Early stage lung cancer with nodal involvement occult to PET-CT: treat the image or treat the disease?

Non-small cell lung cancer (NSCLC) over past 10 years has become the first cancer-related cause of death both in man and women with approx. about 1.3 million new cases and 1.2 million deaths each year worldwide (1-3). Strategies offered to NSCLC patients are vast and highly depend on lung cancer staging and in particular mediastinal lymph nodes status. TNM staging model accepted by IASLC in 2007 clearly identifies the benefits of particular therapies when tailored individually to cancer patients (4). Since then it was modified and adjusted in compliance to developing understanding of lung cancer biology and growing diagnostic accuracy. However, main principles remain intact with surgery representing most appropriate modality for early stage tumors (lung involvement ± hilar nodes) and oncologic management for metastatic disease. Evaluation of mediastinal lymph nodes involvement indicating metastatic progression and in turn questionable surgery benefit has therefore become crucial and of great clinical importance.