PET-CT limitations in early stage non-small cell lung cancer: to whom more aggressive approach in radiotherapy and surgery should be directed?

This editorial comments on the study by Paravati et al., which reported on the incidence of occult regional lymph node metastases in PET-CT T1T2N0 non-small cell lung cancer (NSCLC) patients. A central location and the size of the tumor were shown to be the strongest predictors of the risk of occult nodal disease. Authors comment that in view of limitations of modern imaging, as well as the reported negative predictive value (NPV) of invasive staging methods, the choice of therapeutic options as the extent of surgery (lobectomy or sublobar resection) or radiotherapy [stereotactic body radiation therapy (SBRT) or conformal radiotherapy (RT) with some forms of elective nodal irradiation (ENI)] should consider tumor's characteristics and not be based only on imaging and invasive staging modalities.