Surgical management of non-small cell lung cancer with mediastinal lymphadenopathy

Several issues regarding the surgical management of N2 disease remain unresolved. First, the anatomical attribution of a mediastinal nodal station, especially in certain areas (i.e., azygos recess), is a source of continuous debate. Second, the presence of occult N2, single or multilevel N2, bulky N2, the skip phenomenon and the observation of a different prognostic outlook for specific mediastinal nodal stations are all elements of discussion that cannot clarify whether stage IIIA-N2 non-small cell lung cancer is indeed a locally, albeit advanced, manifestation of the disease or the prodrome of an actual systemic dissemination. In this subset of patients lies the challenge for multidisciplinary treatment modalities, where the surgical role needs to be further defined in the context of an integrated collaborative effort with the medical oncologist and the radiotherapist.