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Background: To review the outcomes of surgically resected lung neuroendocrine neoplasms (LNEN) at a tertiary referral centre and to validate a previously published LNEN-specific staging system (NETL)., Methods: All patients who were identified on histopathology to have LNEN were included. Pre-, intra- and post-operative outcomes were collected, including long-term survival. Patients were staged by both the TNM (seventh and eighth edition) and NETL staging (seventh and eighth edition definitions). Kaplan-Meier (KM) survival analysis was performed according to histopathology and stage, along with uni- and multivariate analyses., Result: A total of 132 patients were included in the study, with a median age of 65 years; 55% were female. Typical carcinoid (TC) was the most common pathology (53.4%) followed by large cell neuroendocrine carcinoma (LCNEC - 23.5%), atypical carcinoid (AC - 20.5%) and small cell carcinoma (3.0%). The most common operation performed was a lobectomy (55.3%). Overall survival at 5 years was 80% (100% TC, 78.2% AC, LCNEC 40.9%) and 5-year disease free survival was 76.8% (TC 94.3%, AC 56.8%, LCNEC 56.4%). KM curves showed a trend towards NETL performing better than TNM, however, in multivariate analysis only the histological subtype was found to be significant in our study., Conclusion: This is the largest known Australian series of LNEN to date, showing survival comparable to international outcomes. We have demonstrated large variations in outcome, driven by histological grade. The TNM system does not correlate with survival and we have not been able to show that currently proposed NETL staging is superior., (© 2023 Royal Australasian College of Surgeons.)

Pulmonary metastases are a sign of advanced malignancy and an omen of poor prognosis. Once primary tumors metastasize, they become notoriously difficult to treat and interdisciplinary management often involves a combination of chemotherapy, radiotherapy, and surgery. Over the last 25 years, the emerging body of evidence has recognized the curative potential of pulmonary metastasectomy. Surgical resection of pulmonary metastases is now commonly considered for patients with controlled primary disease, absence of widely disseminated extrapulmonary disease, completely resectable lung metastases, sufficient cardiopulmonary reserve, and lack of a better alternative systemic therapy. Since the development of these selection criteria, other prognostic factors have been proposed to better predict survival and optimize the selection of surgical candidates. Disease-free interval (DFI), completeness of resection, surgical approach, number and laterality of lung metastases, and lymph node metastases all play a dynamic role in determining patient outcomes. There is a definite need to continue reviewing these prognosticators to identify patients who will benefit most from pulmonary metastasectomy and those who should avoid unnecessary loss of lung parenchyma. This literature review aims to explore and synthesize the last 25 years of evidence on the long-term survival, prognostic factors, and patient selection process for pulmonary metastasectomy.

Background: The treatment of choice for early stage non-small cell lung cancer (NSCLC) is surgical resection. Little is known about the short- and long-term outcomes among very elderly patients. We sought to determine predictors of short- and long-term survival among octogenarians undergoing curative-intent resection for NSCLC in Victoria, Australia., Methods: We retrospectively reviewed data from all patients aged ≥80 years who underwent curative-intent resection for NSCLC over 12 years (January 2005-December 2016) across five tertiary centres. We examined effect of age, stage of disease, extent of surgery and lung function on short- and long-term survival., Results: Two hundred patients aged ≥80 years underwent curative-intent resections. Mortality at 30 and 120 days was 2.9% and 5.9%, respectively. Increased early mortality was observed among those ≥83 years, at 30 days (6.8% versus 0.8%, P = 0.044) and 120 days (12.2% versus 2.3%, P = 0.0096). Early mortality was highest among patients ≥83 years requiring lobectomy, compared to sub-lobar resection at 120 days (17% versus 3.8%, P = 0.019). Long-term survival was predicted by age and stage of disease. Among patients with Stage I disease aged <83 years, lobectomy was associated with superior 5-year survival, compared to sub-lobar resection (83% versus 61%, P = 0.02)., Conclusion: In carefully selected elderly patients undergoing curative-intent resection of early stage NSCLC, both short- and long-term outcomes appear consistent with younger historical cohorts. Early mortality was associated with lobectomy in those with advanced age. Older patients undergoing lobectomy appeared to be at highest risk for early mortality, while younger patients with Stage I disease undergoing at least lobectomy appear to have the best long-term survival., (© 2018 Royal Australasian College of Surgeons.)

Background: Lung cancer has markedly poorer survival in men. Recognized important prognostic factors are divided into host, tumour and environmental factors. Traditional staging systems that use only tumour factors to predict prognosis are of limited accuracy. By examining sex-based patterns of disease-specific survival in non-small cell lung cancer patients, we determined the effect of sex on the prognostic value of additional host factors., Methods: Two cohorts of patients treated surgically with curative intent between 2000 and 2009 were utilized. The primary cohort was from Melbourne, Australia, with an independent validation set from the American Surveillance, Epidemiology and End Results (SEER) database. Univariate and multivariate analyses of validated host-related prognostic factors were performed in both cohorts to investigate the differences in survival between men and women., Results: The Melbourne cohort had 605 patients (61% men) and SEER cohort comprised 55 681 patients (51% men). Disease-specific 5-year survival showed men had statistically significant poorer survival in both cohorts (P < 0.001); Melbourne men at 53.2% compared with women at 68.3%, and SEER 53.3% men and 62.0% women were alive at 5 years. Being male was independently prognostic for disease-specific mortality in the Melbourne cohort after adjustment for ethnicity, smoking history, performance status, age, pathological stage and histology (hazard ratio = 1.54, 95% confidence interval: 1.10-2.16, P = 0.012)., Conclusions: Sex differences in non-small cell lung cancer are important irrespective of age, ethnicity, smoking, performance status and tumour, node and metastasis stage. Epidemiological findings such as these should be translated into research and clinical paradigms to determine the factors that influence the survival disadvantage experienced by men., (© 2016 Royal Australasian College of Surgeons.)

Ablation using Nd:YAG laser has potential in resulting a rough effect on tooth surfaces. The objective of this study is to perform a comparative evaluation of the roughness structure of enamel using the Cynosure Cynergy Nd:YAG laser and 37% phosphoric acid. The results obtained for laser-etched with a pulse width of 300ms show roughed and porous surface with greater depth. Both show remarkable graininess on the surface and fewer indentations. Comparison of the elemental compositions demonstrated that calcium has higher composition when exposed to laser-etch compared to acid-etch. The atomic percentages of calcium in sample A for acid-etched and laser-etched are 5.08 and 9.61, respectively. While acid-etched and laser-etched for sample B are 3.98 and 12.84, respectively. Other elements are not profoundly affected by the technique used in this study. However, carbon and oxygen show inconsistent results for both of the samples. Thus, Nd:YAG laser provides significant effects on the tooth surface but does not primarily modify the element compositions of the tooth. Therefore, Nd:YAG laser can potentially be implemented for etching procedure as a replacement of acid etching technique.

VATS lobectomy was first performed more than twenty years ago. Early experience with the procedure led to the enumeration of contraindications, many of which have been circumvented by increasing familiarity with the approach and equipment changes. These previous contraindications to VATS lobectomy (pleural symphasis, chest wall involvement, sleeve resections, etc.) we define as extended lobectomy. This article reviews the literature and discusses some technical points to facilitate the completion of these operations.

Tracheal resection for adenoid cystic carcinoma (ACC) is a well-documented procedure. Surgical resection of these lesions offers patients the greatest potential chance of survival. Midtracheal tumors are usually resected through a maximally invasive sternotomy or thoracotomy. We report a midtracheal resection of a symptomatic ACC in a 25-year-old man by video-assisted thoracoscopic hilar release and suprasternal anastomotic approaches. The patient's recovery was complicated by chylothorax and pneumonia., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The advent of MIS or VATS techniques, better perioperative anesthesia management, and better postoperative care enables thoracic surgeons to operate on marginal patients, with less risk than previously established. Careful preoperative decision making in a multidisciplinary setting should insure that all patients are given the best potential curative option., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Precision medicine depends on the accurate identification of actionable mutations in a tumor sample. It is unknown how heterogeneous the distribution of such mutations can be in a tumor. Morphological (i.e. histopathological) heterogeneity is well described in lung adenocarcinoma and has been specifically recognized in the most recent official clinico-pathological classification. The most predominant subtype present is now used to classify each lung adenocarcinoma. No molecular profile exists to explain the intratumoral differences in lung adenocarcinoma morphology, despite the consistently observed association between specific predominant subtypes and poorer survival. Given a recent proposal stratifying lung adenocarcinoma into subtypes of differing metastatic potential, we questioned the assumption that major mutations are present uniformly throughout tumors; especially those showing discrete different subtypes. We selected formalin-fixed paraffin embedded lung adenocarcinoma specimens that showed discrete areas of different subtypes, extracted subtype DNA samples from those areas and screened for mutations in hotspot regions of the EGFR, KRAS and BRAF genes using high resolution melting. Sanger sequencing was used to confirm all identified mutations. Chromogenic in situ hybridization (CISH) was used to identify mutant allele specific imbalances in tumors with EGFR mutations. Interestingly, we found that KRAS and BRAF mutations could be confined to morphological domains of higher grade. On the other hand, EGFR mutations were found through all histological subtypes in each tumor consistent with the driver status of this mutation. Intratumoral heterogeneity has major implications for tumorigenesis, chemoresistance and the role of histopathology in molecular screening for precision medicine. This study not only confirms that intratumoral mutational heterogeneity does occur, but also that it is associated with morphologically distinct regions in some tumors. From a practical perspective, small biopsies may not adequately represent a tumor's full mutational profile, particularly for later arising but prognostically important mutations such as those in the KRAS and BRAF genes.

Unlabelled: The identification of robust prognostic factors for patients with early-stage non-small cell lung cancer (NSCLC) is clinically important. The International Association for the Study of Lung Cancer has identified both sex and the maximum standardized uptake value (SUVmax) of (18)F-FDG in the primary tumor as measured by PET as potential prognostic variables. We examined the prognostic value of SUVmax in a surgical cohort of patients with NSCLC and disaggregated the findings by sex., Methods: Patients who had undergone a preoperative PET/CT scan and surgical resection with curative intent from 2001 to 2009 were identified from a prospective database. An SUVmax cutoff was calculated using receiver-operating-characteristic curves. Overall survival was correlated with SUVmax for the whole cohort and disaggregated by sex., Results: Inclusion criteria were met by 189 patients: 127 (67%) men and 62 (33%) women. Five-year survival was 54.6% for the whole cohort, 47.7% for men, and 68.2% for women. SUVmax correlated negatively with survival in a univariate analysis for the whole cohort (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.54-4.09; P < 0.001) and men (HR, 3.42; 95% CI, 1.94-6.05; P < 0.001) but not for women (HR, 1.61; 95% CI, 0.43-3.12; P = 0.77), using 8 as a cutoff. In multivariate analysis, SUVmax correlated with overall survival for the whole cohort (HR, 1.70; 95% CI, 1.05-2.99; P = 0.05) and men (HR, 2.40; 95% CI, 1.32-4.37; P = 0.004) but not for women (HR, 0.80; 95% CI, 0.15-4.47; P = 0.80)., Conclusion: SUVmax independently predicted overall survival for men but not for women in this surgical cohort. Our results suggest that SUVmax is an independent prognostic variable in men with surgically treated early NSCLC.

A rare case of primary cardiac leiomyosarcoma was diagnosed in a 21-year-old man who presented with a groin mass thought to be a sebaceous cyst. Histopathology revealed a high-grade pleomorphic leiomyosarcoma. Combined positron-emission and computed tomography showed a large metabolically active left atrial mass with multiple metastases. Major debulking resection was undertaken, followed by radiation and chemotherapy. At 13 months postoperatively, limited spread has been detected, and the patient had no limitation in daily life.

The available tools for diagnosing and staging lung cancer patients can be broadly categorized into non-invasive, minimally invasive and invasive (surgical) modalities. Non-invasive modalities include CT and PET. Minimally invasive modalities are endoscopic approaches, including endoscopic ultrasound, endobronchial ultrasound and transbronchial fine needle aspiration without ultrasound guidance. This review focuses on the non-invasive and minimally invasive techniques involving imaging. Application of Bayesian principles indicates that tests with a high sensitivity and specificity for detection of both systemic metastases and mediastinal nodal involvement are required for treatment selection and planning in patients with non-small cell lung cancer who would be considered for treatment with curative intent. Combined PET/CT using the glucose analogue fluorine-18 fluorodeoxyglucose currently provides the best diagnostic performance for this purpose and should now be considered the standard of care for staging non-small cell lung cancer. Endoscopic ultrasound and endobronchial ultrasound have important complementary roles to allow further evaluation of equivocal nodal abnormalities on PET or CT and to allow pathological samples to be obtained. Diagnostic CT has an important role in defining tumour relations for patients deemed suitable for surgical resection and as the initial investigation for patients with potential symptoms of lung cancer or proven lung cancer that would not be considered for curative treatment on medical grounds.