© BMJ Publishing Group Limited 2023. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A man in his 70s visited his general practitioner (GP) with neck pain. Medical history consisted of regurgitation and hypertension, well controlled on amlodipine. The GP ordered an Xray of the neck and chest. This revealed a mass on the left lung measuring approximately 8 cm. The patient denied any respiratory symptoms, weight loss, fever or sweating at night. Blood test showed normal white blood cells, electrolytes and C reactive protein. A CT (figure 1) was performed showing an 8.3 cm tumour in the left upper lobe. The tumour was not invading the mediastinum or left lower lobe and contained bone, soft tissue and vessels. A small peripheral atelectasis was seen in the lingular section of the left upper lobe. The positron emission tomography (figure 2) showed uptake of fluorine18flourodeoxyglucose in the tumour at the level of the blood pool. There was no suspicion of local or distant metastases. The patient was discussed at the multidisciplinary team conference, and it was decided to offer the patient primary resection of the tumour without biopsy or mediastinal staging. The patient underwent thoracotomy with resection of the left upper lobe without any complications. Histology of the resected left upper lobe showed an 8.5×8.5×7 cm pulmonary hamartoma with calcifications, vessels and soft tissue (figure 3). Pulmonary hamartomas are benign neoplasm composed of cartilage, connective tissue, muscle, fat and bone. If located in the pulmonary parenchyma, they are most often asymptomatic and found incidentally. However, if the hamartoma is found intratracheal, symptoms are often present. There is a male predominance with a male/female ratio of 2.5:1. Hamartomas are usually less than 2.5–4 cm in size but are from time to time very large. Pulmonary hamartomas are the most common benign lung tumours and typically do not cause symptoms. CT is sometimes able to detect intralesional fat within the hamartoma with negative Hounsfield units. If fat is detected, invasive investigation or followup is often not required. Sometimes calcification is present, either localised within the nodule or generalised. The majority of pulmonary hamartomas are less than 2.5 cm in size. Most often resection is not necessary, either because the nodule shows signs that are classical for a pulmonary hamartoma or because followup confirms absence of growth. However, when the lesion is very large, resection is necessary, due to respiratory symptoms or risk of malignant disease. In this case report, a pulmonary teratoma was initially suspected due to the radiological appearance and it was decided to perform primary resection. Previous case reports have described large hamartomas ranging from 8 to 20 cm in size. 6 However, these patients had significant symptoms such as

Solitary fibrous tumours (SFT) are rare soft tissue tumours with a primarily benign course. Complete surgical resection is the mainstay treatment. In this case report, a 75-year-old man had a massive intrathoracic SFT which was subsequently surgically resected without complications. Although the clinical presentation and CT features of these tumours can mimic lung cancer, the clinical course is significantly more favourable. Diagnostic examination and surgical treatment of intrathoracic SFT should be considered even in patients with increased post-operative risk.

Supplemental Table I. Prognostic clinicopathologic variables as predictors for DSS in 797 NSCLS (univariate analyses,log-rank test)

Supplemental Figure 1. Disease-specific survival curves according to low, intermediate and high stromal CD8+ T-cell density in the Danish cohort (Odense University Hospital, n = 178). (A) Score from the invasive margin tumor area, (B) score from the central parts of the tumor. The maximum score for each patient was used.

Dental care workers are frequently exposed to various types of volatile organic and inorganic compounds. In addition to biological materials, these compounds include silica, heavy metals, and acrylic plastics. Such exposures may cause respiratory symptoms, but the nonspecific nature of these symptoms often means that the etiology is difficult to discern. The disease severity depends on the particle size and type of the inhaled compounds, as well as the duration and intensity of exposure, which varies markedly among dental workers. Here, we present two unique cases with the same occupational exposure. Both patients showed radiological changes in the lungs that were suspicious for lung cancer. The first patient did not undergo a biopsy due to cardiac comorbidities and risk of bleeding, and the diagnosis was based on thoracic computer tomography (CT) which confirmed multiple, bilateral, solid, smooth, partly calcified lung nodules, normal positron emission tomography (PET)-CT and the relevant occupational exposure. In the second case, a CT-guided biopsy and thoracoscopic resection was done with histopathological findings consistent with granuloma. The multi-disciplinary team decision of both cases was consistent with occupational exposure related lunge disease. This is the first case study report whereby same occupational exposure related health condition is compared with two different approaches. Respiratory clinicians should be aware of this potential diagnosis, especially for asymptomatic patients with relevant exposures. Careful attention to the occupational history may help to prevent unnecessary, invasive diagnostic procedures or surgeries.

BACKGROUND:Lung cancer incidence and prevalence is increasing worldwide and there is a focus on prevention, early detection, and development of new treatments which will impact the epidemiological patterns of lung cancer. The clinical characteristics and the trends in incidence, mortality, and prevalence of lung cancer in Denmark from 2006 through 2015 are described and a model for predicting the future epidemiological profile of lung cancer through 2030 is introduced.METHODS:The study population comprised all cases of lung cancer, registered in the Danish Cancer Registry, who were alive on January 1, 2006 or had a first-time ever diagnosis of lung cancer during 2006 through 2015. Information on morphology, stage of the disease, comorbidity and survival was obtained from other Danish health registers. Based on NORDCAN data and estimated patient mortality rates as well as prevalence proportions for the period 2006 through 2015, future case numbers of annual incidence, deaths, and resulting prevalence were projected.RESULTS:A total of 44.291 patients were included in the study. A shift towards more patients diagnosed with lower stages and with adenocarcinoma was observed. The incidence increased and the patient mortality rate decreased significantly, with a doubling of the prevalence during the observation period. We project that the numbers of prevalent cases of lung cancer in Denmark most likely will increase from about 10,000 at the end of 2015 to about 23,000 at the end of 2030.CONCLUSIONS:Our findings support that lung cancer is being diagnosed at an earlier stage, that incidence will stop increasing, that mortality will decrease further, and that the prevalence will continue to increase substantially. Projections of cancer incidence, mortality, and prevalence are important for planning health services and should be updated at regular intervals.

Pulmonary blastoma is an aggressive lung cancer with incidence ranging from 0.25–0.5 of all the reported lung cancers. Although, pulmonary blastoma is seen commonly in childhood its very rare in adults. Surgical treatment is often the treatment of choice, but benefits of neoadjuvant chemotherapy are unclear. People with DICER1 syndrome commonly develop Pulmonary blastoma and do have concomitant or previous history of benign or malignant tumours in extra pulmonary site like kidney, thyroid, ovary cervix testicle and eye. As per our knowledge, this is the first case of adult pulmonary blastoma previously diagnosed with urothelial cancer and a strong familial predilection of malignancy, with negative genetic test for DICER1 mutations.

Immunoglobulin G4 (IgG4)-related disease is a systemic fibroinflammatory disorder that can affect almost any tissue. Isolated IgG4 pleural disease is a rare manifestation and, when present, is usually described in patients presenting with dyspnoea. We present a case of asymptomatic isolated IgG4 pleural effusion and highlight that IgG4-related disease should be remembered as a differential diagnosis in patients with pleural effusion and pleural thickening, even if asymptomatic and without any other organ involvement.

Although small cell lung cancer (SCLC) patients usually respond well to first line treatment, long-term survival remains poor. Most patients are diagnosed late with extensive disease (ED), and only limited development of new treatments has been seen over the last decades. Here, we describe treatment patterns for SCLC patients in a real-life setting in Denmark. SCLC patients diagnosed in Denmark during 2006-2015 were identified in the Danish Cancer Registry, with follow-up through 2018. Patient- and tumor data were linked to data on co-morbidity, resection, chemoradiotherapy [CRT], radiotherapy only [RT], and chemotherapy only [CT] from the National Patient Registry. Survival was estimated using Kaplan-Meier methods. During the study period, 6,353 patients were diagnosed with SCLC. Mean age was 68.5 years, 50.8% were male, 37.1% had ≥1 co-morbidity. Overall, 68.2% had ED (stage IV), 25.7% had limited disease (LD; stage I-III), 6.1% had missing information. Death within 60 days from diagnosis, without completing treatment, was reported for 31.1% and 7.9% for ED and LD, respectively. Median survival for ED and LD was 6.2 and 15 months; and the 5-yr survival was 15% for LD and 2% for ED, respectively. Among patients with ED surviving >60 days, 5.4% received no treatment; 0.3% were resected; 3.2% received RT; 73.1% received CT; 17.9% received CRT, and 0.5% had registered prophylactic cranial irradiation (PCI). For LD, 5.3% received no treatment; 4.3% resection; 3.5% RT; 36.9% CT; 50.0% CRT; and 1.3% registered PCI. Median number of CT treatments registered during one year after initiated CT was 8 for both ED and LD. Median number of RTs registered during one year after initiated RT was 4 and 6 for patients with ED and LD, respectively. Survival of SCLC patients is poor, and many patients die before completing treatment, which highlights a big unmet need for effective therapies. Recent data from clinical trials have shown survival benefit of immunotherapy in combination with chemotherapy in treatment naïve ED SCLC patients. These new treatment strategies may have the potential to improve long-term survival in this severely ill patient population.

Background: Patients with stage III non-small cell lung cancer (NSCLC) is a heterogeneous population with resectable or unresectable tumors. Current standard of care for unresectable disease has since long been either curatively intended chemoradiotherapy (CRT) followed by active surveillance, or palliative treatment for CRT ineligible patients. Recently, published data have shown survival benefit of CRT followed by immunotherapy (durvalumab). The aim was to investigate long-term survival, treatment patterns, and characteristics for unresected stage III NSCLC patients in a real-life setting. Methods: This nationwide study identified all stage III NSCLC patients diagnosed in Denmark during 2006-2015 in the Danish Cancer Registry. Patient and tumor data were linked with data on resection, CRT, radiotherapy only [RT], chemotherapy only [CT] and comorbidity from the National Patient Registry. Survival rates were estimated from date of diagnosis until death, migration, or end of study (2016) using Kaplan-Meier curves. Results: During the study period, 33,747 patients were diagnosed with NSCLC, of which 7390 (22%) had stage III disease. Of these, 5919 (80%) patients were unresected, and they were older (mean age 69.2 vs. 65.8 years), more frequently men (55.0% vs. 51.5%), and had more comorbidity (39.8% vs. 33.6% ≥one comorbidity) compared to the resected patients. Among the unresected patients, 40.5% received CRT, 15.1% RT, 15.6% CT, and 28.8% had no treatment. Patients receiving CRT were younger and had less comorbidity than patients receiving RT or CT only. The 5-year overall survival rates in the unresected group were: 10.6% CRT, 4.5% RT, and 3.6% for patients treated with CT. Among the resected stage III NSCLC patients, 42% survived ≥5 years. Conclusions: The poor long-term survival rates observed among unresected stage III NSCLC patients indicate a high unmet need for more effective therapy. New treatment strategies, including CRT followed by immunotherapy, might improve long-term outcomes for these patients. Increased utilization of biomarkers and correctly targeted therapies has the potential to personalize and improve treatment of stage III NSCLC. Legal entity responsible for the study: Institute of Applied Economics and Health Research Aps, Copenhagen, Denmark. Funding: AstraZeneca. Disclosure: H.N. Christensen: Employed: AstraZeneca. All other authors have declared no conflicts of interest.

Information on the epidemiology of lung cancer and its main subtypes, small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC), is needed to assess the impact of lung cancer subtypes on the current and future health care system. Data from Danish nationwide registers were used to describe trends in lung cancer incidence, mortality, and prevalence in Denmark during the study period January 1, 2006 to December 31, 2015. Annual forecast on prevalence of lung cancer in Denmark up till 2030 was developed using projections of incidence rates from NORDCAN (http://www-dep.iarc.fr/NORDCAN/english/frame.asp) combined with forecasted mortality rates in the study patient population. A total of 44,291 lung cancer patients were identified in the Danish Cancer Registry during the study period, of which 6,353 (14.3%) had pathologically verified SCLC. Among the remaining cases 'NSCLC+other'; 33,747 (89.0%) had verified NSCLC, 4,038 (10.6%) lacked pathology, and 153 (0.4%) had other pathology than indexed lung cancer. Among SCLC, the annual numbers of new cases and deaths were stable, and at similar levels (Figure 1). As a result, the SCLC prevalence was projected to remain at same stable level until 2030. Among NSCLC+other, the annual numbers of new cases increased gradually. The gap between new cases and deaths became greater during the study period due to slowly steadying number of deaths. Hereby, the observed prevalence of NSCLC +others grew exponentially and was projected to continue so. The current and future epidemiological profiles differ according to lung cancer subtype. This finding should be considered when prioritizing and planning for future lung cancer care, particularly in the context of new treatment strategies, where personalized medicine and treatment modalities such as immunotherapy may result in improved prognosis. Further and continuous epidemiological monitoring is recommended to assess the impact of such improvements.

Background: Patients with small cell lung cancer (SCLC) with poor performance status (PS) especially in the elderly may not benefit from chemotherapy. The aim of this study was to compare survival of treated patients with PS 3-4 with untreated patients. Material and methods: We reviewed the medical records and pathology data for 448 patients diagnosed with small cell carcinoma from 2010 to 2015 and selected all patients in PS 3-4 for review. Results: A total of 87 patients fulfilled the inclusion criteria. Of these, 53 (61%) received chemotherapy (CT), while 34 (39%) did not. The median overall survival (OS) was 5.1 months for the treated patients and 0.7 month for the untreated (p Conclusion: CT was associated with improved survival in patients with SCLC with PS 3-4 independent of age and stage of disease. Neither ED, high age, nor poor PS should be used as criteria for omitting CT.

The Danish Lung Cancer Registry (DLCR) has since 2003 reported all cases of lung cancer in Denmark. Since 2012 data on EGFR mutations and ALK translocations have also been included in the registry. The significance of being EGFR mutated on survival in a national population has not yet been reported. All Danish lung cancer patients are ascertained based on coded information in the National Patient Register and the National Pathology Register (NPR). Based on SNOMED coding the subgroups of lung cancer and the EGFR mutation status is identified. The study includes all Danish stage IIIB and IV lung cancer adenocarcinoma patients diagnosed between 2013 and 2015. Treatment modalities including EGFR inhibitors followed international guidelines. Survival of the EGFR mutated patients has been compared to EGFR negative patients and those without any EGFR registration. Prognostic factors were analyzed in a Cox uni- and multivariate analysis. Among 3120 patients identified, 244 were EGFR positive, 2404 EGFR negative and 472 not tested, respectively. Median survival for EGFR positives was 544 days, against 203 for EGFR negatives and 114 for untested. The EGFR mutated group had more female patients, never smokers and lower Charlson Comorbidity Index (CCI) than the 2 other groups. Supplementary data on population characteristics and treatment are to be presented. In univariate Cox analysis EGFR was an independent predictor for survival (HR: 0.68 (95% CI: 0.82-0.74); P=0.000) and in the multivariate analysis adjusted for age, sex, smoking and CCI the effect of EGFR was independent (HR: 0.72 (95% CI: 0.69 – 0.80); P=0.000). In a nationwide total population of advanced lung cancer adenocarcinoma patients, EGFR positives gain approximately 1 year in median overall survival compared to EGFR negatives and untested patients.

The incidence of lung cancer in Denmark is approximately 4600/year. Adenocarcinoma is the most common histologic subtype, and standard treatment for early stage disease is radical surgical resection. According to the latest World Health Organization (WHO) classification the histological subtyping of adenocarcinomas as well as visceral pleural invasion (VPI) are prognostic factors. Vascular invasions (VI) have also been associated with poor survival. This study aimed to validate the revised WHO classification on completely resected stage-I lung adenocarcinomas and investigate the prognostic significance of VPI and VI.

The Danish Lung Cancer Registry (DLCR) has since 2003 reported all cases of lung cancer in Denmark. Since 2012 data on EGFR mutations and ALK translocations have been included. Little is known on the distribution of EGFR mutations and ALK translocations on a national level in a primarily Caucasian population like the Danish lung cancer population. All Danish lung cancer patients are ascertained based on coded information in the National Patient Register. Supplementary information for each patient is obtained from the clinical units as well as from the National Pathology Register (NPR). Based on SNOMED coding by all departments performing lung cancer pathology evaluation and registered in the NPR the subgroups of lung cancer are identified. The patients are tested for EGFR mutations and ALK translocations according to national guidelines and the results are registered in the NPR. It is estimated that 95 % of all Danish lung cancer patients are present or former smokers and that the sex distribution is equal between the sexes. 4667 patients diagnosed in 2015 are included. Table 1. Distribution of EGFR mutations and ALK translocation in the 2015 lung cancer population: 83.3 % of all patients with lung cancer and adenocarcinoma in Denmark are tested for EGFR mutations and 9.4 % are positive. 73.1 % of adenocarcinomas are tested for ALK translocations and 1.4 % is found to be positive. In total only 8.8 % of all tested lung cancer patients are found to be EGFR mutated and 1.3 % has an ALK translocation. Data from primarily Asian lung cancer populations have shown significant higher rates of EGFR mutations and ALK translocations that the findings in this Danish population. Based on these data the cost-effectiveness of the chosen strategy for reflex testing lung cancer patients up front should be reconsidered.

Objective: Exposure to coal dust can cause interstitial lung disease (ILD), but whether this is due to pure coal or to the contents of quartz in coal is less clear. Here, we systematically reviewed the relation between 'pure coal' and ILD. Methods: In a systematic review based on PRISMA criteria 2945 articles were identified. Strict eligibility criteria, which evaluated the 'pure coal effect', led to the inclusion of only nine studies. Results: Among these nine studies six studies indicated an independent effect of the non-quartz part of coal on the development and progression of ILD, two did not demonstrate an effect and one was inconclusive. Conclusions: Although an independent effect of non-quartz coal dust on the development of ILD is supported, due to methodological limitations the evidence is limited and further evidence is needed.

The Danish Lung Cancer Registry has since 2003 reported all cases of lung cancer in Denmark including the pathology. We present the trends over time in the distribution of subgroups of pathology. All Danish lung cancer patients are ascertained based on coded information in the National Patient Register. Supplementary information for each patient is obtained from the clinical units as well as from the National Pathology Register (NPR). Based on SNOMED coding the patients is categorized in 12 subgroups of lung cancer. Figure 1Trends in lung cancer pathology (%)View Large Image Figure ViewerDownload Hi-res image Download (PPT) The increased number of lung cancer falls mainly in the adenocarcinoma group. Moreover, there is a significant relative increase of adenocarcinomas corresponding with a decrease of patients with NOS and NSCC. The occurrences of the other categories, including small cell carcinoma and squamous carcinoma, have remained largely unchanged. The trend of adenocarcinoma as the predominate type of lung cancer is in accordance with the global evolution. The high frequency is partly due to the need for specific subtyping and the agreement of diagnostic criteria which has resulted in a shift from NOS and NSCC categories to adenocarcinoma.