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Following the last revision of the UICC TNM Staging for Lung Cancer in 1997 the IASLC decided that it should establish an International Committee to continue the work of Dr. Clifton Mountain and to inform future revisions. The committee has met on several occasions since its inaugural meeting in June 1999. The membership of the committee has been finalised (enclosed) to ensure representation of all disciplines treating lung cancer and all geographical regions. From its inception it was emphasised that we should seek to ensure that future revisions should be relevant to non-surgical specialities. We have built strong links with the UICC and those stakeholders who had traditionally been involved in this process, the American Joint Committee for Cancer and the Japan Lung Cancer Society. The UICC has now accepted that our committee will be the primary source of recommendations for the next revision of the TNM System due in 2007. We have established working parties to generate an Internationally agreed definition for “complete resection”, to create an Internationally agreed “Nodal Chart”, and, with our colleagues in the Pathology Section of the IASLC, to establish guidelines on the standards for processing pathological material. We have obtained funding for a S-year period and appointed Dr. John Crowley as our statistician and Cancer Research and Biostatistics (CRAB) in Seattle as the datacentre. Our Data Monitoring Group will be conducting their first site visit in July. We have finalised the dataset and data dictionary and are now actively recruiting data from any unit that can provide retrospective staging data on patients treated by all modalities from 1990 to 2002. We have already overtaken the size of database on which the last revision was based! We need the support of the membership of the IASLC. If you have any data please contact the datacentre directly, myself, or Member/Position Contact Details

The case is described of a 36 year old woman who presented with a large left sided haemothorax. A thoracic computed tomographic (CT) scan suggested there was a bony outgrowth arising from the fourth rib. This was resected surgically and found to be an osteochondroma which was surrounded by blood clot. No definite site of bleeding was identified, but it is thought that the tumour may have traumatised the lung, the pericardiacophrenic artery, or the superior pulmonary vein, resulting in life threatening haemorrhage.

Two cases of intracardiac deposits from testicular teratomas diagnosed by echocardiography and angiocardiography, respectively, are described. The importance of recognizing this as an uncommon site of metastasis from germ cell tumours is discussed.

The aim of the study was to investigate the contribution that open lung biopsy makes to the management of children with diffuse interstitial lung disease and to review the procedure-related morbidity in comparison with published literature on other biopsy techniques. The authors reviewed the case notes and histology of patients under 18 yrs who had had an open lung biopsy in 1991-1998 for investigation of diffuse interstitial lung disease. The majority of patients returned from theatre breathing spontaneously and without an intercostal drain. Three out of 27 suffered a complication related to the biopsy that required intervention. A clear histological diagnosis was reached in 25/27 patients resulting in a change of management in 15/27. The most common histological patterns were nonspecific interstitial pneumonitis which generally had a favourable prognosis and follicular bronchiolitis/lymphocytic interstitial pneumonitis where prognosis was largely dependent on that of an underlying systemic disorder. It is concluded that open lung biopsy makes a substantial contribution to the management of diffuse interstitial lung disease in children and considering both diagnostic yield and safety, remains the biopsy technique of choice.

Congenital funnel-shaped trachea is a serious condition, and the survival rate in infants is poor. A slide tracheoplasty is described, with a brief review of other methods of repair. Two cases that demonstrate the operability of congenital funnel-shaped trachea in infancy are reported.

Summary This catalogue of postoperative complications may seem daunting. In reality, the vast majority of patients recover surprisingly quickly and completely following devastatingly destructive operations on the chest. Most postoperative complications have their origins at the time of surgery. Whilst careful postoperative monitoring can minimize the effect of complications, there can be no substitute for diligent preoperative evaluation and careful operative technique. Thorough preoperative evaluation for elective surgery is time consuming and should not be hurried by the anxieties of the patient, his relatives and the referring physician. Surgery, once embarked upon, is usually irreversible.

Background and purpose To assess the efficacy of stereotactic ablative radiotherapy (SABR) for the treatment of non-small cell lung cancer (NSCLC) through a systematic review of all relevant publications from 2006 to the present compared to controls treated with surgery. In the absence of Grade I evidence, the objective outcome data should form the basis for planning future studies and commissioning SABR services. Materials and methods Standard systematic review methodology extracting patient and disease characteristics, treatment and outcome data from published articles reporting patient data from populations of 20 or more Stage I NSCLC patients treated with SABR with a median follow up of minimum of 1year. The individual outcome measures were corrected for stage and summary weighted outcome data were compared to outcome data from a large International Association for the Study of Lung Cancer (IASLC) cohort matched for stage of disease with survival as the principal endpoint and local control (local progression free survival – local PFS) as the secondary endpoint. Results Forty-five reports containing 3771 patients treated with SABR for NSCLC were identified that fulfilled the selection criteria; both survival and staging data were reported in 3171 patients. The 2year survival of the 3201 patients with localized stage I NSCLC treated with SABR was 70% (95% CI: 67–72%) with a 2year local control of 91% (95% CI: 90–93%). This was compared to a 68% (95% CI: 66–70) 2year survival of 2038 stage I patients treated with surgery. There was no survival or local PFS difference with different radiotherapy technologies used for SABR. Conclusions Systematic review of a large cohort of patients with stage I NSCLC treated with SABR suggests that survival outcome in the short and medium term is equivalent to surgery for this population of patients regardless of co-morbidity. As selection bias cannot be assessed from the published reports and treatment related morbidity data are limited, a direct comparison between the two treatment approaches should be a priority. In the meantime, SABR can be offered to stage I patients with NSCLC as an alternative to surgery.

Introduction In 1996, the International Association for the Study of Lung Cancer (IASLC) launched a worldwide TNM staging project to inform the next edition (seventh) of the TNM lung cancer staging system. In this article, we describe the methods and validation approaches used and discuss the internal and external validity of the recommended changes. Methods The International Staging Committee agreed on a number of general principles that guided the decision-making process. Internal validity was addressed by visually assessing the consistency of Kaplan-Meier curves across database types, geographic regions and addressing external validity, by assessing the similarity of curves generated using the population-based Surveillance Epidemiology and End Results cancer registry data to those generated using the project database. Cox proportional hazards regression was used to calculate hazard ratios between the proposed stage groupings with adjustment for cell type, sex, age, and region. Results Calls for data by the International Staging Committee resulted in the creation of an international database containing information on more than 100,000 cases. The present work is based on analyses of the 67,725 cases of non-small cell lung cancer. Validation checks were robust, demonstrating that the suggested staging changes are stable within the data sources used and externally. For example, suggested changes based on tumor size were well supported, with statistically significant hazard ratios ranging from 1.14 to 1.51 between adjacent pairs in the Surveillance Epidemiology and End Results data. Conclusions Lung cancer stage definitions have never been subjected to such an intense validation process. We do accept, however, that this work is limited in ways that can only be addressed by a prospective database, which we intend to develop. In the meantime, we think that this new system will greatly improve the usefulness of TNM lung staging across all of its purposes.

tumor. Ventilation was ensured by using an armored 8F crossfield tracheal cannula through one of the two 1.5-cm access ports. Because cross-field intubation sometimes obstructs the limited visual field through the minithoracotomy, we modified this intubation by forming a loop with the tube. Therefore, strictly speaking, this method is a roundaboutfield intubation rather than a cross-field intubation. References 1. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg. 1990;49:69-77. 2. Rodriguez E, Pombo F, Aguilera C, Capdevila A. Recurring tracheal leiomyoma presenting as a calcified mediastinal mass. Eur J Radiol. 1996;23:82-4. 3. Gitter R, Daniel TM, Kesser BW, Reibel JF, Tribble CG. Membranous tracheobronchial injury repaired with gastric serosal patch. Ann Thorac Surg. 1999;67:1159-60. 4. Okike N, Payne WS, Cortese DA, Dines DE. Pericardial reconstruction of the membranous trachea after resection of adenoid cystic carcinoma (cylindroma). Mayo Clin Proc. 1978;53:808-10. 5. Crouch RD, Nelson LE, Hawley PC, Frank DA, Williams TE Jr. Onlay patch repair of tracheobronchial rupture. Ann Thorac Surg. 1997;64:1158-60. Brief Communications

Right lower lobectomy is indicated whenever the disease process is limited to the right lower lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

This operation is gaining increasing popularity to restore normal swallowing in patients with irresectable tumours of the thoracic portion of the oesophagus or in those not sufficiently fit to permit the extensive resection. It is particularly useful where tumours of the intra-thoracic oesophagus have eroded into adjacent organs such as lung, pleura or the tracheo-bronchial tree. Patients are not suitable if tumour or involved lymph nodes involve the cervical oesophagus or if there is involvement of the proximal stomach.

This extensive operation allows en bloc resection of the oesophagus and adjacent lymph nodes from the level of the carina, extending inferiorly to the coeliac axis. It is undertaken with curative intent and less ambitious resections should be used in patients clearly incurable. The proximal macroscopic extent of tumour as assessed endoscopically and on contrast X-rays must be beyond the lower margin of the aortic arch. At this level sufficient oesophagus can usually be devolved from beneath the aortic arch so as to permit an anastomosis below the aorta, but if additional length is required the oesophagus may be mobilised above the aorta and brought outwith the aortic arch.

This resection is indicated whenever the disease process is limited to the left upper lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Left pneumonectomy should only be performed when a lesser resection will not clear the pathological process. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lung, and lines of resection through vessels and bronchus should be clear of tumour. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. When undertaken for pulmonary sepsis pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right pneumonectomy should only be performed when a lesser resection will not clear the pathological process. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lung, and lines of resection through vessels and bronchus should be clear of tumour. Radical pneumonectomy permits en bloc resection of the tumour with the superior mediastinal lymph nodes. The right lung is the larger of the two, and careful assessment of respiratory function is necessary pre-operatively. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right middle and lower lobectomy is indicated whenever the disease process is limited to the right middle and lower lobes. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobes, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Right upper lobectomy is indicated whenever the disease process is limited to the right upper lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics started with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection, but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Computerised tomography of the thorax has been in clinical use for almost a decade [1] and yet still we do not have a complete appreciation of its value in the surgical assessment of non small cell lung cancer. In the early years the cost of the equipment, at that time unproved, limited the availability of scanners and access to them. There was a need to develope the basic techniques and those of contrast enhancement. Clinicians and radiologists were learning together, often mesmerised by the detail shown by this technique, perhaps making interpretations without critical assessment. Where assessment was made, technological innovation often outstripped us, providing newer and faster scanners and making clinical studies obsolete before publication. The clinician caught in this technological maelstrom is only now regaining his balance and coming to appreciate that sophisticated technology cannot overcome the basic physical limitation of X-rays — they show densities, not histology. Armed with this basic cynicism, let us now look at what C.T. scans can tell us about the patient with presumed or proven non-small cell lung cancer (N.S.C.L.C.) being assessed for surgery.

Bronchial anastomotic stenosis is a potentially serious complication of sleeve resection. A Silastic endobronchial stent that prevents progressive narrowing at the anastomotic site is described. Insertion of the stent offers a simple and effective treatment that allows improved pulmonary performance, clearing of infection, and good quality of life. The long-term prognosis, however, remains questionable.

Right middle lobectomy is indicated whenever the disease process is limited to the right middle lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

Left lower lobectomy is indicated whenever the disease process is limited to the left lower lobe. The commonest such indication in the western world is carcinoma of the bronchus. The tumour and involved lymph nodes must be confined to the lobe, and lines of resection through vessels and bronchus should be clear of tumour. When undertaken for pulmonary sepsis, pre-operative physiotherapy may produce a temporary but important improvement in the patient’s condition and help minimise post-operative sputum difficulties. All patients should be instructed pre-operatively in the physiotherapy manoeuvres which will be undertaken post-operatively. Prophylactic antibiotics commenced with the premedication and continued for 24 h have been shown to reduce the incidence of wound infection but will have no influence on the more serious problems of chest infection and infection of the pleural space.

This is the preferred approach for tumours of the oesophagus at or above the aortic arch. It is a three-stage operation : (a) midline laparotomy to mobilise the stomach and hiatus, allowing assessment of intra-abdominal metastases; (b) right thoracotomy to mobilise the oesophagus and tumour; and (c) a cervical incision to perform the anastomosis. The third step may be omitted and an intra-thoracic anastomosis undertaken (Ivor Lewis operation). However, if the anastomosis is within the chest the consequences of anastomotic leak are disastrous and there is some evidence to suggest that such anastomoses are associated with more troublesome reflux problems.

Although the presence of nodal disease is prognostic in thymic malignancy, the significance of the extent of nodal disease has yet to be defined. Lymph node dissection has not been routinely performed, and there is currently no node map defined for thymic malignancy. To establish a universal language for reporting as well as characterize the staging of this disease more accurately, an empiric node map is proposed here. This was developed using prior classification systems, series reporting specifics of nodal involvement, anatomical studies of lymphatic drainage, and preexisting node maps of the chest as defined by the International Association for the Study of Lung Cancer and the neck as defined by the American Academy of OtolaryngologyHead and Neck Surgery and the American Society for Head and Neck Surgery. The development of this node map was a joint effort by the International Thymic Malignancy Interest Group and the Thymic Domain of the IASLC Staging and Prognostic Factors Committee. It was reviewed and subsequently approved by the members of ITMIG. This map will be used as an adjunct to define node staging as part of a universal stage classification for thymic malignancy. As more data are gathered using definitions set forth by this node map, a revision may be undertaken in the future.