N1 Staging in Non-Small Cell Lung Cancer: Current Situation, Limitations, and the Importance of Peripheral Nodal Assessment

Accurate regional lymph node staging is essential for guiding treatment and predicting outcomes in non-small cell lung cancer. While the 9th edition of the TNM classification introduced prognostic subdivisions for N2 disease, the N1 category remains a single, unified descriptor. However, N1 disease is highly heterogeneous. Evidence shows significant survival differences between single-station (N1a) and multi-station (N1b) involvement, as well as between peripheral (N1p) and hilar (N1h) metastases. Standard medical imaging evaluation and conventional bronchoscopy often fail to detect “occult N1 disease,” leading to postoperative stage migration and suboptimal treatment sequencing. This diagnostic gap affects critical clinical decisions, including the selection of patients for sublobar resection, the administration of neoadjuvant chemoimmunotherapy, and the precision of radiation target volumes. The main obstacle to refining N1 staging has been the limited ability of existing clinical staging modalities to access and accurately assess N1p nodes. However, recent technological advances, particularly in thin convex probe endobronchial ultrasound examination, have renewed interest in bronchoscopic evaluation of N1p and in improving preoperative clinical N1 staging. The purpose of this review is to summarize the biological and immunological basis for N1 subclassification and evaluate how emerging technologies can bridge the gap between clinical and pathological staging. Refining the N1 compartment is vital for a personalized staging system that reflects the true biological spectrum of lung cancer.