Sublobar resection for early-stage lung cancer: the issue of nodal upstaging

The discovery of N2 upstaging on the final pathological examination in a patient operated for clinical stage IA non-small cell lung carcinoma (NSCLC) is a poor prognostic factor. These patients are treated with adjuvant chemotherapy or even radio-chemotherapy sometimes with immunotherapy depending on the case, but their survival at 5 years does not exceed 35%. In the article published in this issue of the EJCTS, Liou et al. address the problem of occult N2 in patients with early-stage NSCLC by questioning if there might be a difference in survival depending on whether the tumour was resected by lobectomy or sublobar resection (SLR), regardless of whether the latter was an anatomical segmentectomy or wedge resection. Their hypothesis was that survival would be superior after lobectomy [1]. The second question was if the discovery of occult N2 in the SLR arm should lead to a reoperation for completion to lobectomy. Not surprisingly, the authors found no difference between the 2 groups. This is because, as they rightly point out, prognosis is related to the presence of N2 nodes and not to the extent of resection. The discovery of an occult N2 node requires chemotherapy and/or immunotherapy regardless of the amount of lung tissue left in place because the recurrence is mainly metastatic which is not the case for N1 disease.