Background/Objectives: Stage III non-small cell lung cancer (NSCLC) is a heterogeneous and clinically challenging disease. Despite therapeutic advances, decisions regarding resectability and treatment sequencing remain complex. Multidisciplinary discussion (MDD) is increasingly recognized as key to personalized, evidence-based care. Methods: The "Integrate 6.0" conference gathered approximately 90 lung cancer specialists, including oncologists, thoracic surgeons, and radiation oncologists, divided into mixed groups simulating multidisciplinary team (MDT) meetings. Groups reviewed complex clinical cases, supported by facilitators providing concise, evidence-based updates. A pre-event survey explored MDT structure and dynamics across institutions. Results: The survey highlighted considerable variability in MDT composition and practices. Most participants had significant involvement in thoracic oncology. Discussions revealed higher consensus in straightforward cases, while complex stage III scenarios-especially with driver mutations or bulky nodal disease-required more nuanced, collaborative decision making. Key topics included neoadjuvant chemoimmunotherapy, surgery in borderline resectable cases, and managing immune-related toxicities. Conclusions: "Integrate 6.0" effectively connected theoretical knowledge with real-world practice through interactive, multidisciplinary dialogue. It underscored the vital role of MDD in managing complex stage III NSCLC and the need for adaptable treatment strategies. Future conferences should assess MDD's impact on outcomes and expand participation to include molecular pathologists and geriatricians.

BACKGROUND:Tumor size was recently proposed as a prognosticator in thymic tumors. The aim of this study is to investigate the prognostic role of tumor size in the different thymic tumor histologies. METHODS:Clinical and pathologic data of patients from the European Society of Thoracic Surgeons thymic database who underwent surgery for thymic epithelial tumors from January 2000 to December 2022 were reviewed, analyzed, and correlated to overall survival and disease-free survival using Kaplan-Meier curves. The log-rank test was used to assess differences between subgroups. RESULTS:The final analysis was conducted on 2,556 patients. Histology results showed thymoma in 2,231 (87.3%), thymic carcinoma in 271 (10.6%), and neuroendocrine tumors in 54 (2.1%) cases. In 1,518 (59.4%) cases, size was >5 cm. The survival difference was significant considering thymoma and thymic carcinoma/neuroendocrine tumor. The 5-and 10-year disease-free survival rates were 85.4% and 78.1% vs 77.6% and 62.4% in ≤5 cm vs >5 cm thymomas (P < .001), and 5- and 10-year overall survival rates were 92.4% and 79.4% vs 88% and 74.5% in ≤5 cm vs >5 cm thymomas (P = .002). For thymic carcinoma/neuroendocrine tumor, the disease-free survival rate in the ≤5 cm group was 61.3% at both 5 and 10 years, compared with 53.3% and 46.9% in the >5 cm group, respectively (P = .042), whereas 5- and 10-year overall survival rates were 84.9% and 79.4% vs 74.9% and 64.9% in ≤5 cm vs >5 cm groups (P = .002). CONCLUSION:Tumor size was a significant prognosticator in thymic epithelial tumor, thymoma, and thymic carcinoma/neuroendocrine tumor, confirming its validity in prognosis prediction of these tumors.

Introduction:Lung squamous cell carcinoma (LUSCC) lacks consistent morphological criteria for tumour grading. Tumour budding (TB), defined as isolated cells or clusters of fewer than 4 cells at the invasive front, is prognostic in several carcinomas but remains insufficiently validated in LUSCC. Objective:To assess histopathological features of aggressiveness (including TB) in resected LUSCC as prognostic parameters and grading factors. Methods:We retrospectively analysed 296 LUSCC cases (2010-2021, University of Turin). Clinical data were collected and slides were reviewed for subtype, nuclear features, mitotic count, infiltration pattern, TB, spread through air spaces (STAS), desmoplasia, pleural/vascular/perineural invasion, and tumour-infiltrating lymphocytes. Associations with recurrence-free and overall survival were tested. Results:High TB (≥ 5 buds) correlated with pleural invasion and advanced T stage and was significantly associated with shorter recurrence-free (HR 1.84, p = 0.008) and overall survival (HR 1.73, p = 0.003), independently of stage. Nuclear enlargement and necrosis also predicted worse outcomes, while surgery had an overall protective impact. Conclusion:TB, necrosis, and nuclear size are independent predictors of outcome in LUSCC. Their inclusion in pathology reports may improve grading, refine prognosis, and guide management.

Objective In addition to the standard R classification for assessing radicality in Non-Small Cell Lung Cancer (NSCLC), the concept of uncertain resection [R (un)] has been introduced. This study aimed to evaluate the prognostic impact of R (un) in a cohort of surgically resected pN2 NSCLC patients and to analyze outcome of a possible change in the R (un) description. Methods We retrospectively analyzed data from prospective databases of four institutions. All consecutive patients with R0 pN2 NSCLC treated between 2016 and 2021 were included. Each case was re-evaluated and classified as either R0 or R (un). We also assessed a modified R (un) classification considering station 7 as hierarchically superior to stations 5 and 6. Results Among 230 patients, 98 (42.6 %) were female. Forty-six patients (20 %) received neoadjuvant therapy, and 178 (77.4 %) underwent lobectomy.Single station pN2 was observed in 143 patients (62.2 %), and 130 (56.5 %) were reclassified as R (un). Adjuvant therapy was administered to 135 patients (58.7 %).Patients classified as R0 had significantly better overall survival (OS, p = 0.044) and disease-free survival (DFS, p = 0.050) compared to those with R (un). However, in multivariable analysis, only adjuvant therapy remained an independent prognostic factor for OS.When applying the modified R (un) definition, R (un) remained associated with worse OS (p = 0.007) and DFS (p < 0.001) and was confirmed as an independent prognostic factor in multivariable analysis. Conclusions Our findings confirm the prognostic relevance of the R classification, including R (un). We propose a possible refinement of the R (un) definition potentially improving its prognostic accuracy.

INTRODUCTION:The integration of immune checkpoint inhibitors (ICIs) into the management of resectable non-small cell lung cancer (NSCLC) has markedly improved pathological response and survival. However, the effect of ICI-based regimens on surgical feasibility, complexity, and perioperative safety remains uncertain. This study aimed to systematically evaluate surgical outcomes following neoadjuvant or perioperative ICI-based therapy, with or without chemotherapy. METHODS:A systematic search of PubMed, EMBASE, Scopus, Cochrane CENTRAL, and Web of Science was conducted from database inception to January 2025 according to PRISMA guidelines. Only prospective single-arm and randomized controlled trials reporting surgical outcomes after ICI-based regimens in resectable NSCLC were included. Pooled event proportions (EP) were estimated using random-effects meta-analysis with Freeman-Tukey transformation. Meta-regression analyses compared chemo-immunotherapy (CTIO) versus immunotherapy-only (IO) protocols. RESULTS:Twenty-seven eligible trials comprising 2691 patients were analyzed. The pooled EP for intraoperative complications was 0.03, postoperative complications 0.27, and postoperative mortality 0.01. Pneumonectomy was performed in 10% of cases. Minimally invasive surgery (MIS) was used in 47% of resections, with a 20% conversion rate and 9% surgical delays. Meta-regression revealed higher intraoperative complications and surgery omission with CTIO protocols, while IO regimens showed higher postoperative mortality. No significant differences were found in pneumonectomy rate, MIS utilization, or conversion. CONCLUSIONS:Surgery following ICI-based therapy is feasible and safe in appropriately selected patients but presents distinct perioperative challenges. Differing risk profiles between treatments underscore the need for multidisciplinary coordination, experienced thoracic surgeons, and treatment centralization in resectable NSCLC within the immunotherapy era.

Background Tumor size is recently proposed as prognosticator in thymic tumors. The aim of this study is to investigate the prognostic role of tumor size in the different thymic tumor histologies. Methods Clinical and pathological data of patients from ESTS thymic database underwent surgery for TETs from 1/2000 to 12/2022 were reviewed, analyzed and correlated to overall survival (OS) and Disease free Survival (DFS) using Kaplan Meier curves. The log-rank test was used to assess differences between subgroups. Results The final analysis was conducted on 2.556 patients. Histology results showed thymoma in 2.231(87.3%), thymic carcinoma in 271(10.6%) and neuroendocrine tumors (NET) in 54 (2.1%) cases. In 1.518 (59.4%) size resulted > 5 cm.The survival difference was significant considering thymoma and thymic carcinoma/NET. The 5-and 10-year DFS of 85.4% and 78.1% versus 77.6% and 62.4% in ≤ 5 cm vs > 5 cm thymomas (p<0.001) and a 5- and 10-year OS of 92.4% and 79.4% versus 88% and 74.5% in ≤ 5 cm versus > 5 cm thymomas (p=0.002). For thymic carcinoma/NET, the DFS rate in the ≤ 5 cm group was 61.3% at both 5 and 10 years, compared to 53.3% and 46.9% in the > 5 cm group, respectively (p=0.042), while 5- and 10-year OS were 84.9% and 79.4% versus 74.9% and 64.9% in ≤ 5 cm versus > 5 cm groups (p=0.002). Conclusions Tumor size resulted a significant prognosticator in TET, thymoma and thymic carcinoma/NET, confirming its validity in prognosis prediction of these tumors.

Background Stage III non-small cell lung cancer (NSCLC) represents one of the most heterogeneous and clinically challenging scenarios in thoracic oncology. The rapid integration of immunotherapy into multimodal treatment strategies has reshaped therapeutic algorithms, particularly for resectable and borderline resectable disease. However, uncertainty persists regarding optimal staging procedures, resectability assessment, and the integration of surgery, systemic therapy, and radiotherapy. Methods A multisocietal Delphi consensus was conducted to address key areas of uncertainty in the multidisciplinary management of stage III NSCLC. Experts in thoracic surgery, medical oncology, radiation oncology, interventional pulmonology, and pathology nominated by four Italian scientific societies participated in a structured consensus process. Sixty-five statements covering baseline evaluation, local treatment, and integrated therapeutic strategies were rated using a 9-point Likert scale across two Delphi rounds. Results Consensus was achieved for 62 of 65 statements. Strong agreement supported comprehensive baseline staging including contrast-enhanced CT, PET imaging, brain MRI, and systematic mediastinal staging with endosonographic techniques. Molecular characterization, including PD-L1 expression and testing for EGFR and ALK alterations, was considered essential for treatment selection. Neoadjuvant chemo-immunotherapy was endorsed as the preferred strategy for most patients with resectable stage III NSCLC without actionable driver alterations. Lung-sparing surgical procedures were strongly favored, while pneumonectomy should be reserved for highly selected cases. For unresectable disease, concurrent chemoradiotherapy followed by consolidation immunotherapy remains the standard of care. Conclusions This multidisciplinary consensus provides an updated framework for the contemporary management of stage III NSCLC, emphasizing accurate staging, molecular profiling, and coordinated multidisciplinary decision-making to optimize multimodal treatment strategies.

Objectives:To clarify the role of limited versus complete thymectomy in stage I thymic epithelial tumors (TETs) using standardized survival measures and predefined oncological outcomes. Methods:An individual patient data (IPD) meta-analysis of studies investigating complete versus limited thymectomy for stage I TETs was conducted. IPD was extracted from published Kaplan-Meier curves using the IPDfromKM method.Primary end point of the study was freedom from recurrence (FFR) in complete versus limited thymectomy. Secondary end points were time to progression (TTP), overall survival, recurrence rate in the overall population and stratified per Masaoka-Koga stage, and survival measures according to resection extension (thymomectomy alone versus hemi-thymectomy versus subtotal thymectomy).Hazard ratios and relative 95% confidence intervals (95% CIs) were estimated with Cox regression analyses. Odds ratio (OR) with 95% CI was used to derive categorical variables. Results:Overall, IPD from 2314 patients (1434 complete thymectomy and 880 limited thymectomy) from seven retrospective studies were retrieved.For FFR, IPD were extracted from three studies including 307 patients receiving complete thymectomy (n = 178) and limited thymectomy (n = 129). Median follow-up was 55.7 months (95% CI 52.3-59). The 10-year FFR for complete versus limited thymectomy was 90.2% versus 92.1%, respectively.No differences were found in TTP, overall survival, and recurrence rate in the two groups.In those patients presenting a Masaoka-Koga stage II disease, OR for recurrence favored complete than limited thymectomy (p = 0.02).Finally, in those receiving limited thymectomy, thymomectomy alone had the worst FFR. Conclusion:No evidence favored limited than complete thymectomy in early stage TET treatment according to standardized survival measures. However, in Masaoka-Koga stage II disease, complete thymectomy demonstrated lower recurrence rate. Finally, among patients receiving limited thymectomy, thymomectomy alone leads to worse prognosis.

Background: Circulating tumor DNA (ctDNA), shed into bodily fluids by cancer cells through apoptosis, necrosis, or active secretion, is currently used in the field of genomic investigation in clinical settings, primarily for advanced stages of non-small-cell lung cancer (NSCLC). However, its potential role in guiding the multi-omic approach to early-stage NSCLC is emerging as a promising area of investigation. Efforts are being made to integrate the genomics not only in surgery, but also in the definition of long-term prognosis after surgical or radiotherapy and for the prediction of recurrence. Methods: An extensive literature search was conducted on PubMed, covering publications from 2000 to 2024. Using the advanced search tool, titles and abstracts were filtered based on the following keywords: ctDNA, early stage, NSCLC. From this search, 20 studies that fulfilled all inclusion criteria were selected for analysis in this review. Results: This review highlights the growing body of evidence supporting the potential clinical use of ctDNA as a genomic biomarker in managing early-stage NSCLC. Baseline ctDNA levels offer valuable information about tumor molecular biology and histological characteristics. Beyond its prognostic value before treatment, liquid biopsy has proven useful for tracking minimal residual disease and forecasting recurrence following curative interventions such as surgery or radiotherapy. Future adjuvant treatment decisions may increasingly rely on predictive models that incorporate liquid biopsy findings alongside other clinical factors. Conclusions: The potential use of this analyte introduces new opportunities for the integration of genomic data in treatment, as well as relapse monitoring with more accurate and innovative than traditional methods, particularly in patients with early-stage NSCLC

Background: Circulating tumor DNA (ctDNA) may be released from neoplastic cells into biological fluids through apoptosis, necrosis, or active release. In patients with non-small-cell lung cancer (NSCLC), ctDNA analysis is being introduced in clinical practice only for advanced disease management. Nevertheless, an interesting and promising field of application is the analysis of ctDNA in the management of early stage non-small-cell lung cancer, both for evaluation before treatment, such as diagnosis and screening, and for prediction of histology or pathological features. Methods: A thorough review of the literature published between 2000 and 2024 was performed on PubMed, utilizing the advanced search feature to narrow down titles and abstracts containing the following keywords: ctDNA, early stage, and NSCLC. A total of 20 studies that met all inclusion criteria were chosen for this review. Results: In this review, we summarize the increasing evidence suggesting that ctDNA has potential clinical applications in the management of patients with early stage NSCLC. ctDNA levels in early stage cancers are very low, posing many technical challenges in improving the detection rate and sensitivity, especially in clinical practice, if it is to be implemented for early detection. Presently, the main limitation of ctDNA experimental and clinical studies, especially in early stage settings, is the lack of definitive standardization and consensus regarding methodology, the absence of systematically validated analyses, and the lack of adoption of sensitive approaches. Conclusions: Possible applications of this analyte open up new fields of diagnosis, treatment, and follow up, which are less invasive and more precise than other approaches currently in use, especially in early stage NSCLC patients.

Objectives: Lung cancer is the leading cause of cancer-related deaths worldwide and mediastinal lymph node involvement is an important negative prognostic factor. Nevertheless, the involvement of a single mediastinal nodal zone has been reported to have favorable outcomes. This study aims to assess whether the prognosis of non-small-cell lung cancer (NSCLC) with single-zone lymph node involvement varies by the affected lymph node zone. Methods: We retrospectively analyzed patients affected by NSCLC with a single lymph node zone involvement who underwent anatomical resection. The prognosis of patients was statistically compared based on the different affected lymph node zones. Results: A total of 135 patients were enrolled. All patients underwent anatomical lung resection and systematic lymph node dissection. Lymph node involvement was observed in 50 cases (37%) for the upper zone, 36 cases (27%) for the aorto-pulmonary (AP) zone, 41 cases (30%) for the subcarinal zone and 8 cases (6%) for the lower zone. The median follow-up was 37 months [ranging from 1 to 115 months]. Cancer recurrence was reported in 64 cases (52%) during this period. The 2-year and 4-year overall survival (OS) were 69% and 49%, respectively. The 2-year and 4-year relapse-free survival (RFS) were 55% and 41%. The OS and RFS change relating to the different involved lymph node zones (p < 0.01). Lower zone involvement predicts worse prognosis, upper zone and subcarinal zone better outcomes, and the AP zone involvement intermediate survival. Conclusions: The location of the affected lymph nodes appears to be an important prognostic factor in patients with NSCLC, with significant impacts on both OS and RFS. It may play a key role in the disease progression and patient survival by providing more personalized therapy.

Three-dimensional (3D) lung models have become a valuable tool in surgical planning and intraoperative navigation by providing detailed visualizations of pulmonary structures (e.g., bronchial tree, pulmonary vasculature, lung parenchyma, and tumor). These models are useful in minimally invasive lung cancer surgery, particularly for more complex segmentectomy procedures, where precise anatomical understanding is important. Enhancing the spatial insight of patient-specific anatomical variations facilitates precise lung nodule localization, supports decision-making regarding the extent of lung resection, and contributes to a smoother surgical procedure and intraoperative efficiency. In contrast to earlier reports that have addressed specific technologies, this review article provides a thorough overview of the advancements in 3D lung modeling, covering various technologies and their clinical applications-from conventional on-screen visualizations to advanced imaging modalities such as virtual reality (VR), augmented reality (AR), mixed reality (MR), and insights into the future of real-time dynamic lung simulations in minimally invasive lung cancer surgery. In addition, this review touches upon the various segmentation methods, such as surface rendering, volume rendering, and artificial intelligence (AI) algorithms, and different types of software programs (i.e., commercial and open-source software programs) for developing these 3D lung models. It emphasizes its practical integration in thoracic surgical practice, highlighting the clinical value in preoperative planning and intraoperative guidance, with evidence showing improved surgical outcomes and reduced surgery duration for both segmentectomy and lobectomy, along with the added value for education, training purposes, and enhanced patient counseling. Evidence should be strengthened through more robust comparative studies evaluating different (advanced) imaging modalities and software programs to demonstrate their cost-effectiveness. Moreover, technical challenges in the integration of these 3D modeling tools must be overcome to limit the need for specialized software and personnel.

To evaluate the reproducibility of the PEARL approach to decrease pneumothorax rates by different board-certified radiologists across multiple medical centers using standard CT units. This multicenter observational study included four average volume centers in two countries. Data for the PEARL cohort were prospectively collected between January 2022 and May 2023, while the control cohort data were retrospectively collected from procedures performed between June 2021 and April 2022. Patient demographics, lesion characteristics, intraprocedural data, complications, and procedural accuracy were compared. A total of 413 CT-guided lung biopsies were performed (204 PEARL vs 209 Control) without differences in patient demographics, lesion size (26.8 mm ± 20.3 PEARL group vs 27.7 mm ± 19.6 Control, p = 0.4), or emphysema rate (34

Background: The heritage of occupational and environmental asbestos exposure in Piedmont, Italy, has resulted in an enduring diffuse pleural mesothelioma (DPM) epidemic. Our study aimed to investigate the accuracy of Pleural biopsy (PB) via thoracoscopy (or video-assisted thoracic surgery-VATS) and analyze the diagnostic path of patients who experienced an initial DPM misdiagnosis. Methods: Patients who underwent PB by VATS for suspected DPM from 2004 to 2013 were analyzed. The Registry of Malignant Mesothelioma (RMM) records were examined to cross-check incident cases and identify misdiagnosed DPM. The sensitivity and specificity of the initial PB assessment versus the final classification of cases by RMM were evaluated. Results: Data from 552 patients were analyzed, and DPM was diagnosed in 178 cases (32%). Sensitivity and specificity were 93% and 100%, respectively. The number of false-negative PBs was 14 (2%). Of those, 10 (71%) had an initial diagnosis of chronic pleuritis, 3 (28.5%) were initially classified as mesothelial proliferation, and 1 had reactive mesothelial proliferation. All of them reported a history of asbestos exposure, and the correct diagnosis was reached after a median of 160 days. One- and four-year survival rates were 52% and 10% in DPM PB-positive cases and 50% and 19% in false-negative cases. Conclusions: When a strong clinical suspicion after a negative PB remains, iterative biopsy attempts should be considered, especially if a history of asbestos exposure is reported. In high-volume centers, the DPM misdiagnosis rate remains low, and future advancements in diagnostic technologies could further increase the accuracy and efficacy of histologic diagnosis.

BACKGROUND:The use of immunotherapy (IOT) in treating non-small-cell lung cancer (NSCLC) has revolutionized care standards. However, full compliance with neoadjuvant, perioperative, and adjuvant treatment protocols remains a challenge. This study aims to evaluate compliance rates with IOT-based protocols in neoadjuvant, adjuvant, and perioperative settings. METHODS:A systematic review and meta-analysis were conducted on prospective clinical trials involving preoperative, perioperative, and postoperative IOT protocols in resectable NSCLC up to December 2024. Primary outcomes included compliance with medical treatment (e.g., omission of therapy rate, incomplete therapy rate, and omission of surgery rate), surgical outcomes (R0 resection rate), and post-treatment severe adverse events (AEs). RESULTS:A total of 30 studies, with 10,493 patients, were included. In the neoadjuvant settings, 26 studies (16 neoadjuvant; 10 perioperative) investigated IOT alone or in combination with chemotherapy. Almost all patients received at least one therapy administration, while 11.3 % experienced incomplete cycles. Surgery was not performed in 16.1 % of cases, and an R0 resection was achieved in 80.5 % of patients. Grade ≥ 3 AEs were observed in 67.7 % of patients. In the adjuvant setting, 14 studies evaluated IOT (4 adjuvant; 10 perioperative). Complete omission of adjuvant therapy occurred in 9,6 % of patients, while 34,6 % required a discontinuation or cycle reduction. Grade ≥ 3 were AEs observed in 19.0 % of patients. Overall protocol compliance was superior in neoadjuvant protocols (effect size: 0.78 [IC 95 %: 0.70-0.85]) compared to adjuvant protocols (effect size: 0.61 [IC 95 %: 0.53-0.69]) and perioperative protocols (effect size: 0.49 [IC 95 %: 0.43-0.55]). However, perioperative protocols showed similar compliance and Grade ≥ 3 AE rates compared to preoperative and postoperative protocols. CONCLUSIONS:Compliance with treatment protocols in NSCLC remains a critical factor, particularly for radical surgery candidates. This study represents a landmark effort in synthesizing comprehensive data on compliance with immunotherapy protocols in resectable NSCLC. Improving protocol compliance through tailored strategies and multidisciplinary coordination is essential to maximize the therapeutic potential of immunotherapy in resectable NSCLC and enhance patient outcomes.

Background:In the last years, the knowledge about the non-small cell lung cancer (NSCLC) biology led to development of target therapies and immunotherapy. However, most indication were to advanced stages, with large nodal involvement or presence of distant metastases. However, the clinical response may be unpredictable, and in some cases, it is possible to see a large clinical response with resolution of the parameter that contraindicated surgical treatment. In these cases, surgery could be re-considered, performing a salvage surgery approach, but evidences regarding the feasibility of this approach in these clinical scenarios are still missing. The objective of this study is to describe the clinical, surgical and pathological characteristics of patients who underwent salvage surgery after target therapy or immunotherapy, for initially non-resectable NSCLC. Methods:Data of patients undergone salvage surgery after target therapy or immunotherapy from three different centres from January 1, 2015 to December 31, 2022 were retrospectively collected and analyzed. Results:The final analysis was led on 30 patients meeting inclusion criteria. Preoperatively, 22 patients presented stage III disease, 8 presented stage IV. For 22 patients without distant metastases, initial contraindication to surgery was due to bulky/multi-stations N2 involvement, advanced tumor (T) stage with concomitant N1/N2 involvement, N3 involvement. Target therapy mutations were anaplastic lymphoma kinase (ALK) rearrangement (treated with alectinib) and epidermal growth factor receptor (EGFR; treated with gefitinib, osimertinib and afatinib) in 8 total cases. Other 22 patients underwent immunotherapy alone or in association with chemotherapy in 4 cases. Surgery consisted mostly of lobectomy/bilobectomy (27 patients), and was considered feasible in all cases but 2, with local involvement. No peri-operative mortality was reported. Complications occurred in 6 (20%) and the length of stay was averagely 5.9±2.8 days. Pathological examination showed downstaging in 26 patients, with 11 (36%) patients that presenting pathological complete response (pCR). pCR occurred in 37% adenocarcinoma and 33% squamous cell carcinomas. Complete pathological response was observed in 10 out of 22 patients treated with immunotherapy, 1 patient treated with alectinib. Median follow up was 12 months. Five patients had recurrence and 4 died due to cancer related causes. Conclusions:Salvage surgery after target therapy or immunotherapy resulted to be a possible approach in selected patients.

Traditional surgical training methods often lack the immersive and interactive elements necessary for optimal skill acquisition. Virtual reality (VR) technology has emerged as a transformative tool in surgical education, offering realistic simulations that enhance technical proficiency, psychomotor skills, and cognitive planning. This paper presents a novel collaborative cross-platform VR framework that supports multi-user interaction, enabling trainees and instructors to engage in a shared virtual environment. Structured around a modular digital hospital, the system facilitates real-time training sessions, interactive knowledge sharing, and procedural simulations with integrated feedback mechanisms. A user study demonstrated a significant reduction in errors, improved precision, and faster task completion, underscoring the system’s effectiveness in enhancing surgical training efficiency. Participants rated usability highly, highlighting the system’s intuitive design, engagement, and potential for democratizing surgical education.