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Backgrounds Victoria (Australia) and Denmark have comparable population sizes and high-quality healthcare systems. Lung cancer surgery, however, is performed in more than 20 Victorian hospitals compared to four in Denmark. Such differences in centralization may influence outcomes. We engaged clinical quality registries to enable international benchmarking by exploring patterns of lung cancer surgery including mortality and survival. Methods All patients undergoing lung cancer surgery between 2015 and 2018 registered in the Victorian Lung Cancer Registry and the Danish Lung Cancer Registry were included. Analyses on stage concordance, 30 and 90-day mortality, and overall survival were restricted to a selected subgroup with NSCLC and no neo-adjuvant therapy or metastatic disease and only one operation. Results We included 1554 Victorian and 4319 Danish patients. The resection rate was 26.3% in Victoria and 28% in Denmark, but a higher proportion of Victorian patients underwent wedge resection (19.1% versus 8.8%). Stage concordance was 59.6% and 54.9% in Victoria and Denmark, respectively. The 30- and 90-day mortality was 1.3% and 2.6% in Victoria, compared to 1.4% and 2.8% in Denmark with no difference in overall survival (p = 0.28) or risk-adjusted survival (HR: 1.10 (95% CI: 0.89-1.37); p = 0.38). Conclusion High-quality surgical lung cancer care was confirmed by similar high resection and low mortality rates including no overall survival difference. The drivers and consequences of stage discordance and differences in patterns of resection deserve further exploration. This study provides a model for international benchmarking using clinical quality registries, although caution remains in the interpretation given disparities in data completeness.

BACKGROUND: Many extrapulmonary neoplasms metastasize to the lungs. We conducted a retrospective review of all patients who underwent pulmonary metastasectomy for oligometastatic disease at two centres in order to determine long-term outcomes. METHODS: The study institutions' thoracic surgery databases were searched for all patients who underwent pulmonary metastasectomy from 2000 to 2017. RESULTS: There were a total of 476 patients who underwent pulmonary metastasectomy. Mean age at time of surgery was 57.2 ± 15.9 years. Mean number of pulmonary lesions was 1.9 ± 1.6. Mean disease-free interval (DFI) was 3.6 ± 4.3 years. The most common primary neoplasms were colorectal cancer (CRC) in 35.1% (167/476), sarcoma in 23.9% (114/476), melanoma in 16.2% (77/478), renal cell carcinoma (RCC) in 7.3% (35/476) and germ cell tumour (GCT) in 4.4% (21/476). Hospital mortality was 0.4% (2/476). Mean follow-up time was 3.8 ± 2.9 years. Survival was 88.9% (95% confidence interval 85.77-91.5) at 1 year and 49.6% (95% confidence interval 44.4-54.6) at 5 years. On multivariate Cox-regression analysis GCT (P = 0.004), CRC (P = 0.03), DFI of 36+ months (P = 0.007), R0 resection (P = 0.002) and non-anatomical, sub-lobar (wedge) resection (P = 0.002) were protective against mortality. CONCLUSION: Pulmonary metastasectomy is associated with survival of 50% at 5-year follow-up. DFI of over 36 months, R0 resections, lesions resectable by wedge resection rather than anatomic resection and GCT and CRC primary cancers were associated with improved survival.

BACKGROUND Pulmonary metastases are a sign of advanced malignant disease. Interdisciplinary management of metastatic cancer mandates the consideration of all treatment options, and in selected patients pulmonary metastasectomy can be performed with curative intent. This study aims to analyze the prognostic factors associated with survival and optimize the selection of surgical candidates. The sarcoma subset analysis aims to examine the role of multiple repeat resections for pulmonary metastatic recurrence. METHODS A total of 243 patients were analyzed in this retrospective cohort study. Overall survival was estimated using Kaplan-Meier analysis. Univariate analyses with log-rank tests and multivariate analysis with Cox proportional hazards model were undertaken to determine the independent prognostic factors for survival. RESULTS Multivariate analyses identified germ cell cancer (P = 0.01) and a disease-free interval of >36 months (P = 0.006) as significant independent prognostic factors for improved survival, whilst synchronous metastases (P = 0.04), multiple metastases (P = 0.005) and incomplete resection (P

BackgroundLung cancer has markedly poorer survival in men. Recognized important prognostic factors are divided into host, tumour and environmental factors. Traditional staging systems that use only tumour factors to predict prognosis are of limited accuracy. By examining sex-based patterns of disease-specific survival in non-small cell lung cancer patients, we determined the effect of sex on the prognostic value of additional host factors.

Background: Mediastinal endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a recognized diagnostic and staging procedure for non-small cell lung carcinoma (NSCLC). The aim of this study was to report the experience of mediastinal EUS in an Australian tertiary hospital. Methods: A retrospective review was conducted on all patients undergoing mediastinal EUS from February 2002 until August 2007 at St Vincent's Hospital, Melbourne. Data were obtained from the EUS databases at St Vincent's Hospital and patient endoscopy reports. The results of EUS-FNA were compared with final diagnosis to calculate sensitivity and specificity. Surgical pathology or long-term follow-up was used to identify false positive or negative results. Results: One hundred forty-eight mediastinal EUS procedure were performed. Males comprised 63.5% and the mean age was 64.3 (range 27–85). Referrals (47%) were from respiratory physicians and 27% were from cardiothoracic surgeons. Indications for EUS-FNA included unexplained mediastinal lymphadenopathy and/or lung lesion for investigation and staging of known NSCLC. Full data were available on 124 (83.8%) cases. Data were analysed from a subset of 112 where FNA was performed. For each indication, EUS-FNA had a high sensitivity and specificity: staging of known NSCLC (sensitivity 92.9%, specificity 88.9%), mediastinal lymphadenopathy (sensitivity 100%, specificity 100%) and lung lesion (sensitivity 94.4%, specificity 85.7%). There were no major complications. Conclusion: This large series of mediastinal EUS shows that it is an important and useful tool for the assessment of mediastinal pathology. It is safe and highly accurate, and should be incorporated into the staging algorithm for NSCLC.

Lung cancer has markedly poorer survival in men. Recognized important prognostic factors are divided into host, tumour and environmental factors. Traditional staging systems that use only tumour factors to predict prognosis are of limited accuracy. By examining sex-based patterns of disease-specific survival in non-small cell lung cancer patients, we determined the effect of sex on the prognostic value of additional host factors.Two cohorts of patients treated surgically with curative intent between 2000 and 2009 were utilized. The primary cohort was from Melbourne, Australia, with an independent validation set from the American Surveillance, Epidemiology and End Results (SEER) database. Univariate and multivariate analyses of validated host-related prognostic factors were performed in both cohorts to investigate the differences in survival between men and women.The Melbourne cohort had 605 patients (61% men) and SEER cohort comprised 55 681 patients (51% men). Disease-specific 5-year survival showed men had statistically significant poorer survival in both cohorts (P 0.001); Melbourne men at 53.2% compared with women at 68.3%, and SEER 53.3% men and 62.0% women were alive at 5 years. Being male was independently prognostic for disease-specific mortality in the Melbourne cohort after adjustment for ethnicity, smoking history, performance status, age, pathological stage and histology (hazard ratio = 1.54, 95% confidence interval: 1.10-2.16, P = 0.012).Sex differences in non-small cell lung cancer are important irrespective of age, ethnicity, smoking, performance status and tumour, node and metastasis stage. Epidemiological findings such as these should be translated into research and clinical paradigms to determine the factors that influence the survival disadvantage experienced by men.

Background: Hand-assisted laparoscopic surgery (HALS) is an emerging technique that is gaining acceptance for a wide range of abdominal procedures. We drew upon our growing experience with hand-assisted laparoscopic and thoracoscopic surgery to manage a case that was felt to require a major thoracoabdominal incision if it were to be completed by conventional open surgery. Methods: A technique is described that combines the advantages of both laparoscopic and open surgery in the form of hand-assisted laparoscopic surgery to permit safe dissection of a retrocrural mass extending into the chest. Results: We used this technique successfully to completely resect a nodal deposit of metastatic embryonal carcinoma previously thought to be inaccessible to surgical resection. Conclusion: The use of hand-assisted laparoscopic surgery improves tactile and visual feedback for the operator. This allows complex procedures involving delicate dissection to be completed safely and with less morbidity than open surgery.

Background: Non-small-cell lung cancer is a leading cause of cancer morbidity and mortality in Australia. Brain metastases are common, and rapidly fatal if untreated. Optimal management consists of resection and whole brain irradiation. However, there is a paucity of local data documenting survival after such treatment. Methods: Medical records for all patients who underwent complete resection of non-small-cell lung cancer at one institution between January 1999 and December 2003 were reviewed in order to determine survival after initial surgery. The survival of all patients was compared with patients who underwent resection of synchronous or metachronous brain metastases and whole brain irradiation as part of their lung cancer management. Results: Between 1 January 1999 and 31 December 2003, 170 patients underwent complete resection of non-small-cell lung cancer by a thoracic surgeon. Resection of synchronous or metachronous brain metastases followed by whole brain irradiation was also carried out on 15 of these patients. Complete cerebral resection was achieved in 12 cases. The overall 5-year survival after attempted curative resection of brain metastases and successful complete resection was 60% and 70%, respectively. The survival of patients with both cerebral metastasectomy and lung cancer resection approximated that of the cohort of patients that only required complete resection of their lung cancer. Conclusions: Control of local disease at each site and long-term survival after lung resection and resection of either synchronous or metachronous brain metastasis and whole brain irradiation is readily achievable. We believe this should continue as the standard of care for this presentation.

Introduction Post-operative survival after surgery for early stage non-small cell lung cancer (NSCLC) is influenced by factors such as stage of disease and co-morbidities. We sought to assess the performance of 2 models in predicting 1 year survival after resected NSCLC. Methods The Colinet Simplified Co-Morbidity Score (SCS) (1) and a prognostic model by Birim (2) were retrospectively applied to a cohort of patients with surgically resected NSCLC. End-point was 1 year survival obtained from clinical follow-up and data-linkage with the Cancer Council of Victoria. Results 216 patients were treated from Feb 1999 to Dec 2005. 52 patients were excluded due to missing data, leaving 164 patients for analysis. Mean patient age was 66.4 ± 10.3. Pathological stage was 1 in 61%, 2 in19% and 3 in 17%. Observed 1 year survival was 78.7%. SCS was predictive of 1 year survival: mean SCS 9.24 for survivors and 11.03 for non-survivors (p = 0.001 by t-test). Patient’s with low SCS (0-9) had a higher 1-year survival than those with high SCS (>9); 87.2% vs 69.2% (p = 0.005 by chi-square test). SCS discriminated fairly for 1 year survival (area under ROC curve 0.66). The predicted survival using the Birim model (74.2%) was similar to the observed survival (p = 0.43). The model predicted survival well in both low (predicted 83% vs observed 88%, p = 0.51) and high (66 vs 70%, p = 0.74) risk groups. Birim model discriminated well for 1 year survival (area under ROC curve 0.70). Conclusion SCS and the Birim model can both be used to estimate 1-year survival. They may aid the clinician in deciding who should be considered for surgical resection.

Background: Radical lobectomy for early-stage Non-Small Cell Lung Cancer (NSCLC) by way of Video-assisted Thoracic Surgery (VATS) is a safe procedure with reduced post-operative morbidity. It has yet to gain world wide acceptance due to a perceived oncological inadequacy. Mediastinal Lymph Node Dissection (MLND) has a confirmed 4-year survival advantage over lymph node (LN) sampling (HR 0.78; 95% CI: 0.63–0.93). We aim to compare the quality of MLND samples from VATS and Open lobectomies. Methods: VATS lobectomies were compared with open lobectomy controls from 2000 to 2008. Retrospective pathology reviews were performed on all MLND samples. LN was counted according to each IASLC nodal zones. The number of LN per zone and in total was compared. Anatomical location of the lobectomy and the 7th ed. cTNM stage was recorded. Results: We included 132 VATS and 157 Ospen lobectomies (132:157). Stage distribution for VATS and Open were: Stage IA (64:55), State IB (64:68), Stage IIA (3:17), Stage IIB (1:14), Stage IIIA (0:3). Mean tumour diameter was 26 mm and 37 mm for VATS and Open respectively. Anatomical location of lobectomies for VATS and Open were: Right (91:100), Left (49:64). The mean number of LN dissected by VATS was higher in the upper mediastinal (Mean 7.2 vs. 4.0; p < 0.05), aorto-pulmonary (Mean 3.0 vs. 2.6), subcarinal (3.0 vs. 2.4), and hilar/interlobar zones (2.0 vs. 1.8). In total, VATS averaged 23 LN per case compared with 18 for Open (p < 0.05). Open lobe MLND performed better for the lower mediastinal zone. Conclusion: The quality of VATS MLND is often better than that of a thoracotomy, and therefore an adequate oncological procedure for early-stage NSCLC with reduced post-operative morbidity.