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Thymic epithelial tumors are presently staged using a consistent TNM classification developed by the International Association for the Study of Lung Cancer (IASLC) and approved by the Union for International Cancer Control and the American Joint Committee on Cancer. The stage classification is incorporated in the eight edition of the TNM classification of thoracic malignancies. The IASLC Staging and Prognostic Factors Committee (SPFC)-Thymic Domain (TD) is in charge for the next (ninth) edition expected in 2024. The present article represents the midterm report of the SPFC-TD: in particular, it describes the unresolved issues identified by the group in the current stage classification which are worth being addressed and discussed for the ninth edition of the TNM classification on the basis of the available data collected in the central thymic database which will be managed and analyzed by Cancer Research And Biostatistics. These issues are grouped into issues of general importance and those specifically related to T, N, and M categories. Each issue is described in reference to the most recent reports on the subject, and the priority assigned by the IASLC SPFC-TD for the discussion of the ninth edition is provided.

For a patient with stage I or II non-small cell lung cancer (NSCLC) surgical resection remains the treatment of choice on condition that the patient is functionally operable. A complete resection should be obtained. Often lobectomy is feasible by a minimally invasive approach. For patients with compromised cardiopulmonary function stereotactic radiotherapy is an alternative treatment. For patients who are functionally operable, no definite recommendation can be made as no large, randomised studies have been performed with a sufficient number of patients and long-term follow-up. For this reason, it is important to discuss every patient within a multidisciplinary team with participation of thoracic surgeons and radiation oncologists. To provide personalised advice, the primary tumour, its extension, the patient's comorbidities and his respiratory and cardiac function have to be considered.

Objective: Breast reconstructions with perforator flaps from the lower abdomen, commonly known as Deep Inferior Epigastric artery Perforator flap (DIEP-flap), have become the golden standard for autologous breast reconstruction after breast amputation. During this surgical procedure multiple challenging steps are encountered such as the selection of a suitable perforator that provides sufficient blood supply for the flap, surgical dissection of the chosen perforator, determination of perfusion area of the chosen perforator, microsurgical anastomosis, flap inset and shaping the flap into a breast. The current gold standard for perforator mapping is Computed Tomography Angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, Dynamic Infrared Thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion, to monitor integrity of the perforator after dissection and to monitor the patency of the pedicle of the free flap after the anastomosis, during flap inset and flap shaping. Study design: In this clinical study we present the results of the use of DIRT in 33 DIEP-flaps in 21 patients after mastectomy. The same standardized measurement set-up was used for all the flaps in the pre-, intraand postoperative period. Results: In the pre-operative period DIRT confirmed the location of the 69 perforators shown on the CTA. In the intra-operative period the rate and pattern of rewarming was successfully observed. One perforator was severely damaged during dissection and the DIEP flap was converted to a Muscle Sparing free Transverse Rectus Abdominis Muscle (TRAM) flap, after viability check of the flap by DIRT. DIRT diagnosed one kinking of the pedicle after microsurgical anastomosis. Two flaps were monitored successfully postoperatively. All 33 breast reconstructions were with good outcome. Conclusion: The use of DIRTwith our standardized measurement setup is a useful, non-invasive tool during breast reconstructions with free DIEP-flaps in all the phases of the reconstruction (pre-, intraand post-operative). This study confirms that DIRT with the standardized measurement setup provides information on perforator location, blood supply and patency of the anastomosis without interference with the operating surgeon. (C) 2020 Elsevier B.V. All rights reserved.

For patients with locally advanced non-small cell lung cancer (NSCLC) or positive N1 nodes, multimodality treatment is indicated. However, the optimal management of patients presenting with ipsilateral positive mediastinal nodes (N2 disease) has not been determined yet. Different treatment regimens consisting of chemotherapy, radiation therapy, and surgery have been proposed and implemented previously. In more recent years, immunotherapy and targeted therapies have been added as therapeutic options. The role of surgery is currently redefined. Recent studies have shown that surgical resection after induction immunotherapy or targeted therapy is feasible and yields good short-term results. In this review, we summarize the latest data on multimodality treatment options for stage IIIA-N2 locally advanced NSCLC, depending on the extent of nodal involvement.

The current coronavirus disease 2019 (COVID-19) pandemic has forced healthcare providers worldwide to adapt their practices. Our understanding of the effects of COVID-19 has increased exponentially since the beginning of the pandemic. Data from large-scale, international registries has provided more insight regarding risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and has allowed us to delineate specific subgroups of patients that have higher risks for severe complications. One particular subset of patients that have significantly higher risks of SARS-CoV-2 infection with higher morbidity and mortality rates are those that require surgical treatment for lung cancer. Earlier studies have shown that COVID-19 infections in patients that underwent lung cancer surgery is associated with higher rates of respiratory failure and mortality. However, deferral of cancer treatments is associated with increased mortality as well. This creates difficult situations in which healthcare providers are forced to weigh the benefits of surgical treatment against the possibility of SARS-CoV-2 infections. A number of oncological and surgical organizations have proposed treatment guidelines and recommendations for patients planned for lung cancer surgery. In this review, we summarize the latest data and recommendations for patients undergoing lung cancer surgery in the COVID-19 circumstance.

Pulmonary ossifications have often been regarded as rare, post-mortem findings without any clinical significance. We have investigated the occurrence of pulmonary ossifications in patients undergoing thoracic procedures, and how this may affect the differential diagnosis of solitary pulmonary nodules. In addition, we have performed a literature search on the occurrence and possible pathogenesis of these ossifications. From January 2008 until August 2019, we identified pulmonary ossifications in 34 patients who underwent elective pulmonary surgery. Pre-operative imaging was unable to differentiate these ossifications from solid tumors. A definitive diagnosis was made by an experienced pathologist (VS, ML). The PubMed database was researched in December 2019 with the search terms “pulmonary ossifications”, “heterotopic ossifications”, and “solitary pulmonary nodule”. In total, 27 patients were male, with a mean age of 63 ± 12 years (age 41 to 82 on diagnosis). All lesions were identified on thoracic CT and marked for resection by a multidisciplinary team. A total of 17 patients were diagnosed with malignancy concurrent with ossifications. There was a clear predilection for the right lower lobe (12 cases, 35.3%) and most ossifications had a nodular form (70.6%). We could not identify a clear association with any other pathology, either cancerous or non-cancerous in origin. Oncologic or pulmonary comorbidities did not influence patient survival. Pulmonary ossifications are not as seldom as thought and are not just a curiosity finding by pathologists. These formations may be mistaken for a malignant space-occupying lesion, both pre-and perioperatively, as they are indistinguishable in imaging. We propose these ossifications as an underestimated addition to the differential diagnosis of a solitary pulmonary nodule.

Stage IIIA-N2 non-small cell lung cancer (NSCLC) comprises a very heterogeneous group of locally advanced tumors for which optimal treatment strategies remain highly controversial although results of large randomized controlled trials are available (1). In general, recommended treatment for pathologically proven, clinical stage IIIA-N2 NSCLC consists of concomitant chemoradiotherapy (CRT) (2). However, the prognosis for this patient group remains poor (3). The role of surgery in the multimodality setting is intensively debated and different treatment recommendations have been proposed.

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. It is estimated that 50% of all patients with CRC develop metastases, most commonly in the liver and the lung. Lung metastases are seen in approximately 10–15% of all patients with CRC. A large number of these patients with metastatic CRC can only receive palliative treatment due to invasion of other organs and disseminated disease. However, a subset of these patients present with potentially resectable metastases. Pulmonary metastasectomy is considered to be a potentially curative treatment for selected patients with resectable metastatic CRC. Current data suggest that patients that undergo pulmonary metastasectomy have 5-year survival rates of approximately 40%. However, the majority of data published regarding lung metastasectomy is based on small, retrospective case series. Due to this lack of prospective data, it is still unclear which subset of patients will benefit most from curative-intent surgery. Furthermore, there is also controversy regarding which prognostic and genetic factors are related to survival outcomes and whether there is a difference between open and thoracoscopic approaches in terms of overall and disease-free survival. In this review, we aim to summarize the latest data on prognostic factors and survival outcomes after pulmonary metastasectomy in patients with metastatic CRC.

In the last two decades, robotic-assisted approaches have gained popularity as alternatives to conventional open and minimal-invasive surgery (MIS). The robotic approach combines the concepts of the traditional MIS with the latest technological advancements, enabling the surgeon to control the instrumentation using a robotic device connected to a remote console. With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception and hand-eye coordination. Since its introduction, numerous robotic-assisted procedures have been developed and tested across nearly all surgical fields. Data from previous studies have shown that a great majority of these techniques are feasible and have favourable treatment outcomes. In the field of thoracic and vascular surgery, two disciplines often combined in Belgium, robotic approaches have been implemented in the treatment of a wide array of disorders including lung cancer, mediastinal tumours, thoracic outlet syndrome, diaphragmatic paralysis, sympathectomy, aortobifemoral bypass surgery and division of the arcuate ligament for median arcuate ligament syndrome (MALS). Despite this increasing popularity, there are still a number of controversies regarding robotic surgery. There are only limited data on the cost-effectiveness of robotic surgery and its objective proven benefit over conventional MIS. In this review, we summarise the latest data on robotic approaches for the most relevant thoracic and vascular disorders.

Objective: In this review, we aim to summarize the most recent data on the surgical management of oligometastatic non-small cell lung cancer (NSCLC). Background: Approximately 60-70% of all patients with NSCLC initially present with advanced stages of cancer at time of diagnosis. These patients are generally treated with chemotherapy, radiation therapy, or a combination of these modalities. Patients with late-stage disease are usually not considered to be amenable for curative-intent treatments due to poor prognoses. Despite advances in systemic therapies, 5-year overall survival rates in these patients remain poor. However, technological advances in imaging modalities and new imaging strategies have substantially increased tumor detection rates and have resulted in a shift towards earlier diagnosis of NSCLC, possibly in stages in which metastatic disease is limited and still treatable. Studies in recent years have shown that there is a distinct group of patients with metastatic lesions at one or a few sites, often referred to as oligometastatic disease, that may have better survival outcomes compared to patients with more disseminated diseases. Furthermore, it is suggested that these patients may benefit from a combination of systemic treatment and local treatment aimed at the metastatic site(s). However, the role of surgery in this setting remains a controversial subject, with many unanswered questions. Methods: The PubMed/MEDLINE database and the Cochrane database were searched to find relevant articles regarding oligometastatic NSCLC. Specifically, articles regarding definitions of oligometastatic disease, oligometastatic tumor biology, diagnosis, and the treatment of oligometastatic disease were identified. Conclusions: Oligometastatic NSCLC represents a wide spectrum of diseases and encompasses a heterogeneous patient population. Current data suggests that local ablative treatment of oligometastatic lesions with surgery or stereotactic body radiation therapy may result in improved overall survival and progression-free survival rates. However, more data from multi-center prospective trials are necessary to shed light on which therapeutic modalities are most suitable for the treatment of oligometastatic NSCLC. Integration of clinical and molecular staging data is necessary to allow for more personalized treatment approaches.

A 70-year-old woman was referred to the department of thoracic and vascular surgery after a floating mural thrombus was found in the distal aortic arch with extension into the proximal descending aorta. Imaging and clinical examination did not show signs of embolization and treatment with aspirin and low–molecular weight heparin was started. Follow-up after 2 weeks and 6 months showed a complete resolution of the aortic mural thrombus.

Objective: The role and timing of surgery for malignant pleural mesothelioma (MPM) in a multimodal setting remains a controversial topic. Earlier studies suggest that pleurectomy/decortication (P/D) achieves similar or better oncological results and overall survival rates compared to extrapleural pneumonectomy. The aim of this study is to investigate outcomes in patients undergoing P/D for MPM at a single centre. Methods: Clinical and pathological characteristics of MPM patients treated by P/D between January 2013 and January 2020 were reviewed. Overall 30- and 90-day mortality and 1- and 2-year survival rates were calculated. Univariate and regression analyses of factors related to long-term survival were performed. Kaplan-Meier curves and the long-rank test were used to analyse differences between induction and adjuvant chemotherapy. Results: A total of 41 patients (31 male and 9 female) with a mean age of 65±7.8 years underwent P/D for MPM. The 30- and 90-day mortality rates were 2.5% and 5.4%, respectively. Overall 1-, and 2-year survival (OS) rates were 67.6% and 41.4%, respectively. Progressive disease occurred in 63.2% of all patients. Multiple regression analysis revealed age>70 years, asbestos exposure, T-status, N-status, tumour pathology, (neo)adjuvant therapy, postoperative morbidity, and progressive disease as significant prognostic factors (p Conclusion: Patients treated with P/D for MPM in a multimodal setting have acceptable overall survival rates. The findings suggest that induction chemotherapy results in better OS than adjuvant chemotherapy.

Opinion statementRobotic-assisted videothoracoscopic surgery (R-VATS) has become increasingly popular and widely used since its introduction and is nowadays considered a standard treatment approach in many centres for the treatment of non-small cell lung cancer. R-VATS was initially developed to overcome the drawbacks of VATS by offering surgeons more flexibility and three-dimensional optics during thoracoscopic surgery. The effectiveness of R-VATS lobectomy regarding oncological outcomes, morbidity, mortality, and postoperative quality of life (QoL) has been shown in an increasing number of studies. More recently, these results have also been corroborated for sublobar resections, more specifically for segmentectomy. However, no well-powered, multicentre randomized trials have been performed to demonstrate the superiority of R-VATS compared with open surgery or conventional types of VATS (total VATS, uniportal VATS, etc.). The majority of the evidence currently available is based on non-randomized studies, and many studies report conflicting results when comparing R-VATS and conventional VATS. Moreover, there is a lack of data regarding the cost and the cost-efficiency of robotic surgery compared with VATS and open surgery. Current evidence suggests that R-VATS costs are higher than VATS and that a deficit can only be prevented when up to 150-300 thoracic surgery procedures are performed annually. Finally, robotic-assisted laparoscopic surgery showed better ergonomics and reduced musculoskeletal disorders compared with non-robotic laparoscopic surgery.

Robotic-assisted thoracoscopic surgery has increased in popularity during the past two decades because it offers 3-dimensional optics, increased instrument and wrist flexibility compared to classical video-assisted thoracoscopic surgery, and, for patients, improved quality of life and shorter hospital stays compared to open surgery. In this video tutorial, we demonstrate a robotic-assisted thoracoscopic surgery lobectomy in a patient with a tumor in the right middle lobe. The patient had an excellent recovery with no perioperative or postoperative complications.

Breast reconstruction with an autologous free Deep Inferior Epigastric Perforator (DIEP) flap is one of the preferred options following mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. The current golden standard for perforator mapping is computed tomography angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, dynamic infrared thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion. Multiple studies have been performed with the use of DIRT, unfortunately without standardisation of the measurement set-up. In this technical note we propose a standardised and reproducible measurement set-up for the use of DIRT during breast reconstructions with a free DIEP flap. This set-up can be used pre-, intra- and postoperatively. A standardised measurement set-up will improve the quality of measured data and ensure reproducibility.

The optimal treatment of malignant pleural mesothelioma (MPM) has not yet been established and is still under investigation. Surgery is one of the pillars in the multimodality approach with the purpose of removing as much as visible tumor as possible and to relieve symptoms. To date, two major surgical procedures are available for removal or debulking of MPM that is considered to be resectable: [extended (e)] pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP). Historically, EPP was regarded as the only way to achieve a macroscopic complete resection. However, in the last years, there is a shift in literature towards (e) P/D as the preferred surgical procedure whenever possible as several retrospective studies and meta-analyses showed a similar or lower long-term survival and higher perioperative mortality and postoperative morbidity in patients who been treated with EPP. On the other hand, no randomized-controlled trials regarding surgical treatment with (e) P/D or EPP exist and therefore level A evidence favoring one surgical procedure is lacking. In this review we provide a nuanced and well-considered answer to the question whether EPP is still indicated in the surgical treatment of MPM.

Thymic epithelial tumours (TETs) are rare lesions that represent less than 1% of all malignancies in adults. Presentation occurs in three ways: asymptomatic, with local thoracic symptoms or with paraneoplastic symptoms. Heterotopic ossifications are rare histological features in neoplasms and non-neoplastic lesions. Here, we present a 49-year-old male patient with a thymoma type B2 mimicking an aortic aneurysm. Alongside the thymoma, a cholesterol granuloma with unusual ossification features was found as well. This clinical presentation and pathological diagnosis are unusual findings.

Simple Summary For patients with locally advanced non-small cell lung cancer (NSCLC) or positive N1 nodes, multimodality treatment is indicated. However, the optimal management of patients presenting with ipsilateral positive mediastinal nodes (N2 disease) has not been determined yet. Different treatment regimens consisting of chemotherapy, radiation therapy, and surgery have been proposed and implemented previously. In more recent years, immunotherapy and targeted therapies have been added as therapeutic options. The introduction of these newer modalities has raised questions on the role of surgery after targeted therapy or immunotherapy. Recent studies have shown that surgical resection after induction immunotherapy or targeted therapy is indeed feasible, but is associated with a higher risk of conversion and increased morbidity due to hilar inflammation. In this review, we summarize the latest data on outcomes of patients undergoing surgical resection after induction immunotherapy and/or targeted therapy. Treatment outcomes have to be carefully evaluated to determine the contribution of surgery in multimodality treatment regimens including immunotherapy and targeted therapies. Multimodality therapy for locally advanced non-small cell lung cancer (NSCLC) is a complex and controversial issue, especially regarding optimal treatment regimens for patients with ipsilateral positive mediastinal nodes (N2 disease). Many trials investigating neoadjuvant immunotherapy and targeted therapy in this subpopulation have shown promising results, although concerns have risen regarding surgical feasibility. A thorough literature review was performed, analyzing all recent studies regarding surgical morbidity and mortality. Despite the fact that two major trials investigating this subject were terminated early, the overall consensus is that surgical management seems feasible. However, dissection of hilar vessels may be challenging due to hilar fibrosis. Further research is necessary to identify the role of surgery in these multimodality treatment regimens, and to define matters such as the optimal treatment regimen, the dosage of the different agents used, the interval between induction therapy and surgery, and the role of adjuvant therapy.

Resume Du fait d’une maladie longtemps asymptomatique, la majorite des patients diagnostiques pour un cancer du poumon non a petites cellules presentent d’emblee une maladie a un stade localement avance ou metastatique. Les stades III doivent etre separes en stade IIIA qui represente un groupe heterogene, et en stade IIIB et IIIC suivant la 8e edition de la classification TNM. L’atteinte N2 definit le sous-groupe du stade IIIA le plus frequent mais egalement le plus heterogene. Ce qui concerne le stade IIIA, une intervention peut etre envisage pour les tumeurs T3N1 et T4N0-1 si une resection complete peut etre obtenue, dans certains cas apres une therapie d’induction ou suivi d’une therapie adjuvante. Le sous-groupe N2 reste le plus controverse. Lorsque l’atteinte N2 est decouverte par hasard pendant une thoracotomie, une resection peut etre accomplie pourvu qu’elle soit complete. La plupart des patients chez lesquels l’atteinte N2 est prouvee par une technique peu invasive ou invasive, sont traites par therapie d’induction suivie de chirurgie ou de radiotherapie. Une lobectomie peut etre conseillee chez des patients avec une clairance mediastinale apres une therapie d’induction. Des patients avec une atteinte N2 massive et non resecable sont a traiter par une chimioradiotherapie combinee. L’extreme variabilite du stade III est a l’origine de controverses qui durent depuis plus de trente ans, avec un debat qui persiste. Le consensus repose neanmoins sur la necessite d’une evaluation exhaustive conjointe de la maladie loco-regionale ainsi que du patient dans sa globalite. Chaque patient doit etre discute a une reunion de concertation pluridisciplinaire.

In 2016, the International Association for the Study of Lung Cancer (IASLC) published a number of revisions of the seventh edition of the tumor, node and metastasis (TNM) classification for malignant pleural mesothelioma (MPM). The purpose was to establish a set of recommendations for the eighth edition of the TNM staging system. A large number of patients were included in the IASLC database and subsequently analysed to determine new definitions for the components of the TNM classification. A number of important changes were introduced for the T component. Survival analysis of the different T categories showed no significant difference in categories T1a and T1b. This has resulted in a collapse of categories T1a and T1b into one category T1. In addition, tumor thickness was also significantly associated with overall survival. The descriptors for the N components have been redefined as well for the eighth TNM classification. A major revision is the removal of category N3 in the N component. Both intrapleural and extrapleural (N1 and N2 in the seventh edition) are now combined into a single category N1. Lymph nodes that were previously categorized as N3 are now considered N2. For the M component, no redefinition has been published. However, a recommendation has been made to only consider M1 involvement as stage IV disease. This is in contrast to the seventh edition in which T4 and N3 disease were considered stage IV as well. In conclusion, a number of important revisions for the eighth TNM classification of MPM have been published as a result of this IASLC project. This type of large-scale and international joint efforts are key in establishing effective staging systems. Research into using tumor thickness as a prognostic instrument will be an important part of any future editions of the TNM classification.

A 64-year-old man presented with a large amount of right-sided pleural fluid on imaging, together with calcified pleural plaques and an enlarged nodular structure in the prevascular mediastinum, presumably an enlarged lymph node. Pleural biopsies were obtained during video-assisted thoracoscopic surgery to exclude malignancy. Histopathology showed an epithelial malignant pleural mesothelioma. Induction chemotherapy with cisplatin and pemetrexed was administered followed by an extended pleurectomy and decortication with systematic nodal dissection. Histopathology confirmed the diagnosis of a ypT3N0M0 (stage IB) mesothelioma, and an unexpected thymoma type B2 (stage II) was discovered in the prevascular nodule. Simultaneous occurrence of a mesothelioma and thymoma is extremely rare. (C) 2018 by The Society of Thoracic Surgeons

Until recently, distant metastatic involvement was considered to be a generalized state of disseminated disease with a very poor prognosis, in clear contrast to those patients without any evidence of metastatic spread. Some years ago, the concept of oligometastatic disease emerged representing patients with only a few or “oligo” metastases (1). At major lung cancer conferences this remains a hotly debated topic focused on the question whether there really exists an intermediate state in-between patients without distant metastases and those with multiple metastatic involvement in one or more distant organs (2).

Currently, the standard of care for resectable, early-stage and functionally operable nonsmall cell lung cancer (NSCLC) is complete surgical resection [1]. However, for elderly patients and patients with multiple comorbidities, surgery may not be the preferred option due to higher surgical morbidity and mortality [2]. An alternative treatment for this group of patients is stereotactic body radiotherapy (SBRT), which administers a high local dose of radiation in fewer fractions as an ablative treatment [3]. In recent years, SBRT has gained in popularity as it has shown better local control rates and less toxicity to surrounding structures when compared to conventional fractionated radiotherapy (CFRT). This was confirmed by the recently published CHISEL phase III randomised controlled trial (RCT) [4].