Background:Neoadjuvant chemoimmunotherapy is increasingly used in resectable stage III non-small-cell lung cancer. The objective was to compare oncological effectiveness, surgical complexity and perioperative safety of neoadjuvant chemoimmunotherapy compared to chemotherapy. Methods:A multicentre cohort study was performed within the Registry of the Spanish Society of Thoracic Surgery. Consecutive patients with stage III non-small-cell lung cancer treated with chemoimmunotherapy or chemotherapy followed by anatomical resection (January 2023-April 2025) were analysed (114 patients: chemoimmunotherapy 77; chemotherapy 37). Oncological variables were pathological complete response, downstaging and complete resection (International Association for the Study of Lung Cancer criteria). Surgical and perioperative outcomes were compared, including complications and mortality. Propensity-score matching was used to reduce confounding and outcomes were compared using paired tests. Results:After matching, 68 patients remained (34 pairs). Chemoimmunotherapy yielded higher pathological complete response [38% vs. 12%; relative risk (RR) 3.3, 95% confidence interval (CI): 1.2-9.0; P=0.02], downstaging (79% vs. 56%; RR 1.4, 95% CI: 1.0-2.0; P=0.057) and complete resection (74% vs. 41%; RR 1.8, 95% CI: 1.1-3.1; P=0.049). Median operative time was longer (240 vs. 180 minutes; P=0.048). Overall postoperative complications were higher (41% vs. 21%; RR 2.0, 95% CI: 0.9-4.3; P=0.12), whereas major morbidity, reoperations and in-hospital, 30-day and 90-day mortality were low and comparable. Conclusions:Neoadjuvant chemoimmunotherapy for resected stage III non-small-cell lung cancer improved pathological complete response, downstaging and complete resection versus chemotherapy, at the expense of longer operations and higher morbidity, without an increase in severe complications or early mortality.

Accurate mediastinal nodal staging is essential for the management of non-small cell lung cancer (NSCLC), as it refines prognosis, guides multimodal treatment, and improves survival. This joint consensus document from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Thoracic Surgeons (SECT) updates and expands the 2011 SEPAR guidelines, incorporating the 9th edition of the TNM classification and extending recommendations to the entire perioperative setting, including both preoperative and intraoperative mediastinal staging. The recommendations were developed through a structured review of the literature and multidisciplinary expert consensus. This document synthesizes current evidence on the role of endoscopic and surgical approaches for perioperative invasive staging, including endobronchial and oesophageal ultrasound-guided techniques, mediastinoscopy and its variants, transcervical lymphadenectomies and intraoperative lymphadenectomies. In addition, the consensus integrates the International Association for the Study of Lung Cancer (IASLC) definitions of completeness of resection and proposes quality standards for intraoperative lymphadenectomy. A practical staging algorithm is provided, stratifying tumours according to risk factors of occult mediastinal disease such as tumour size and radiological nodal involvement. The new recommendations emphasise that invasive mediastinal staging is not required for T1a and T1b tumours without radiological evidence of nodal disease, regardless of their location. Conversely, particular attention is given to the role of N1 disease, which is now recognised as a setting associated with a high risk of unsuspected mediastinal involvement. For cases with intermediate suspicion of mediastinal disease, surgical staging techniques demonstrate superior accuracy compared with endosonography alone. Overall, these recommendations aim to harmonize perioperative invasive staging across disciplines, minimize under- and overstaging, and support precise therapeutic decision-making in the evolving era of targeted and immune-based treatments for NSCLC.

Background: Reliable mediastinal restaging after neoadjuvant treatment to rule out persistent nodal disease is essential to select patients for resection. Main endpoints of this study are: to analyse the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and to determine the rate of persistent N2-3 in patients with clinical N2-3 (cN2-3) non-small cell lung cancer (NSCLC) after neoadjuvant treatment. Methods: Prospective observational single-centre study of patients with NSCLC and histologically proven mediastinal involvement (cN2-3), treated with neoadjuvant therapy who underwent VAMLA for restaging. Patients with negative VAMLA underwent lung resection. Systematic nodal dissection (SND) was considered the reference test to confirm negative VAMLAs. Staging values were calculated based on pathologic findings using the standard formulas. Results: From 2017 to 2023, 41 patients with cN2-3 NSCLC received neoadjuvant therapy and thereafter underwent VAMLA for restaging. Neoadjuvant treatments: concomitant cisplatin-based chemotherapy and radical radiotherapy (n=33), chemoradiotherapy and immunotherapy (n=2), chemotherapy (n=2), chemotherapy and immunotherapy (n=2), tyrosine kinase inhibitor and immunotherapy (n=1) and immunotherapy (n=1). VAMLA was feasible in all patients. Restaging values with VAMLA were: sensitivity, 1 [95% confidence interval (CI): 0.72-1]; negative predictive value (NPV), 1 (95% CI: 0.89-1); and diagnostic accuracy, 1 (95% CI: 0.91-1). Rate of persistent N2 of the whole series: 29% (12/41). Complication rate was 9.7%. Conclusions: This preliminary series of patients with cN2-3 NSCLC treated with neoadjuvant treatment and restaged by VAMLA demonstrated high accuracy and high rate of persistent N2. VAMLA should be included in restaging algorithms to select patients with potentially resectable cN2-3 NSCLC.

BACKGROUND:We compared systematic endobronchial ultrasound-guided transbronchial needle aspiration (S-EBUS-TBNA) [sampling every lymph node (LN) > 5 mm regardless of its appearance on positron emission tomography/computed tomography (PET/CT)] with targeted (T) EBUS-TBNA (sampling only abnormal LNs on PET/CT) for mediastinal staging of locally advanced non-small cell lung cancer (NSCLC). PATIENTS AND METHODS:Patients with NSCLC with N2 involvement on PET/CT who underwent S-EBUS-TBNA were retrospectively included. For T-EBUS-TBNA, the results of the samplings of abnormal PET/CT LNs during S-EBUS-TBNA were considered. The percentage of cases where S-EBUS-TBNA diagnosed a larger extent of mediastinal disease compared with T-EBUS-TBNA (upstaging from N2a to N2b/N3 and upstaging from N2b to N3) was estimated. RESULTS:A total of 89 patients were included: 61 had N2a and 28 had N2b on PET/CT. Of the 61 with N2a S-EBUS-TBNA diagnosed N3 disease in 2 cases, N2b in 4, N2a in 43, and N0/1 in 12. These 12 patients underwent video-assisted mediastinoscopy (VAM) that showed N2a involvement in 3 and N0/1 in 9. Of the 28 with N2b, S-EBUS-TBNA proved N3 disease in 2 cases, N2b in 10 cases, N2a in 7, and N0/1 in 9. These nine patients underwent confirmatory VAM that showed N2a in two and N0/1 in 7. S-EBUS-TBNA diagnosed a larger extent of mediastinal disease compared with T-EBUS-TBNA staging in 9% of cases: 4 patients with N3 disease that had N2 on PET/CT and four with N2b that had N2a on PET/CT. CONCLUSIONS:In patients with NSCLC, S-EBUS-TBNA diagnoses a larger extent of mediastinal disease compared with T-EBUS-TBNA.

Background: Malignant pleural mesothelioma (MPM) is an aggressive neoplasm with limited long-term survival despite multimodal treatment. Recent clinical trials have shown that the addition of a surgical approach has not demonstrated survival benefit and increases the morbidity. Pathologic complete response (pCR) after multimodality treatment is rare. Few cases, mainly of epithelioid type, have been reported with short follow-up. The objective of this case report is to highlight the importance of prolonged follow-up even after pCR and the relevance of multimodal treatment of recurrence in a patient who had recurrent MPM 16 years after pCR. Case Description: In November 2008, a 56-year-old man, with past medical history of hypertension, atrio-ventricular block and occupational exposure to asbestos, presented with right pleural effusion on a preoperative X-ray of the chest for an inguinal hernioplasty. Thoracoscopic pleural biopsies were diagnositc of MPM epithelial subtype and talc poudrage was performed. After multidisciplinary tumour board discussion, the patient received 3 cycles of cisplatin and pemetrexed. Objective tumour response was assessed with a computed tomography, a positron emission tomography, a mediastinoscopy and peritoneal biopsy by laparoscopic approach before performing an extrapleural pneumonectomy (EPP). Adjuvant radiotherapy (50 Gy in 25 sessions) was administered to the right hemithorax. The patient remained under routine clinical and computed tomography follow-up. In 2024, a right chest wall recurrence was detected by computed tomography and confirmed by an ultrasound-guided biopsy. After multidisciplinary tumour board evaluation chemotherapy (3 cycles of carboplatin and pemetrexed) was proposed and, after confirming tumour response and absence of progression, the patient underwent surgical excision of the residual chest wall lesion. Histopathologic study of the resected specimen revealed residual foci of MPM. Adjuvant radiotherapy (50 Gy in 28 sessions) was administered to the chest wall. The patient remains free of disease 1 year after diagnosis of recurrence. Conclusions: This case report highlights the importance of prolonged follow-up to diagnose early recurrences and to plan new treatment. The systematic, prolonged follow-up enabled the early diagnosis of a local recurrence and the possibility of new multimodality treatment that allowed the complete resection of the recurrent tumour.

Introduction: there is experience in pulmonary tumours, not small cell, where the superior vena cava (SVC) is resected with total or partial repair of it. Case report: 37-year-old man with stage IIIB cT4N2M0 lung adenocarcinoma. In the TAC is highlighted 86 mm tumour to LSD with wide contact with right mediastinal pleura with compression of upper vena cava that is not circumferentially enveloped by the tumour and with the right-side face of the carina. After performing co-adjuvant treatment with chemotherapy and radiation therapy, it is intervened with resection of the tumour and the upper cavity. Single bypass to left tuberculosis is carried out from the upper vena cava at the border with the 14mm Gore-tex (R) atrial prosthesis. During the 45-minute clamping, extracorporeal yugulofemoral shunt is opened by connecting two-7F sheet introducer placed by Eco guided punction prior to thoracotomy. Discussion: superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) has been described. Patch techniques can be done in partial resections. But in other cases, total SVC resection is required, and a bypass is the best technical option. The PTFE prosthesis is more often used, being 14mm the most common diameter, optionally ringed. Shunt techniques have been used, during the clamping in order to avoid venous hypertension complications.

Objectives: The aim of this study is to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the unsuspected (u) N2/3 rates in patients with non-small cell lung cancer (NSCLC) and normal mediastinum by integrated positron emission tomography-computed tomography. Methods: Prospective observational single-center study of 603 consecutive VAMLAs from 2010 to 2022. Exclusion criteria: other indications (n = 32), tumors different from NSCLC (n = 91), and clinical (c) N2/3 tumors by positron emission tomography-computed tomography (n = 46). Systematic nodal dissection was the gold standard to validate negative VAMLAs. Those patients with negative VAMLA and missing reference standard test were excluded. uN2/3 rates were analyzed in the global series and in the subgroups of tumors according to their clinical nodal and tumor categories. Pathologic findings were reviewed, and staging values were calculated. Results: Three hundred eighty-three patients with cN0/1 NSCLC underwent VAMLA. Staging values of VAMLA were: sensitivity, 0.98 (95% CI, 0.92-0.99); negative predictive value, 0.99 (95% CI, 0.98-1); and diagnostic accuracy, 0.99 (95% CI, 0.98-1). The uN2/3 rate for the whole series (N = 383) was 18.8%. The uN2/3 rates according to presurgical nodal and tumor categories determined by positron emission tomography computed tomography were: 3.6% (4 out of 111) in cT1N0; 16.3% (18 out of 110) in cT2N0; 10.25% (4 out of 39) in cT3N0; and 32% (7 out of 22) in cT4N0. Forty-two percent (39 out of 93) in cN1; complication rate was 7%. Conclusions: This series of NSCLC with normal mediastinum staged by VAMLA demonstrates a high accuracy of this technique and a high rate of uN2/3 disease (specially in cN1 and cT4N0). VAMLA could be considered the reference staging procedure for staging cN0/1 NSCLC.

Background: Despite advances in lung cancer treatment and the subsequent improvement in oncological outcomes, the optimal frequency of radiological follow-up remains unclear. Current recommendations lack consensus and do not consider individual patient characteristics and tumor factors. This study aimed to examine the impact of radiological follow-up frequency on oncological outcomes following lung cancer resection. Methods: A prospective multicenter study, involving patients who underwent anatomical lung resection in the GEVATS database between December 2016 and March 2018. The relationship between surveillance frequency and oncological outcomes was evaluated. Two groups were established based on follow-up frequency: low frequency (LF) and high frequency (HF). Subgroup analyses were performed based on tumor stage, histology, lymphadenectomy, and adjuvant therapy. Propensity score matching (PSM) was applied to balance the groups. Results: A total of 1,916 patients were included in the study, LF 444 (23.17%), HF 1,472 (76.83%). Factors associated with HF surveillance included higher stage, adjuvant chemotherapy and adjuvant radiotherapy. Subanalyses were performed after PSM for various factors, revealing significant differences between LF and HF groups in cancer-specific survival among who received adjuvant therapy {LF 53.021 months [95% confidence interval (CI): 48.622-57.421] vs. HF 58.836 months (95% CI: 55.343-62.330); HR 0.453, 95% CI: 0.242-0.849; P=0.013}, as well as overall survival for patients with squamous cell carcinoma [LF 54.394 months (95% CI: 51.424-57.364) vs. HF 61.578 months (95% CI: 59.091-64.065); HR 0.491, 95% CI: 0.299-0.806; P=0.005] and those who received adjuvant therapy LF 50.176 months [95% CI: 45.609- 54.742) vs. HF 57.189 months (95% CI: 53.599-60.778); HR 0.503, 95% CI: 0.293-0.865; P=0.013]. Conclusions: Findings suggest that high-frequency surveillance only improves survival outcomes in lung cancer patients who received adjuvant treatment or had squamous cell carcinoma. Therefore, future guidelines for lung cancer follow-up should consider individualizing the frequency of radiological surveillance based on patients' risk profiles.

Background: The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) validated with video-assisted mediastinoscopic lymphadenectomy (VAMLA) for mediastinal restaging of patients with non-small cell lung cancer (NSCLC) after induction therapy has never been described. Objective: To report on our experience in this clinical setting. Design: Retrospective analysis of a prospectively built database. Methods: Patients with stage IIIA (N2) NSCLC who underwent EBUS-TBNA for mediastinal restaging after induction therapy were included. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and diagnostic accuracy of EBUS-TBNA and VAMLA for mediastinal restaging were calculated. The number of patients needed to undergo confirmatory VAMLA (NNT) after a negative EBUS-TBNA for mediastinal restaging to avoid a case of pathologic (p) N2 disease after resection was also calculated. Results: Forty-six patients underwent EBUS-TBNA which was positive in 12 patients and negative in 34. Patients with a negative EBUS-TBNA underwent VAMLA which was positive in seven cases. Of the other 27 patients with a negative VAMLA, 26 underwent resection that did not show N2 disease. The sensitivity, specificity, NPV, PPV, and diagnostic accuracy of EBUS-TBNA for restaging were 63.1%, 100%, 79.4%, 100%, and 84.7%, respectively. The sensitivity, specificity, NPV, PPV, and diagnostic accuracy of confirmatory VAMLA after EBUS-TBNA was 100%. The NNT confirmatory VAMLA after a negative EBUS-TBNA to avoid a case of pN2 disease at resection was five patients. Conclusion: EBUS-TBNA must remain as the first-choice test for invasive mediastinal restaging. However, the results of our study in terms of sensitivity and NPV, even considering the small size of our population, suggest that negative results of EBUS-TBNA should be interpreted with caution and surgical exploration of the mediastinum (specially VAMLA, if available) should be considered in these patients.

Objectives: The objective of this study was to assess the diagnostic performance of combined computerised tomography (CT) and positron emission tomography (PET) in mediastinal staging of surgical lung cancer based on data obtained from the prospective cohort of the Spanish Group for Video-Assisted Thoracic Surgery (GEVATS). Methods: A total of 2782 patients underwent surgery for primary lung carcinoma. We analysed diagnostic success in mediastinal lymph node staging (cN2) using CT and PET. Bivariate and multivariate analyses were performed of the factors involved in this success. The risk of unexpected pN2 disease was analysed for cases in which an invasive testing is recommended: cN1, the tumour centrally located or the tumour diameter >3 cm. Results: The overall success of CT together with PET was 82.9% with a positive predictive value of 0.21 and negative predictive value of 0.93. If the tumour was larger than 3 cm and for each unit increase in mediastinal SUVmax, the probability of success was lower with OR 0.59 (0.44-0.79) and 0.71 (0.66-0.75), respectively. In the video-assisted thoracic surgery (VATS) approach, the probability of success was higher with OR 2.04 (1.52-2.73). The risk of unexpected pN2 increased with the risk factors cN1, the tumour centrally located or the tumour diameter >3 cm: from 4.5% (0 factors) to 18.8% (3 factors) but did not differ significantly as a function of whether invasive testing was performed. Conclusions: CT and PET together have a high negative predictive value. The overall success of the staging is lower in the case of tumours >3 cm and high mediastinal SUVmax, and it is higher when VATS is performed. The risk of unexpected pN2 is higher if the disease is cN1, the tumour centrally located or the tumour diameter >3 cm but does not vary significantly as a function of whether patients have undergone invasive testing. (C) 2022 AEC. Published by Elsevier Espani a, S.L.U. All rights reserved.

Objectives: To determine the incidence of occult N1/N2 nodal metastases and associated risk factors in patients with non-small cell lung cancer no larger than 3 cm and deemed cN0 by CT and PET-CT in a prospective, multicentre national database.Methods: Patients with a NSCLC no larger than 3 cm, deemed cN0 by PET-CT and CT scan, who had undergone at least a lobectomy, were selected from a national multicentre database of 3533 patients who had undergone anatomic lung resection between 2016 and 2018. Clinical and pathological variables of patients with pN0 and patients with pN1/N2 were compared to identify factors associated with the presence of lymph node metastases. Chi2 and the Mann-Whitney U test were used for categorical and numerical variables, respectively. All variables with p < 0.2 in the univariate analysis were included in the multivariate logistic regression analysis. Results: The study included 1205 patients from the cohort. The incidence of occult pN1/N2 disease was 10.70% (95%CI, 9.01-12.58).The multivariable analysis revealed that the degree of differentiation, size, location (central or peripheral) and SUV of the tumour in PET, surgeon experience and number of lymph nodes resected were associated with occult N1/N2 metastases. Conclusions: The incidence of occult N1/N2 in patients with bronchogenic carcinoma with cN0 tumours no larger than 3 cm is no negligible. Data about the degree of differentiation, tumour size in CT scan, maximal uptake of the tumour in PET-CT, location (central or peripheral), number of lymph nodes resected and surgeon seniority is relevant in order to detect patients at risk.& COPY; 2023 SEPAR. Published by Elsevier Espan & SIM;a, S.L.U. All rights reserved.