Survival of Patients With Unsuspected pN2 Non-Small Cell Lung Cancer After an Accurate Preoperative Mediastinal Staging

Mediastinal lymphadenectomy fulfilling NCCN criteria may improve the outcome of clinical N0–1 and pathological N2 non-small cell lung cancer

“…The proposed algorithm according to European Society of Thoracic Surgeons guidelines of nodal staging showed a 5.5% of unsuspected pN2 disease during practice (17). Therefore, combination of preoperative non-invasive and invasive procedures might be feasible to eliminate the possibility of occult positive N2 node as much as possible.…”

“…Obiols et al (17) reported 40% of 5 years OS in unexpected pN2 group and they suggested resection of properly staged unsuspectedpN2 NSCLC is reasonable and surgery should not be avoided if complete resection could be achieved. Cerfolio et al (18) reported a 35% of 5-year OS in 148 patients with unsuspected N2 disease.…”

Cons: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

“…The reported 5-year survival of PET-CT staged patients with unsuspected N2 disease at the time of resection is 35-40% (4,15). Again, up to 80% of patients with unsuspected N2-disease have single station N2 disease (4).…”

“…If the 2014 ESTS guidelines for preoperative mediastinal nodal staging are followed rigorously, the rate of unsuspected N2 disease at surgery is as low as 5.5% with a negative predictive value of 0.91 (4).…”

Rebuttal from Dr. Obiols and Dr. Call

“…As they have commented in their manuscript, following the recommendations of the European Society of Thoracic Surgeons (ESTS) guidelines for preoperative mediastinal nodal staging, high negative predictive values (91-95%) and low rates of unsuspected pathologic (p) N2 disease (5.1-5.5%) are achieved (1,2). The majority of patients with unsuspected pN2 have single station involvement and better survival compared with the global cohort of pN2 (2). In cIA tumours, neither endoscopic techniques nor mediastinoscopy have shown enough accuracy to certify mediastinal involvement (3,4).…”