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Vol. 62. Issue 8.
Pages 531-610 (August 2026)
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Vol. 62. Issue 8.
Pages 531-610 (August 2026)
SEPAR's voice

SEPAR–SECT Recommendations for Perioperative Invasive Mediastinal Staging of Non-small Cell Lung Cancer

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Sergi Calla,b,,
Corresponding author
scall@mutuaterrassa.cat

Corresponding author.
, Maribel Botana-Rialc,d,, Rosa Cordovillae,f, Carlos Gálvezg, David Gómez de Antonioh,i, Virginia Leiro-Fernándezc,d, Carlos Martínez-Barenysj, José Luís Recuero-Díazk,l, José Sanz-Santosm,n, Pere Serra-Mitjào, Ramón Rami-Portaa,p
a Department of Thoracic Surgery, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Terrassa, Spain
b Department of Morphological Sciences, School of Medicine and Health Sciences, Universitat Autònoma de Barcelona, Bellaterra, Spain
c Pulmonary Department, Hospital Álvaro Cunqueiro, EOXI Vigo, Spain
d Pneumovigo I+I Research Group, Health Research Institute Galicia Sur (IIS Galicia Sur), CIBERES-ISCIII, Vigo, Spain
e Pulmonary Department, Salamanca University Hospital, Salamanca, Spain
f Institute of Biomedical Investigation of Salamanca (IBSAL), Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
g Department of Thoracic Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain
h Department of Thoracic Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
i Department of Surgery, School of Medicine and Health Sciences, Universidad Autónoma de Madrid, IDIPHISA, Madrid, Spain
j Department of Thoracic Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
k Department of Thoracic Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
l Aragón Health Research Institute, IIS Aragón, Zaragoza, Spain
m Pulmonology Department, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Barcelona, Spain
n Department of Medicine, School of Medicine and Health Sciences, Universitat de Barcelona, Terrassa, Spain
o Pulmonary Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
p Network of Centres for Biomedical Research in Respiratory Diseases (CIBERES) Lung Cancer Group, Terrassa, Barcelona, Spain
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Abstract

Accurate mediastinal nodal staging is essential for the management of non-small cell lung cancer (NSCLC), as it refines prognosis, guides multimodal treatment, and improves survival. This joint consensus document from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Thoracic Surgeons (SECT) updates and expands the 2011 SEPAR guidelines, incorporating the 9th edition of the TNM classification and extending recommendations to the entire perioperative setting, including both preoperative and intraoperative mediastinal staging. The recommendations were developed through a structured review of the literature and multidisciplinary expert consensus. This document synthesizes current evidence on the role of endoscopic and surgical approaches for perioperative invasive staging, including endobronchial and oesophageal ultrasound-guided techniques, mediastinoscopy and its variants, transcervical lymphadenectomies and intraoperative lymphadenectomies. In addition, the consensus integrates the International Association for the Study of Lung Cancer (IASLC) definitions of completeness of resection and proposes quality standards for intraoperative lymphadenectomy. A practical staging algorithm is provided, stratifying tumours according to risk factors of occult mediastinal disease such as tumour size and radiological nodal involvement. The new recommendations emphasise that invasive mediastinal staging is not required for T1a and T1b tumours without radiological evidence of nodal disease, regardless of their location. Conversely, particular attention is given to the role of N1 disease, which is now recognised as a setting associated with a high risk of unsuspected mediastinal involvement. For cases with intermediate suspicion of mediastinal disease, surgical staging techniques demonstrate superior accuracy compared with endosonography alone. Overall, these recommendations aim to harmonize perioperative invasive staging across disciplines, minimize under- and overstaging, and support precise therapeutic decision-making in the evolving era of targeted and immune-based treatments for NSCLC.

Keywords:
Non-small cell lung cancer
Mediastinal staging
Perioperative staging
Endoscopic staging
Surgical staging
Intraoperative mediastinal staging
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