N2 Disease Discovered at the Time of Vats Lung Resection: Resect or Abort?

Major pulmonary resection by VATS (video-assisted thoracoscopic surgery) has become a standard therapeutic approach, not only for early stage lung tumors but also for patients with locally advanced disease. However, while in cases of clinical N2 disease surgical resection after neoadjuvant therapy is an established treatment protocol, more uncertainty exists on whether the intraoperative discovery of unexpected N2 disease should lead to following through with surgical resection or aborting it in favor of pre-operative treatment. A literature review using the PICO framework was conducted to compare the short and long-term oncological outcomes of the different therapeutic strategies. Although survival outcomes appear to be only moderately superior in patients treated by neoadjuvant therapy followed by surgery compared with those undergoing adjuvant therapy, an important issue is that slightly more than 50% of the operated patients eventually undergo post-operative chemotherapy. Surgical morbidity is certainly responsible for this reduced treatment completion rate; therefore, favoring VATS over thoracotomy may improve the feasibility of adjuvant treatment protocols. Furthermore, there is now evidence that the thoroughness of lymphadenectomy and the complete resection rates are as satisfactory by VATS as by thoracotomy, resulting in equal oncological outcomes. Therefore, in light of the earlier functional recovery of patients operated on by VATS and their greater ability to withstand postoperative adjuvant therapies, considering the effectiveness of this treatment protocol compared to the detrimental effects of an exploratory surgery, we recommend that, in case of unexpected N2 involvement, the surgeon should proceed with a complete resection and systematic mediastinal lymphadenectomy through the same VATS approach.