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Introduction: The M component and TNM stage groupings for malignant pleural mesothelioma (MPM) have been empirical. The International Association for the Study of Lung Cancer developed a multinational database to propose evidence-based revisions for the eighth edition of the TNM classification of MPM. Methods: Data from 29 centers were submitted either electronically or by transfer of existing institutional databases. The M component as it currently stands was validated by confirming sufficient discrimination (by Kaplan-Meier analysis) with respect to overall survival (OS) between the clinical MO (cM0) and cM1 categories. Candidate stage groups were developed by using a recursive partitioning and amalgamation algorithm applied to all cM0 cases. Results: Of 3519 submitted cases, 2414 were analyzable and 84 were cM1 cases. Median OS for cM1 cases was 9.7 months versus 13.4 months (p = 0.0013) for the locally advanced (T4 or N3) cM0 cases, supporting inclusion of only cM1 in the stage IV group. Exploratory analyses suggest a possible difference in OS for single- versus multiple-site cM1 cases. A recursive partitioning and amalgamation generated survival tree on the OS outcomes restricted to cM0 cases with the newly proposed (eighth edition) T and N components indicates that optimal stage groupings for the eighth edition will be as follows: stage IA (T1N0), stage IB (T2-3N0), stage II (T1-2N1), stage IIIA (T3N1), stage IIIB (T1-3N2 or any T4), and stage IV (any M1). Conclusions: This first evidence-based revision of the TNM classification for MPM leads to substantial changes in the T and N components and the stage groupings. (C) 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

For nearly 40 years, there was no generally accepted staging system for malignant pleural mesothelioma. In 1994, members of the International Mesothelioma Interest Group, in collaboration with the International Association for the Study of Lung Cancer, proposed a TNM staging system based on analyses of outcomes in retrospective surgical series and small clinical trials. Subsequently accepted by the American Joint Commission on Cancer and the Union for International Cancer Control for the sixth editions of their staging manuals, this system has since been the international staging standard. However, it has significant limitations, particularly with respect to clinical staging and to the categories for lymph node staging. Here we provide an overview of the development of the International Association for the Study of Lung Cancer malignant pleural mesothelioma staging database, which was designed to address these limitations through the development of a large international data set. Analyses of this database, described in papers linked to this overview, are being used to inform revisions in the eighth editions of the American Joint Commission on Cancer and Union for International Cancer Control staging systems. ispartof: Journal of Thoracic Oncology vol:11 issue:12 pages:2082-2088 ispartof: location:United States status: published

Introduction: The current T component for malignant pleural mesothelioma (MPM) has been predominantly informed by surgical data sets and consensus. The International Association for the Study of Lung Cancer undertook revision of the seventh edition of the staging system for MPM with the goal of developing recommendations for the eighth edition. Methods: Data elements including detailed T descriptors were developed by consensus. Tumor thickness at three pleural levels was also recorded. An electronic data capture system was established to facilitate data submission. Results: A total of 3519 cases were submitted to the database. Of those eligible for T-component analysis, 509 cases had only clinical staging, 836 cases had only surgical staging, and 642 cases had both available. Survival was examined for T categories according to the current seventh edition staging system. There was clear separation between all clinically staged categories except T1a versus T1b (hazard ratio = 0.99, p = 0.95) and T3 versus T4 (hazard ratio = 1.22, p = 0.09), although the numbers of T4 cases were small. Pathological staging failed to demonstrate a survival difference between adjacent categories with the exception of T3 versus T4. Performance improved with collapse of T1a and T1b into a single T1 category; no current descriptors were shifted or eliminated. Tumor thickness and nodular or rindlike morphology were significantly associated with survival. Conclusions: A recommendation to collapse both clinical and pathological T1a and T1b into a T1 classification will be made for the eighth edition staging system. Simple measurement of pleural thickness has prognostic significance and should be examined further with a view to incorporation into future staging. (C) 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

Background: Low-dose computed tomography (CT) screening can detect early stage lung cancer in high-risk populations. However, no data on repeated annual screening over more than 5 years are available, and the impact of screening on lung cancer mortality is controversial. Methods: We analysed outcomes in high-risk asymptomatic volunteers (smokers and former smokers, >50 years) enrolled in a pilot study over 1 year from June 2000, who received annual low-dose CT for 7 years. Cumulative lung cancer incidence and survival were represented by Kaplan-Meier curves. Standardized incidence and mortality ratios were used to estimate risks relative to the general Italian and US population. Results: Compliance was 86% at the end of the seventh year in 1035 recruited volunteers (71% men, mean age 58 years). Lung cancer was diagnosed in 54 (5.3%); radical surgery was possible in 48/54 (87%); 39/54 (72%) had stage I disease. Five-year survival was 63% overall, 89% for stage I cases. During 6308 person-years of observation, 47 participants had died versus 75 expected in the Italian general population standardised for age and sex. Fourteen lung cancer deaths were registered versus 27 expected in a standardised US smoker population. Conclusions: Seventy percent of screening-diagnosed patients had stage I disease, and the survival of screen-detected cancer patients was high. Lung cancer mortality was favourable compared to age- and sex-matched population of US smokers, suggesting that mortality can be lowered by screening, although larger trials with longer follow-up are necessary to confirm these findings. © the authors; licensee ecancermedicalscience.

Subjective factors of the patient such as age, weight, occupation, expectations, etc. must be carefully evaluated in terms of surgery. It is always important to remember life expectancy, and the choice of a surgical procedure must be based on it. Limited survival and possible radiation therapy must eliminate methods that require long healing times: we no longer use bone grafts because the risk of healing time taking up too much of the time left for the patient is too high. Reconstructions must have an immediate solidity allowing early use of the limb. Thus, in the proximal femur, we above all use protheses (traditional or modular RPS); in acetabular lesions that do not involve the joint surface, our treatment of choice is curettage with liquid nitrogen and cement, armed with screws and nails. Prostheses, which are always cemented, are assembled using bipolar cups; cases where lysis is so wide on the cotyloid side as to require THR are rare. The cotyles, in cases such as these, are those that allow for anchoring with several sites (Octopus type), the McMinn or, at times, common cotyles in PE.

In the surgical treatment of metastatic lesions of the proximal humerus it is important to find solutions that eliminate pain and solve the mechanical problem in a short time and with reduced costs. In 90% of cases, intralesional curettage, freezing with liquid nitrogen and cement enhanced intramedullary instrumentation is capable of brilliantly solving the problems of these patients. When, instead, osteolysis involves the greater tuberosity and/or the joint region, resection of the proximal humerus followed by reconstruction with a modular prosthesis is indicated. Of those available on the market, the RPS system (LIMA) has features that make it equivalent to others, but at costs considerably lower. However, in reconstructions with prostheses, active abduction is significantly limited. A personal series of 20 patients is presented.

Mediastinal goiter is a well known benign disease, usually resectable through a cervical approach with minimal morbidity and mortality. Only occasionally a median sternotomy or a lateral thoracotomy may be required. The present case is worthy of presentation because of the exceptional dimension of the disease and the surgical challenge that it presented. In a 72-year-old woman a large intrathoracic goiter of the right thorax caused a severe dyspnoea due to an important contralateral mediastinal shift with compression of the lung, superior vena cava system and trachea. At surgical exploration, through a cervico-sternotomic approach, the mediastinal structures dislocation and the strong adherences between the anomalous neovascularized capsula of the mass and the surrounding structures, complicated the surgical dissection. An accidental lesion of the innominate artery required its reimplantation on the ascending aorta. An immense mass, was finally removed and pathological examination revealed a rare case of neovascularized, pseudosarcomatoid capsula among a benign hyperplastic proliferation. In spite of its benign nature, a giant goiter caused a life-threatening compression of the respiratory tract and lung parenchyma in this patient. The dimension of the lesions, the mediastinal anatomy alterations and the severe intraoperative haemorrhage represented major technical difficulties during surgical resection.

Trans-sternal closure of the bronchial stump is an effective procedure to treat bronchopleural fistula after pneumonectomy. The paper reports a modified video-assisted Abruzzini technique that, maintaining the same results, should determine a lower surgical risk. Three simultaneous approaches are used: cervical video-mediastinoscopy, right anterior parasternal mediastinotomy, left parasternal thoracoscopic access. The dissection of the bronchial stump is performed entirely through the mediastinotomy approach after having controlled mediastinal vessels. The bronchial stump reamputation is achieved by a roticulator endoGIA introduced through the cervicotomy either for the right or left fistulae. The technique proposed might reach the same result as the classic approach with lower surgical risks.

Localized fibrous tumor is an unfrequent mesenchymal neoplasm. The malignant variant of the pleura is exceptional and differential diagnosis with the more frequent benign type or with other neoplasms such as soft tissue sarcoma and mesothelioma is rarely possible in a preoperative setting. The best treatment of this disease is radical surgical resection. No definitive data exist about the role of chemotherapy. We report a case of a giant right intrathoracic mass whose preoperative diagnosis, from an open biopsy, was consistent with sarcoma and, in a second review, with fibrous tumor of the pleura without any indication about malignancy. A right pleuropneumonectomy and pericardial resection was performed through a right hemiclam-shell approach. Histology demonstrated an aggressive behaviour: high mitosis rate, Ki 67 of 34% and diffuse necrosis were present. In consideration of the apparent local radicality we did not perform any adjuvant treatment. Six months after the operation a wide local recurrence was evident and a systemic treatment with Ifosfamide and Adriamicina is still in progress. So far a good response has been documented. Preoperative diagnosis of malignancy has an important role as a therapeutic strategy in management of fibrous tumours of the pleura. When there is suspicion of a malignant form neoadjuvant chemotherapy can represent a further tool to control poorly differentiated and large tumors, and a wide surgical resection of the lesion must be performed.

Postoperative air leaks and pleural residual spaces are often encountered during partial lung resections and may adversely affect the immediate outcome prolonging the hospital stay. At present the only treatment consists of maintenance of the chest drainage under suction until resolution of the leaks.From January 1995 to December 1997 the authors have operated on and subsequently treated 12 patients presenting prolonged air leaks with residual pleural spaces after lobectomies for lung cancer. The patients underwent respectively: left or right lower lobectomies (n=7), left upper lobectomies (n=3), right upper lobectomies (n=2). In this study the air leak was considered prolonged if it continued and delayed the discharge after surgery beyond the postoperative day 8. The pneumoperitoneum was carried out under local anesthesia. The air was insufflated through a needle inserted just above the umbilical scar as for laparoscopic surgery access up to an amount of about 1200 cc-1300 cc.We have obtained in all cases and without complications an immediate reduction in the air leaks and a complete resolution of the residual pleural spaces. Chest drainages were removed from 3 to 4 days after the procedure.The good results achieved suggest that this procedure might be considered for selected cases, being a minor procedure, performed under local anesthesia and with minimum discomfort for the patient.

Cowden's disease is an inheritable multiple neoplastic syndrome represented by benign and malignant lesions of skin, digestive tract, mucosae, breast and thyroid. The syndrome, first described by Lloyd and Dennis in 1963, includes benign lung lesions, described in the literature only as hamartomas. The unusual condition of our case consists of multiple and bilateral lipomatous lesions of the lung and of adipose colonic polyps, diagnosed respectively by video assisted mini-thoracotomy and by endoscopic biopsies.

Improvements in surgical equipment have rendered video-assisted thoracic surgery (VATS) an effective device for thoracic surgeons and nowadays several intrathoracic diseases can benefit from this approach. This development has expanded potential use and recently the technical feasibility of major lung resections by VATS has been demonstrated. The authors present their experience with a standard muscle-sparing utility thoracotomy (UT) utilized for all VATS procedures, including major lung resections.From November 1996 to October 1997, 30 patients were operated on. There were 22 males and 8 females (medium age 58 years; range 24-78). There were 13 anatomical lung resections (i.e.: 11 lobectomies, 1 left pneumonectomy, 1 segmental resection), 8 wedge resections, 3 lung biopsies, 2 debridements of pleural empyema, 2 mediastinal nodes biopsies, 1 esophageal resection for leiomyoma, 1 excision of benign mediastinal cyst.No mortality or major morbidity were recorded, as well as no rib fractures due to the rib spreader. Two patients suffered from prolonged air-leaks after respectively left upper lobectomy and lung biopsy and required prolonged chest drainage. Concerning anatomic major lung resections the medium hospital stay was 7.9 days and medium chest tube time was 5.6 days. The utility thoracotomy through the auscultatory triangle proved to be a safe approach and confirmed the technical feasibility of various type of surgical procedures with results comparable to standard open thoracotomy. Our data shows that VATS approach did not seriously affect the duration of hospital stay, chest tube time, the overall morbidity or lung function.As the real benefit of this approach remains controversial, the majority of the studies comparing the VATS approach to conventional muscle-sparing thoracotomy neither nor prospective nor randomized, and several parameters are difficult to evaluate in the literature further study are mandatory.

Two cases of infected aneurysms of the subrenal abdominal aorta observed in the last year are reported. In this study some specific aspects of this unusual pathology are analyzed: the high mortality rate, the difficulties involved in the diagnosis and the surgical solutions.

Low-potassium (LP) solution with Dextran (Dx) improves lung preservation. Nevertheless, the role of Dx in simple cold storage is not established yet. This study was designed to investigate the relationship between molecular weight and concentration of Dx in LP solutions and its effects on cell viability after prolonged hypothermic preservation.Human fetal lung fibroblasts (WI-38) were preserved at 10 degrees C for 16 hrs in five solutions containing respectively Dx11, Dx17, Dx39.2, Dx71, Dx178 at 2% and at 5% concentrations and in LP solution without Dx. Cell viability was assessed by means of both the analysis of the total protein content (cytotoxicity index) and the rate of protein synthesis (index of cellular functioning).No differences were recorded in total protein content among the solutions tested. By contrast, the index of cellular functioning was significantly higher using LPDx178 at both concentrations. However, LPDx178 exerted a more significant cytotoxic effect than did LP alone.These effects were not mediated by the variation of osmolarity; two factors probably influenced this protection: the low oncotic pressure of the LPDx178 solution and an effect chemically specific due to the increased molecular weight of Dx still unknown. Nevertheless, during 10 degrees C preservation, WI-38 cells were better preserved with LP solution without Dx confirming, thus, that during simple cold storage the presence of an oncotic pressure might be harmful.

Consumption coagulopathy with clinical symptoms reveals aortic arterial aneurysms in less than 5% of cases. The authors report a case of abdominal aortic aneurysm: surgical repair is able to remove the hemostasis abnormalities for a long time. Implications of the consumption coagulopathy are analyzed: diagnosis, preoperative correction of the coagulopathy, surgical technique.

The research on lung preservation for transplantation is directed to synthesize a solution, in order to prolong the preservation period, thus avoiding the damage to lung tissues caused by ischemia. In recent years some in vivo experimental papers have been published, in which good results were obtained by adding trehalose, a non-reducing disaccharide able to stabilize the cell membrane, to the storage solutions.In this study we have evaluated the effects on human lung fibroblasts of commonly used storage solutions like Euro-Collins (EC) and Low Potassium Dextran (LPD), in which trehalose has respectively replaced glucose (T-EC) or was added (LPD-T). The cultures were incubated for 8 hours at 10 degrees C in standard and modified solutions.The data relative to EC compared to EC-T showed that the total protein content and the rate of protein synthesis, that is in other words cell viability, are drastically compromised. Concerning LPD-T, compared to standard LPD, a slightly decrease of the total protein content and of the rate of protein synthesis in the cells incubated in the modified solution were observed. The reasons for these unexpected data are related to the hypothesis that during the ischemic period membrane stabilization is neither the main nor the only factor responsible for the cellular damage. Moreover the role of trehalose in preservation solutions, is still not clear and should be further investigated.With the limits of the study of single cells in vitro, the advantages of trehalose containing solutions proved ineffective and toxic especially as for as EC-T is concerned.

Percutaneous Transthoracic Needle Biopsy (PTNB) is an accepted technique for the diagnosis of suspected intrathoracic malignancy and, although the appropriate indications have not been clearly defined yet, its use has rapidly expanded in the last years. The authors reviewed retrospectively their experience over one-year time biopsies and analyzed some controversies regarding this diagnostic procedure.

Resection of pulmonary recurrences after pneumonectomy for metastases is exceptional. Nevertheless in carefully selected patients surgery on the residual lung might be successfully performed. From January 1987 to February 1996, 5 patients underwent metastasectomy on single lung after pneumonectomy performed for the same metastatic disease. There were 3 male and 2 female with a mean age of 38 years at the time of surgery on single lung. All patients had a FEV140%. One patient (n degree 1) had 2 consecutive operations (wedge resections) on the right lower lobe followed 17 months later by right inferior lobectomy for metastases of soft tissue sarcoma. Three patients had only an operation on the residual lung (patient n degree 2 had 2 wedge resections for carcinoma; patient n degree 3 had 7 wedge resections for carcinoma; patient n degree 4 had 6 wedge resections for osteogenic sarcoma). The last patient (n degree 5) had 2 wedge resections on the right upper lobe and a large wedge resection on the right lower lobe for metastases of malignant corticosurrenaloma using a cardiopulmonary femoro-femoral by-pass without cardiac arrest. She postoperatively developed a right lower lobe venous infarction treated subsequently with a completion right lower lobectomy. She died in the postoperative course from cardiorespiratory insufficiency. The other patients had an uneventful postoperative course. Two patients (n degree 2 and n degree 4) died of their disease 14 and 12 months respectively after the surgery on the residual lung; by contrast 2 patients (40%) (n degree 1 and n degree 3) are still alive without recurrences 36 and 27 months after the last resection. In selected patients aggressive surgery for metastases on the residual lung can be successfully performed but the benefits in terms of long-term disease-free survival remain to be determined.

Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma of the lung that accounts for 3% of the total pulmonary malignancies. On the basis of literature on the topic, the following were taken into consideration, the history, the incidence, the epidemiology, the aetiopathogenesis, the clinical characteristics, the diagnostic as well as the surgical therapy of this kind of cancer. The authors reviewed our surgical experience of 23 patients treated at the Department of General, ThoracicVascular Surgery of the University of Parma during a 10-years period from 1985 to 1995.

A considerable difficulty in surgical management of apical chest tumors is represented by the potential involvement of the thoracic outlet anatomic structures (i.e.: vertebral body, subclavian vessels, first rib). Among the various techniques proposed, the anterior trans-cervical approach popularized by Dartevelle significantly improved the radical treatment of these tumors. This approach offers a wide access to the thoracic outlet with satisfactory control of subclavian vessels, safe dissection of brachial plexus and upper part of the mediastinum, permitting a radical treatment. However, this approach is associated invariably with aesthetic deformity, severe impairment in shoulder mobility (due to medial half clavicle sacrifice) and respiratory failure in case of chest wall resection. The authors present their experience with an alternative approach, the trans-manubrial osteomuscular sparing approach to anteriorly situated apical chest tumors recently standardized by Grunenwald and Spaggiari. From June 1996 to June 1997 5 patients were operated on through this approach: 3 non-small-cell lung cancer, 1 pseudotumor, 1 desmoid tumor of the first rib. In 2 cases the resection was extended respectively to the vertebral body (D1-2-3 hemivertebrectomy) and to the subclavian vessels. This patient died on 10-postoperative day for massive pulmonary ernbolism, whereas no other complications were recorded. This technique compared to the approach popularized by Dartavelle presents the same oncological radicality, with a better surgical exposure and with the complete sparing of osteomuscular components that allow the maintainance of shoulder girdle movements associated excellent functional and cosmetic results.

New applications of the video-assisted technique for the management of intrathoracic diseases continue to be developed, including major lung resections for cancer. The differences in the techniques proposed from various centers reflect the fact that the procedure is not accurately standardized yet and that prospective randomized trials with long-term follow-up data are needed. The authors report the results of their preliminary experience with a mini-invasive modern approach for video-assisted anatomic lobectomy: an utility muscle-sparing minithoracotomy through the auscultatory triangle. Eight patients successfully undergone this surgical procedure (7 for non-small cell lung cancer in early stage, 1 for benign disease). No mortality, nor complications (including minor morbidity: i.e. rib fractures) were recorded. Medium hospital stay time was 9.25 days (range 7-16) and chest drainage time 6 days (range 4-11). This operation proved to be technically feasible, although an accurate selection of patients and an adequate training in thoracoscopic procedures are mandatory. According to the more recent literature no significant differences are noted in operation's time, postoperative pain, chest drainage time, hospital stay compared to the standard posterolateral thoracotomy incisions. Otherwise the approach described enables to perform a truly "conservative" operation in conformity with the philosophy of the minimal invasive surgery and the patient's comfort and functional recover 2-3 weeks after surgery seems to be improved.

The reconstruction of the trachea after wide resections remains a critical surgical problem. Our aim has been to replace trachea with a tissue easy to be vascularized, that permits a simple reconstruction, not requiring an immunosuppressive regimen. We have used a segment of cryopreserved aorta. In the first phase the thoracic aorta of 10 rabbits was excised obtaining 20 segments that were cryopreserved. Ten segments were implanted in the omentum of 10 rabbits that were sacrificed on postoperative day 7, 14 and 21. The histologic examination of the grafts showed the presence of neovascularization after 7 days with obliteration of the lumen by fibroblasts after 14 days. In the next phase the cryopreserved aorta replace an excised segment of trachea. The survived animals were sacrificed 7 and 14 days after the operation. The histologic examination showed the neovascularization of the graft and the absence of rejection.

The preoperative diagnosis of the involvement of the N2 lymph nodes is very important in patients with NSCLC for the most appropriate treatment. The classical diagnostic techniques for mediastinal exploration, mediastinoscopy and left anterior mediastinotomy, have been recently integrated by videothoracoscopy. FromJanuary 1993 to April 1994 186 patients with NSCLC suitable for surgery, were observed in our Department. 18 patients (9%) had CT evidence of N2 disease. In 10 cases the sites of the nodal enlargement were the right paratracheal station (#2 according to Naruke) and the right tracheobronchial station (#4), in 4 the subcarinal station (#7), in 2 the subaortic (#5) and in the remaining 2 cases the paraaortic station (#6). 14 mediastinoscopies were performed to investigate the stations 2,4 and 7,2 videothoracoscopies for station 5 and 2 left anterior mediastinotomies for station 6. The histological diagnosis was obtained in all cases without intraoperative or postoperative complications. Because the sequence chemotherapy-surgery seems to obtain the best results in the treatment of N2 disease the preoperative diagnosis of nodal involvement is of outstanding importance. Until recently mediastinoscopy and anterior left mediastinotomy were considered the standard techniques to explore mediastinum, now also videothoracoscopy has been introduced. In our experience, the integration of all the above techniques allowed a complete study of each suspect N2 site. Particularly the videothoracoscopy is very useful to safely biopsy under direct vision the aortic window lymph nodes.

The lack of an ideal heart-lung preservation solution is one of the principal factor that limits the wide spread of transplantation. The aim of this work was to investigate the efficacy of Haemaccel (HM) on isolated human pulmonary artery endothelial cells comparing its effects with those of University of Wisconsin (UWS). Subcultures of HPAEC were inoculated at the density of 5,000 cells per cm2 in 9 cm2 well-plates. Cells were incubated with HM and UWS for 6 hrs at 10 degrees C. Cellular viability was analysed by the total protein content (cytotoxicity index) and by the rate of protein synthesis (metabolic index). The results showed that HM and UWS did no show a significant differences in the toxicity when compared with the control; on the contrary, HM seems to determine a less inhibitory effect on cellular metabolism permitting a more rapid cellular metabolic recovery than UWS. Thus, HM appears to be more suitable for the preservation of isolated HPAEC than UWS.

Primary pulmonary lymphomas are uncommon tumours arising from mucosa associated lymphoid tissue (MALT). The authors report a case diagnosed by transbronchial biopsy and treated by surgery only. They discuss the distinct clinicalpathological features and debate the different ways of treating this condition.