OBJECTIVES Invasive mediastinal staging is advised by guidelines in patients with resectable non-small cell lung cancer (NSCLC) and suspicious lymph nodes (cN1-3) or for central, FDG-non-avid or peripheral tumours >3 cm. Our objective was to assess current guideline adherence and consequent unforeseen N2 disease (uN2) in NSCLC patients having various indications for mediastinal staging. MATERIALS AND METHODS We analysed the Dutch Lung Cancer Audit - Surgery data of all patients who underwent a primary lung resection with lymph node dissection for NSCLC in 2017-2018. Based on the 2015 ESTS-ERS-ESGE guideline we assessed the use of initial endosonography and confirmatory mediastinoscopy as well as uN2 rates. RESULTS A total of 2238 patients were analysed. 43 % (95 %-CI 41-45) underwent initial endosonography followed by a confirmatory mediastinoscopy in 44 % (95 %-CI40-47) of them, resulting in a 19 % (95 %-CI 17-20) rate of properly staged patient according to the guidelines. uN2 was demonstrated in 12.5 % (95 %-CI 9.7-16.0) of correctly staged patients compared to 10.9 % (95 %-CI 9.6-12.4) who were not (p = .36). The highest uN2 rate was found in cN1-3 patients who were not staged (23.0 %, 95 %-CI 16.4-31.2) compared to 13.0 % (95 %-CI 9.7-17.1) who were (p = .01). CONCLUSION Guideline adherence in Dutch NSCLC patients with an indication for invasive mediastinal staging is poor. The highest uN2 rate was found in unstaged cN1-3 patients, suggesting that this subgroup may benefit from an appropriate staging conform guidelines. V.OBJECTIVES Treatment options for malignant pleural mesothelioma (MPM) are limited but some studies on immune checkpoint inhibitors (ICIs) in MPM have reported antitumor activity. Very little is known about immune-related predictive factors. MATERIALS AND METHODS Here we report the case of a 45-year-old woman presenting with dyspnea and evidence of pleural effusion. She was diagnosed with malignant epithelioid pleural mesothelioma with brain metastasis and peritoneal carcinosis, refractory to initial standard chemotherapy treatment. Because of high PDL1 expression (100 %), she was treated with the anti-PD1 agent, pembrolizumab. RESULTS Chemotherapy with cisplatin and pemetrexed was started, imaging studies showing stable disease after 3 treatment cycles. The patient underwent pleural decortication but rapidly progressed and thus started chemotherapy with carboplatin and gemcitabine. After 2 cycles she experienced seizures caused by a brain metastasis. This secondary lesion was surgically removed and confirmed ry nodules, with stable liver metastases. The patient is still undergoing immunotherapy and has no cancer-related symptoms. CONCLUSIONS Our findings indicate that the use of immunotherapy in MPM warrants further investigation. Furthermore, the impressive clinical response obtained by our patient suggests that immune checkpoint inhibitors could help in the management of the disease after the failure of other treatments. OBJECTIVES NSCLC patients harboring EGFR mutation invariably developed resistance to EGFR TKI. We postulated that oligoresidual disease (ORD) after initial TKI might harbor resistant clones. This study aimed to test if preemptive local ablative therapy (LAT) can improve progression free survival (PFS) or not compared to historic data. MATERIALS AND METHODS Patients indicated for EGFR TKI who possessed ORD (≤ 4 PET-avid lesions) after an initial 3-month TKI therapy were enrolled. After screening PET-CT, eligible patients with PET-avid ORDs were treated by LAT, either by stereotactic ablative radiotherapy (SABR) or surgery per clinicians' discretion. TKI was continued after LAT until it was considered ineffective. PET-CT was repeated on the 3rd and 12th month post-LAT (or at progression) apart from regular imaging. Further LAT was allowed in oligoprogressive disease. Primary endpoint was PFS rate at one-year from enrollment. Overall survival (OS), PFS and treatment safety were secondary endpoints. A post hoc comparison with screen failure cohort was performed. RESULTS Eighteen patients were enrolled from 2014-17. Recruitment was stopped before the planned number (34) due to slow accrual. Two were excluded due to consent withdrawal and significant protocol violation. Median follow up was 39.1 months. Among the 16 analyzed patients, the one-year PFS rate (i.e. 15 month post TKI) was 68.8 %. Median OS was 43.3 months. All LAT were done by SABR, and none experienced ≥ grade 3 SABR related toxicities. Compared with screen failure cohort (n = 48), pre-emptive LAT effectively reduced risk of progression (HR 0.41, p = 0.0097). CONCLUSION Preemptive LAT in ORD appeared to be safe and feasible. The 1-year PFS rate was encouraging. However, potential biases and the limitations of the study should not be overlooked. Further randomized studies are warranted. INTRODUCTION Papillary carcinoma accounts for approximately 80% of all thyroid carcinomas. It is associated with relatively good survival. Distant metastases occur in approximately 10% of the patients, with the lung and bone being the most commonly reported sites. We present a case of unusual metastasis to the sphenoid bone and sella turcica from papillary thyroid carcinoma with an insular component. CASE PRESENTATION We present a case of 70 years old female patient who presents a voluminous goiter with an 11 cm mass of the left sixth rib. Trans-parietal biopsy proved its metastatic origin from a thyroid papillary carcinoma. The patient was treated with total thyroidectomy and radiation therapy as the metastatic tissue is radioiodine refractory. Pathology revealed a papillary carcinoma with an insular component. A year later, the patient develops another metastasis to the sphenoid bone extending to the sella turcica, cavernous sinus, and carotid arteries. Treatment was based on kinase inhibitor. DISCUSSION Metastatic invasion of the skull develops in 2.5%-5.8% of differentiated thyroid carcinoma and mostly affects the sella turcica, pituitary gland, cavernous sinus and sphenoid sinus. The presence of an insular component in a well-differentiated thyroid carcinoma seems to be associated with a poor prognosis. For cases where the metastatic disease is found to be resistant to conventional therapies, some clinical trials show promise with the use of tyrosine kinase inhibitors such as Sorafenib.  https://www.selleckchem.com/products/ew-7197.html  CONCLUSION Management of such uncommon cases remains challenging and should take in consideration evidence based guidelines, prognostic factors, disease progression path and treatment morbidity.