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BACKGROUND: Correctly staging lung cancer is important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies including chest CT scanning and positron emission tomography (PET) scanning are available. Understanding the test characteristics of these noninvasive staging studies is critical to decision making. METHODS: Test characteristics for the noninvasive staging studies were updated from the first iteration of the lung cancer guidelines using systematic searches of the MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, including selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables. RESULTS: The pooled sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were 51% (95% confidence interval [CI], 47 to 54%) and 85% (95% CI, 84 to 88%), respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, the pooled estimates of sensitivity and specificity for identifying mediastinal metastasis were 74% (95% CI, 69 to 79%) and 85% (95% CI, 82 to 88%), respectively. These findings demonstrate that PET scanning is more accurate than CT scanning. If the clinical evaluation in search of metastatic disease is negative, the likelihood of finding metastasis is low. CONCLUSIONS: CT scanning of the chest is useful in providing anatomic detail, but the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is poor. PET scanning has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum, and distant metastatic disease can be detected by PET scanning. With either test, abnormal findings must be confirmed by tissue biopsy to ensure accurate staging. [ABSTRACT FROM AUTHOR]

Lung cancer is usually suspected in individuals who have abnormal chest radiograph findings or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer or non-small cell lung cancer), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. Achieving a diagnosis and staging are usually done in concert because the most efficient way to make a diagnosis often is dictated by the stage of the cancer. The best sequence of studies and interventions in a particular patient involves careful judgment of the probable reliability of a number of presumptive diagnostic issues, so as to maximize the sensitivity and to avoid performing multiple or unnecessary invasive procedures. In this article, we consider all manner of clinical presentations of lung cancer in light of currently available diagnostic procedures. Published data supporting a particular diagnostic approach is weighed based on the quality of the benefit as well as the estimated net benefit. Recommendations are graded in terms of strength to provide clinicians with guidance as to the most efficient and approach to the diagnosis of lung cancer in individual patients. [ABSTRACT FROM AUTHOR]

Study Objectives: To determine the test performance characteristics of CT scanning, positron emission tomography (PET) scanning, MRI, and endoscopic ultrasound (EUS) for staging the mediastinum, and to evaluate the accuracy of the clinical evaluation (ie, symptoms, physical findings, or routine blood test results) for predicting metastatic disease in patients in whom non-small cell lung cancer or small cell lung cancer is diagnosed.Design, Setting, and Participants: Systematic searches of MEDLINE, HealthStar, and Cochrane Library databases to July 2001, and of print bibliographies. Studies evaluating the staging results of CT scanning, PET scanning, MRI, or EUS, with either tissue histologic confirmation or long-term clinical follow-up, were included. The performance of the clinical evaluation was compared against the results of brain and abdominal CT scans and radionuclide bone scans.Measurement and Results: Pooled sensitivities and specificities for staging the mediastinum were as follows: for CT scanning: sensitivity, 0.57 (95% confidence interval [CI], 0.49 to 0.66); specificity, 0.82 (95% CI, 0.77 to 0.86); for PET scanning: sensitivity, 0.84 (95% CI, 0.78 to 0.89); specificity, 0.89 (95% CI, 0.83 to 0.93); and for EUS: sensitivity, 0.78 (95% CI, 0.61 to 0.89); specificity, 0.71 (95% CI, 0.56 to 0.82). For the evaluation of brain metastases, the summary estimate of the negative predictive value (NPV) of the clinical neurologic evaluation was 0.94 (95% CI, 0.91 to 0.96). For detecting adrenal and/or liver metastases, the summary NPV of the clinical evaluation was 0.95 (95% CI, 0.93 to 0.96), and for detecting bone metastases, it was 0.90 (95% CI, 0.86 to 0.93).Conclusions: PET scanning is more accurate than CT scanning or EUS for detecting mediastinal metastases. The NPVs of the clinical evaluations for brain, abdominal, and bone metastases are > or = 90%, suggesting that routinely imaging asymptomatic lung cancer patients may not be necessary. However, more definitive prospective studies that better define the patient population and improved reference standards are necessary to more accurately assess the true NPV of the clinical evaluation. [ABSTRACT FROM AUTHOR]

Correctly staging lung cancer is extremely important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies are available to aid in identifying disease both within and outside of the chest. Chest CT scanning is useful in providing anatomic detail that better identifies the location of the tumor, its proximity to local structures, and whether or not lymph nodes in the mediastinum are enlarged. Unfortunately, the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is unacceptably low. Whole-body positron emission tomography (PET) scanning provides functional information on tissue activity and has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum. In addition, metastatic disease can be detected by PET scan. Still, positive findings of PET scans can occur from nonmalignant etiologies (eg, infections), so that tissue sampling to confirm the suspected malignancy must be performed. The clinical evaluation tool, which is composed of a thorough history and physical examination, remains the best predictor of metastatic disease. If the findings from the clinical evaluation are negative, then imaging studies such as a CT scan of the head, a bone scan, or an abdominal CT scan are unnecessary, and the search for metastatic disease is complete. If signs, symptoms, or findings from the physical examination suggest the presence of malignancy, then sequential imaging, starting with the most appropriate study based on the clues obtained by the clinical evaluation, should be performed. Abnormalities detected by all of the aforementioned imaging studies are not always cancer. Unless overwhelming evidence of metastatic disease is present on an imaging study, in situations in which it will make a difference in treatment, all abnormal scan findings require tissue confirmation of malignancy so that patients are not precluded from having potentially curative surgery. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary high-grade neuroendocrine carcinoma (NEC) includes SCLC and large cell NEC (LCNEC). The seventh and eighth editions of the TNM classification for lung cancer confirmed the applicability of this staging system for SCLC. With the proposal of N2 and M1c subcategories for the ninth edition classification, we assessed the applicability to NECs., Methods: The database included NEC cases diagnosed between January 2011 and December 2019. Eligible cases, with valid survival time and eighth edition TNM stage, were classified as pure SCLC, combined SCLC with NSCLC, and LCNEC. Survival was calculated using the Kaplan-Meier method, pairwise differences using a log-rank test, and prognostic groups using a Cox regression analysis., Results: There were 6181 pure and combined SCLC and 697 LCNEC cases available. For SCLC, survival outcome analyses included 4453 cases with clinical stage and 583 with pathologic stage data. The corresponding numbers for LCNEC were 585 and 508. The SCLC data validated the ninth edition classification for lung cancer, including the proposed new subcategories, N2a, single-station ipsilateral mediastinal or subcarinal lymph node involvement, and N2b, involvement of multiple ipsilateral or subcarinal stations. The data also validated the subcategorization of M1c into M1c1 (multiple lesions in a single extrathoracic organ system) and M1c2 (involvement of multiple extrathoracic organ systems). The LCNEC data were insufficient for complete survival analysis, but the available data reported decreasing survival with increasing clinical and pathologic stages., Conclusions: The ninth edition TNM classification applies to patients with NEC and is the appropriate standard for use in clinical practice., Competing Interests: Disclosure Dr. Tsao discloses research grants from AstraZeneca and Sanofi and serves on the Board of Directors for IASLC (International Association for the Study of Lung Cancer). Dr. Nicholson has received consultancy fees from Merck, Boehringer Ingelheim, Novartis, AstraZeneca, Bristol Myer Squib, Roche, AbbVie, Oncologica, Takeda UK, and Sanofi; grant and consultancy fees from Pfizer, and payment for educational materials from UpToDate, European Society for Oncology, and Liberum. Dr. Eberhardt has received research grants from AstraZeneca, consultancy fees from AstraZeneca, Daiichi Sankyo, Merck Sharp & Dohme, Roche, Amgen, Novartis, Pfizer, Sanofi-Aventis, Regeneron, Eli Lilly, Bohringer Ingelheim, and Pierre Fabre, and payment for educational lectures from AstraZeneca, Daiichi Sankyo, Merck Sharp & Dohme, Roche, Amgen, Novartis, Boehringer Ingelheim, Eli Lilly, Regeneron, Pfizer, Sanofi-Aventis, and onkowissen.de. Dr. Lievens serves as an unpaid member of the ESTRO Scientific Committee and the Belgian College of Oncology. Dr. Lim has received research grants from AstraZeneca, Boehringer Ingelheim, Medela, Johnson and Johnson/Ethicon, Covidien/Medtronic, Guardant Health, Takea, Eli Lilly Oncology, and Bayer. He discloses consultancy fees from BeiGene, Roche, and Bristol-Myers Squibb, and lecture honoraria payment from Medela. He discloses two patents for imperial innovations. He is a founder of My Cancer Companion, Healthcare Companion Ltd., and discloses three NIHR HTA financial interests. Dr. Yatabe discloses contracted research for Merk Biopharma, Chugai-pharma, Konica-Minolta REALM, and Optieum Biotechnologies, has received consultancy fees from AstraZeneca, Merck Sharp & Dohme, AbbVie, Novartis, Amgen, Daiichi-Sankyo, Janssen Pharma, Konica-Minolta REALM, and has received honoraria for lectures from Merck Sharp & Dohme, Chugai-pharma, AstraZeneca, Merck Biopharma, Novartis, Amgen, Daiichi-Sankyo, Thermo Fisher Science. Dr. Nishimura discloses research contract funding, consultancy fees, honoraria, and travel support from the IASLC. Dr. Travis reports an NCI research grant. Dr. Osarogiagbon discloses a research grant, consultancy fees from GE Healthcare and Median Technologies, honoraria from AstraZeneca, one patent, and stock in Eli Lilly, Immunocore, Pfizer, and BridgeBio. He serves on the Board of Scientific Advisors for NCI, the Chair of the ASCO Research Committee, and the Steering Committee for the National Lung Cancer Roundtable. Dr. Rusch discloses travel funding support from IASLC, MSKCC, and the American College of Surgeons. She serves as a part-time consultant at the American College of Surgeons Health Outreach Program for Equity in Global Surgery (ACS H.O.P.E.). Dr. Asamura reports lecture payments from Johnson and Johnson. The remaining authors declare no conflict of interest., (Copyright © 2025 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Lung cancer remains the leading cause of cancer-related deaths worldwide, mainly due to late diagnosis and the presence of metastases. Several countries around the world have adopted nation-wide LDCT-based lung cancer screening that will benefit patients, shifting the stage at diagnosis to earlier stages with more therapeutic options. Biomarkers can help to optimize the screening process, as well as refine the TNM stratification of lung cancer patients, providing information regarding prognostics and recommending management strategies. Moreover, novel adjuvant strategies will clearly benefit from previous knowledge of the potential aggressiveness and biological traits of a given early-stage surgically resected tumor. This review focuses on proteins as promising biomarkers in the context of lung cancer screening. Despite great efforts, there are still no successful examples of biomarkers in lung cancer that have reached the clinics to be used in early detection and early management. Thus, the field of biomarkers in early lung cancer remains an evident unmet need. A more specific objective of this review is to present an up-to-date technical assessment of the potential use of protein biomarkers in early lung cancer detection and management. We provide an overview regarding the benefits, challenges, pitfalls and constraints in the development process of protein-based biomarkers. Additionally, we examine how a number of emerging protein analytical technologies may contribute to the optimization of novel robust biomarkers for screening and effective management of lung cancer., (Copyright © 2024 The Authors. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: The TNM classification of lung cancer is periodically revised. The International Association for the Study of Lung Cancer collected and analyzed a new database to inform the forthcoming ninth edition of the TNM classification. The results are herewith presented., Methods: After exclusions, 76,518 patients from a total of 124,581 registered patients were available for analyses: 58,193 with clinical stage, 39,192 with pathologic stage, and 62,611 with best stage NSCLC. The proposed new N2 subcategories (N2a, involvement of single ipsilateral mediastinal or subcarinal nodal station, and N2b, involvement of multiple ipsilateral mediastinal nodal stations with or without involvement of the subcarinal nodal station) and the new M1c subcategories (M1c1, multiple extrathoracic metastases in one organ system, and M1c2, multiple extrathoracic metastases in multiple organ systems) were considered in the survival analyses. Several potential stage groupings were evaluated, using multiple analyses, including recursive partitioning, assessment of homogeneity within and discrimination between potential groups, clinical and statistical significance of survival differences, multivariable regression, and broad assessment of generalizability., Results: T1N1, T1N2a, and T3N2a subgroups are assigned to IIA, IIB, and IIIA stage groups, respectively. T2aN2b and T2bN2b subgroups are assigned to IIIB. M1c1 and M1c2 remain in stage group IVB. Analyses reveal consistent ordering, discrimination of prognosis, and broad generalizability of the proposed ninth edition stage classification of lung cancer., Conclusions: The proposed stages for the ninth edition TNM improve the granularity of nomenclature about anatomic extent that has benefits as treatment approaches become increasingly differentiated and complex., Competing Interests: Disclosure Dr. Nishimura and Ms. Giroux report that statistical consulting by Cancer Research And Biostatistics (CRAB) employees for data collection, analysis, and manuscript preparation in the Staging Project is funded by the International Association for the Study of Lung Cancer (IASLC). Dr. Fong reports payments made to his institution by Competitive Research Grant, MRFF EPCDR Improving Diagnosis in Cancers Low Survival Rates; Competitive Research Grant, NHMRC Ideas grant: Early lung cancer biomarkers; Competitive Research Grant, MRFF Next Generation Clinical Researchers Program - Practitioner Fellowship; Competitive Research Grant, NHMRC Project: Novel biomarkers for lung cancer; Competitive Research Grant, NHMRC Low dose computed tomography (LDCT) to diagnose lung cancer; payments to himself by UpToDate Reviewer and Cochrane Clinical Answers Reviewer; payment for travel support to WCLC, ATS in 2022 and PCCP in 2023; payments for travel support by the 2023 Asia Pacific Coalition Against Lung Cancer; and payments from the Asia Pacific Society of Respirology former President and EXCO member; support with loan bronchoscopes for the purpose of a research study—no financial funding from Olympus; and software licensing for Computer Aided Diagnosis research in the International Lung Screen Trial (ILST) from Mevis Veolity. Dr. Giuliani reports receiving payments for Advisory Board member from AstraZeneca and Bristol Myers Squibb; and being Section Editor, of the International Journal of Radiation Oncology, Biology and Physics. Dr. Marom reports receiving honorarium for lectures from Boehringer Ingelheim, Merck Sharp & Dohme, and AstraZeneca. Dr. Nicholson reports receiving personal fees from Merck, Boehringer Ingelheim, Novartis, AstraZeneca, Bristol-Myers Squibb, Roche, AbbVie, Oncologica, UpToDate, the European Society of Oncology, and Liberum; and grants and personal fees from Pfizer, outside of the submitted work. Dr. Van Schil reports receiving lecture and consulting institutional fees from AstraZeneca and Janssen and lecture and consulting personal fees from Bristol Myers Squibb, Merck Sharp & Dohme, and Roche; and having leadership positions in BACTS (Belgian Association for Cardiothoracic Surgery) as treasurer and IASLC (International Association for the Study of Lung Cancer) as president with no fees. Dr. Travis reports receiving a grant from the National Cancer Institute: MSKCC Core Grant: P30 CA008748. Dr. Rusch reports receiving support for the present manuscript from NIH Cancer Support Grant P30-CA008748; institutional funding for a clinical trail from Genentech; and miscellaneous honoraria for lectures of no commercial interest at various universities; funding for meeting preparation and attendance by NIH Thoracic Malignancy Steering Committee (Co-Chair); and reports being a committee member of MARS II and RAMON trials (Cancer Research UK). Dr. Asamura reports receiving funding for analyses of results and manuscript preparation and support from the IASLC for attending meetings. The remaining authors report no conflict of interest., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Introduction: An international database was created by the International Association for the Study of Lung Cancer to inform on the ninth edition of the TNM classification of lung cancer. The present analyses concern its T component., Methods: Data on 124,581 patients diagnosed with lung cancer from January 1, 2011 to December 31, 2019 were submitted to the International Association for the Study of Lung Cancer database. Of these, 33,982 met the inclusion criteria for the clinical T analysis, and 30,715 met the inclusion criteria for the pathologic postsurgical analysis. Survival was measured from the date of diagnosis or operation for clinically and pathologically staged tumors, respectively. T descriptors were evaluated in univariate analysis and multivariable Cox regression analysis adjusted for age, sex, pathologic type, and geographic region., Results: Comprehensive survival analysis revealed that the existing eighth edition T component criteria performed adequately in the ninth edition data set. Although pathologic chest wall or parietal pleura involvement (PL 3) yielded a worse survival compared with the other T3 descriptors, with a similar survival as T4 tumors, this difference was not observed for clinical chest wall or PL 3 tumors. Because of these inconsistent findings, no reallocation of chest wall or PL 3 tumors is advised., Conclusions: The T subcommittee members proposed not to implement any changes and keep the current eighth-edition T descriptors for the ninth edition., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Introduction: The accurate assessment of nodal (N) status is crucial to the management and prognostication of nonmetastatic NSCLC. We sought to determine whether the current N descriptors should be maintained or revised for the upcoming ninth edition of the international TNM lung cancer staging system., Methods: Data were assembled by the International Association for the Study of Lung Cancer on patients with NSCLC, detailing both clinical and pathologic N status, with information about anatomical location and individual station-level identification. Survival was calculated by the Kaplan-Meier method and prognostic groups were assessed by a Cox regression analysis., Results: Data for clinical N and pathologic N status were available in 45,032 and 35,009 patients, respectively. The current N0 to N3 descriptors for both clinical N and pathologic N categories reflect prognostically distinct groups. Furthermore, single-station N2 involvement (N2a) exhibited a better prognosis than multistation N2 involvement (N2b) in both clinical and pathologic classifications, and the differences between all neighboring nodal subcategories were highly significant. The prognostic differences between N2a and N2b were robust and consistent across resection status, histologic type, T category, and geographic region., Conclusions: The current N descriptors should be maintained, with the addition of new subdescriptors to N2 for single-station involvement (N2a) and multiple-station involvement (N2b)., (Copyright © 2023 International Association for the Study of Lung Cancer. All rights reserved.)

Introduction: This study analyzed all metastatic categories of the current TNM classification of NSCLC to propose modifications of the M component in the next edition (ninth) of the classification., Methods: A database of 124,581 patients diagnosed between 2011 and 2019 was established; of these, 14,937 with NSCLC in stages IVA to IVB were available for this analysis. Overall survival was calculated using the Kaplan-Meier method, and prognosis was assessed using multivariable-adjusted Cox proportional hazards regression., Results: The eighth edition M categories revealed good discrimination in the ninth edition data set. Assessments revealed that an increasing number of metastatic lesions were associated with decreasing prognosis; because this seems to be a continuum and adjustment for confounders was not possible, no specific lesion number was deemed appropriate for stage classification. Among tumors involving multiple metastases, decreasing prognosis was found with an increasing number of organ systems involved. Multiple assessments, including after adjustment for potential confounders, revealed that M1c patients who had metastases to a single extrathoracic organ system were prognostically distinct from M1c patients who had involvement of multiple extrathoracic organ systems., Conclusions: These data validate the eighth edition M1a and M1b categories, which are recommended to be maintained. We propose the M1c category be divided into M1c1 (involvement of a single extrathoracic organ system) and M1c2 (involvement of multiple extrathoracic organ systems)., Competing Interests: Disclosure Dr. Fong reports receiving grants and contracts from MRFF EPCDR, NHMRC Ideas Grant, MRFF Next Generation Clinical Researchers Program, NHMRC; receiving funds from UpToDate as reviewer and Cochrane Clinical Answers as reviewer; and receiving equipment support from Olympus and Mevis Veolity. Mr. Rosenthal reports receiving fees for service from IASLC to complete work associated with publication. Ms. Giroux reports receiving fees for service from IASLC to complete work associated with publication. Dr. Nishimura reports receiving fees for service from IASLC to complete work associated with publication. Dr. Erasmus reports receiving honoraria from Canadian Association of Radiologists. Dr. Lievens reports receiving grants and contracts for the ImmunoSABR EU Project, HERO-VBHC chair; consulting fees from AstraZeneca; and honoraria from Merck Sharp & Dohme. Dr. Marom reports receiving honoraria from Boehringer Ingelheim, Merck, and AstraZeneca. Dr. Putora reports receiving grants or contracts from Bayer, Takeda, and AstraZeneca. Dr. Suárez reports receiving consulting fees from AstraZeneca and Roche; honoraria from AstraZeneca. The remaining authors declare no conflict of interest., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Lobectomy has been the standard treatment for stage I lung cancer in healthy patients, largely based on a randomized trial published in 1995. Nevertheless, research has continued regarding the role of sublobar resection. Three additional randomized trials addressing resection extent in healthy patients have recently been published. These 4 trials involve differences in design, eligibility, interventions, and intraoperative processes. Patients were ineligible if intraoperative assessment demonstrated stage > IA or inadequate resection margins. All trials consistently show no differences in perioperative morbidity, mortality, and postoperative changes in lung function between sublobar resection and lobectomy-consistent with other nonrandomized evidence. Long-term outcomes are generally encouraging of lesser resection, but some inconsistencies are apparent. The 2 larger recent trials demonstrated no overall survival difference while the others suggested better survival after lobectomy versus sublobar resection. Recurrence-free survival was found to be the same after lobectomy versus sublobar resection in 3 trials, despite higher locoregional recurrences after sublobar resection. The low 5-year recurrence-free survival (64%, regardless of resection extent) in 1 recent trial highlights the need for further optimization. Thus, there is high-level evidence that sublobar resection is a reasonable alternative to lobectomy in healthy patients. However, variability in long-term results suggests that aspects of patients, tumors and interventions need to be better understood. Therefore, we propose to apply sublobar resection cautiously; especially because there are no short-term benefits. Sublobar resection requires careful attention to intraoperative details (nodes, margins), and may be best suited for less aggressive (eg, ground glass, slow growing) tumors., Competing Interests: Disclosure GA Woodard discloses research grants from the American Cancer Society, International Lung Cancer Foundation Young Investigator Award, and Yale Lung Cancer SPORE Career Enhancement Program; also AstraZeneca Advisory board consulting fees – all of these activities are unrelated to this work. All other authors (Frank Detterbeck, Sora Ely, Brooks Udelsman, Justin Blasberg, Daniel Boffa, Andrew Dhanasopon, Vincent Mase) have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: R0 resection and radiation therapy have been associated with improved overall survival (OS) in patients with thymic carcinoma (TC). Here, we analyzed which subgroups of patients derive the greatest benefit from postoperative radiation therapy (PORT)., Methods: Clinical, pathologic, treatment, and survival information of 462 patients with TC from the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons database were analyzed. Variables included age, sex, continent of treatment, paraneoplastic syndrome, carcinoma subtype, tumor size, pathologic Masaoka stage, resection status, and use of chemotherapy. OS was the primary end point using the Kaplan-Meier method. Time to recurrence (TTR) was the secondary end point using a competing risk analysis. A 3-month landmark analysis was performed., Results: PORT was associated with a significant OS benefit (5-y OS 68% versus 53%, p = 0.002). In patients with R0 resection, PORT was associated with increased OS for advanced (stages III-IV, p = 0.04), but not early (stages I-II, p = 0.14) stage TC. In patients with an R1/2 resection of advanced-stage TC, PORT was associated with significantly longer OS (5-y OS 53% versus 38%; p < 0.001). Subset analyses did not reveal clear associations of PORT with TTR. On multivariable analysis, lower pathologic stage, PORT, and R0 resection status were associated with an OS benefit, whereas only higher age and lower pathologic stage had an association with longer TTR., Conclusions: In the largest individual patient data set on patients with TC reported to date, PORT was associated with a meaningful OS benefit in patients with advanced-stage TC after an R0 or R1/2 resection., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Abstract: The coronavirus disease 2019 (COVID-19) pandemic disrupted health care systems, including implementation of lung cancer screening programs. The impact and recovery from this disruption on screening processes is not well appreciated. Herein, the radiology database of a Northeast tertiary health care network was reviewed before and during the pandemic (2013-2022). In the 3 months before the pandemic, an average of 77.3 lung cancer screening with computed tomography scans (LCS-CT) were performed per month. The average dropped to 23.3 between April and June of 2020, whereas COVID-19 hospitalizations peaked at 1604. By July, average hospitalizations dropped to 50, and LCS-CTs rose to >110 per month for the remaining year. LCS-CTs did not decline during COVID-19 surges in December of 2021 and 2022. The LCS-CT performance grew by 4.5% in 2020, 69.6% in 2021, and 27.0% in 2022, exceeding projected growth by 722 examinations. This resiliency indicates a potentially smaller impact of COVID-19 on lung cancer diagnoses than initially feared., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Pathologists are staging thymic epithelial tumors (TET) according to the 8th UICC/AJCC TNM system. Within the French RYTHMIC network, dedicated to TET, agreement on pathologic tumor stage (pT) among the pathology panelists was difficult. The aim of our study was to determine the interobserver reproducibility of pT at an international level, to explore the source of discrepancies and potential interventions to address these., Methods: An international panel of pathologists was recruited through the International Thymic Malignancy Interest Group (ITMIG). The study focused on invasion of mediastinal pleura, pericardium, and lung. From a cohort of cases identified as challenging within the RYTHMIC network, we chose a series of test and validation cases (n = 5 and 10, respectively)., Results: Reproducibility of the pT stage was also challenging at an international level as none of the 15 cases was classified as the same pT stage by all ITMIG pathologists. The agreement rose from slight (κ = 0.13) to moderate (κ = 0.48) between test and validation series. Discussion among the expert pathologists pinpointed two major reasons underlying discrepancies: 1) Thymomas growing with their "capsule" and adhering to the pleurae, pericardium, or lung were often misinterpreted as invading these structures. 2) Recognition of the mediastinal pleura was identified as challenging., Conclusion: Our study underlines that the evaluation of the pT stage of TET is problematic and needs to be addressed in more detail in an upcoming TNM classification. The publication of histopathologic images of landmarks, including ancillary tests could improve reproducibility for future TNM classifications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

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., (Copyright © 2023 International Association for the Study of Lung Cancer. All rights reserved.)

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., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2023. Published by Elsevier Inc.)

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., (Copyright © 2023 International Association for the Study of Lung Cancer. All rights reserved.)

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., (Copyright © 2023. Published by Elsevier Inc.)

Background: Interactions between immune and tumor cells are critical to determining cancer progression and response. In addition, preclinical prediction of immune-related drug efficacy is limited by interspecies differences between human and mouse, as well as inter-person germline and somatic variation. To address these gaps, we developed an autologous system that models the tumor microenvironment (TME) from individual patients with solid tumors., Method: With patient-derived bone marrow hematopoietic stem and progenitor cells (HSPCs), we engrafted a patient's hematopoietic system in MISTRG6 mice, followed by transfer of patient-derived xenograft (PDX) tissue, providing a fully genetically matched model to recapitulate the individual's TME. We used this system to prospectively study tumor-immune interactions in patients with solid tumor., Results: Autologous PDX mice generated innate and adaptive immune populations; these cells populated the TME; and tumors from autologously engrafted mice grew larger than tumors from non-engrafted littermate controls. Single-cell transcriptomics revealed a prominent vascular endothelial growth factor A (VEGFA) signature in TME myeloid cells, and inhibition of human VEGF-A abrogated enhanced growth., Conclusions: Humanization of the interleukin 6 locus in MISTRG6 mice enhances HSPC engraftment, making it feasible to model tumor-immune interactions in an autologous manner from a bedside bone marrow aspirate. The TME from these autologous tumors display hallmarks of the human TME including innate and adaptive immune activation and provide a platform for preclinical drug testing., Competing Interests: Competing interests: HHMI lab heads have previously granted a non-exclusive CC BY 4.0 license to the public and a sublicensable license to HHMI in their research articles. Pursuant to those licenses, the author-accepted manuscript of this article can be made freely available under a CC BY 4.0 license immediately upon publication. RF is an advisor to GlaxoSmithKline, EvolveImmune, and Ventus Therapeutics., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

The status of lymph node involvement is a major component of the TNM staging system. The N categories for lung cancer have remained unchanged since the fourth edition of the TNM staging system, partly because of differences in nodal mapping nomenclature, partly because of insufficient details to verify possible alternative approaches for staging. In preparation for the rigorous analysis of the International Association for the Study of Lung Cancer database necessary for the ninth edition TNM staging system, members of the N-Descriptors Subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee reviewed the evidence for alternative approaches to categorizing the extent of lymph node involvement with lung cancer, which is currently based solely on the anatomical location of lymph node metastasis. We reviewed the literature focusing on NSCLC to stimulate dialogue and mutual understanding among subcommittee members engaged in developing the ninth edition TNM staging system for lung cancer, which has been proposed for adoption by the American Joint Committee on Cancer and Union for International Cancer Control in 2024. The discussion of the range of possible revision options for the N categories, including the pros and cons of counting lymph nodes, lymph node stations, or lymph node zones, also provides transparency to the process, explaining why certain options may be discarded, others deferred for future consideration. Finally, we provide a preliminary discussion of the future directions that the N-Descriptors Subcommittee might consider for the 10th edition and beyond., (Copyright © 2022 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2022 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Lung cancer screening is slowly but steadily entering the realm of preventive health maintenance. Standardization of reporting of positive findings identified on screening low-dose CT (LDCT) scans, specifically lung nodules, is a key element of high-quality lung cancer screening. The American College of Radiology developed the Lung CT Screening Reporting and Data System (Lung-RADS) system for this purpose. In addition to detailed categorization of lung nodules, Lung-RADS identifies category S for other incidental findings identified on screening LDCT scans. In contrast to the highly structured reporting for nodules, category S findings are reported at the discretion of individual readers, with the potential for high variability of reporting. Incidental findings on lung cancer screening studies are common, may trigger unwarranted evaluation with potential harm and cost, and may precipitate patient distress. In response to these concerns, our multidisciplinary lung cancer screening program developed a structured system for standardized reporting of category S findings based on recommendations of the American College of Radiology and relevant specialty societies., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Purpose: To provide evidence-based recommendations to practicing clinicians on management of patients with stage III non-small-cell lung cancer (NSCLC)., Methods: An Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary oncology, community oncology, research methodology, and advocacy experts was convened to conduct a literature search, which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations., Results: The literature search identified 127 relevant studies to inform the evidence base for this guideline., Recommendations: Evidence-based recommendations were developed to address evaluation and staging workup of patients with suspected stage III NSCLC, surgical management, neoadjuvant and adjuvant approaches, and management of patients with unresectable stage III NSCLC.Additional information is available at www.asco.org/thoracic-cancer-guidelines., Competing Interests: Megan E. DalyEmployment: University of CaliforniaLeadership: International Journal of Radiation Oncology Biology Physics, Practical Radiation OncologyConsulting or Advisory Role: Boston Scientific, Triptych Health PartnersResearch Funding: EMD Serono, Genentech (Inst), Merck (Inst)Travel, Accommodations, Expenses: Boston ScientificOther Relationship: TeleSecurity Sciences/Imatex Nofisat IsmailaEmployment: GlaxoSmithKline (I)Stock and Other Ownership Interests: GlaxoSmithKline (I) Douglas A. ArenbergUncompensated Relationships: American College of Chest Physicians, CHEST JournalOpen Payments Link: https://openpaymentsdata.cms.gov/physician/47744/summary Jeffrey BradleyHonoraria: AstraZeneca/MedImmune, Mevion Medical SystemsConsulting or Advisory Role: Varian Medical Systems, Genentech Elizabeth DavidHonoraria: AstraZenecaTravel, Accommodations, Expenses: Intuitive Surgical Martin FrühConsulting or Advisory Role: BMS (Inst), AstraZeneca (Inst), MSD (Inst), Takeda (Inst), Roche (Inst), Lilly (Inst), Roche (Inst)Speakers' Bureau: Pfizer (Inst)Research Funding: BMS (Inst), AstraZeneca (Inst), AstraZeneca (Inst) Matthew A. GubensConsulting or Advisory Role: Bristol Myers Squibb, AstraZeneca, Sanofi/Regeneron, ITeos TherapeuticsResearch Funding: Celgene (Inst), Merck (Inst), Novartis (Inst), Genentech/Roche (Inst), OncoMed (Inst), Trizell (Inst), Amgen, Johnson & Johnson/Janssen Amy C. MooreConsulting or Advisory Role: Guardant Health, Merck (Inst) Sukhmani K. PaddaHonoraria: CME Solutions, Janssen, MECC Global Meetings (CME), Nanobiotix, Physician Education Resource (CME), Jazz PharmaceuticalsConsulting or Advisory Role: AstraZeneca, G1 Therapeutics, Blueprint Medicines, AstraZeneca (Steering Committee), Genentech, Jazz Pharmaceuticals, Mirati Therapeutics, Janssen Oncology, GenzymeResearch Funding: EpicentRx (Inst), Bayer (Inst), Boehringer Ingelheim (Inst)Other Relationship: OncLive/MJH Life Sciences Jyoti D. PatelConsulting or Advisory Role: AbbVie, AstraZeneca, Takeda Science FoundationResearch Funding: Bristol Myers Squibb (Inst) Tanyanika PhillipsTravel, Accommodations, Expenses: City of Hope Angel QinResearch Funding: Takeda (Inst), Clovis Oncology (Inst), Merck Sharp & Dohme (Inst) Clifford RobinsonLeadership: RadialogicaStock and Other Ownership Interests: RadialogicaConsulting or Advisory Role: Varian Medical Systems, AstraZeneca, EMD Serono, Quantitative Radiology SolutionsResearch Funding: Varian Medical Systems (Inst), Merck (Inst)Patents, Royalties, Other Intellectual Property: Noninvasive imaging and treatment system for cardiac arrhythmias WO 2017078757 A1, US Provisional Application No. 62/598,162 Entitled System and Method for Determining Segments for Ablation Charles B. Simone IIHonoraria: Varian Medical SystemsNo other potential conflicts of interest were reported.

Background: Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underused. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand the factors associated with guideline-adherent nodal staging., Research Question: What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging?, Study Design and Methods: A web-based survey of a random sample of pulmonologists and thoracic surgeons identified as members of American College of Chest Physicians (CHEST) was conducted in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs toward implementation, and perceived barriers to guideline adherence., Results: Among 453 responding physicians, 29% were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes toward the guidelines were favorable, with 91% agreeing guidelines are generalizable and 90% agreeing that recommendations improved their staging and treatment decisions. Approximately 80% responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50% stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%)., Interpretation: Among physicians who responded to our survey, more than one-quarter were unaware of invasive nodal staging guidelines. Attitudes toward guideline recommendations were positive, although 20% reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multilevel interventions are likely needed to increase rates of guideline-recommended invasive nodal staging., (Copyright © 2022. Published by Elsevier Inc.)

This overview of the fifth edition of the WHO classification of thymic epithelial tumors (including thymomas, thymic carcinomas, and thymic neuroendocrine tumors [NETs]), mediastinal germ cell tumors, and mesenchymal neoplasms aims to (1) list established and new tumor entities and subtypes and (2) focus on diagnostic, molecular, and conceptual advances since publication of the fourth edition in 2015. Diagnostic advances are best exemplified by the immunohistochemical characterization of adenocarcinomas and the recognition of genetic translocations in metaplastic thymomas, rare B2 and B3 thymomas, and hyalinizing clear cell carcinomas. Advancements at the molecular and tumor biological levels of utmost oncological relevance are the findings that thymomas and most thymic carcinomas lack currently targetable mutations, have an extraordinarily low tumor mutational burden, but typically have a programmed death-ligand 1 high phenotype. Finally, data underpinning a conceptual advance are illustrated for the future classification of thymic NETs that may fit into the classification scheme of extrathoracic NETs. Endowed with updated clinical information and state-of-the-art positron emission tomography and computed tomography images, the fifth edition of the WHO classification of thymic epithelial tumors, germ cell tumors, and mesenchymal neoplasms with its wealth of new diagnostic and molecular insights will be a valuable source for pathologists, radiologists, surgeons, and oncologists alike. Therapeutic perspectives and research challenges will be addressed as well., (Copyright © 2021 International Association for the Study of Lung Cancer. All rights reserved.)

Purpose: Several sentinel phase III randomized trials have recently been published challenging traditional radiation therapy (RT) practices for small cell lung cancer (SCLC). This American Society for Radiation Oncology guideline reviews the evidence for thoracic RT and prophylactic cranial irradiation (PCI) for both limited-stage (LS) and extensive-stage (ES) SCLC., Methods: The American Society for Radiation Oncology convened a task force to address 4 key questions focused on indications, dose fractionation, techniques and timing of thoracic RT for LS-SCLC, the role of stereotactic body radiation therapy (SBRT) compared with conventional RT in stage I or II node negative SCLC, PCI for LS-SCLC and ES-SCLC, and thoracic consolidation for ES-SCLC. Recommendations were based on a systematic literature review and created using a consensus-building methodology and system for grading evidence quality and recommendation strength., Results: The task force strongly recommends definitive thoracic RT administered once or twice daily early in the course of treatment for LS-SCLC. Adjuvant RT is conditionally recommended in surgically resected patients with positive margins or nodal metastases. Involved field RT delivered using conformal advanced treatment modalities to postchemotherapy volumes is also strongly recommended. For patients with stage I or II node negative disease, SBRT or conventional fractionation is strongly recommended, and chemotherapy should be delivered before or after SBRT. In LS-SCLC, PCI is strongly recommended for stage II or III patients who responded to chemoradiation, conditionally not recommended for stage I patients, and should be a shared decision for patients at higher risk of neurocognitive toxicities. In ES-SCLC, radiation oncologist consultation for consideration of PCI versus magnetic resonance surveillance is strongly recommended. Lastly, the use of thoracic RT is strongly recommended in select patients with ES-SCLC after chemotherapy treatment, including a conditional recommendation in those responding to chemotherapy and immunotherapy., Conclusions: RT plays a vital role in both LS-SCLC and ES-SCLC. These guidelines inform best clinical practices for local therapy in SCLC., (Copyright © 2020. Published by Elsevier Inc.)

Introduction: Mediastinal lesions are uncommon; studies on their distribution are, in general, small and from a single institution. Furthermore, these studies are usually based on pathology or surgical databases and, therefore, miss many lesions that did not undergo biopsy or resection. Our aim was to identify the distribution of lesions in the mediastinum in a large international, multi-institutional cohort., Methods: At each participating institution, a standardized retrospective radiology database search was performed for interpretations of computed tomography, positron emission tomography-computed tomography, and magnetic resonance imaging scans including any of the following terms: "mediastinal nodule," "mediastinal lesion," "mediastinal mass," or "mediastinal abnormality" (2011-2014). Standardized data were collected. Statistical analysis was performed., Results: Among 3308 cases, thymomas (27.8%), benign mediastinal cysts (20.0%), and lymphomas (16.1%) were most common. The distribution of lesions varied among mediastinal compartments; thymomas (38.3%), benign cysts (16.8%), and neurogenic tumors (53.9%) were the most common lesions in the prevascular, visceral, and paravertebral mediastinum, respectively (p < 0.001). Mediastinal compartment was associated with age; patients with paravertebral lesions were the youngest (p < 0.0001). Mediastinal lesions differed by continent or country, with benign cysts being the most common mediastinal lesions in the People's Republic of China, thymomas in Europe, and lymphomas in North America and Israel (p < 0.001). Benign cysts, thymic carcinomas, and metastases were more often seen in larger hospitals, whereas lymphomas and thymic hyperplasia occurred more often in smaller hospitals (p < 0.01)., Conclusions: Our study confirmed that the spectrum and frequency of mediastinal lesions depend on mediastinal compartment and age. This information provides helpful demographic data and is important when considering the differential diagnosis of a mediastinal lesion., (Copyright © 2019 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Infection of the pleural space is an ancient and common clinical problem, the incidence which is on the rise. Advances in therapy now present clinicians of varying disciplines with an array of therapeutic options ranging from thoracentesis and chest tube drainage (with or without intrapleural fibrinolytic therapies) to video-assisted thoracic surgery (VATS) or thoracotomy. A framework is provided to guide decision making, which involves weighing multiple factors (clinical history and presentation, imaging characteristics, comorbidities); multidisciplinary collaboration and active management are needed as the clinical course over a few days determines subsequent refinement. The initial choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process. Antibiotics alone are rarely successful and can be justified only in specific circumstances. Early drainage with or without intrapleural fibrinolytics is usually required. This is successful in most patients; however, when surgical decortication is needed, clear benefit and low physiologic impact are more likely with early intervention, expeditious escalation of interventions, and care at a center experienced with VATS., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: We queried the European Society of Thoracic Surgeons (ESTS) prospective thymic database for descriptive analysis and for comparison with the ESTS retrospective thymic database (1990-2010)., Methods: Data were retrieved (January 2007-November 2017) for 1122 patients from 75 ESTS institutions., Results: There were 484 (65%) thymomas, 207 (28%) thymic carcinomas and 49 (7%) neuroendocrine thymic tumours. Staging (Masaoka) included 483 (67%) stage I and II, 100 (14%) stage III and 70 (10%) stage IV tumours. The new International Association for the Study of Lung Cancer/International Thymic Malignancies Interest Group tumour, node and metastasis (TNM) classification was available for 224 patients and including 177 (85%) stage I-II, 37 (16%) stage IIIA and 10 (4%) stage IIIB tumours. Chemotherapy as induction and adjuvant treatment was used in 14% and 15% of the patients. Radiotherapy was almost exclusively used postoperatively (24%). A minimally invasive surgical approach (video-assisted thoracic surgery/robotic-assisted thoracic surgery) was used in 276 (33%) patients. The overall recurrence rate was 10.8% (N = 38). Compared to the ESTS retrospective database, the increased prevalence of thymic carcinomas (from 9% to 28%) and neuroendocrine thymic tumours (from 2% to 7%), an increase in the use of minimally invasive techniques (from 6% to 34%) and a wider use of chemotherapy as induction (from 9% to 15%) and adjuvant (from 2% to 16%) treatment were observed in the prospective database. The introduction of a set of variables considered essential for the data use ('minimum dataset') resulted in an increased average completeness rate., Conclusions: The reported data from the ESTS prospective thymic database confirm the recent trends in the management of thymic tumours. The ESTS prospective thymic database represents a powerful resource open to all ESTS members for the global effort to manage these rare tumours., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Lung cancer mortality rate can be significantly reduced by up to 20% through routine low-dose computed tomography (LDCT) screening, which, however, has high sensitivity but low specificity, resulting in a high rate of false-positive nodules. Combining PET with CT may provide more accurate diagnosis for indeterminate screening-detected nodules. In this work, we investigated low-dose dynamic 18 F-FDG PET in discrimination between benign and malignant nodules using a virtual clinical trial based on patient study with ground truth. Six patients with initial LDCT screening-detected lung nodules received 90 min single-bed PET scans following a 10 mCi FDG injection. Low-dose static and dynamic images were generated from under-sampled list-mode data at various count levels (100%, 50%, 10%, 5%, and 1%). A virtual clinical trial was performed by adding nodule population variability, measurement noise, and static PET acquisition start time variability to the time activity curves (TACs) of the patient data. We used receiver operating characteristic (ROC) analysis to estimate the classification capability of standardized uptake value (SUV) and net uptake constant K i from their simulated benign and malignant distributions. Various scan durations and start times (t * ) were investigated in dynamic Patlak analysis to optimize simplified acquisition protocols with a population-based input function (PBIF). The area under curve (AUC) of ROC analysis was higher with increased scan duration and earlier t * . Highly similar results were obtained using PBIF to those using image-derived input function (IDIF). The AUC value for K i using optimized t * and scan duration with 10% dose was higher than that for SUV with 100% dose. Our results suggest that dynamic PET with as little as 1 mCi FDG could provide discrimination between benign and malignant lung nodules with higher than 90% sensitivity and specificity for patients similar to the pilot and simulated population in this study, with LDCT screening-detected indeterminate lung nodules.

Background: Pulmonary nodules are common; some are inconsequential while others are malignant. Management of solitary pulmonary nodule (SPN) in Brazil appears to be highly variable, potentially leading to suboptimal outcomes. Assessment of the variability and the association with the degree of availability of resources can provide a foundation for development of clinical guidelines for management of SPN specific for the Brazilian setting., Methods: A web-based survey was developed by thoracic surgeons, pulmonologists and radiologists to evaluate SPN perception and management. This survey was sent to their respective national societies members and answers collected between August and December 2016. That included multiple choice questions regarding age, specialty, SPN management, accessibility to exams and interventional procedures characterizing public (SUS) and supplementary private working settings., Results: A total of 461 questionnaires were answered. More than half of participants live in cities with over one million people. Specialties were reasonable equilibrated with 43.5% radiologists, 33.5% thoracic surgeons, 20.3% pulmonologists and 2.6% others. Most of the respondents work in both public and private sector (72.7%). Private has a similar reality compared to well-developed nations regarding exams accessibility and interventions. SUS setting has a significant variability access according to the participants. CT is only easily available in 31.9% of cases, PET-CT is easily available in 24.4%, bronchoscopy is easily available for 42.8%, transthoracic needle biopsy is only easily available in 13.9% and video-assisted thoracoscopic surgery (VATS) biopsy is not available in 19.5%. When there is a probability of malignancy of 50% or higher, 46.5% of participants would be comfortable recommending surgical biopsy. When the probability is higher than 10%, only 36.9% would be comfortable following up radiologically., Conclusions: Brazil has a very different setting for public and private patients regarding exams accessibility and management options. That might explain why participants have a higher tendency to choose interventional diagnosis and explains why current guidelines may not be applicable to developing countries reality., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.