The Landmark Series: Advances in Preoperative Mediastinal Lymph Node Staging for Non-small Cell Lung Cancer (NSCLC)

Accurate mediastinal staging is essential for determining the extent of lung cancer, predicting prognosis, and guiding treatment strategies. Current clinical guidelines recommend preoperative invasive mediastinal staging for most patients with potentially resectable lung cancer, as imaging modalities alone often lack sensitivity and specificity. Invasive mediastinal staging techniques are categorized into surgical (e.g., cervical mediastinoscopy, video-assisted thoracic surgery) and nonsurgical (i.e., minimally invasive) approaches. Although cervical mediastinoscopy has historically been the gold standard, minimally invasive techniques have gained prominence in recent decades. These approaches, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), and combined EBUS/EUS, provide improved accuracy and reduced morbidity compared with traditional surgical methods. EBUS-TBNA facilitates access to a broad range of lymph node stations with real-time ultrasound guidance, while EUS-FNA complements EBUS by enabling transesophageal lymph node sampling. Together, these techniques enable a more comprehensive mediastinal staging. This review examines five key trials that explore the expanding role of endobronchial and endoscopic techniques in mediastinal staging for non-small cell lung cancer, demonstrating how these advancements have transformed the diagnostic landscape.