Controversies of the optimal surgical management for the lymph nodes in non-small cell lung cancer

Lobectomy with lymph nodal dissection is currently the standard surgical strategy for resectable non-small cell lung cancer (NSCLC). This is largely dependent on the only randomized prospective trial comparing lobectomy with sublobar resections reported by Lung Cancer Study Group in 1995 (1). With regard to the appropriate lymph nodal dissection for surgically resected NSCLC, complete hilar and mediastinal lymphadenectomy, i.e., radical systematic mediastinal lymph nodal dissection, is widely recognized as an essential local management strategy ever since reported by Cahan in 1960 (2). In general, complete hilar and mediastinal lymphadenectomy requires “en bloc” resection of the lymph nodes based on the established anatomical boundaries. It is considered that patients with positive lymph nodal metastases could have a potential risk for the locoregional and/or distant recurrence of lung cancer. Hence, complete lymphadenectomy for NSCLCs plays a pivotal role in that it provides the most reliable information regarding cancer staging and prognosis. In addition, radical lymphadenectomy could reduce the risk of undetected positive lymph nodes which may result in a thorough retrieve of the remnants, and proper delivery of optimal postoperative treatment which may contribute to the survival outcomes (3,4). However, it is still controversial with regard to the actual oncological benefit which the radical lymphadenectomy would provide for.