Current advances in mediastinal staging for non-small cell lung cancer: a narrative review

Background and Objective: Mediastinal staging, whether through non-surgical or surgical approaches, plays a pivotal role in the management of non-small cell lung cancer (NSCLC) due to its impact on therapeutic decision-making and prognosis. This narrative review aims to provide a comprehensive overview of evidence-based strategies for mediastinal staging/restaging. Methods: This review analyzes current evidence on the role of non-invasive methods [endobronchial ultrasound (EBUS), endoscopic ultrasound (EUS), cryobiopsy, robotic-assisted bronchoscopy] and surgical techniques in mediastinal staging/restaging. A literature search was conducted using the PubMed/Medline/Embase/CENTRAL/CINAHL databases for relevant English-language studies published since 1996. Studies were selected based on clinical relevance, diagnostic performance, and integration into staging algorithms. A critical appraisal of indications, advantages, limitations, and future developments is provided. Key Content and Findings: The combination of EBUS and EUS offers high sensitivity and specificity for mediastinal lymph node assessment, with a favorable safety profile. Surgical staging remains crucial in selected cases, particularly when minimally invasive approaches yield inconclusive results or are negative in patients with high-risk features. Emerging technologies, including robotic-assisted platforms, may further enhance diagnostic accuracy. Conclusions: EBUS and EUS have become first-line tools for mediastinal staging in NSCLC, while surgical techniques continue to serve a complementary role. Cryobiopsies and robotic-assisted biopsies may represent a useful diagnostic tool even if so far large prospective data are missing. Future research should aim to refine patient selection, improve diagnostic precision, and personalize staging strategies.