Defining Surgical Eligibility in N2 Early-Stage NSCLC

Patients with N2 lymph node involvement can be appropriate candidates for surgical resection within multimodal treatment approaches, with recent clinical trial data supporting surgery for both single-station and carefully selected multistation N2 disease. Health care providers recognize that tumor biology rather than simply anatomic nodal station involvement determines treatment response and patient outcomes. The distinction between bulky and invasive N2 disease becomes clinically relevant, as bulky but encapsulated lymph nodes are often easier to resect completely than invasive disease that lacks clear tissue boundaries.

Treatment decisions for patients with N2 disease require careful consideration of the planned surgical procedure, as patients requiring pneumonectomy for multistation N2 disease face higher risks of systemic disease and postoperative complications. Health care teams increasingly recognize that lobectomy with multistation N2 involvement may represent a reasonable surgical target, particularly when combined with effective neoadjuvant and adjuvant systemic therapies. The concept of intentional incomplete resection (R1 resection) followed by adjuvant therapy represents an evolving approach for selected patients where complete resection would require prohibitively extensive surgery.

Patient selection for N2 surgical approaches requires integration of multiple factors, including nodal characteristics, primary tumor features, patient fitness, and available alternative treatments. Health care providers must balance the superior local control achieved through surgical resection against the potential morbidity of extensive procedures and the effectiveness of definitive chemoradiation approaches. Patients benefit from multidisciplinary evaluation that considers all available treatment modalities, with surgical resection reserved for cases where complete or near-complete resection can be achieved with acceptable morbidity and where the patient’s overall condition suggests they will benefit from the multimodal treatment approach.