Lymph node (LN) status is a highly significant component of staging non-small cell lung cancer (NSCLC). Staging of NSCLC provides prognostic data related to risk of recurrence as well as overall survival (1). Lymph node

Transl Lung Cancer Res 2012;1(4):230-233 www.tlcr. org Lymph node (LN) status is a highly significant component of staging non-small cell lung cancer (NSCLC). Staging of NSCLC provides prognostic data related to risk of recurrence as well as overall survival (1). Lymph node metastasis alters treatment decisions, including surgical resectability and appropriateness of adjuvant interventions. Current pathologic LN sampling techniques often evaluate a low number of LNs (2-4). Goals of current staging techniques include sampling at minimum three N1 (hilar) nodes examined in settings of resectable disease (5). Patients harboring N1 metastatic disease are a heterogeneous group with a calculated 5 year overall survival (OS) of 38% (1) with widely variable range from 27-67% (1,6,7). In a recent article by Ramierz et al. (8), “Incomplete Intrapulmonary Lymph Node Retrieval After Routine Pathologic Examination of Resected Lung Cancer”, traditional pathologic LN staging was compared with a specialized technique for intrapulmonary LN sampling. The special pathologic examination (SPE) was used to detect additional LNs via re-dissection of 73 lobectomy (or greater) specimens following curative intent resection for NSCLC. Re-dissection consisted of 3-5 mm cuts of all discarded specimen following routine pathologic examination (RPE) with isolation of intrapulmonary LNs as well as identification of satellite metastatic nodules that did not meet LN criteria. Each SPE was compared to its own RPE, thus providing an internal control. All cases had appropriate pre-surgical staging. Of the 374 LNs examined with RPE 34 nodes harbored metastatic disease, a total of 22 of 73 patients. An additional 514 LNs were examined with the SPE technique with a median of 6 additional N1 nodes discovered, 4 from hilar/intralobar zone (range, 0-31) and 1 from peripheral zone (range, 0-15). Fifty six of the 514 nodes recovered with SPE were involved with metastatic disease, 20 of 73 patients. Of the 20 patients identified as having metastatic disease by SPE, 6 who were staged as N0 following RPE were found to have metastatic disease while 14 had previously been identified as having metastatic disease with RPE alone. A total of 8 of 73 patients (11%) were upstaged with alteration in management in 4 patients (5.4%). Two patients were upstaged from IIB to IIIA, one patient from stage IIA to IIIA (with malignant satellite nodules), and one from IIB to IIIA (with malignant satellite nodules). Median time to perform the SPE decreased from 44 minutes (range, 25-80 minutes) to 15 minutes (range, 10-30 minutes) in the last batch of 10 specimens examined. Lymph node retrieval rate remained stable despite this change in dissection duration. While a modest number of patients had upstaging from this technique (8 of 73), only half of these patients (4 of 73) had alteration to their therapy secondary to these findings. Furthermore, of the 4 patients with treatment alteration only 2 were secondary to N1 disease, the other 2 were found to have metastatic satellite lesions. Thus, it is difficult to deduce a survival advantage for the small number of patients who had an altered treatment based on the use of this intrapulmonary staging technique. Secondarily, drawing conclusions related to prognosis of the 8 patients with upstaged disease is difficult. The current staging system, and thus prognostic data, is based on our existing pathologic LN dissection techniques which often involves evaluation of few intrapulmonary nodes (9-11). Would we be treating these patients more aggressively without benefit? The question of ability to cross compare outcomes remains unanswered. Editorial