The seventh edition of the TNM Classification of Malignant Tumours was published in 2009. This study was conducted to investigate the prognostic factors of p-T1aN0M0 pulmonary adenocarcinoma, which is the earliest stage defined in the new TNM classification.

We retrospectively studied 122 patients who underwent lobectomy at our institution for p-T1aN0M0 adenocarcinoma, as re-categorized in the seventh TNM classification. The patients were separated into groups on the basis of the following clinicopathologic parameters: age, <70 vs. >70 years; gender, male vs. female; preoperative serum carcinoembryonic antigen (CEA) level, <5.0 vs. ≥5.0 ng/dl; tumour size, <10 vs. >10 mm; intratumoral vascular or lymphatic invasion, positive vs. negative. Univariate and multivariate analyses of disease-free survival were performed.

The median follow-up period was 41.4 months. Univariate analysis showed that prognostic factors such as age, CEA elevation and intratumoral vascular or lymphatic invasion were significant (age, <70 vs. >70 years; 97.1% vs. 82.0%, P = 0.0027; preoperative serum CEA level, <5.0 vs. >5.0 ng/dl; 93.3% vs. 33.3%, P < 0.0001; intratumoral vascular or lymphatic invasion, positive vs. negative; 31.3% vs. 96.5%, P < 0.0001). Multivariate analysis demonstrated that only intratumoral vascular or lymphatic invasion was a significantly independent prognostic factor (P = 0.0039, Hazard Ratio, 0.066; 95% Confidence Interval, 0.011–0.419).

Intratumoral vascular or lymphatic invasion should always be studied and included in the final pathology report in order to consider potential clinical and therapeutic relevance. The efficacy of adjuvant chemotherapy for these patients should also be evaluated in clinical trials.

Patients with extrathoracic synchronous solitary metastasis and non-small cell lung cancer (NSCLC) are rare. The effectiveness of both tumour sites resection is difficult to evaluate because of the high variability among clinical studies. We reviewed our experience regarding the management and prognosis of these patients.

The charts of 4668 patients who underwent lung cancer surgery from 1983 to 2006 were retrospectively reviewed. We analysed the epidemiology, treatment, pathology and prognostic characteristics of those with extrathoracic synchronous solitary metastasis amenable to lung cancer surgery on a curative intend.

There were 94 patients (sex ratio M/F 3.2/1, mean age 56 years). Surgery included pneumonectomy (n = 27), lobectomy (n = 65) and exploratory thoracotomy (n = 2). Pathology revealed adenocarcinomas (n = 57), squamous cell carcinoma (n = 20), large cell carcinoma (n = 14) and other NSCLC histology (n = 3). Lymphatic extension was N0 (n = 46), N1 (n = 17) and N2 (n = 31). Metastasis involved the brain (n = 57), adrenal gland (n = 12), bone (n = 14), liver (n = 5) and skin (n = 6). Sixty-nine metastases were resected. Five-year survival rate was 16% (median 13 months). Induction therapy, adenocarcinoma, N0 staging and lobectomy were criteria of better prognosis, but metastasis resection was not.

These results suggest that extrathoracic synchronous solitary metastasis of pN0 adenocarcinoma may achieve long-term survival in the case of lung resection with or without metastasis resection. This pattern may reflect a specific tumour biology whose solitary metastasis benefits both from surgical or non-surgical treatment.

Conventional thoracoscopy, routinely performed in patients with pleural diseases, is not always conclusive in staging of pleural spread. Fluorescence diagnosis (FD) with 5-aminolaevulinic acid (5-ALA) has been used in the diagnostic purpose for various malignancies. The impact of fluorescence thoracoscopy on diagnosis and staging of pleural malignancies was examined.

A total of 23 patients with non-conclusive pleural effusions were enrolled in the prospective single-institution trial. Eligible patients were administered 25 mg/kg of 5-ALA (‘Alasense’, Niopik, Russian Federation) per os 3 h before video-assisted thoracoscopy. After conventional inspection with white light, thorough fluorescence investigation of the visceral and parietal pleura was performed (D-LIGHT Auto Fluorescent System, Karl Storz, Germany). Biopsy specimens of both normal and abnormal sites, as determined from white-light and FD inspection, were obtained for histological examination.

There was no morbidity or mortality due to the procedure. A definitive diagnosis was obtained in all cases: malignant mesothelioma in 13 cases, other malignancies (pleural metastases) in 8 cases and non-specific inflammation in 3 patients. A total of 118 biopsy specimens were available for histological examination. In 20 patients, all pleural deposits (n = 60) detected by white-light thoracoscopy had bright red fluorescence during FD and were proved to be malignant. Upstaging occurred in 12 patients (57.2%) (unsuspected 21 tumour deposits) due to FD examination. Micrometastases of macroscopically normal pleura were detected, only by FD, in one patient. Comparing the results of histological examination of specimens detected by conventional thoracoscopy with that by fluorescence thoracoscopy, we obtained 82 true positive, 10 false-negative, 23 true negative, 3 false-positive results with a specificity of 88.4%, sensitivity of 89.1% and diagnostic accuracy of 88.9%.

FD using 5-ALA in the pleural cavity is a feasible diagnostic tool when used in addition to white-light thoracoscopy. It improves visualization of additional lesions or even micrometastases in patients with pleural malignancy.