eComment. Radical vs selective lymphadenectomy for non-small-cell lung cancer: which is the optimal procedure?

We read with great interest the article by Shien et al. [1] on a series of 184 patients with non-small-cell lung cancer (NSCLC) occurring in the left lingular division. In this study, the Authors reported their findings regarding the intraoperative pathological examination of the regional lymph node stations and proposed selective mediastinal node dissection in this subset of patients. To date, nodal status represents the most significant prognostic factor for NSCLC-patients both in terms of overall and cancer-specific survival and in the setting of the kind of pre- and postoperative therapy. However, although surgery is the mainstay of treatment for early stage NSCLC, the choice of lymph node dissection is still a challenging issue for most thoracic surgeons. In this context, lymph node sampling is considered ineffective to accurately assess the N status by some authors. Furthermore, it may be associated with an increased incidence of local recurrence [2]. Furthermore, Massard and coll. [2] reported a low sensitivity rate (51.6%) related to such procedure: in particular, the whole sample of pN2-patients and those with N2-multilevel NSCLC were correctly identified by intraoperative evaluation in 52 and 40% of cases, respectively. On the other hand, the prognostic impact of a radical lymphadenectomy has been recently analyzed and proposed in literature. Bria et al. [3] evaluated a prognostic model taking into account the number of dissected lymph nodes and node ratio (between metastatic and resected nodes), confirming an improved survival in those patients undergoing a thorough mediastinal node excision. These data were further confirmed by the analysis of the SEER database in the subset of pN0 patients, which reported an improved outcome when a large amount of lymph nodes (6-20) were harvested [4].

Based on data reported, we would really appreciate the Authors' reflections and reactions on the real benefit of selective mediastinal lymph node dissection in light of the recent findings reporting no significant differences in terms of morbidity and hospital stay when comparing selective and radical node dissection [5].

Conflict of interest: none declared.

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