eComment: Lymph node dissection or sampling in patients with non-small cell lung cancer?

We have read with great interest the paper of Hughes et al. [1]. Lymph-node staging during pulmonary resection for non small-cell lung cancer (NSCLC) has been greatly debated for some time. The present best evidence topic identifies a light advantage of mediastinal lymph-node dissection (MLND) compared to lymph node sampling (LNS) in respect of the rates of survival in stage II-IIIa. In addition, MLND is able to identify more multiple levels of N2 disease. It is possible to derive some practical suggestions from the Hughes’ study. Considering that the majority of patients requiring surgery for NSCLC lie in clinical stage I but some of them are shown to be understaged at pathological examination even in the ‘PET era’, it seems advisable to offer the advantages of MLND to all patients needing surgery. A second point arises from everyday experience where a node judged negative at surgery may be shown to be metastatic at pathological examination and, conversely, a node considered positive during dissection may be shown to be negative at pathological examination. In this scenario, we believe that MLND is more effective in determining the real node staging in practical surgery. Finally, it should be considered that research is progressing in molecular lymph-node staging and molecular technology could overtake the traditional hematoxylin-eosin in the near future [2–4]. Once again, MLND seems to be the only way to accurately collect the material for advanced lymph-node staging. In conclusion, we thank Hughes and co-workers for highlighting the thin but important superiority of MLND compared to LNS. We hope that through MLND and precise detection of metastases (molecular staging), we may reach the definitive and correct stage for all patients affected by NSCLC.