Purpose of review: To describe the state-of-the-art of the surgical management of stage IIIA-N2 nonsmall cell lung cancer.
Recent findings: When completely resected, occult N2 found at thoracotomy, skip metastases, and single-level N2 in selected locations are reported to portend acceptable survival rates. Conversely, preoperatively proven ipsilateral mediastinal nodal involvement requires a multidisciplinary approach on the basis of neoadjuvant chemotherapy or chemoradiation. In these patients, complete resection of the primary tumor remains among the strongest prognosticators of survival. When technically feasible, radical mediastinal lymphadenectomy could be of added value. Given the demonstrated increase in postoperative morbidity and mortality, pneumonectomy should be avoided when possible, whereas lobectomy and parenchymal sparing resections should be favored if compatible with the resection of the original extent of the primary on tumor-free margins.
Summary: Only selected patients with N2 disease may benefit from primary surgery. The impact of postoperative morbidity after induction treatment is still being evaluated. In this setting, differences in treatment sequence and combination (chemotherapy alone or chemoradiation) may influence postsurgical outcome. Patients' selection revolves around the modern concepts of oncologic operability and surgical resectability intended as assessment of survival benefit and ability to completely resect all residual tumor after neoadjuvant therapy.