Contemporary Lung Cancer Nodal Staging and Therapeutic Decision-Making in the 9th TNM Era

In the era of precision medicine, managing non-small cell lung cancer (NSCLC) requires pathological confirmation, accurate nodal staging, and comprehensive biomarker profiling performed rapidly and concurrently. In the 9th edition of the TNM classification, the N2 category is subdivided into single-station (N2a) and multistation (N2b) subcategories, highlighting the clinical importance of precise mediastinal staging. This refinement necessitates systematic nodal evaluation using minimally invasive modalities such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to appropriately stratify patients for surgery, neoadjuvant therapy, and definitive chemoradiotherapy. Concurrently, although N1 has not been formally subclassified because of the lack of standardized clinical diagnostic criteria, the increasing use of sublobar resection for early-stage NSCLC requires more precise hilar and intrapulmonary nodal assessments, which can potentially be facilitated by emerging technologies such as thin convex-probe EBUS. Concurrently, adequate tissue acquisition is essential for timely biomarker testing. Before administering neoadjuvant immune checkpoint inhibitors, actionable driver alterations, such as epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements, must be identified to select appropriate treatment and prevent severe sequential toxicities associated with subsequent targeted therapies. This review highlights the indispensable role of endoscopic nodal staging and multidisciplinary collaboration in adapting to the updated TNM classification and optimizing personalized treatment strategies for patients with NSCLC.