Today, we are featuring the American Association for Thoracic Surgery (AATS) expert consensus document, Evaluation and Management of N2+ Non-Small Cell Lung Cancer (NSCLC). NSCLC remains a challenging disease that often requires multimodal therapy, including surgery and chemoradiation. This expert consensus document utilizes recent literature to support clinical decision-making in the evaluation and management of patients with N2+ NSCLC.

Below are key highlights from the document. Refer to the full-text version for the complete and most thorough explanation of this expert consensus document.

Key Highlights from the 2026 Expert Consensus Document 
  • Incomplete (R1/R2) resection in N2 NSCLC patients is associated with poor survival. It is recommended that every attempt is made to achieve an R0 resection. 
  • The determination of resectability, involving a surgeon experienced in thoracic oncologic surgery, should be made prior to initiation of therapy. 
  • In patients with locally advanced non-small cell lung cancer (cT2a or greater, cN1, or cN2), pathologic mediastinal staging (EBUS or cervical mediastinoscopy) is recommended pre-treatment to verify the presence of N2 disease and rule out N3 disease. 
  • Resection can be beneficial in select T4N2 patients. Multidisciplinary discussion of these patients should be performed prior to determination of treatment. 
  • In addition to fluoro-deoxyglucose positron emission tomography/CT scan, patients with suspected N2 disease should undergo diagnostic contrast-enhanced CT chest prior to determination of treatment. 
  • Direct extension of tumor in continuity with bulky mediastinal nodal disease should be considered unresectable. 
  • Multi-station N2 disease with nodes >3cm or invasion to adjacent structures should be considered unresectable.
  • It is recommended that patients with NSCLC with clinical or pathological N2 disease and actionable epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) mutations receive targeted therapy as opposed to induction chemoimmunotherapy. 
  • The degree of benefit derived from adjuvant immunotherapy in patients who have received neoadjuvant chemoimmunotherapy is unclear. Omittance of adjuvant immunotherapy may be considered in patients with pathologic complete response, especially in those who have had complications from such treatment in the neoadjuvant setting. 
  • Routine pathologic re-staging should not be performed unless there is a concern for the presence of new N3 or M1 disease. 
  • For medically operable patients with resectable N2 NSCLC, the rates of treatment-related adverse events during neoadjuvant treatment with chemo immunotherapy are low, and the majority of patients undergo surgical resection without significant delay. 
  • Surgical resection can be performed safely after neoadjuvant chemo immunotherapy in patients with resectable N2 NSCLC, with low rates of pneumonectomy and high rates of R0 resection. 
  • For medically operable patients with resectable N2 NSCLC disease, and without actionable EGFR or ALK mutations, neoadjuvant chemoimmunotherapy is preferred over neoadjuvant chemotherapy, in order to optimize both pathologic response and long-term survival. 

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