The International Association for the Study of Lung Cancer Thymic Epithelial Tumors Staging Project: Proposals for the N and the M Components for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors.

INTRODUCTION: Stage classification is an important underpinning of management in patients with cancer and rests on a combination of three components-T for tumor extent, N for nodal involvement, and M for distant metastases. This article details the revision of the N and the M components of thymic epithelial tumors for the ninth edition of the TNM classification of malignant tumors proposed by the Thymic Domain of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee. METHODS: The N and M components of the eighth edition staging system were verified by a large international collaborative data source through a data-driven analysis. A total of 9147 cases were included for analysis, including 7662 thymomas, 1345 thymic carcinomas, and 140 neuroendocrine thymic tumors. RESULTS: Lymph node involvement rates were 1.5% in thymomas and 17.6% and 27.7% in thymic carcinomas and neuroendocrine thymic tumors, respectively. Rates of lymph node metastasis were increasingly higher in tumors with higher T stage and higher-grade histologic type. Survival analysis validated the differences in the N and M categories proposed in the eighth edition staging system. Good discrimination in overall survival was detected among pathologic (p)N and pM categories in patients with thymoma and thymic carcinoma. CONCLUSIONS: No changes are proposed from the eighth edition for the N and M components. The proposed stage classification will provide a useful tool for management of the disease among the global thymic community.

The International Association for the Study of Lung Cancer Thymic Epithelial Tumors Staging Project: An Overview of the Central Database Informing Revision of the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors.

INTRODUCTION: In 2014, a TNM-based system for thymic epithelial tumors was proposed. The TNM stage classification system was published as a result of a joint project from the International Association for the Study of Lung Cancer and the International Thymic Malignancy Interest Group for the eighth edition of the American Joint Commission on Cancer and the Union for International Cancer Control stage classification system. The Thymic Domain of the Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer received the mandate to make proposals for the ninth edition of the TNM stage classification. METHODS: A central thymic database was collected by the Cancer Research And Biostatistics with the contribution of the major thymic associations in the world. RESULTS: A total of 11,347 patients were collected. Submitting organizations were the following: Japanese Association for Research in the Thymus, European Society of Thoracic Surgeons, Chinese Alliance for Research in Thymoma, Korean Association for Research in the Thymus, International Thymic Malignancy Interest Group, and Réseau tumeurs THYMiques et Cancer. Additional contributions came from centers in the United States, United Kingdom, Turkey, Australia, Spain, and Italy. A total of 9147 cases were eligible for analysis. Eligible cases for analysis came from Asia and Australia (5628 cases, 61.5%), Europe (3113 cases, 34.0%), and North America (406 cases, 4.4%). CONCLUSIONS: This report provides an overview of the database that has informed the proposals for the updated T, N, and M components and the stage groups for the ninth TNM of malignant tumors.

The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: A Re-Assessment of the International Thymic Malignancy Interest Group/International Association for the Study of Lung Cancer Lymph Node Map for Thymic Epithelial Tumors for the Forthcoming Ninth Edition of the TNM Classification of Malignant Tumors.

INTRODUCTION: A lymph node map is the pillar on which accurate assignment and documentation of nodal classification stands. The International Thymic Malignancy Interest Group created the first map for thymic epithelial malignancies in conjunction with the eighth edition of the TNM classification, representing the first official TNM classification of thymic epithelial malignancies. The map was based on clinical experience and published studies, but it was largely empirical because of limited available data. Dissemination of the map and implementation of a standard thymic stage classification across the world in 2017 have provided more consistent and granular data. METHODS: More than twice as many cases of node involvement are available for analysis in the current database compared with that of the eighth edition database, allowing validation of many aspects of the eighth edition map. This article details the process and considerations for refinement of the thymic map for the ninth TNM used by the Thymic Domain of the Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer. The committee evaluated a large international collaborative data set, published anatomical and clinical studies pertaining to lymph node spread from thymic epithelial tumors, in conjunction with the analysis underlying refinements of the TNM components for the ninth edition TNM classification. RESULTS: The node map boundaries of the N1 and N2 categories remain unchanged. Visual clarifications have been added to the nomenclature of nodal stations within these regions. CONCLUSIONS: On the basis of the recommendation to keep the N component unchanged for the ninth edition TNM classification, the lymph node map remains unchanged as well; however, clarifications have been added to facilitate clinical use.

The International Association for the Study of Lung Cancer Thymic Epithelial Tumors Staging Project: Proposal for a Stage Classification for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors.

INTRODUCTION: A TNM-based system for all types of thymic epithelial tumors was introduced in the eighth edition of the TNM classification of thoracic malignancies. The Thymic Domain of the Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer, composed of multispecialty international experts, was charged to develop proposals for the ninth edition. This article outlines the proposed definitions for the T, the N, and the M components and their combination into stage groups. METHODS: A large central database of 11,347 patients with thymic epithelial tumors was assembled thanks to the contribution of the major thymic organizations worldwide and analyses were carried out for the T, the N, and the M components and the stage groups. Overall survival was the outcome measure for patients with completely and incompletely resected tumors, and recurrence for those with complete resection. When the number of patients was sufficient, analyses were performed separately for thymomas, thymic carcinomas, and neuroendocrine thymic tumors. RESULTS: Tumor size is included in the T1 category as T1a (≤5cm) and T1b (>5 cm); the mediastinal pleura is dropped as a T descriptor; invasion of the lung or phrenic nerve is reclassified as T2 (instead of T3). No changes are proposed for the N and the M components from the eighth edition. The stage groups remain the same. CONCLUSIONS: The proposed changes for the ninth edition of the TNM classification set the stage for further progress in the future for these rare tumors.

The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: Proposal for the T Component for the Forthcoming (Ninth) Edition of the TNM Classification of Malignant Tumors.

INTRODUCTION: A TNM-based stage classification system of thymic epithelial tumors was adopted for the eighth edition of the stage classification of malignant tumors. The Thymic Domain of the Staging and Prognostics Factor Committee of the International Association for the Study of Lung Cancer developed a new database with the purpose to make proposals for the ninth edition stage classification system. This article outlines the proposed definitions for the T categories for the ninth edition TNM stage classification of thymic malignancies. METHODS: A worldwide collective database of 11,347 patients with thymic epithelial tumors was assembled. Analysis was performed on 9147 patients with available survival data. Overall survival, freedom-from-recurrence, and cumulative incidence of recurrence were used as outcome measures. Analysis was performed separately for thymomas, thymic carcinomas, and neuroendocrine thymic tumors. RESULTS: Proposals for the T categories include the following: T1 category is divided into T1a (≤5 cm) and T1b (>5 cm), irrespective of mediastinal pleura invasion; T2 includes direct invasion of the pericardium, lung, or phrenic nerve; T3 denotes direct invasion of the brachiocephalic vein, superior vena cava, chest wall, or extrapericardial pulmonary arteries and veins; and T4 category remains the same as in the eighth edition classification, involving direct invasion of the aorta and arch vessels, intrapericardial pulmonary arteries and veins, myocardium, trachea, or esophagus. CONCLUSIONS: The proposed T categories for the ninth edition of the TNM classification provide good discrimination in outcome for the T component of the TNM-based stage system of thymic epithelial tumors.

Mediastinal Bronchogenic Cysts Resection in Adults: Results of Vats and Thoracotomy Procedures.

BACKGROUND: The objectives of our study are to evaluate our surgical experience of mediastinal bronchogenic cyst (MBC) and to determine the results of resection by video-assisted thoracic surgery (VATS) and posterolateral thoracotomy (PLT). METHODS: The demographic characteristics, clinical and radiological features intraoperative data, outcomes and fol- low-up information were reviewed and analyzed from 38 patients who underwent resection of a MBC between 2008 and 2019. RESULTS: cystectomy was performed for thirty eight patients included in the present study. Seventeen of them, benefited from VATS cystectomy (VATS group) with 1 conversion to thoracotomy (5.9%) and 21 underwent PLT cystectomy (PLT group). In our series 27 (71.1%) were male. Their average age was 42.6 years. While 09 patients (23.7%) had no symptoms pre-operatively, 29 patients (76.3%) were symptomatic. There were no operative deaths and 3 patients (7.9%) presented postoperative complications. The average duration of hospital stay was 3.2 days for patients who had VATS, but 5.8 days for those who had thoracotomy. Long-term follow-up (range, 1 to 8 years) showed no late complications and no recurrence. CONCLUSION: VATS and PLT are main approaches for the surgical resection of MBCs VATS is a safe procedure, with less pain and time spent at the hospital. Early surgical procedures of MBCs may be recommended to prevent complications. Surgical adhesions are unfavorable conditions to thoracoscopic treatment.

Does Myasthenia Gravis Affect Long-Term Survival in Thymic Carcinomas? An ESTS Database Analysis.

Background: Thymic carcinoma is a rare and highly malignant tumor with a dismal prognosis, which occasionally coexists with myasthenia gravis (MG). This study aims to investigate the MG incidence on a surgical cohort of patients with thymic carcinoma and to explore its influence on long-term survival. Methods: the prospectively collected data from the ESTS database on thymic epithelial tumors were reviewed. Clinical, pathological, and survival information on thymic carcinoma were analyzed. Results: the analysis was conducted on 203 patients, with an equal gender distribution (96 males and 107 females). MG was detected in 22 (10.8%) patients, more frequently elderly (>60 years, p = 0.048) and male (p = 0.003). Induction therapy was performed in 22 (10.8%) cases. After surgery, 120 (59.1%) patients had a Masaoka stage II−III while complete resection (R0) was achieved in 158 (77.8%). Adjuvant therapy was performed in 68 cases. Mean follow-up was 60 (SD = 14) months. The 3-year, 5-year and 10-year survival rates were 79%, 75% and 63%, respectively. MG did not seem to influence long-term survival (5-year survival in non-MG−TCs 78% vs. 50% in MG−TCs, p = ns) as age < 60 years, female gender, early Masaoka stage, and postoperative radiotherapy did, conversely. Conclusions: myasthenia occurred in about 10% of thymic carcinomas and it did not seem to affect significantly the long-term prognosis in surgically treated thymic carcinoma-patients.

Osteoid osteoma of the rib: A report of an extremely rare condition.

INTRODUCTION: Osteoid osteoma (OO) is a type of benign bone tumor that usually affects long bones of the lower extremities. In this case report, we describe a successful surgical resection of an OO located in the rib which is an extremely rare location. CASE PRESENTATION: This is a 23-year-old man, referred to our thoracic surgery department for a very intense nocturnal right chest pain for over two months, the physical examination was normal without clinically palpable chest mass. The CT scan showed an osteocondensing lesion at the junction of the middle and posterior arches of the right 6th rib suggesting Ewing's sarcoma, a PET CT was then requested showed an appearance of a regular non-hypermetabolic inhomogeneous condensation at the junction of the middle and posterior arcs of the 6th right rib. After multidisciplinary concertation, a CT-guided biopsy of the lesion was performed, the histological examination of which revealed an osteoid osteoma, then a complete resection of the lesion was performed under posterolateral thoracotomy which histology confirmed a costal osteoid osteoma. The patient is currently in good health condition with complete disappearance of chest pain after one month of the operation and does not present any complications for the long-term follow-up. DISCUSSION: Osteoid osteoma (OO) is a benign primary bone tumor with unknown pathogenesis. That occurs in patients during the first two decades of life in about 60 to 75% of cases with a strong predilection for long bones, in 60 to 70% of cases. Flat bones, such as the skull, jawbones, innominate bones, and ribs are rarely described (McDermott et al., 1996 [1]). The standard treatment for OO is complete surgical excision, which is offered to the patient when the pain is chronic and not relieved by medical treatment (Osteoid osteoma: the results of surgical treatment [Internet] [2]). CONCLUSION: The osteoid osteoma of the rib is a very rare entity of bone neoplasms, this is the first case in our department that demonstrates that the OO of the rib must be suspected affront any painful rib and that complete surgical excision when it's possible, is a safe and effective treatment.

The International Association for the Study of Lung Cancer Thymic Epithelial Tumor Staging Project: Unresolved Issues to be Addressed for the Next Ninth Edition of the TNM Classification of Malignant Tumors.

Thymic epithelial tumors are presently staged using a consistent TNM classification developed by the International Association for the Study of Lung Cancer (IASLC) and approved by the Union for International Cancer Control and the American Joint Committee on Cancer. The stage classification is incorporated in the eight edition of the TNM classification of thoracic malignancies. The IASLC Staging and Prognostic Factors Committee (SPFC)-Thymic Domain (TD) is in charge for the next (ninth) edition expected in 2024. The present article represents the midterm report of the SPFC-TD: in particular, it describes the unresolved issues identified by the group in the current stage classification which are worth being addressed and discussed for the ninth edition of the TNM classification on the basis of the available data collected in the central thymic database which will be managed and analyzed by Cancer Research And Biostatistics. These issues are grouped into issues of general importance and those specifically related to T, N, and M categories. Each issue is described in reference to the most recent reports on the subject, and the priority assigned by the IASLC SPFC-TD for the discussion of the ninth edition is provided.

Thoracic metastasis of malignant melanoma of unknown primary: A case report and literature review.

INTRODUCTION: Metastatic melanoma of unknown primary (MUP) is an unusual entity found in distant sites without evident skin lesion. We report a case of 45-year-old woman who underwent monobloc resection of a metastatic thoracic malignant melanoma of unknown primary, and who is currently under immunotherapy without local or distant recurrence during a follow-up of 18 months. We demonstrate through this case that R0 resection of an MUP associated with immunotherapy improves the prognosis and survival in these patients. CASE REPORT: This is a 45-year-old woman who underwent monobloc resection of a mass carrying the anterior arch of the second left rib associated with a wedge resection of a nodule at the left upper lobe. Histology confirmed that it was a malignant melanoma. Her history was negative for melanocytic lesions, physical examination and imaging had failed to identify a primary lesion. The patient is currently under nivolumab for Stage IV melanoma and does not present any complications or recurrence during the long term follow up. DISCUSSION: Metastatic melanoma of unknown primary (MUP) is a melanocytic lesion in distant sites in the absence of apparent skin involvement and is rare, accounting for 3, 2% of all incident melanomas as well as being yet poorly understood in terms of pathogenesis (Bae et al., 2015) [1]. MUP is clinically understudied, investigators to date have reported largely on the use of localized treatment for MUP (surgery or radiotherapy), while the efficacy of systemic therapy in MUP patients remains unexplored. Clinical trials of immunotherapy and targeted therapy in patients with advanced cutaneous melanoma have not explicitly reported response rates specific to MUP patient subgroups due to its low incidence and lack of annotation. MUP's response to these now FDA-approved therapies could add to the discussion of MUP's elusive biological characteristics, as well as aid in making clinical recommendations (Utter et al., 2017). CONCLUSION: Metastatic MUP is an extremely rare entity which is still poorly understood, few cases are described in the literature, its treatment remains controversial and there are no specific treatment recommendations for patients with MUP. Several authors recommend local treatment when possible and tend to apply similar strategies for patients with paired stage primary known melanoma (PKM).

Sternal metastasis as first manifestation of a papillary thyroid carcinoma: A case report.

INTRODUCTION: Papillary thyroid carcinomas (PTC) are differentiated forms of thyroid carcinoma. Sternal metastases from differentiated thyroid cancers (DTCs) are rare and are of particular prognostic interest. Radioiodine therapy has traditionally been the treatment of choice for metastases from differentiated thyroid cancers; however, bone metastases are known to be resistant to this form of treatment. Surgical resection of distant metastases from DTCs offers a better chance of achieving long survival and a better quality of life. We report the case of a 59-year-old women who presented a presternal mass for one year revealing metastatic papillary thyroid carcinoma, a total thyroidectomy with lymph node dissection and reconstruction of the sternal defect were performed. Overall, we demonstrate that radical resection of sternal metastases can be performed safely even in patients with poor prognosis to achieve palliation and potentiation of Radioiodine therapy. CASE REPORT: This is a 59-year-old women referred by the endocrinology service for a sternal metastasis of a papillary thyroid carcinoma, who presented a painless, firm and fixed presternal mass for one year, a total thyroidectomy with lymph node dissection was performed with En-bloc resection and reconstruction as a one-stage procedure. Reconstruction of the chest wall was obtained by the rigid reconstruction with titanium bars and coverage with polymesh dual prosthesis, followed by radioiodine therapy and substitution with L-thyroxine. The patient is currently in good health condition, and does not present any complications and was in euthyroidism under substitution for the long term follow up. DISCUSSION: Thyroid cancer is the fastest increasing cancer in the United States, It is expected to replace colon cancer as the fourth leading cancer by 2030.2 More than 90% of thyroid carcinoma cases are classified as papillary or follicular carcinoma, both referred to as differentiated thyroid carcinomas (DTCs) and are associated with a 97%-98% 10-year survival rate. However, this rate can decrease to 14%-21% when patients present with bone metastases. Bone metastases have been reported to occur in 2%-13% of patients with DTC (Osorio et al. [1]). Several techniques have been used to repair after wide sternal resection for metastatic malignancies. Furthermore, choice of the reconstruction techniques depends on the size and the site of the defect and the preference of the surgeon (Lequaglie et al. [2]). CONCLUSION: Sternal metastases from papillary thyroid carcinomas are rare,few cases of sternal metastasis as first presentation of a well-differentiated PTC are described in the literature. Operative management of these metastases is still controversial, but radical resection offer patients an optimal probability of long-term survival.

Ectopic mediastinal thyroid removed by U-VATS approach. A case report.

INTRODUCTION: Ectopic thyroid tissue is a rare entity, and accounts for approximately 1% of all mediastinal tumours. It is a differential diagnosis of the mediastinum tumors or metastatic deposits from an orthotopic gland, as well as other benign or malignant masses. Although most cases are asymptomatic and discovered incidently by imaging, symptoms related to tumor size and its compression of adjacent structures may also appear which necessites explorations and lead to diagnosis. CASE PRESENTATION: This is a 59-year-old women, followed for glaucoma and operated for bilateral congenital cataract reffered to our structure by the service of pnemology for a right laterotracheal mediastinal mass. The patient presented respiratory symptoms over four months, and the physical examination found patient in good condition with PS 0 and normal vital signs, a poor oral health was noticed. The CT scann showed a left basal opacity and a right laterotracheal mediastinal mass at the upper right mediastinum, pushing forward the superior vena cava and compressing the trachea on the contralateral side, with well-defined borders and without signs of infiltration of adjacent structure. The brochoscopy was perfomed which showed the yellowish granulous aspect and the pathophysiology revealed a pulmonary actinomycosis. The patient was treated with antibiotic based on parenteral infusion of penicillin G at 20 million / day for 6 weeks relayed by oral administration of 3 g / day for 3 months with a good response and the left basal opacity disappeared on the CT control but the mediastinal mass persisted. After multidisciplinary concertation, the mediastinoscopy was perfomed and has revealed an ectopic thyroid which was removed by Uniportal Videoassisted Thoracoscopic Surgery (U-VATS) approach. DISCUSSION: The first case of ectopic thyroid gland was described by Hickman in 1869, since a few cases have been reported by the literature. Its prevalence is about 1 per 100 000-300 000 people, rising to 1 per 4000-8000 patients with thyroid disease. The main techniques indicated in the management of undetermined lesions of the anterior mediastinum, are midline exploratory sternotomy, anterior lateral thoracotomy and VATS. U-VATS has demonstrated its feasibility and safety compared to conventional techniques by several advantages. CONCLUSION: Ectopic mediastinal thyroid is an unusual presentation of thyroid pathology. Complete surgical resection remains a therapeutic and a key diagnosis. The aim of this study is to prouve the feasibility, efficiency and efficacity of U-VATS approach as minimally invasive thoracic surgery for mediastinal mass resection.

Video-assisted thoracoscopic pneumonectomy for destroyed lung.

AIM: Destroyed lung refers to destruction of a large portion of a lung induced by chronic or recurrent lung infections. The aim of this single-center retrospective review was to evaluate patients with a diagnosis of destroyed lung undergoing pneumonectomy via video-assisted thoracoscopic surgery, in terms of surgical technique, postoperative morbidity and mortality, and long-term outcomes. METHODS: Data of 15 patients who underwent video-assisted thoracoscopic pneumonectomy for destroyed lung during a 4-year period were analyzed retrospectively. There were 9 (60%) males and 6 (40%) females with a median age of 33.87 years (range 8-52 years). Bronchiectasis (n = 7), tuberculosis (n = 5), and fungal infection (n = 3) were the main etiologies. Hemoptysis was the most common presenting symptom (n = 8, 53.3%). Destroyed lung was detected on the left side in 13 (86.7%) patients and on the right side in 2 (13.3%). Seven patients showed narrowing or thickening of the main bronchus. RESULTS: Video-assisted thoracoscopic pneumonectomy was attempted in all patients but 5 (33.3%) were converted to a thoracotomy. The mean operative time was 273.8 min. The postoperative morbidity rate was 13.3%. The mortality rate was 6.67%. The median length of hospital stay was 3.5 days. The mean follow-up period was 23.7 months. Significant improvement was observed in inflammatory symptoms and quality of life in all patients. The overall 1-year survival was 93.3%. CONCLUSION: Video-assisted thoracoscopic pneumonectomy for destroyed lung is a safe and feasible option in selected patients, which can be used as an alternative to thoracotomy.

The International Association for the Study of Lung Cancer Thymic Tumors Staging Project: The Impact of the Eighth Edition of the Union for International Cancer Control and American Joint Committee on Cancer TNM Stage Classification of Thymic Tumors.

OBJECTIVES: The International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee-Thymic Domain conducted a web-based cross-sectional survey to assess the acceptance of the TNM thymic staging system in the thoracic community. METHODS: A 50-item, web-based questionnaire was circulated among the members of the major thymic organizations worldwide from September to December 2018. The survey consisted of six sections (general information; overall perception of the TNM system; pretreatment staging; T category; N category; and perioperative treatments). RESULTS: In total, 217 responses were collected from 37 countries in four continents. The TNM classification was considered useful by 78% of the responders (N = 169); the Masaoka-Koga staging system was being used by 87% of the responders (N = 189). With regard to the T category, most responders (mostly surgeons) felt that the capsular and mediastinal pleural involvements should be considered separate T categories. As for the N category, 48% of the responders (N = 105) used the International Thymic Malignancies Interest Group/International Association for the Study of Lung Cancer thymic nodal map, and lymph node dissection (N1/N2) was performed for 50%/21% thymomas and 66%/41% thymic carcinomas. While analyzing the results by the three continents (Europe, Asia, and Americas), responders in Asia were found to report the largest use of the TNM system, the greatest attention to the N category, and the best participation in international thymic databases. CONCLUSIONS: The survey indicates that the Union for International Cancer Control/American Joint Committee on Cancer TNM stage classification of thymic tumors is gaining acceptance among the scientific community. The present results will guide the work of the Staging and Prognostic Factors Committee-Thymic Domain for the revision of the ninth edition of the TNM stage classification of thymic tumors.

The IASLC Lung Cancer Staging Project: Analysis of Resection Margin Status and Proposals for Residual Tumor Descriptors for Non-Small Cell Lung Cancer.

OBJECTIVE: Our aim was to validate the prognostic relevance in NSCLC of potential residual tumor (R) descriptors, including the proposed International Association for the Study of Lung Cancer definition for uncertain resection, referred to as R(un). METHODS: A total of 14,712 patients undergoing resection with full R status and survival were analyzed. The following were also evaluated: whether fewer than three N2 stations were explored, lobe-specific nodal dissection, extracapsular extension, highest lymph node station status, carcinoma in situ at the bronchial resection margin, and pleural lavage cytologic examination result. Revised categories of R0, R(un), R1, and R2 were tested for survival impact. RESULTS: In all, 14,293 cases were R0, 263 were R1, and 156 were R2 (median survivals not reached, 33 months, and 29 months, respectively). R status correlated with T and N categories. A total of 9290 cases (63%) had three or more N2 stations explored and 6641 cases (45%) had lobe-specific nodal dissection, correlated with increasing pN2. Extracapsular extension was present in 62 of 364 cases with available data (17%). The highest station was positive in 942 cases (6.4%). The pleural lavage cytologic examination result was positive in 59 of 1705 cases (3.5%): 13 had carcinoma in situ at the bronchial resection margin. After reassignment because of inadequate nodal staging in 56% of cases, 6070 cases were R0, 8185 were R(un), 301 were R1, and 156 were R2. In node-positive cases, the median survival times were 70, 50, and 30 months for R0, R(un) (p < 0.0001), and R1 (p < 0.001), respectively, with no significant difference between R0 and R(un) in pN0 cases. CONCLUSIONS: R descriptors have prognostic relevance, with R(un) survival stratifying between R0 and R1. Therefore, a detailed evaluation of R factor is of particular importance in the design and analyses of clinical trials of adjuvant therapies.

Early and long-term results of lung resection for non-small-cell lung cancer in patients with severe ventilatory impairment.

OBJECTIVE: To study clinical characteristics, surgical treatment modalities, early and long-term outcome of patients with severe ventilatory impairment undergoing lung resection for NSCLC. METHODS: We performed a retrospective review of clinical records of all patients with severe chronic ventilatory impairment (FEV1 and/or FVC< or =50% of predicted values) operated on for NSCLC in a 21-year period (1983-2003). RESULTS: One hundred and six patients were operated on. Mean FEV1 and FVC were 40% (range 23-50%) and 69% (17-117%), respectively. An obstructive pattern was observed in 87 cases (82%). Extent of maximal exeresis was based on the assessment of predicted post-operative FEV1 (ppoFEV1). Major resections were contraindicated if ppoFEV1 was lower than 30%. Sixteen pneumonectomies, 73 lobectomies and 17 sublobar resections were carried out. Pathologic stages were I, II, IIIA and IIIB in 58, 26, 18 and 4 cases, respectively. Resection was complete in 104 patients. Operative mortality and morbidity were 8.5% (n=9) and 70% (n=74), respectively. Twenty-two patients needed prolonged (>48 h) mechanical ventilation. Overall mean ppoFEV1 loss was 9.1% (0-34%). If ppoFEV1 loss was >15%, the morbidity rate was 100%. Mean PaCO2 and ppoFEV1 loss were higher among patients who died (41 mmHg versus 37 mmHg, P=0.02 and 13.2% versus 8.5%, P=0.025, respectively) as compared with operative survivors. Among patients with PaCO2>39 mmHg and ppoFEV1 loss>15% (n=9), mortality rate was 33%. Overall 1-year and 5-year survival rates were 82 and 33%, respectively. Respiratory failure was the cause of late death in 2 patients. Among patients available at follow-up (n=85), respiratory function was considered subjectively improved, stable and worsened in 6 (7%), 62 (73%) and 17 (20%) cases, respectively. Eleven patients needed continuous oxygen therapy. CONCLUSIONS: Lung resection should not be denied a priori in patients with severe ventilatory impairment. Evaluation of predicted post-operative function often allows major resections, which are functionally economic, at the price of a high operative morbidity. Operative mortality, long-term survival and respiratory function are acceptable in the absence of a valid therapeutic alternative.

Peripheral intrapulmonary lymph node metastases of non-small-cell lung cancer.

Since the development and progress of computed tomographic imaging, peripheral intrapulmonary lymph nodes (IPLNs) have become increasingly described and well-known entities. Intrapulmonary lymph nodes may appear as a solitary pulmonary nodular shadow mimicking a non-small-cell lung cancer (NSCLC) or as multiple nodules masquerading as carcinoma metastases. We describe a case in which IPLNs presented as a clinical "nodular" T4 N0 NSCLC that finally proved to be a pathologic T2 N1 NSCLC, thus raising new questions on this entity.