Abstract Objectives To review the historical evolution, current evidence, and future perspectives regarding lymphadenectomy in non-small-cell lung cancer (NSCLC), with a particular focus on its role in accurate staging, nodal upstaging, and therapeutic decision-making. Methods This narrative review was conducted through a literature search of PubMed and Scopus from 1950 to March 2025, using the terms non-small-cell lung cancer, lymphadenectomy, nodal upstaging, and mediastinal dissection. Reference lists of relevant studies and guidelines were also screened. Both randomized controlled trials and large observational studies were included, together with international guidelines and recent conference abstracts (Asia-Pacific Innovative Thoracic Surgery Symposium APITS 2025). Results Evidence consistently demonstrates that systematic mediastinal lymphadenectomy enhances staging accuracy, increases the detection of occult nodal disease, and improves prognostic stratification. Pathologic upstaging is a frequent and clinically relevant phenomenon in clinically node-negative patients, directly influencing indications for adjuvant systemic therapy. Guideline-based nodal dissection remains a cornerstone of curative-intent surgery, with at least 3 mediastinal stations and 1 hilar station recommended. Comparative studies show that when a station-based approach is rigorously applied, minimally invasive and robotic techniques achieve staging outcomes equivalent to open surgery. Recent technological innovations, including radiomics, deep learning, and artificial intelligence applied to positron emission tomography/computed tomography (PET/CT) and endobronchial ultrasound, hold promise for refining preoperative risk prediction but remain adjuncts to systematic surgical clearance. Conclusions Lymphadenectomy is central to the surgical management of NSCLC. Beyond its role in accurate staging and prognostic assessment, it guides multimodality treatment and underpins long-term outcomes. Future advances are likely to derive not from platform choice but from integrating technology to ensure that systematic, station-based lymphadenectomy is performed safely, consistently, and comprehensively.
Ceccarelli et al. (Tue,) studied this question.