What to do with “Surprise” N2?: Intraoperative Management of Patients with Non-small Cell Lung Cancer

There is debate about how patients should be managed when malignant involvement of mediastinal lymph nodes is encountered at the time of lung resection. A comprehensive review of the literature demonstrates that differences in which outcomes are reported and how extensively patients were staged preoperatively explain much of the conflicting data. Certain negative and positive prognostic factors can be defined, but in general the outcomes justify proceeding with resection unless it is clear that disease will be left behind. Reasonable arguments can be made that the approach should include a mediastinal lymph node dissection and adjuvant therapy.