State-of-the-Art Mediastinal Staging in Non-Small-Cell Lung Cancer: Integration of Combined Endosonographic Techniques with Updated IASLC TNM 9th Classification

Mediastinal staging remains a critical step in the management of non-small-cell lung cancer (NSCLC), as it directly impacts treatment planning, surgical decision-making, and overall prognosis. For many years, mediastinoscopy was considered the standard approach; however, in routine practice, less invasive techniques have largely taken its place. Endobronchial Ultrasound (EBUS) and Endoscopic Ultrasound (EUS) have become widely adopted because they allow real-time sampling of lymph nodes with good accuracy and a low complication rate. In clinical seĴings, these techniques are often used together rather than separately, as each provides access to different nodal stations. This combined approach improves diagnostic yield and reduces the number of patients who require surgical staging. At the same time, recent updates in the IASLC TNM classification, including the proposed 9th edition, have introduced more detailed nodal categories, making accurate tissue confirmation even more important in daily practice. In this review, we summarize the current use of combined EBUS and EUS in mediastinal staging, focusing on their practical advantages, limitations, and roles across different clinical scenarios. We also discuss their relevance in the context of molecular testing and evolving treatment strategies. Despite their strengths, there are situations in which negative results should be interpreted with caution and confirmed surgically. Overall, these techniques have reshaped the approach to mediastinal staging and are now central to modern lung cancer care.