Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery.

Stage III nonsmall cell lung cancer (NSCLC) comprises about one-third of NSCLC patients and is very heterogeneous with varying and mostly poor prognosis. It is also called "locoregionally or locally advanced disease". Due to its heterogeneity a general schematic management approach is not appropriate. Usually a combination of local therapy (surgery or radiotherapy, depending on functional, technical and oncological operability) with systemic platinum-based doublet chemotherapy and, recently, followed by immune therapy is used. A more aggressive approach of triple agent chemotherapy or two local therapies (surgery and radiotherapy, except for specific indications) has no benefit for overall survival. Until now tumour stage and the general condition of the patient are the most relevant prognostic factors. Characterising the tumour molecularly and immunologically may lead to a more personalised and effective approach. At the moment, after an exact staging and functional evaluation, an interdisciplinary discussion amongst the tumour board is warranted and offers the best management strategy.

https://err.ersjournals.com/content/errev/28/152/190024.full.pdf

Interdisciplinary multimodality management of stage III nonsmall cell lung cancer.

Localized malignant mesothelioma, an unusual and poorly characterized neoplasm of serosal origin: best current evidence from the literature and the International Mesothelioma Panel

In case of suspicious lymph nodes on computed tomography (CT) or fluorodeoxyglucose positron emission tomography (FDG-PET), advanced tumour size or central tumour location in patients with suspected non-small cell lung cancer (NSCLC), Dutch and European guidelines recommend mediastinal staging by endosonography (endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS)) with sampling of mediastinal lymph nodes. If biopsy results from endosonography turn out negative, additional surgical staging of the mediastinum by mediastinoscopy is advised to prevent unnecessary lung resection due to false negative endosonography findings. We hypothesize that omitting mediastinoscopy after negative endosonography in mediastinal staging of NSCLC does not result in an unacceptable percentage of unforeseen N2 disease at surgical resection. In addition, omitting mediastinoscopy comprises no extra waiting time until definite surgery, omits one extra general anaesthesia and hospital admission, and may be associated with lower morbidity and comparable survival. Therefore, this strategy may reduce health care costs and increase quality of life. The aim of this study is to compare the cost-effectiveness and cost-utility of mediastinal staging strategies including and excluding mediastinoscopy. This study is a multicenter parallel randomized non-inferiority trial comparing two diagnostic strategies (with or without mediastinoscopy) for mediastinal staging in 360 patients with suspected resectable NSCLC. Patients are eligible for inclusion when they underwent systematic endosonography to evaluate mediastinal lymph nodes including tissue sampling with negative endosonography results. Patients will not be eligible for inclusion when PET/CT demonstrates ‘bulky N2-N3’ disease or the combination of a highly suspicious as well as irresectable mediastinal lymph node. Primary outcome measure for non-inferiority is the proportion of patients with unforeseen N2 disease at surgery. Secondary outcome measures are hospitalization, morbidity, overall 2-year survival, quality of life, cost-effectiveness and cost-utility. Patients will be followed up 2 years after start of treatment. Results of the MEDIASTrial will have immediate impact on national and international guidelines, which are accessible to public, possibly reducing mediastinoscopy as a commonly performed invasive procedure for NSCLC staging and diminishing variation in clinical practice. The trial is registered at the Netherlands Trial Register on July 6th, 2017 (
 NTR 6528
 ).

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MEDIASTinal staging of non-small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial): study protocol of a multicenter randomised controlled trial

Malignant pleural mesothelioma is an aggressive, incurable cancer that is usually caused by asbestos exposure several decades before symptoms arise. Despite widespread prohibition of asbestos production and supply, its incidence continues to increase. It is heterogeneous in its presentation and behaviour, and diagnosis can be notoriously difficult. Identification of actionable gene mutations has proven challenging and current treatment options are largely ineffective, with a median survival of 10–12 months. However, the past few years have witnessed major advances in our understanding of the biology and pathogenesis of mesothelioma. This has also revealed the limitations of existing diagnostic algorithms and identified new treatment targets. Recent clinical trials have re-examined the role of surgery, provided new options for the management of associated pleural effusions and heralded the addition of targeted therapies. The increasing complexity of mesothelioma management, along with a desperate need for further research, means that a multidisciplinary team framework is essential for the delivery of contemporary mesothelioma care. This review provides a synthesised overview of the current state of knowledge and an update on the latest research in the field.

https://err.ersjournals.com/content/errev/30/159/200226.full.pdf

Update on biology and management of mesothelioma.

In 2016, the International Association for the Study of Lung Cancer (IASLC) published a number of revisions of the seventh edition of the tumor, node and metastasis (TNM) classification for malignant pleural mesothelioma (MPM). The purpose was to establish a set of recommendations for the eighth edition of the TNM staging system. A large number of patients were included in the IASLC database and subsequently analysed to determine new definitions for the components of the TNM classification. A number of important changes were introduced for the T component. Survival analysis of the different T categories showed no significant difference in categories T1a and T1b. This has resulted in a collapse of categories T1a and T1b into one category T1. In addition, tumor thickness was also significantly associated with overall survival. The descriptors for the N components have been redefined as well for the eighth TNM classification. A major revision is the removal of category N3 in the N component. Both intrapleural and extrapleural (N1 and N2 in the seventh edition) are now combined into a single category N1. Lymph nodes that were previously categorized as N3 are now considered N2. For the M component, no redefinition has been published. However, a recommendation has been made to only consider M1 involvement as stage IV disease. This is in contrast to the seventh edition in which T4 and N3 disease were considered stage IV as well. In conclusion, a number of important revisions for the eighth TNM classification of MPM have been published as a result of this IASLC project. This type of large-scale and international joint efforts are key in establishing effective staging systems. Research into using tumor thickness as a prognostic instrument will be an important part of any future editions of the TNM classification.

/pdf/the-eighth-tnm-classification-for-malignant-pleural-8nl89ze45m.pdf

The eighth TNM classification for malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare disease of the pleura and is largely related to asbestos exposure. Despite recent advancements in technologies and a greater understanding of the disease, the prognosis of MPM remains poor; the median overall survival rate is about 6 to 9 months in untreated patients. The main therapeutic strategies for MPM are surgery, chemotherapy, and radiation therapy (RT). The two main surgical approaches for MPM are extrapleural pneumonectomy (EPP), in which the lung is removed en bloc, and pleurectomy/decortication, in which the lung stays in situ. Chemotherapy usually consists of a platinum-based chemotherapy, such as cisplatin, often combined with a folate antimetabolite, such as pemetrexed. More recently, immunotherapy has emerged as a possible therapeutic strategy for MPM. Evidence suggests that single-modality treatments are not an effective therapeutic approach for MPM. Therefore, researchers have started to explore different multimodality treatment approaches, in which often combinations of surgery, chemotherapy, immunotherapy, and RT are investigated. There is still no definitive answer to the question of which multimodality treatment combinations are most effective in improving the poor prognosis of MPM. Research into the effects of trimodality treatment approaches have found that radical approaches such as EPP and hemithoracic RT post-EPP are less effective than was previously assumed. In general, there are still a great number of unanswered questions and unknown factors regarding the ideal treatment approach for MPM. Hopefully, more research into multimodality therapy will provide insight into which combination of treatment modalities is most effective.

/pdf/multimodality-treatment-of-malignant-pleural-mesothelioma-ngb8li925t.pdf

Multimodality treatment of malignant pleural mesothelioma.

According to the eighth edition of the tumor-node-metastasis classification, stage III non-small cell lung cancer is subdivided into stages IIIA, IIIB, and IIIC. They represent a heterogeneous group of bronchogenic carcinomas with locoregional involvement by extension of the primary tumor and/or ipsilateral or contralateral lymph node involvement. Surgical indications have not been definitely established but, in general, long-term survival is only obtained in those patients in whom a complete resection is obtained. This mini-review mainly focusses on stage IIIA disease comprising patients with locoregionally advanced lung cancers. Different subcategories of N2 involvement exist, which range from unexpected N2 disease after thorough preoperative staging or "surprise" N2, to bulky N2 involvement, mostly treated by chemoradiation, and finally, the intermediate category of potentially resectable N2 disease treated with a combined modality regimen. After induction therapy for preoperative N2 involvement, best surgical results are obtained with proven mediastinal downstaging when a lobectomy is feasible to obtain a microscopic complete resection. However, no definite, universally accepted guidelines exist. A relatively new entity is salvage surgery applied for recurrent disease after full-dose chemoradiation when no other therapeutic options exist. Equally, only a small subset of patients with T4N0-1 disease qualify for surgical resection after thorough discussion within a multidisciplinary tumor board on the condition that a complete resection is feasible. Targeted therapies and immunotherapy have recently become part of our therapeutic armamentarium, and it might be expected that they will be incorporated in current regimens after careful evaluation in randomized clinical trials.

/pdf/surgical-management-of-stage-iiia-non-small-cell-lung-cancer-4gj4xu0qgn.pdf

Surgical Management of Stage IIIA Non-Small Cell Lung Cancer.

Breast reconstruction with an autologous free Deep Inferior Epigastric Perforator (DIEP) flap is one of the preferred options following mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. The current golden standard for perforator mapping is computed tomography angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, dynamic infrared thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion. Multiple studies have been performed with the use of DIRT, unfortunately without standardisation of the measurement set-up. In this technical note we propose a standardised and reproducible measurement set-up for the use of DIRT during breast reconstructions with a free DIEP flap. This set-up can be used pre-, intra- and postoperatively. A standardised measurement set-up will improve the quality of measured data and ensure reproducibility.

/pdf/dynamic-infrared-thermography-dirt-in-deep-inferior-2erveqbqkv.pdf

Dynamic infrared thermography (DIRT) in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: standardization of the measurement set-up.

Lawek Berzenji

Papers

The eighth TNM classification for malignant pleural mesothelioma

Multimodality treatment of malignant pleural mesothelioma.

Surgical Management of Stage IIIA Non-Small Cell Lung Cancer.

Dynamic infrared thermography (DIRT) in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: standardization of the measurement set-up.

Dynamic Infrared Thermography (DIRT) in DIEP flap breast reconstruction: A clinical study with a standardized measurement setup