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The 2026 American Association for Thoracic Surgery Expert Consensus Document: Evaluation and management of N2+
Philip Linden1, Linda W Martin2, Brendon Stiles3
1Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
Objective:
Multimodal therapy is recommended for the optimal treatment of N2 positive non-small cell lung cancer (NSCLC). Recent advancements in the use of immune checkpoint inhibitors and targeted therapy have dramatically changed the landscape of treatment. We reviewed recent trials and literature to develop consensus statements concerning the evaluation and treatment of potentially resectable NSCLC with N2 involvement.
Methods:
The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an international panel of medical oncologists, radiation oncologists, radiologists, and thoracic surgeons. A focused literature review was performed with the assistance of a medical librarian. The panel used a modified Delphi method to develop expert consensus statements with class of recommendation and level of evidence on issues related to the treatment of potentially resectable N2 positive NSCLC.
Results:
Consensus was reached on 13 statements on topics related to staging, determinants of unresectable disease, use of chemoimmunotherapy or targeted therapies, proper use of neoadjuvant and/or adjuvant therapy, restaging, and the safety of resection after chemoimmunotherapy.
Conclusions:
NSCLC with N2 disease remains a challenging, heterogeneous disease. These expert consensus recommendations are meant to provide guidance to identify appropriate surgical patients and to formulate the best multimodality treatment of patients with N2-positive NSCLC.
Insights
Multimodal therapy, including chemoimmunotherapy and targeted treatments, offers new hope for N2 positive non-small cell lung cancer (NSCLC). These guidelines help identify surgical candidates and optimize treatment for this challenging lung cancer.
Area of Science:
- Thoracic Oncology
- Medical Oncology
- Radiation Oncology
Background:
- N2 positive non-small cell lung cancer (NSCLC) requires multimodal therapy.
- Immune checkpoint inhibitors and targeted therapies have advanced NSCLC treatment.
- Potentially resectable NSCLC with N2 involvement necessitates updated treatment strategies.
Purpose of the Study:
- To develop expert consensus statements for evaluating and treating potentially resectable N2 positive NSCLC.
- To provide guidance on optimal multimodality treatment approaches.
- To address recent advancements in NSCLC therapy.
Main Methods:
- An international panel of experts (medical oncologists, radiation oncologists, radiologists, thoracic surgeons) was convened.
- A modified Delphi method was employed.
- A focused literature review guided the consensus process.
Main Results:
- Thirteen consensus statements were developed.
- Key topics included staging, unresectable disease determinants, chemoimmunotherapy/targeted therapy use, neoadjuvant/adjuvant therapy, restaging, and post-treatment resection safety.
- Consensus was reached on optimal treatment pathways.
Conclusions:
- N2 positive NSCLC is a complex and heterogeneous disease.
- These recommendations aim to guide the identification of surgical candidates.
- The consensus provides a framework for formulating optimal multimodality treatment plans for N2 positive NSCLC patients.
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