Response to editorial titled ‘Intrapulmonary lymph node retrieval: unclear benefit for aggressive pathologic dissection’

The TNM staging system is currently our best prognostic tool in lung cancer, but poor application of this tool is an increasingly recognized worldwide problem in thoracic oncology (1-3). The main deficiency appears to be suboptimal pathologic lymph node staging, an important problem because lymph node metastasis is the gravest prognostic feature in patients without distant metastasis, who are candidates for curative surgical intervention. The statistics are startling: 17% of lung cancer resections in the US have no lymph nodes examined (pNX) (4), 40-50% of all resections (67% of resections with ‘pN0/pN1’ disease) have no mediastinal lymph nodes examined (5,6), 12% of patients have no hilar/intrapulmonary (N1) lymph nodes examined (7), the median total lymph node count is only 4-5 and less than 15% of patients have more than 10 lymph nodes examined (8-10).