Reply to Nosotti et al.

Abstract

[6] admitted ‘attempting to make a loose comparison for patients in particular radiographic subgroups, with recognition that this assessment must be taken with a large grain of salt’. The definition of ‘peripheral’ is a loose one and creates a loop hole that might give excuses for omitting SND. Based on the American College of Chest Physicians clinical practice guidelines, ‘invasive staging is probably not needed in patients with peripheral tumours with no nodal involvement on CT and PET scans’. Logically it follows that this category should also be exempt from routine mediastinoscopy, a recommendation that is missing from both guidelines of the ACCP and the European Society for Thoracic Surgeons. In our series, we have shown clearly that mediastinal involvement [N2] in patients with cT1-3 N0 M0 was 10%. These patients had a completely innocent mediastinum, within the radiological group 1–2 of Detterbeck’s classification. We therefore believe that an SND is mandatory for every patient with NSCLC even if mediastinal involvement was thought unlikely, and irrespective of the how peripheral the primary is.