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The tumor, node and metastasis (TNM) classification of malignant tumors was proposed by Pierre Denoit in the mid-20(th) century to code the anatomic extent of tumors. Soon after, it was accepted by the Union for International Cancer Control and by the American Joint Committee on Cancer, and published in their respective staging manuals. Till 2002, the revisions of the TNM classification were based on the analyses of a database that included over 5,000 patients, and that was managed by Clifton Mountain. These patients originated from North America and almost all of them had undergone surgical treatment. To overcome these limitations, the International Association for the Study of Lung Cancer proposed the creation of an international database of lung cancer patients treated with a wider range of therapeutic modalities. The changes introduced in the 7(th) edition of the TNM classification of lung cancer, published in 2009, derived from the analysis of an international retrospective database of 81,495 patients. The revisions for the 8(th) edition, to be published in 2016, will be based on a new retrospective and prospective international database of 77,156 patients, and will mainly concern tumor size, extrathoracic metastatic disease, and stage grouping. These revisions will improve our capacity to indicate prognosis and will make the TNM classification more robust. In the future the TNM classification will be combined with non-anatomic parameters to define prognostic groups to further refine personalized prognosis.

Lobectomy and mediastinal lymph node dissection is the standard surgical management of early stage non-small cell lung cancer (NSCLC) because more limited resections have been associated with a higher risk of local recurrence. Nevertheless, recent lung cancer screening studies have led to the detection of an increasing number of “very early” NSCLC (defined as less than 2 cm in size) and of good-prognosis histologic subtypes, bronchioloalveolar carcinoma (BAC), and adenocarcinoma (AC), mixed subtypes that are potentially appropriate for sublobar resection. The precise indications for sublobar resection remain unclear and are the subject of ongoing clinical trials, but it seems that very early, peripherally located, node-negative AC of a predominantly BAC pattern may be adequately treated in this manner. Multifocal AC and BAC, either synchronous or metachronous, are also effectively treated by complete resection, using limited resections whenever possible. The pneumonic form of BAC, the rarest variant of this disease spectrum, continues to have a poor prognosis despite complete resection. Very limited experience suggests that lung transplantation leads to prolonged survival in highly selected patients with this histologic subtype. To improve our management of very early AC, much more information is needed about the molecular abnormalities of AC and their relationship to clinical outcomes.

Structural adaptations that occur in the diaphragm muscle of patients with chronic obstructive pulmonary disease (COPD), namely an increase in type I fibers and a decrease in type II fibers, have been explored in terms of the active contractile properties of the diaphragm. The aim of this study was to test the passive properties of the diaphragm by measuring the force response of relaxed diaphragm muscle fibers to stretching to determine the effect of COPD on these properties. Costal diaphragm biopsies were taken from patients with COPD and from controls with normal pulmonary function. From these biopsies, titin expression was assessed in diaphragm homogenates by gel electrophoresis, and the restoring force was measured by incremental stretching of single fibers in the relaxed state and measuring the force response to stretching. A quadratic model was used to illustrate the relationship between restoring force and muscle fiber length, and it revealed that COPD fibers generate significantly lower restoring forces than control fibers as judged by the area under the force-length curve. Furthermore, this finding applies to both type I and type II fibers. Gel electrophoresis revealed different titin isoforms in COPD and controls, consistent with the conclusion that COPD results not only in a change in muscle fiber-type distribution but in a structural change in the titin molecule in all muscle fiber types within the diaphragm. This may assist the muscle with the energetic changes in the length of the diaphragm required during breathing in COPD.

An activating point mutation in codon 12 of the HRAS gene was the first somatic point mutation identified in a human cancer and established the role of somatic mutations as the common driver of oncogenesis. Since then, there have been over 11,000 mutations in the three RAS (HRAS, KRAS and NRAS) genes in codons 12, 13 and 61 reported in the literature. We report here the identification of recurrent somatic missense mutations at alanine 146, a highly conserved residue in the guanine nucleotide binding domain. In two independent series of colorectal cancers from Hong Kong and the United States we detected KRAS A146 mutations in 7/126 and 2/94 cases, respectively, giving a combined frequency of 4%. We also detected KRAS A146 mutations in 2/40 (5%) colorectal cell lines, including the NCI-60 colorectal cancer line HCC2998. Codon 146 mutations thus are likely to make an equal or greater contribution to colorectal cancer than codon 61 mutations (4.2% in our combined series, 1% in the literature). Lung adenocarcinomas and large cell carcinomas did not show codon 146 mutations. We did, however, identify a KRAS A146 mutation in the ML-2 acute myeloid leukemia cell line and an NRAS A146 mutation in the NALM-6 B-cell acute lymphoblastic leukemia line, suggesting that the contribution of codon 146 mutations is not entirely restricted to colorectal cancers or to KRAS.

ObjectiveThe use of tissue glues has been advocated to reduce post-thoracotomy alveolar air leaks, but outcomes have been inconclusive. The aim of this study was to determine the effectiveness of BioGlue (CryoLife Europa Ltd, Hampshire, United Kingdom) in eliminating post-thoracotomy alveolar air leaks.MethodsA prospective, randomized, single-blind, controlled trial was conducted in which patients were stratified according to the severity of post-thoracotomy air leak that could not be controlled by conventional surgical techniques. They were allocated to a control arm (surgical treatment only) or an interventional arm (surgical treatment and BioGlue). Duration of air leak, intercostal drainage, and hospital stay comprised primary study end points.ResultsFrom December 2002 to January 2005, 52 patients were randomized, 29 (56%) of whom were men. The mean age was 59 ± 15 years, and other characteristics were comparable in both groups. Indications for surgery were malignancy in 46 patients (88%), carcinoid tumor in 2 patients (4%), and infective disease in 4 patients (8%). Patients in the BioGlue arm had shorter median duration of air leaks, 1 (0-2) versus 4 (2-6) days (P < .001); intercostal chest drainage, 4 (3-4) versus 5 (4-6) days (P = .012); and hospital stay, 6 (5-7) versus 7 (7-10) days (P = .004), compared with controls. No major complications were encountered using BioGlue.ConclusionsThis study demonstrates clear benefit from BioGlue in the treatment of alveolar air leaks through reduction of air leak duration, chest drainage time, and hospital stay. Systematic use of BioGlue may be warranted in adult thoracic surgical procedures (except pneumonectomy and decortication) when an air leak remains after all other steps to control it have failed.

The tumor, node, metastasis system for cancer staging evolved in the middle of the last century. It was adopted for the staging of lung cancer by the American Joint Committee on Cancer in 1973 and used by the Union Internationale Contre le Cancer (UICC) in 1974 for its second edition of the Classification of Malignant Disease . Subsequent revisions of the international tumor, node, metastasis staging system in lung cancer, up to and including the fifth revision enacted in January 1997, were largely based on Dr. Clifton Mountain's database in Houston. The International Association for the Study of Lung Cancer established its International Staging Committee in 1997 to collect data on lung cancer cases from around the world treated by all modalities. This project has now collected over 100,000 cases and has been accepted as the primary source of recommendations by the UICC for the next revision of the International Staging System for Lung Cancer due to be enacted in January of 2009. This article describes the achievements of this project and the present state of the database. The authors set out the steps that are necessary before the International Association for the Study of Lung Cancer is able to submit its recommendations to the UICC at the end of 2006. Subject to editorial review, these recommendations will be disseminated to the lung cancer community through a series of publications in this Journal . This article will set the scene for these subsequent publications and, possibly, will garner support and ideas for the next phase of this long-term project.

Objective: TheNussprocedureis a minimallyinvasive pectusrepair. This studyrepresents an attempttowardsexploringthechanges inquality oflife andoverallsatisfaction inyoungmaleadultswhounderwenta Nussprocedure.Methods: We haveincluded20 malepatientswith a median age of 18 years (range: 14—37 years). We have used two specific questionnaires: the two-step Nuss evaluation Questionnaire modified for Adults (NQ-mA)and a new SingleStep Questionnaire(SSQ). Thedatawasanalysed usingWilcoxonsignedrank testto determine statisticalsignificanceof differences, with a

How we do it: the anterior thoraco-cervical approach to tumours of the thoracic inlet center dot Tumours that arise in the thoracic inlet and superior mediastinum may be benign or malignant and present the surgeon with a difficult problem of access. center dot The standard approach to the thoracic inlet from below offers limited exposure to the vascular and neural structures superior to the tumours. center dot The anterior thoraco-cervical approach to the root of the neck and superior mediastinum combines the anterior cervical approach with a limited upper median sternotomy. If further access is required to achieve surgical clearance a full sternotomy split can be performed. center dot The approach offers excellent exposure and helps to facilitate complete resection of benign and malignant tumours, which would otherwise be deemed inoperable or difficult to resect completely through other standard approaches. center dot In contrast to previously described anterior transcervical thoracic approaches which required resection of part of the clavicle or manubrium as well as thoracotomy with increased morbidity, the anterior thoraco-cervical approach is associated with little morbidity and the postoperative stay is short.

Endobronchial valve placement improves pulmonary function in some patients with chronic obstructive pulmonary disease, but its effects on exercise physiology have not been investigated. In 19 patients with a mean (SD) FEV(1) of 28.4 (11.9)% predicted, studied before and 4 weeks after unilateral valve insertion, functional residual capacity decreased from 7.1 (1.5) to 6.6 (1.7) L (p = 0.03) and diffusing capacity rose from 3.3 (1.1) to 3.7 (1.2) mmol . minute(-1) . kPa(-1) (p = 0.03). Cycle endurance time at 80% of peak workload increased from 227 (129) to 315 (195) seconds (p = 0.03). This was associated with a reduction in end-expiratory lung volume at peak exercise from 7.6 (1.6) to 7.2 (1.7) L (p = 0.03). Using stepwise logistic regression analysis, a model containing changes in transfer factor and resting inspiratory capacity explained 81% of the variation in change in exercise time (p < 0.0001). The same variables were retained if the five patients with radiologic atelectasis were excluded from analysis. In a subgroup of patients in whom invasive measurements were performed, improvement in exercise capacity was associated with a reduction in lung compliance (r(2) = 0.43; p = 0.03) and isotime esophageal pressure-time product (r(2) = 0.47; p = 0.03). Endobronchial valve placement can improve lung volumes and gas transfer in patients with chronic obstructive pulmonary disease and prolong exercise time by reducing dynamic hyperinflation.

Study objectives The objective of this study was to evaluate the feasibility of the sentinel lymph node (SLN) biopsy in peripheral clinically stage I or II non-small cell lung cancer (NSCLC) using 99m Tc colloid and a hand-held gamma detection probe, associated with a blue dye technique. Design Prospective study. Setting Royal Brompton Hospital, London, UK; and Hopital Nord, Saint Etienne, France. Methods After thoracotomy, a total of 2 mL patent blue dye mixed with 1,600 μCi 99m Tc-albumin or 99m Tc-colloid was injected into each quadrant of lung tissue immediately surrounding the tumor. Routine lymphadenectomy was carried out. The first lymph nodes to stain blue or radioactive, if any, were considered SLNs. Results Twenty-four patients were evaluated. We successfully identified 17 SLNs in 13 patients (detection rate, 54.2%). Mean time from injection to identification of SLNs was 18 min (range, 5 to 30 min). In nine cases, the SLN was blue and radioactive, in six cases only blue, and in two cases only radioactive. The pathologic status of the SLN reflected the pathologic status of other nodes of the routine lymphadenectomy except one case of false-negative SLN (14%). Four SLNs were in N2 stations (23.5%). Conclusions The sentinel node mapping in NSCLC with blue dye and radioisotopic techniques is feasible, but the detection rate has to be improved. This technique is an accurate method of identifying the first node draining a tumor, although it is not yet sufficiently sensitive to have a role in reducing the extent of nodal dissection.

Idiopathic tracheal stenosis, a rare benign chronic inflammatory and fibrotic entity, has previously been reported in the literature in adults, but never in children. Here we report two pediatric cases, one with the rarer condition of idiopathic bronchial stenosis, and we discuss the management and histopathologic findings.

Objectives For patients undergoing lung resection for cancer, macroscopic evidence of metastasis is clearly associated with adverse prognosis. However, less is known about the significance of tumor cells detected by using tests such as pleural lavage cytology. To ascertain the frequency and quantify the effect of this finding on survival, we performed a prospective study of intraoperative pleural lavage cytology. Methods Pleural lavage cytology consisted of cytologic analysis of 100 mL of saline irrigated over the lung surface immediately after thoracotomy. Patients were excluded if they had an existing effusion, extreme adhesions, or lateral chest wall invasion or if resection was not performed. Survival was calculated by means of Kaplan-Meier analysis and compared by using log-rank tests. Cox regression was used to ascertain independent predictors of prognosis. Results From 1995 through 2003, we performed pleural lavage cytology on 292 patients undergoing thoracotomy for lung cancer. The mean age was 64 (SD, 10) years, and 196 (67%) patients were men. Of 292 samples, 13 (4.5%) showed evidence of malignant cells. The median time to follow-up was 15 months (interquartile range, 1-40 months), with a median survival of 49 months for patients with negative pleural lavage cytology results and 13 months for patients with positive pleural lavage cytology results ( P = .002). Univariate prognostic predictors were positive pleural lavage cytology status ( P = .03), stage ( P = .03), adenocarcinoma ( P = .06), and parietal pleural involvement ( P = .01). In the final multivariate model only positive pleural lavage cytology status ( P = .006) and stage ( P = .03) remained significant. Conclusions Intraoperative pleural lavage cytology is a simple addition to intrathoracic staging and an independent predictor of prognosis. Positive results potentially affect survival by upstaging patients to stage IIIB or greater.

An early response to cigarette smoke is an influx of leukocytes into the lung. Alveolar epithelial type II (ATII) cells may contribute by releasing chemokines in response to cigarette smoke and neutrophil elastase (NE). Human ATII cells were purified from normal regions of lungs resected for carcinoma (n = 14). In vitro, these cells exhibited ATII cell characteristics: lamellar bodies, apical microvilli, tight junctions, and expressed surfactant apoprotein C. Basal ATII cell release of five chemokines ranked as follows: monocyte chemotactic protein (MCP)-1 > interleukin (IL)-8 > growth-related oncogene (GRO)-alpha > macrophage inflammatory protein (MIP)-1alpha > regulated on activation, normal T cell expressed and secreted (RANTES). MIP-1alpha and RANTES were often not detectable. After stimulation with a mixture of lipopolysaccharide/endotoxin (LPS), tumor necrosis factor-alpha, IL-1beta, and IFN-gamma, MCP-1 and IL-8 secretion rose 4-6-fold, whereas GRO-alpha rose 25-fold. NE stimulated IL-8 mRNA expression, and 10nM NE stimulated IL-8 secretion; however, 100 nM NE caused a decrease in extracellular IL-8, MCP-1, and GRO-alpha, attributed to proteolysis. Cigarette smoke extract (CSE) inhibited IL-8 mRNA expression and release of all chemokines. Glutathione protected against the effects of CSE, suggesting oxidative mechanisms. GRO-alpha, important in growth and repair, was sensitive to both stimulation, by LPS:cytokines, and inhibition, by CSE. Thus, contrary to the original hypothesis, high concentrations of NE and CSE resulted in reduced extracellular chemokine levels. We hypothesize that reduced ATII cell-derived chemokine levels compromise alveolar repair, contributing to cigarette smoke-induced alveolar damage and emphysema.

Only approximately 5% to 15% of small cell lung cancer (SCLC) presents at an early stage when surgery can be beneficial in its management. This is especially the case when a solitary pulmonary nodule is resected and is a stage Ia SCLC. In this case, complete resection, usually followed by chemotherapy, offers a chance of cure similar to non-SCLC. If the diagnosis of SCLC is known preoperatively, then complete thoracic and distant staging (including mediastinoscopy) is mandatory, and surgery is only indicated for stage I or II disease and postoperative chemotherapy is indicated. The prognosis for stage II disease is clearly guarded, but at present, there is no reliable method to stage hilar lymph nodes before surgery. Outside of a clinical trial, there clearly is no role for surgery in stage III and IV SCLC. Surgery also can be required to palliate symptoms of SCLC in selected cases.

An asymptomatic 8‐week-old male infant was referred for assessment. A prenatal ultrasound had been suggestive of a congenital cystic adenomatoid malformation (CCAM). Following delivery, he had a plain chest radiograph (fig. 1⇓) and went on to have a computed tomography (CT) scan of the thorax (fig. 2⇓), which showed an extrapulmonary mass close to the vertebral column. He proceeded to have magnetic resonance imaging of the thorax to look for intraspinal extension. The appearances were not anticipated, in that the lesion appeared to be intrapulmonary with no extension into the mediastinum, spinal canal or chest wall. The diaphragm was reported as being intact and separating the lesion from the abdominal cavity. There were no abnormal vessels reported. These features were in keeping with an intrapulmonary cystic lesion and the infant was referred for a surgical opinion. As the infant remained well, surgery was deferred until the child was 1‐yr old. Fig. 1.— Plain chest radiograph showing a left-sided abnormality. Fig. 2.— Thoracic computed tomography scan. A routine pre-operative CT scan (fig. 3⇓) was performed onthe day before the planned surgery followed by a barium swallow (fig. 4⇓). A surgical procedure for what wasnow presumed to be a diaphragmatic hernia was carried out. Fig. 3.— Second computed …

Background The diagnostic and staging value of cervical mediastinoscopy is well established. Left anterior mediastinotomy is of further value in assessing left upper lobe tumors. However the efficacy and safety of both these procedures after median sternotomy for cardiac surgery is unknown. Methods We undertook a retrospective review of our experience of mediastinal exploration by cervical mediastinoscopy with or without left anterior mediastinotomy in patients with prior sternotomy between 1980 and 2001. Results During this period 28 patients (25 male and 3 female; mean age, 63 ± 10 years), all with prior sternotomy for cardiac surgery (14 had left internal mammary artery graft), underwent mediastinal exploration. The mean interval between sternotomy and mediastinal exploration was 7.2 ± 5.1 years. Additionally, 3 patients also had superior vena cava obstruction. Cervical mediastinoscopy was performed in all 28 patients and additionally left anterior mediastinotomy was undertaken in 7 of 28 patients (4 with left internal mammary artery graft). Indications for exploration were staging of lung cancer in 22 patients (cervical mediastinoscopy, n=22; left anterior mediastinotomy, n=7) and diagnostic biopsy of mediastinal mass in 6 patients (cervical mediastinoscopy, n=6). Thorough mediastinal assessment was possible in all 28 patients. In the 22 patients with lung cancer the median number of lymph node stations sampled during mediastinoscopy was 3 (range, 1 to 5). A specific diagnosis was obtained in 16 patients (metastatic lung cancer, n=10; lymphoma, n=3; sarcoidosis, sinus histiocytosis, and metastatic melanoma, n=1 each). The other 12 patients with negative findings underwent pulmonary resection and only 1 of 12 (8%) patients had unexpected N2 disease, a similar proportion to our overall experience with lung cancer. There were no operative complications. Conclusions Prior sternotomy for cardiac surgery does not compromise the efficacy and the safety of mediastinoscopy and mediastinotomy.

The purpose of this study was to review cases of congenital cystic adenomatoid malformations (CCAMs) arising in children and adults, in order to assess the recently expanded classification system for these lesions and their association with malignant transformation. Of 28 CCAMs, there were 16 type 1, 4 type 2, and 8 type 4 lesions, 12 of which presented in adults. Five of 16 type 1 CCAMs were accompanied by microscopic foci of bronchioloalveolar carcinoma; two others showed focal mucous cell hyperplasia. In two further cases, foci of nonmucinous atypical adenomatous hyperplasia were identified in the adjacent lung parenchyma. The bronchioloalveolar carcinomas showed less cytologic atypia, proliferative activity (Ki-67), and p53 expression than a comparative group of bronchioloalveolar carcinomas arising de novo, but this was not statistically significant (p = 0.15). Neither bronchioloalveolar carcinomas nor hyperplasia was identified in type 2 or type 4 CCAMs. Four of the eight type 4 CCAMs showed focal stromal hypercellularity, and one case subsequently developed a pleuropulmonary blastoma. We conclude that classification according to the current system is of clinical value. Bronchioloalveolar carcinomas arise in association with type 1 CCAMs, but recurrence following resection is exceptional. Type 4 CCAMs show histologic overlap with grade 1 pleuropulmonary blastomas, and distinction between these entities may not be possible on histology alone. However, stromal cellularity in a type 4 CCAM should raise the possibility of blastomatous transformation.

Study objectives To determine whether the new classification system for thymic carcinoid tumors/neuroendocrine carcinomas provides prognostic data, and to study the presentation, diagnosis, treatment, and prognostic factors of these rare tumors. Design Retrospective analysis. Setting Royal Brompton Hospital, London, UK. Results Eight men and four women with a median age of 58 years. Complete excision was possible in nine patients. Postoperative staging revealed two stage I tumors, two stage II tumors, three stage III tumors, one stage IVA tumor, and four stage IVB tumors. All tumors demonstrated the histopathologic features of neuroendocrine tumors, which were confirmed by positive immunohistochemical staining for chromogranin A in 11 of 12 tumors and for CD56 in 12 of 12 tumors, and the presence of dense core granules on ultrastructural analysis in 9 of 9 tumors. All 12 tumors did not stain positively for somatostatin receptors. Three tumors were grade 1, six cases were grade 2, and three cases were grade 3. Follow-up was available in all patients. One patient died 1 month postoperatively. Distant metastasis developed in nine patients (82%). Local recurrence was evident in six patients, of whom five had not received postoperative radiotherapy. Seven patients died of distant metastasis (22 to 83 months after surgery). Two are alive and disease-free (at 67 and 81 months), and two are alive with disease (at 60 and 86 months) Conclusions Neither grading as neuroendocrine carcinomas nor any individual histologic parameter showed a significant association with prognosis. Initial aggressive treatment, including complete surgical excision and adjuvant radiotherapy, appears to offer the best hope for prolonged survival. Adjuvant chemotherapy also should be considered, since the incidence of distant relapse is high.

ObjectivePulmonary fibrosis is associated with an increased risk of lung cancer and outcome of surgical resection in this setting is unknown.MethodsWe studied 22 patients (24 operations) with pulmonary fibrosis and non-small cell lung cancer treated between 1991 and 2000 (study group) and compared outcome with 951 other patients (964 operations) treated for non-small cell lung cancer over the same period (control patients).ResultsThe two groups did not differ significantly in age (68 vs 65 years), smoking history (86% vs 95% smokers), forced expiratory volume in 1 second (2.5 L/min vs 2.3 L/min) or forced vital capacity (3.2 L vs 3.7 L), but patients with pulmonary fibrosis were more likely to be male (72% vs 58%, P < .05). The operative mortality was higher in patients with pulmonary fibrosis than in control patients (17% vs 3.1%, P < .01) and there was a higher procedure-specific mortality in pulmonary fibrosis for pneumonectomy (33% vs 5.1%, P < .01) and lobectomy (12% vs 2.6%, P < .01). Patients with pulmonary fibrosis had a higher incidence of postoperative lung injury, (21% vs 3.7%, P < .01) and a longer mean hospital stay (17 vs 9 days, P < .05). In patients with pulmonary fibrosis, the actuarial 3-year survival was 54%. There were 11 deaths in the study group, 4 postoperatively (all acute respiratory distress syndrome) and 7 late deaths (metastatic disease, n = 2; progressive pulmonary fibrosis, n = 5). Median follow-up (to death or last review) was 13 months (range, 0-120 months). Five patients developed postoperative acute respiratory distress syndrome and in 4 of these patients this proved to be fatal. Postoperative acute respiratory distress syndrome was associated with lower preoperative total lung carbon monoxide diffusion capacity (median, 58% vs 70%, P = .03) and lower preoperative carbon monoxide diffusion capacity corrected for alveolar volume (median, 48% vs 58%, P = .05) and a higher preoperative composite physiological index (median, 44 vs 33, P = .008). None of the preoperative lung function parameters or operative finding were predictors of late death.ConclusionPatients with pulmonary fibrosis undergoing pulmonary resection for non-small cell lung cancer have increased postoperative morbidity and mortality, but an important subgroup has a good long-term outcome. Postoperative acute respiratory distress syndrome is associated with low preoperative gas transfer and a high composite physiological index. Resection of non-small cell lung cancer is appropriate in pulmonary fibrosis, provided that the level of functional impairment is carefully factored into patient selection.

Background We reviewed our experience to determine the role of endoscopic airway stents in children with tracheobronchial obstruction. Methods Seventeen children (10 boys and 7 girls) aged 2 months to 16 years underwent tracheobronchial stenting. Etiology of the tracheobronchial obstruction included external vascular compression (n = 9); tracheobronchial anastomotic strictures after heart-lung/lung transplantation (n = 4); airway compression by malignant mediastinal mass (n = 2), and subglottic/high tracheal stenosis after prolonged intubation with a tracheostomy in situ (n = 2). Indications for airway stenting were failure to wean from ventilator after a mean of 82.5 days (range, 2 to 210) in 8 children; and dyspnea or stridor in the remaining 9 children. Results Ten children had a total of 24 uncovered self-expanding metal stents (either Magic Wallstent or Ultraflex Microvasive) and 7 children had silicone stents (2 straight, 3 Y and 2 T tube stents). At follow-up at 1 week to 72 months (median 21), only 8 of 17 (47%) children were alive but all the deaths were secondary to the underlying pathology and not related to tracheobronchial stenting. Six of 8 ventilator-dependent children were extubated after a mean of 5.3 days (range, 2 to 11) after airway stenting. For the 9 children stented for dyspnea, mean Medical Research Council dyspnea score decreased from 3.0 to 1.6 after stenting. Conclusions Tracheobronchial stenting in children is only rarely needed and often undertaken in dire circumstances. The procedure has led to significant symptomatic benefit in dyspneic children and has enabled ventilator-dependent children to be extubated. Medium-term outlook after stenting with self-expanding metal stents for vascular compression of the airway is encouraging. The long-term outcome remains uncertain, however, and is ultimately influenced by the underlying disease.

Background Large cell neuroendocrine carcinoma (LCNEC) and large cell carcinoma with neuroendocrine morphology of the lung are both currently classified as subtypes of large cell carcinomas according to the World Health Organization IASLC classification system for lung and pleural tumors. Prognosis is reported as similar to that of small cell carcinomas. There is no consensus on management of this subset and adjuvant chemotherapy is recommended by some for early stage LCNEC to impact long-term prognosis. We retrospectively reviewed a cohort of patients at our institution who had this type of tumor to determine factors that might influence survival. Methods Twenty-one cases of LCNEC and large cell carcinoma with neuroendocrine morphology were identified in the files of the Royal Brompton Hospital between 1986 and 1999. All patient data were reviewed, and complete follow-up was achieved with 20 of these patients. Results Of the 21 patients identified, 20 underwent resection with systematic nodal dissection in 18. There was no in-hospital mortality. Of those patients fully staged by systematic nodal dissection, 9 were stage I, 5 were stage II and 4 were stage III. Median follow-up was 25 months (range, 2 to 120 months). At the time of review, 11 patients were alive and free of disease. One patient was alive and free of disease when lost to follow-up. Nine patients had died, 7 related and 2 unrelated to disease. The 5-year actuarial survival for the entire group was 47%. The actuarial survival of accurately staged, stage I patients at 5 years was 88%. The actuarial survival of patients in stage II and III was 28% at 5 years. Conclusions LCNEC and large cell carcinoma with neuroendocrine morphology are aggressive tumors, but patients with completely resected disease after systematic nodal dissection have a better prognosis than previously described. Patients with more advanced disease have a poor prognosis.

Recent studies have demonstrated the possibility to detect genetic changes in plasma DNA of cancer patients. The goal of this study was to validate a panel of molecular markers for lung cancer detection in plasma DNA. Three markers, p53, FHIT and microsatellite alterations at loci on chromosome 3, were used to detect mutations in tumor and plasma DNA of 64 stage I-III non small cell lung cancer patients. p53 mutations were studied by direct sequencing of exons 5 through 8 in tumor DNA and by plaque hybridization assay and sequencing in plasma DNA. Allelic losses were evaluated by fluorescent PCR in tumor and plasma DNA. p53 genomic mutations were detected in 26 (40.6%) of 64 tumor DNA samples and the identical mutation was identified in plasma of 19 (73.1%) of them. Microsatellite alterations at FHIT and 3p loci were observed in 40 (62.5%) tumors and in 23 (35.9%) plasma samples. Of the 40 patients showing microsatellite alterations in tumors, 19 (47.5%) displayed the same change in plasma DNA. At least 1 of the 3 genetic markers (p53, FHIT and 3p) was altered in plasma of 51.6% of all patients and 60.7% of stage I patients. Moreover, genetic markers in plasma identified 29 of 45 (64.4%) of all stages and 15 of 22 (68.2%) of stage I patients whose tumors had an alteration. These results provide the proof of principle that plasma DNA alterations are tumor-specific in most cases and support blood testing as a noninvasive strategy for early detection.

Aims: Sclerosing haemangiomas typically comprise a mixture of four architectural patterns (papillary, sclerotic, solid and haemorrhagic) and two cell types, eosinophilic cuboidal epithelial lining cells and sheets of rounded cells with either eosinophilic or clear cytoplasm. In most instances, recognition of these architectural and cytological features provides sufficient evidence for diagnosis. This study presents and discusses the histogenesis of four cases where difficulties in diagnosis were encountered, and reports the value of the antibody TTF-1 in making the diagnosis. Methods and results: Four cases with focal areas reminiscent of sclerosing haemangioma were reviewed and immunostained with an antibody panel including antibodies to TTF-1 and surfactant apoprotein A. Of these, one case was classified as sclerosing haemangioma combined with typical carcinoid, in which there was a mediastinal lymph node metastasis solely comprising the solid component of sclerosing haemangioma. The second was classified as an alveolar adenoma with sclerosing haemangioma-like areas. In the remaining two cases, diagnosis was confounded by presentation with predominantly cystic masses, the largest 70 mm in diameter. Immunohistochemically, TTF-1 was of greater value than surfactant apoprotein, in particular in identifying the solid component of sclerosing haemangioma when this was solely present. Conclusion: Sclerosing haemangiomas should be considered in the differential diagnosis of cystic pulmonary masses. They may also present histologically as combined tumours and metastasize to mediastinal nodes, indicating an, albeit low, malignant potential. TTF-1 is a valuable antibody in identifying the presence of a sclerosing haemangioma when typical features are absent.

The proceedings of the International Workshop on Intrathoracic Staging, sponsored by the IASLC and organised in London in October, 1996, concluded that the IASLC should consider setting up an International Staging Committee to ‘establish internationally agreed definitions of complete and incomplete resection’, ‘coordinate the development of an International Nodal Chart’, ‘co-ordinate the exchange of data’ and to ‘represent the IASLC in negotiations with the UICC and AJCC with regard to future revisions of classification’ [1]. This committee has now been established, is fully funded and is setting about its work. That being so

Inflammatory polyps of the airways are now regarded as histopathologically distinct nonneoplastic endobronchial lesions, which in adults are associated with a variety of chronic inflammatory insults. However, their clinical presentation in the pediatric population is extremely rare, with the etiology of such polyps poorly defined. The clinical and histopathological data from four pediatric patients, identified in the histopathology files of the Royal Brompton Hospital, were retrospectively reviewed. Three out of 4 patients had a history of mechanical ventilation in the neonatal period. In these 3 patients, the polyps were all situated in the proximal airways on the right side. These 3 patients presented at 6 weeks, 7 weeks, and 2 years, respectively, and were successfully treated by polypectomy at rigid bronchoscopy, with subsequent return to normality. One patient, presenting at 12 years of age without history of iatrogenic intervention, underwent a left lower lobectomy for a polyp sited in a segmental bronchus. Presentation in 3 of the 4 patients was with lobar collapse. The fourth patient presented with hyperinflation. We conclude that inflammatory endobronchial polyps may be associated with a history of mechanical ventilation in the neonatal period, polyp formation perhaps being secondary to airway trauma. The small caliber of the main airways in neonates may also be a contributory factor in presentation.

Background. Cystic lung lesions are found in the adult and pediatric populations. We present our 19-year experience with such lesions from a single institution. Methods. We retrospectively reviewed our experience with such lung pathology, comparing the pediatric and adult populations with regard to their spectrum of pathology, presentation, surgical procedures, and postoperative morbidity and mortality. Results. Forty-six operations were performed on 44 patients (24 children and 20 adults). Cystic adenomatoid malformation was the most common pathology in the pediatric group (53.9%), followed equally by simple cysts and sequestrations (15.4%). In three of the pediatric patients malignant features were identified after resection; bronchoalveolar carcinoma in 2 patients with cystic adenomatoid malformation and pleuropulmonary blastoma in 1 patient with bilateral cystic disease. In the adult population the most common pathology was simple cysts in 8 (40%), followed by cystic adenomatoid malformation in 5 (25%) and sequestrations in 2 patients (10%). The majority of the children, 16 (61.5%), required operation because of expanding or infected cysts, recurrent cysts, or chest infections; 4 were operated on as an urgent basis. In contrast, the majority of adults 11 (55%) were asymptomatic or had no specific symptoms, and all operations were elective. A larger number of major resections (65.4% versus 55%) were necessary in the pediatric group, possibly due to differences in the pathology. However, morbidity was comparable in the two groups with no mortality. Conclusions. Operation for cystic lung disease is safe. Asymptomatic cysts in children should be resected to avoid later complications of the cysts, which could make operation more difficult. Patients should be evaluated for associated congenital anomalies. Conservative anatomic resections should be attempted to salvage functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy.

Immunohistochemical markers in the differentiation of thymic and pulmonary neoplasms. Aims: The histopathological features of some thymic neoplasms overlap with those of pulmonary squamous and large-cell undifferentiated carcinomas, and identification of the primary site may be difficult on routine staining. We have assessed a panel of antibodies that may help to distinguish between neoplasms from these two sites. Methods and results: Antibodies identifying cytokeratin 7 (CK7), CD5, CD10, CD1a and thyroid transcription factor-1 (TTF-1) were applied to a series of 20 thymic neoplasms (thymic carcinomas, atypical thymomas and thymomas), 10 primary squamous cell carcinomas of the lung and 10 large-cell undifferentiated carcinomas of the lung. Staining for TTF-1 was positive in 3/10 large-cell undifferentiated carcinomas, but negative in all other tumours. CD5 showed strong membranous staining in 3/6 thymic carcinomas and 1/14 thymomas, but only focal staining in 1/20 pulmonary carcinomas. CD1a was consistently positive in thymic lymphocytes in both typical and atypical thymomas, but only focally in 1/6 thymic carcinomas. CD1a stained dendritic cells in 7/20 pulmonary carcinomas. but did not stain lymphocytes. Staining for CK7 and CD10 did not aid in differentiating between a pulmonary or thymic origin of the tumour. Conclusion: Staining for TTF-1, CD5 and CD1a have potential use in distinguishing between pulmonary and thymic neoplasms.

Background . Systematic nodal dissection is accepted as an important component of the intrathoracic staging of patients undergoing thoracotomy for lung cancer. Several lymph node maps have been proposed in an attempt to ensure uniformity in designating lymph node stations. The Japan Lung Cancer Society has published detailed definitions for each nodal station adopting the Naruke map. However, since these definitions had not been interpreted into other languages, they have not been universally accepted. The objective of this study was to assess the inter-observer variability in the interpretation of lymph node stations. Methods . A total of 424 lymph node stations were removed from 41 patients undergoing thoracotomy for non-small cell lung cancer. All nodal stations were labeled using the Naruke map. As each station was excised, it was designated in a blind fashion by one of two surgeons trained in the UK and one surgeon trained in Japan. The designation accorded to each nodal station was analyzed. Results . The total concordance was 68.5% (right side 67.0%, left side 69.9%). The concordance rate for individual nodal stations varied from 0% to 100%. Considerable discordance existed between the Japanese and European surgeons in the designation of nodal stations 2, 4, 8 and N 1 station 12. In 14 (34.1%) patients, discordance in the labeling of lymph nodes led to disease being categorized as N 1 by one observer, whereas the other considered the same nodes to be N 2 . Conclusions . Considerable discordance in the designation of nodal station has been demonstrated. We would expect similar inter-observer variability elsewhere between surgeons, institutions, or countries. More detailed nodal charts and precise, easily understood definitions of nodal stations are needed for intrathoracic staging. The first English version of the Japan Lung Cancer Society staging manual goes some way to address this.

Fibromatosis is a rare fibroproliferative disorder with a tendency for local infiltrative and destructive growth. Local recurrence is frequent, despite apparent complete resection after radical excision. We present a case of a 22-year-old woman with massive recurrent thoracic fibromatosis extending into the neck and impairing the function of her right upper limb. This required a multidisciplinary approach to surgery to salvage the limb. The case highlights the fact that while every attempt should be made to achieve negative histologic margins, local recurrence is not uncommon. Therefore, if fibromatosis occurs adjacent to or involves vital structures, these should not be sacrificed to achieve negative margins. Function and structure preserving procedures are important as the primary goal, if not even more important.

The article by Strand et al. 1 on the evaluation of the new tumour, node, metastasis (TNM) classification and staging system for lung cancer raises important questions on the validity of the classification and its therapeutic implications in clinical practice. The authors analysed a population-based series of 1,885 patients who underwent operation for lung cancer and who were registered at the Cancer Registry of Norway from 2001 to 2005. They pathologically classified these tumours according to the 6th 2 and 7th 3 editions of the TNM classification to assess their prognostic capacity, and found that the 7th edition did not improve the overall predictive ability of the staging system. Moreover, based on the current indications of therapy, nearly one-fifth of the patients could be offered different treatment options because of the rearrangement of some TNM subsets in different stages. Whether this different treatment will result in an improved prognosis is unknown. Regarding the prognostic capacity of the 7th edition of the TNM classification, the authors' results contradict those of the International Association for the Study of Lung Cancer (IASLC), whose database of >100,000 patients collected worldwide was used to revise the 6th edition of the classification 4, and those of others whose patient series have validated most of the changes introduced in the 7th edition. Soon after the publication of the recommended changes for the new edition, independent groups validated them based on their own data or on data from registries. Zell et al. 5 and Ou and Zell 6, 7 found that the proposed changes better reflected survival for advanced bronchioloalveolar carcinoma and for small cell lung cancer, and validated the revisions of the T4 and M descriptors, respectively. …

Surgical treatment of lung metastases from melanoma is highly controversial as the expected outcome is much poorer than for other primary tumours and a reliable system for selecting patients is lacking. This study evaluated the long-term results of lung metastasectomy for melanoma, with the aim of defining a subset of patients with better prognosis. By reviewing the data of the International Registry of Lung Metastases (IRLM), we identified 328 patients who underwent lung metastasectomy for melanoma in the period 1945–1995. Survival was calculated by Kaplan–Meier estimate, using log-rank test and Cox regression model for statistical analysis. After complete pulmonary metastasectomy (282 patients) the 5- and 10-year survival was 22% and 16%, respectively. In this group of patients, a time to pulmonary metastases (TPM) shorter than 36 months or the presence of multiple metastases were independent unfavourable prognostic factors. There were no long-term survivors after incomplete resection (46 patients, P< 0.01). Using the IRLM grouping system, patients without risk factors (TPM > 36 months and single lesion) experienced the best survival (29% at 5 years), followed by those with one risk factor only (20% at 5 years). On the other hand, those with two risk factors or incomplete resection showed a significantly poorer survival (7% and 0% at 5 years). Surgery plays an important role in carefully selected cases of pulmonary metastatic melanoma. The prognostic grouping system proposed by the International Registry of Lung Metastases provides a simple and effective method for improving the selection of surgical candidates. © 2000 Cancer Research Campaign

Although many patients with severe emphysema have undergone lung-volume-reduction surgery, the benefits are uncertain. We conducted a randomized, controlled trial of the surgery in patients with emphysema. Patients with isolated bullae were excluded because such patients are known to improve after bullectomy.Potentially eligible patients were given intensive medical treatment and completed a smoking-cessation program and a six-week outpatient rehabilitation program before random assignment to surgery or continued medical treatment. After 15 patients had been randomized, the entry criteria were modified to exclude patients with a carbon monoxide gas-transfer value less than 30 percent of the predicted value or a shuttle-walking distance of less than 150 m, because of the deaths of 5 such patients (3 treated surgically and 2 treated medically).Of the 174 subjects who were initially assessed, 24 were randomly assigned to continued medical treatment and 24 to surgery. At base line in both groups, the median forced expiratory volume in one second (FEV1) was 0.75 liter, and the median shuttle-walking distance was 215 m. Five patients in the surgical group (21 percent) and three patients in the medical group (12 percent) died (P=0.43). After six months, the median FEV1 had increased by 70 ml in the surgical group and decreased by 80 ml in the medical group (P=0.02). The median shuttle-walking distance increased by 50 m in the surgical group and decreased by 20 m in the medical group (P=0.02). There were similar changes on a quality-of-life scale and similar changes at 12 months of follow-up. Five of the 19 surviving patients in the surgical group had no benefit from the treatment.In selected patients with severe emphysema, lung-volume-reduction surgery can improve FEV1, walking distance, and quality of life. Whether it reduces mortality is uncertain.

The aim of this study was to investigate the effect on lung function of lung biopsy used in the diagnosis of diffuse lung disease carried out by an open procedure or by video-assisted thoracoscopy. One hundred and sixteen patients with diffuse lung disease who attended the Royal Brompton Hospital were studied retrospectively. Thirty five patients underwent open lung biopsy, and 33 video-assisted thoracoscopic biopsy and 48 had their diagnosis made without biopsy. All patients underwent lung function tests before and after surgery, or at an interval of 3-6 months in those who did not undergo biopsy. No significant differences were found in changes in lung function between those who had and had not undergone biopsy, and the proportions of patients whose lung function improved or deteriorated were similar. Lung biopsy by an open procedure or by video-assisted thoracoscopy did not differ in its effects on lung function. The results for older patients, those with severe disease and those with fibrosing alveolitis were the same as for the whole group. Open lung biopsy for the diagnosis of diffuse lung disease does not deleteriously affect lung function whether carried out by an open or a minimally invasive procedure.

Postpneumonectomy pulmonary oedema (PPO) develops in approximately 5% of patients undergoing pneumonectomy or lobectomy, and has a high associated mortality (>50%). In its extreme form, PPO follows a clinical and histopathological course indistinguishable from acute respiratory distress syndrome. Perioperative fluid overload, impaired lymphatic drainage following node dissection and trauma caused by surgical manipulation have been implicated in the pathogenesis of PPO. However, PPO more probably represents the pulmonary manifestation of a panendothelial injury consequent upon inflammatory processes induced by the surgical procedure, which involves collapse and re-expansion of the operative lung to permit hilar dissection and pulmonary resection. High inspired oxygen concentrations are required to overcome the effects of shunt. Animal studies have shown that pulmonary ischaemia/reperfusion can result in oedema formation, possibly due to the generation of pro-oxidant forces. Moreover, plasma taken from patients undergoing lobectomy or pneumonectomy (but not lesser resections) shows evidence of oxidative damage. Such evidence suggests either that the high inspired oxygen concentrations associated with one-lung ventilation, or ischaemia/reperfusion injury, may modulate post-pneumonectomy pulmonary oedema. Mechanisms by which redox imbalance may result in tissue damage and postpneumonectomy pulmonary oedema are discussed.

LVRS works, but can we make it safer? There are now five controlled trials showing that lung reduction for emphysema can alter lung function, increase walking distance, and improve quality of life.1–5 There are problems with each study in terms of design, duration, and small sample size but, taken together, they give a strong message that lung volume reduction surgery (LVRS) has a role in the management of chronic obstructive pulmonary disease (COPD). However, we need much more evidence before we can define exactly what this role is and when to recommend surgery. In particular, we need better ways of predicting benefit and risk. We also need to understand how LVRS works in order to develop better and safer ways of doing it. The large National Emphysema Treatment Trial (NETT) study6 which began 2 years ago and is expected to take 4 years to complete will provide some of the answers, and early results are helping to define a high risk group. In an unusual move the New England Journal …

Pulmonary hypertension is characterized by hypertrophy and hyperplasia of vascular smooth muscle occurring via an unknown mechanism. Cyclooxygenase (COX)-2 and inducible nitric oxide synthase (iNOS) are expressed under inflammatory conditions and produce mediators that regulate growth in some tissues. We have therefore addressed the question of COX-2 and iNOS involvement in proliferation of human and rat pulmonary artery (PA) smooth-muscle cells (SMC). Interleukin (IL)-1beta suppressed proliferation of both human and rat PA SMC. Moreover, IL-1beta induced COX-2 expression in both cell types. By contrast, IL-1beta stimulated the expression of iNOS protein in rat cells only. COX-2 induced in human cells inhibited proliferation, whereas COX-2 products in rat cells were without affect. However, iNOS activity in rat cells suppressed their proliferation. We conclude that human and rat evolution has diverged such that COX-2 and iNOS, although induced by the same mediator, have different levels of activity and functions in the two species. In humans, induction of COX-2 during pulmonary hypertension may be beneficial for long-term treatment of this disease.

Objective: We have used a continuous suture technique for all tracheal and bronchial anastomoses with satisfactory results in our institution. The objective of this article is to review our experience with sleeve resections using this technique and report the associated morbidity and mortality in 100 consecutive cases. Methods: Our experience with sleeve resection using a continuous suture (3-0 polypropylene) technique was reviewed in 100 consecutive cases. The median age of the patients was 53.3 years with a range of 21 to 81 years. There were 54 male patients and 46 female patients. Resection was undertaken for malignant disease in 81 patients, acquired stricture in 14 patients, benign tumor in 4 patients, and trauma in 1 patient. Among 28 patients in whom lung parenchyma was not resected, 16 patients had tracheal resection and 12 had bronchial sleeve resection. Sleeve pneumonectomy was undertaken in 2, sleeve lobectomy in 66, and sleeve segmentectomy in 4. Results: There were 12 postoperative complications (12%) and 2 postoperative deaths resulting from bronchoatrial fistula and pneumonia (2%). Stricture as a late complication occurred in 5 patients, 2 of whom required a bronchial stent. Other late complications were bougienage, reanastomosis, and completion pneumonectomy (1 each). Conclusion: Our experience suggests that the results of continuous suture technique are comparable with those from reported series using interrupted suture technique for tracheal and bronchial anastomosis. (J Thorac Cardiovasc Surg 1999;117:1112-7)

Objective: Although systematic nodal dissection is accepted as an important component of the intrathoracic staging of disease in patients undergoing thoracotomy for lung cancer, many surgeons still do not routinely perform it. We reviewed our practice to assess the information provided by its routine application even when lymph node metastases are considered unlikely. Methods: The records of 240 patients undergoing thoracotomy for clinically staged cT1-3 N0-1 non–small cell lung cancer were reviewed. In 5 cases (2%) mediastinal dissection was not performed because of specific contraindications and in 8 cases (3%) exploratory thoracotomy was performed. The pathologic findings in the 227 patients who underwent pulmonary resection with systematic nodal dissection were analyzed. Results: The median number of nodal stations, including N1 and N2, examined and submitted separately for histologic assessment was 7 per patient (range 3-13). N2 disease was disclosed in 46 patients overall (20%), including 41 of the 227 patients undergoing pulmonary resection (18%) and 5 of those undergoing exploratory thoracotomy (62.5%). No subgroup had a 0% incidence of N2 metastases. Multivariate analysis showed that younger age, increasing tumor size, left lower lobe origin, and bronchial origin were significant independent variables for prediction of lymph node metastases at the N1 level, the N2 level, or both. Conclusions: Because no clinical or pathologic subset of patients with a negligible incidence of N2 disease could be discriminated, systematic nodal dissection must be routinely employed for accurate intrathoracic staging of non–small cell lung cancer. (J Thorac Cardiovasc Surg 1999;117:246-51)

Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. The patient is then positioned lying, shoulder elevated and undressed to the waist, with the arm abducted at 90°. The fourth intercostal space just anterior to the mid-axillary line is usually chosen. The surgical field is prepared with antiseptic solution, and lidocaine is injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make an incision large enough to comfortably admit the index finger. Blunt dissection is undertaken using a Roberts clamp. Once the deep fascia is reached, the intercostal space becomes distinctive. Further lidocaine is used to create a field block by injecting multiple intercostal nerves. After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure spreading the intercostal muscles apart. When the Roberts clamp enters the pleural cavity, a gush of air is normally audible. The jaw of the Roberts clamp is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. Once satisfied that there is no lung tissue adhering to the chest wall, a 28 French gauge drain is introduced into the pleural space without a trocar. Once the drain is sited, it is attached to an underwater seal, and the drain is then secured with a silk suture.

Minimally invasive repair of pectus excavatum (MIRPE) provides a minimal access approach to correct pectus excavatum deformities. Cardiovascular complications represent a rare but catastrophic complication of this cosmetic operation. We describe a modification to the technique following a case of cardiac puncture.

Postpneumonectomy pulmonary oedema (PPO) complicates a significant number of thoracic surgical procedures involving lung resection and in its extreme form is indistinguishable from the acute respiratory distress syndrome. This study investigated the possibility that ischaemia-reperfusion (I-R) injury contributes to PPO via the production of damaging reactive oxygen species. In a prospective, observational, comparative study, patients undergoing pneumonectomy, lobectomy, or wedge resection or open lung biopsy were investigated for perioperative changes in lung function indicative of lung injury and changes in plasma indices of oxidative damage. Significant percentage perioperative falls in plasma protein thiol levels (-17.9+/-7.0% for pneumonectomy, -24.3+/-5.5% for two-lobe lobectomy and -10.2+/-2.2% for one-lobe lobectomy, p

Abdominal compartment syndrome is an increasingly recognized phenomenon. We report the case of an otherwise fit and healthy 42-year-old man who underwent plication of the right hemidiaphragm for idiopathic phrenic paresis. His postoperative recovery was complicated by abdominal compartment syndrome, which was managed conservatively. We believe this is the only report of this complication after diaphragmatic plication and one of very few reported thoracic causes of abdominal compartment syndrome.

International audience

Oesophageal leiomyomatosis and idiopathic eosinophilic oesophagitis are both extremely rare. The former is a diffuse proliferation of smooth muscle in the muscularis propria, whilst the latter is an idiopathic inflammatory condition, thought to be associated with background atopy and characterized by an infiltrate of eosinophils throughout the full thickness of the oesophagus. However, two recent cases of oesophageal leiomyomatosis showed similar full thickness infiltration of the oesophageal wall by eosinophils and this inflammatory cell infiltrate was investigated in conjunction with one case of idiopathic eosinophilic oesophagitis. All three had a similar allergic profile characterized by CD45RO-positive primed T-lymphocytes, EG2-positive (i.e., activated) eosinophils, and tryptasepositive mast cells, together with gene expression for interleukin 4. Previous descriptions of leiomyomatosis describe an association with systemic mastocytosis and urticaria and the possibility that there is a common underlying allergic component to both disorders is raised.

The IASLC sponsored an International Workshop on Intrathoracic Staging held at the Royal Brompton Hospital, London on 28 and 29 October 1996. The faculty consisted of 18 IASLC members from USA (4), Japan (5), Belgium (1), UK (4), Germany (2), France (1) and Italy (1). In addition there were 49 participants from 16 countries. The programme, consisting of formal presentations and video demonstrations, covered the following topics: The international staging system and its defects; The relevance of intrathoracic staging and present position; Radical mediastinal node dissection; Accuracy of pathological assessment of lymph nodes; The German staging system; Stage migration; the Will Rogers effect; Lymphatic dissection: acute lung injury and ARDS; Lymphatic dissection: immunological consequences?; The Naruke map and the Japanese staging system; Stage changes after induction therapy; The ATS nodal map; Pleural lavage as a staging tool; Monoclonal antibodies in nodal examination; The present status of biological staging; and Future prospects for biological markers. The following institutions presented their experience in intrathoracic staging: Genoa, Italy; Heidelberg-Rohrbach, Germany; Memorial Sloan-Kettering, USA; Royal Brompton, UK; National Cancer Centre, Japan; Choisy, France; and Kanazawa, Japan. The following video presentations on staging techniques were shown: Nodal dissection at right thoracotomy (Dr P. Goldstraw); Nodal dissection at left thoracotomy (Dr P. Goldstraw); Nodal dissection by VATS (Dr T. Naruke); Nodal evaluation at mediastinoscopy (Dr U. Pastorino); Nodal dissection at midline sternotomy (Dr D. Grunenwald); and Mediastinal and hilar nodal dissection (Dr R. Tsuchiya). On the second afternoon the Workshop split into two task forces

The 7th edition of TNM for Lung Cancer represented a major advance from previous editions, in the process of revision, the size and breadth of the data base used, its international character, the intensity of the analysis and the critical nature of the internal and external validation undertaken before its launch in January 2010. This all came about by the involvement of the International Association for the Study of Lung Cancer (IASLC), which assumed the role previously performed by Dr. Mountain, of developing data-driven revisions for the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC). In taking on this task the IASLC made the global lung cancer community aware of the limitations of previous revisions and now stand accountable and subject to the same scrutiny. In this article we describe the achievements of the IASLC TNM and Prognostic Factors Committee, but also the short-comings of the 7th edition, as an essential step towards rectifying deficiencies and further improving the classification in future revisions.