Imaging features of pulmonary nodules affecting lymph node metastasis in cT1-stage non-small cell lung cancer_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHAO Jinlong ¹ , ZHANG Fengwei ² , JIANG Dazhi ¹ , YOU Cuiping ³ , LÜ Baotao ⁴ , ZHANG Minghui ⁴ , GUO Hongwei ⁵ , CHEN Rong ¹ ,  WANG Haiqin ⁶

1. Department of Thoracic Surgery, Linyi People's Hospital, Linyi, 276000, Shandong, P. R. China;
2. Department of Cardiac Surgery, Linyi People's Hospital, Linyi, 276000, Shandong, P. R. China;
3. Department of Clinical Laboratory, Linyi People's Hospital, Linyi, 276000, Shandong, P. R. China;
4. Department of Radiology, Linyi People's Hospital, Linyi, 276000, Shandong, P. R. China;
5. Department of Pathology, Linyi People's Hospital, Linyi, 276000, Shandong, P. R. China;
6. Department of Rehabilitation, Linyi People's Hospital, Linyi, 276000, Shandong, P. R. China;

Corresponding author：

WANG Haiqin, Email: wh200624@163.com

Keywords：

Non-small cell lung cancer; pulmonary nodule; imaging features; prediction model; lymph node metastasis

DOI：

10.7507/1007-4848.202501053

Video：

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Objective To evaluate lymph node metastasis status based on pulmonary nodule imaging characteristics, thereby providing a basis for determining lymph node dissection strategies. Methods A retrospective analysis was conducted on the imaging features and postoperative pathological results of cT1 non-small cell lung cancer (NSCLC) patients who underwent surgical treatment at Linyi People's Hospital from July 2019 to July 2022. Patients were grouped and analyzed according to lymph node metastasis status. Results A total of 1 127 patients were included, comprising 475 males and 652 females, with a median age of 59 years. Comparative analysis revealed that sex, age, nodule location, nodule size on imaging, solid component size, consolidation tumor ratio (CTR), average CT value, and tumor proximity to the pleura all influenced lymph node metastasis. A nomogram was constructed, indicating that the probability of lymph node metastasis in cT1 NSCLC was positively correlated with solid component size, CTR, and average CT value of the pulmonary nodule, and negatively correlated with patient age. Conclusion For cT1 NSCLC patients, the probability of lymph node metastasis can be predicted by measuring the solid component size, CTR, and average CT value of the pulmonary nodule, in conjunction with patient age. However, relying solely on pulmonary nodule imaging characteristics is insufficient to determine a specific lymph node dissection strategy.

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2.	Darling GE. Lymph node assessment in early stage non-small cell lung cancer lymph node dissection or sampling? Gen Thorac Cardiovasc Surg, 2020, 68(7): 716-724.
3.	Li C, Chen Q, Tian Y, et al. 68Ga-FAPI-04 PET/CT in non-small cell lung cancer: Accurate evaluation of lymph node metastasis and correlation with fibroblast activation protein expression. J Nucl Med, 2024, 65(4): 527-532.
4.	Schwalk AJ, Niroula A, Schimmel M. What is new in mediastinal staging? Curr Opin Pulm Med, 2024, 30(1): 25-34.
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7.	Sato J, Yanagawa M, Nishigaki D, et al. Radiologists versus AI-based software: Predicting lymph node metastasis and prognosis in lung adenocarcinoma from CT under various image display conditions. Clin Lung Cancer, 2025, 26(1): 58-71.
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15.	Seok Y, Yang HC, Kim TJ, et al. Frequency of lymph node metastasis according to the size of tumors in resected pulmonary adenocarcinoma with a size of 30 mm or smaller. J Thorac Oncol, 2014, 9(6): 818-824.
16.	Hayashi H, Ashizawa K, Ogihara Y, et al. Comparison between solid component size on thin-section CT and pathologic lymph node metastasis and local invasion in T1 lung adenocarcinoma. Jpn J Radiol, 2017, 35(3): 109-115.
17.	Cho JY, Leem CS, Kim Y, et al. Solid part size is an important predictor of nodal metastasis in lung cancer with a subsolid tumor. BMC Pulm Med, 2018, 18(1): 151.
18.	Kim H, Goo JM, Suh YJ, et al. Implication of total tumor size on the prognosis of patients with clinical stage ⅠA lung adenocarcinomas appearing as part-solid nodules: Does only the solid portion size matter? Eur Radiol, 2019, 29(3): 1586-1594.
19.	Li Z, Pan C, Xu W, et al. Distinct impacts of radiological appearance on lymph node metastasis and prognosis based on solid size in clinical T1 non-small cell lung cancer. Respir Res, 2024, 25(1): 96.
20.	高健, 齐清怡, 李浩, 等. 肺混合密度磨玻璃结节中临床影像学信息对淋巴结转移的预测价值. 中国肺癌杂志, 2023, 26(2): 113-118.Gao J, Qi Q, Li H, et al. Prediction of lymph node metastasis of mixed ground-glass nodules based on clinical imaging information. Chin J Lung Cancer, 2023, 26(2): 113-118.
21.	Sacher AG, Dahlberg SE, Heng J, et al. Association between younger age and targetable genomic alterations and prognosis in non-small-cell lung cancer. JAMA Oncol, 2016, 2(3): 313-220.
22.	Han CB, Ma JT, Li F, et al. EGFR and KRAS mutations and altered c-Met gene copy numbers in primary non-small cell lung cancer and associated stage N2 lymph node-metastasis. Cancer Lett, 2012, 314(1): 63-72.
23.	Schmid K, Oehl N, Wrba F, et al. EGFR/KRAS/BRAF mutations in primary lung adenocarcinomas and corresponding locoregional lymph node metastases. Clin Cancer Res, 2009, 15(14): 4554-4560.
24.	Thakor P, Siddiqui MQ, Patel TR. Analysis of the interlink between glucose-6-phosphate dehydrogenase (G6PD) and lung cancer through multi-omics databases. Heliyon, 2024, 10(15): e35158.
25.	Wu B, Zhu Y, Hu Z, et al. Machine learning predictive models and risk factors for lymph node metastasis in non-small cell lung cancer. BMC Pulm Med, 2024, 24(1): 526.
26.	Ishiguro F, Matsuo K, Fukui T, et al. Effect of selective lymph node dissection based on patterns of lobe-specific lymph node metastases on patient outcome in patients with resectable non-small cell lung cancer: A large-scale retrospective cohort study applying a propensity score. J Thorac Cardiovasc Surg, 2010, 139(4): 1001-1006.
27.	Zhang W, Mu G, Huang J, et al. Lymph node metastasis and its risk factors in T1 lung adenocarcinoma. Thorac Cancer, 2023, 14(30): 2993-3000.
28.	Guo W, Lu T, Song Y, et al. Lymph node metastasis in early invasive lung adenocarcinoma: Prediction model establishment and validation based on genomic profiling and clinicopathologic characteristics. Cancer Med, 2024, 13(14): e70039.

1. Ettinger DS, Wood DE, Aisner DL, et al. NCCN guidelines insights: Non-small cell lung cancer, version 2. 2023. J Natl Compr Canc Netw, 2023, 21(4): 340-350.
2. Darling GE. Lymph node assessment in early stage non-small cell lung cancer lymph node dissection or sampling? Gen Thorac Cardiovasc Surg, 2020, 68(7): 716-724.
3. Li C, Chen Q, Tian Y, et al. 68Ga-FAPI-04 PET/CT in non-small cell lung cancer: Accurate evaluation of lymph node metastasis and correlation with fibroblast activation protein expression. J Nucl Med, 2024, 65(4): 527-532.
4. Schwalk AJ, Niroula A, Schimmel M. What is new in mediastinal staging? Curr Opin Pulm Med, 2024, 30(1): 25-34.
5. Roberts PF, Follette DM, Von HD, et al. Factors associated with false-positive staging of lung cancer by positron emission tomography. Ann Thorac Surg, 2000, 70(4): 1154-1160.
6. Kanzaki R, Higashiyama M, Fujiwara A, et al. Occult mediastinal lymph node metastasis in NSCLC patients diagnosed as clinical N0-1 by preoperative integrated FDG-PET/CT and CT: Risk factors, pattern, and histopathological study. Lung Cancer, 2011, 71(3): 333-337.
7. Sato J, Yanagawa M, Nishigaki D, et al. Radiologists versus AI-based software: Predicting lymph node metastasis and prognosis in lung adenocarcinoma from CT under various image display conditions. Clin Lung Cancer, 2025, 26(1): 58-71.
8. Zhang Y, Deng C, Zheng Q, et al. Selective mediastinal lymph node dissection strategy for clinical T1N0 invasive lung cancer: A prospective, multicenter, clinical trial. J Thorac Oncol, 2023, 18(7): 931-939.
9. Zhao JL, Guo HW, Yang P, et al. Selective lymph node dissection for clinical T1 stage non-small cell lung cancer. Transl Cancer Res, 2019, 8(8): 2820-2828.
10. Detterbeck FC, Boffa DJ, Kim AW, et al. The eighth edition lung cancer stage classification. Chest, 2017, 151(1): 193-203.
11. Okada M, Tsubota N, Yoshimura M, et al. Proposal for reasonable mediastinal lymphadenectomy in bronchogenic carcinomas: Role of subcarinal nodes in selective dissection. J Thorac Cardiovasc Surg, 1998, 16(6): 949-953.
12. Moon Y, Park JK, Lee KY, et al. Consolidation/tumor ratio on chest computed tomography as predictor of postoperative nodal upstaging in clinical T1N0 lung cancer. World J Surg, 2018, 42(9): 2872-2878.
13. Nishio W, Yoshimura M, Maniwa Y, et al. Re-assessment of intentional extended segmentectomy for clinical T1aN0 non-small cell lung cancer. Ann Thorac Surg, 2016, 102(5): 1702-1710.
14. Zheng X, He B, Hu Y, et al. Diagnostic accuracy of deep learning and radiomics in lung cancer staging: A systematic review and meta-analysis. Front Public Health, 2022, 10: 938113.
15. Seok Y, Yang HC, Kim TJ, et al. Frequency of lymph node metastasis according to the size of tumors in resected pulmonary adenocarcinoma with a size of 30 mm or smaller. J Thorac Oncol, 2014, 9(6): 818-824.
16. Hayashi H, Ashizawa K, Ogihara Y, et al. Comparison between solid component size on thin-section CT and pathologic lymph node metastasis and local invasion in T1 lung adenocarcinoma. Jpn J Radiol, 2017, 35(3): 109-115.
17. Cho JY, Leem CS, Kim Y, et al. Solid part size is an important predictor of nodal metastasis in lung cancer with a subsolid tumor. BMC Pulm Med, 2018, 18(1): 151.
18. Kim H, Goo JM, Suh YJ, et al. Implication of total tumor size on the prognosis of patients with clinical stage ⅠA lung adenocarcinomas appearing as part-solid nodules: Does only the solid portion size matter? Eur Radiol, 2019, 29(3): 1586-1594.
19. Li Z, Pan C, Xu W, et al. Distinct impacts of radiological appearance on lymph node metastasis and prognosis based on solid size in clinical T1 non-small cell lung cancer. Respir Res, 2024, 25(1): 96.
20. 高健, 齐清怡, 李浩, 等. 肺混合密度磨玻璃结节中临床影像学信息对淋巴结转移的预测价值. 中国肺癌杂志, 2023, 26(2): 113-118.Gao J, Qi Q, Li H, et al. Prediction of lymph node metastasis of mixed ground-glass nodules based on clinical imaging information. Chin J Lung Cancer, 2023, 26(2): 113-118.
21. Sacher AG, Dahlberg SE, Heng J, et al. Association between younger age and targetable genomic alterations and prognosis in non-small-cell lung cancer. JAMA Oncol, 2016, 2(3): 313-220.
22. Han CB, Ma JT, Li F, et al. EGFR and KRAS mutations and altered c-Met gene copy numbers in primary non-small cell lung cancer and associated stage N2 lymph node-metastasis. Cancer Lett, 2012, 314(1): 63-72.
23. Schmid K, Oehl N, Wrba F, et al. EGFR/KRAS/BRAF mutations in primary lung adenocarcinomas and corresponding locoregional lymph node metastases. Clin Cancer Res, 2009, 15(14): 4554-4560.
24. Thakor P, Siddiqui MQ, Patel TR. Analysis of the interlink between glucose-6-phosphate dehydrogenase (G6PD) and lung cancer through multi-omics databases. Heliyon, 2024, 10(15): e35158.
25. Wu B, Zhu Y, Hu Z, et al. Machine learning predictive models and risk factors for lymph node metastasis in non-small cell lung cancer. BMC Pulm Med, 2024, 24(1): 526.
26. Ishiguro F, Matsuo K, Fukui T, et al. Effect of selective lymph node dissection based on patterns of lobe-specific lymph node metastases on patient outcome in patients with resectable non-small cell lung cancer: A large-scale retrospective cohort study applying a propensity score. J Thorac Cardiovasc Surg, 2010, 139(4): 1001-1006.
27. Zhang W, Mu G, Huang J, et al. Lymph node metastasis and its risk factors in T1 lung adenocarcinoma. Thorac Cancer, 2023, 14(30): 2993-3000.
28. Guo W, Lu T, Song Y, et al. Lymph node metastasis in early invasive lung adenocarcinoma: Prediction model establishment and validation based on genomic profiling and clinicopathologic characteristics. Cancer Med, 2024, 13(14): e70039.

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