e \u003cp\u003eNSCLC, non-small cell lung cancer\u003c/p\u003e \u003cp\u003eOS, overall survival\u003c/p\u003e \u003cp\u003ePA, pulmonary artery\u003c/p\u003e \u003cp\u003ePD-L1, programmed death-ligand 1\u003c/p\u003e \u003cp\u003ePET, positron emission tomography\u003c/p\u003e \u003cp\u003eTKI, tyrosine kinase inhibitor\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study was approved by the Nara Medical University Institutional Review Board (March 31, 2025; reference number: 3945). The requirement for informed consent was waived due to the retrospective design. The study was conducted in accordance with the Declaration of Helsinki and its amendments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.Y. designed the study, collected the data, performed the data analysis, and drafted the manuscript. R.M. and T.K. contributed to data collection and reviewed the manuscript. M.H. supervised the study and reviewed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eWe would like to thank Editage (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.editage.jp\" target=\"_blank\"\u003ewww.editage.jp\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.editage.jp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for English language editing.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eNot applicable. This manuscript does not report data generation or analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMurakami J, Ueda K, Hayashi M, Sano F, Hamano K. Simultaneous stapling of the lobar bronchus and pulmonary artery: is it actually dangerous? 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Jpn J Clin Oncol. 2021;51:1349\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuisier F, Cousse S, Jeanvoine M, Thiberville L, Salaun M. A rationale for surgical debulking to improve anti-PD1 therapy outcome in non small cell lung cancer. Sci Rep. 2019;9:16902.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSekino Y, Hishida T, Yoshioka H, Wakabayashi M, Mitome N, Shiono S, et al. Protocol summary of a randomized phase III study: comparing systemic therapy with and without debulking surgery (primary tumour resection) for clinical stage IVA (cT1-2bN0-1M1a) non-small cell lung cancer with radiologically undetermined pleural dissemination JCOG2103 (DEBULK-LUNG). Jpn J Clin Oncol. 2025;55:176\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"en bloc stapling, pulmonary artery, bronchus, non-small cell lung cancer, lobectomy","lastPublishedDoi":"10.21203/rs.3.rs-8518736/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8518736/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study investigates the safety and postoperative outcomes of en bloc stapling of the pulmonary artery branches, bronchial branches, and lymph nodes using an auto-stapler during lobectomy for non-small cell lung cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective chart review was conducted to identify consecutive patients who underwent lobectomy for non-small cell lung cancer with en bloc stapling of the pulmonary artery branches, bronchial branches, and lymph nodes using an auto-stapler between 2019 and 2024. Patient characteristics, perioperative outcomes, and long-term survival rates were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEighteen patients were included, with the median age of 76.5 years and the median follow-up of 35.1 months. Thirteen patients underwent complete resection, whereas five patients had incomplete resection due to adherent metastatic lymph nodes around the pulmonary artery and bronchus. The incidences of grade\u0026thinsp;\u0026ge;\u0026thinsp;3 intraoperative and postoperative complications were 0% and 11%, respectively, with no procedure-related events such as bronchovascular fistula. The five-year overall survival rates in patients who underwent complete and incomplete resections were 44.0% and 50.0%, respectively. Among patients with incomplete resection, four experienced disease progression, and two died of lung cancer. Two patients receiving targeted therapies remained alive at 31.4 and 73.8 months postoperatively, without any evidence of disease progression.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEn bloc stapling of the pulmonary artery branches, bronchial branches, and lymph nodes using an auto-stapler during lobectomy for non-small cell lung cancer is feasible and safe. Even in cases involving lymph node metastases near the stapling site, multimodal therapy guided by genetic profiling of surgical specimens may contribute to acceptable long-term outcomes in carefully selected patients.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Contemporary outcomes of en bloc stapling of the pulmonary artery, bronchus, and lymph nodes during lobectomy for non-small cell lung cancer: a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 13:23:00","doi":"10.21203/rs.3.rs-8518736/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-05T12:58:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T00:58:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T23:05:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64063352052498081802351937820323772864","date":"2026-04-28T14:51:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T13:08:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205969030458647105438832943704629655016","date":"2026-04-26T11:32:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145823481991703413086917860587103749568","date":"2026-04-25T14:41:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93731251639135619758696927695726469091","date":"2026-04-20T06:40:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104508839605965564017921209093552628945","date":"2026-04-20T06:28:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222179103165185455307153617974854742406","date":"2026-04-19T17:17:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204116608675267216547531958724166047817","date":"2026-04-18T06:15:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T18:21:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325717297987126328948709422537919990556","date":"2026-02-10T02:41:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156194771563531927042762890757563741619","date":"2026-02-05T10:22:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T17:42:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-09T12:42:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-09T12:39:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2026-01-05T08:12:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02a75656-11b4-4c0d-967e-627407cf9318","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-05T12:58:33+00:00","index":156,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T00:58:39+00:00","index":155,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T13:23:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 13:23:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8518736","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8518736","identity":"rs-8518736","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}