Should #5 and #6 lymph node station be biopsied in every patient with NSCLC?

Back in 1988, Patterson and colleges described a better 5 year survival for those patients with isolated metastasis to LN stations #5 and 6 when a complete resection was done (around 42% 5-year survival). This is a much better 5- survival than the described for patients with N2 disease in other mediastinal LN stations. Cerfolio compared three different methods of getting to these stations: EUS, Chamberlain procedure and left VATS are compared, concluding that VATS achieves the best sensibility and specificity for these locations. There are other ways of getting these nodes, but to me a left VATS is the easiest one. However, is it always necessary to get these stations? I certainly do not routinely biopsy this station in every patient with a left upper lobe tumor, I just do it when the patient is not a good candidate for lung resection and I want to prove mediastinal disease. The situation is different when CT scan or PET scan is positive for this location. Two options are possible: the first one is to biopsy these nodes and send the patient for induction therapy if nodes are positive and the second one to do surgery right from the beginning if reasonable in terms of tumor size, absence of disease elsewhere and operative risk for lung resection. I don’t know which one is the right answer. I usually feel more like resecting these patients and doing the best possible lymphadenectomy, followed by adjuvant therapy if indicated by the path report. There is evidence that isolated metastasis to stations #5 and 6 behave more as N1 disease in terms of survival and this is the rationale I use for this decision. What I’m sure about is that tailoring a strategy for each particular patient is the best way to treat them, until we have solid evidence on how to deal with patients in this particular situation.
What do you usually do in these patients?
Sebastian

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