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Objective: The introduction of modern staging systems such as computed tomography (CT) and positron emission tomography/CT (PET/CT) with fluorodeoxyglucose ([ 18 F]FDG) has increased the detection of small peripheral lung cancers at an early stage. We analyzed the behavior of pathological T1 non-small-cell lung cancer (NSCLC) to identify criteria predictive of nodal involvement, and the role of cancer size in lymph node metastases. Methods: We retrospectively analyzed 219 patients with pathological T1 NSCLC. All patients were staged by high-resolution CTand PETas stage I, and underwentanatomical resectionand radical lymphadenectomy. Our data were collected based on pathological nodulesize (0— 10 mm; 11—20 mm; and 21—30 mm); morphological features of lung nodule and FDG uptake of the tumor measured by standardized uptake value (SUV). Results:A total of 190 patients (87%) were pN0, 14 (6%) pN1, and 15 (7%) pN2. No nodal involvement was observed in any of the 62 patients with nodule size less than 10 mm, in 20 out of 120 patients (17%) with nodule size 11—20 mm, and in nine out of 37 tumors (28%) 21—30 mm in size (p = 0.0007). All 55 patients with nodule SUV < 2.0 and all 26 non-solid lesions were pN0 (respectively, p = 0.0001 and p = 0.03). All nodal metastases occurred amongthe group of 132patients with size larger than 10 mm and SUV higher than 2.0 with a 22% rate of nodalinvolvement of (29 patients) (p < 0.0001). Conclusions: The low probability of lymph node involvement in NSCLC

of disease aggressiveness regarding microvascular invasion [4] and gene mutations [5] despite the stage. The trend is to find evidence of benefit from adjuvant therapy to epidermal growth factor-muted patients, even for early stage of lung cancer (e.g., the Randomized, Double-Blind Trial in Adjuvant NSCLC with Tarceva (RADIANT) trial, double-blind randomized of erlotinib in the adjuvant setting of I–IIIa NSCLC). Moreover, the authors have accurately stated that extended lymphadenectomy is not more morbid than sampling. As a conclusion, regarding the benefit/risk expected of extended lymphadenectomy and the absence of accuracy of PET/CT for small-size structures, I was expecting the authors to conclude that PET/CT is not relevant for small-size tumor or node metabolic evaluation. A trial evaluating the omission of extended lymphadenectomy in small-size tumors with no lymph node uptake on PET–CT appears unethical and obviously exposes the arm of patient without lymphadenectomy to a loss of chance (risk of under staging and under treatment). In addition, a ‘wait-for–grow-’ attitude for non-uptaking nodes with suspect morphologic characteristics is a misbenefit of technology. REFERENCES

Background: To address whether systematic lymph node dissection is always necessary in early lung cancer, we identified factors predicting nodal involvement in a screening series and applied them to nonscreening-detected cancers. Methods: In the 97 patients with clinical T1-2N0M0 lung cancer (10 mm and maxSUV ≤2.0 (p = 0.002 versus the other 62 cases). In the nonscreening series, 42 of 43 cases with negative PET-CT (usually maxSUV 10 mm were pN+ (p = 0.001 versus the 43 cases). Conclusions: This limited experience suggests that in early-stage clinically N0 lung cancers with maxSUV