Intraoperative staging and surgical management of stage IIIA/N2 non-small cell lung cancer

Staging of the mediastinum is an integral component of the operative treatment of NSCLC. Systematic sampling and systematic lymph node dissection provide similar and accurate staging information. Systematic lymph node dissection is more likely to identify multiple levels of N2 disease, however, and may be associated with improved survival. During surgery for a right lung cancer, at least mediastinal lymph node levels 4 should be sampled or dissected. When removing a left lung cancer, at least nodal levels 5 and 7 should be assessed. Although every effort should be made to identify N2 disease before surgery, if intraoperative metastases to mediastinal lymph nodes are discovered, the planned operation should proceed. Cisplatin-based adjuvant chemotherapy has moderate but proven survival benefit after resection of N2 disease. The role of PORT remains uncertain.