Evaluation of lymph node metastasis in lung cancer: Who is the chief justice?

Accurate determination of the diagnosis and the stage of lung cancer play a critical role to ensure that patients are provided the optimal treatment. However, the process is usually beyond complex. Early studies have suggested lymph nodes (LNs) >1.0 cm in size on computed tomography (CT) are considered as metastatic nodes, while the sensitivity of this criterion is not satisfied. Subsequently, positron emission tomography-computed tomography (PET-CT) was shown to be superior to CT alone on assessment of nodal involvement and was widely used to estimate suitability for resection with curative intent, but the dependability also remains controversial. Furthermore, transbronchial needle aspiration (TBNA) with and without endobronchial ultrasound (EBUS), as a well-accepted minimally invasive approach for LN biopsy, has been documented as an efficient tool in evaluation of CT and PET-CT negative LNs. Additionally, radiographic features including ground-glass/solid nodules ratio, referring as imaging biomarker, were indicated to be correlated with metastasis. Hence, we highlight the importance of comprehensive estimation of mediastinal and hilar LNs, and we suggested the judgment of LNs by radiographic tools alone might not be reliable and TBNA is indispensable in certain circumstances.