The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.

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Summary Four patients underwent intraoperative photodynamic therapy after surgery with meso-tetra-(hydroxyphenyl)-chlorin (mTHPC-PDT) for diffuse malignant mesothelioma. Preliminary procedures were performed in two patients in order to establish the efficacy of mTHPC-PDT and to optimise its tumoricidal effect. The (Faber, 1988). Improved local control does require additional measures, but the disease responds poorly to radio-and chemotherapy (Lerner et al., 1983). As photodynamic therapy (PDT) has been reported to be effective in human mesothelioma xenografts (Feins et al., 1990), it might allow for an appropriate 'clean-up' of the thoracic cavity after surgery. For clinical purposes, the currently used sensitisers for PDT are haematoporphyrin derivatives (HpD) and dihaematoporphyrin ether (DHE) . However, PDT with meso-tetra-(hydroxyphenyl)-chlorin (mTHPC) was superior to DHE-PDT with respect to antitumour activity and tissue selectivity in rodents without causing significant toxicity (Berenbaum, 1989). mTHPC might therefore be better fitted to large surface PDT as required for diffuse malignant mesothelioma treatment. A pilot study was done to evaluate mTHPC-PDT for diffuse malignant mesothelioma with respect to its antitumour activity and the feasibility of a combined modality approach under clinical conditions. Patients and methodsFour patients underwent mTHPC-PDT for diffuse malignant mesothelioma. Each patient was informed in detail about the experimental nature of the procedure and consent was obtained from each patient and from the local Human Investigations Committee of our institution.The four men were aged 46 (patient 1), 48 (patient 2), 65 (patient 3) and 50 years (patient 4), all having had possible occupation related exposure to asbestos. The main symptoms at admission were dyspnoea due to pleural effusion, chest pain and loss of weight. There was no evidence of disease in the peritoneal and contralateral chest cavity on CT-scans at admission. The right side was involved in patients 1, 2 and 4 and the left in patient 3. Previous biopsies revealed an epithelial (Figure la), a biphasic (Figure 2a), a sarcomatous and a mixed type of mesothelioma in the four patients and was confirmed in every case by immunohistologic examinations.Preliminary PDT To establish the efficacy of mTHPC-PDT and to optimise its tumouricidal effect, preliminary PDT was performed in patients 1 and 2 prior to its definitive application. Modulations of mTHPC dose, light dose and of the time interval between mTHPC application and activation were tested. mTHPC (Scotia Pharmaceuticals Ltd, Guildford, UK) was dissolved in 20% ethanol, 30% polyethylene glycol 400 and 50% H20 and administered over 15 min i.v. through a bacterial filter under sterile conditions within 60 min of preparation. Argon-pumped dye laser light of 650 nm (Coherent Innova 200 and Dye CR 599, GMP SA, Lausanne, Switzerland) was delivered through a sterilised optical fibre on tumour areas of 3 cm diameter. The power at the end of the optical fibre was measured wi...

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Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacity.