Multimodal Treatment of Pleural Mesothelioma with Cytoreductive Surgery and Hyperthermic Intrathoracic Chemotherapy: Impact of Additive Chemotherapy

Cytoreductive surgery (CRS) combined with hyperthermic intrathoracic chemoperfusion (HITOC) is a promising treatment strategy for pleural mesothelioma (PM). The aim of this study was to evaluate the impacts of this multimodal approach in combination with systemic treatment on disease-free survival (DFS) and overall survival (OS). In this retrospective multicenter study, clinical data from patients after CRS and HITOC for PM at four high-volume thoracic surgery departments in Germany were analyzed. A total of 260 patients with MPM (220 epithelioid, 40 non-epithelioid) underwent CRS and HITOC as part of a multimodal treatment approach. HITOC was administered with cisplatin alone (58.5%) or cisplatin and doxorubicin (41.5%). In addition, 52.1% of patients received neoadjuvant and/or adjuvant chemotherapy. The median follow-up was 48 months (IQR = 38 to 58 months). In-hospital mortality was 3.5%. Both the resection status (macroscopic complete vs. incomplete resection) and histologic subtype (epithelioid vs. non-epithelioid) had significant impacts on DFS and OS. In addition, adjuvant chemotherapy (neoadjuvant/adjuvant) significantly increased DFS (p = 0.003). CRS and HITOC within a multimodal treatment approach had positive impacts on the survival of patients with epithelioid PM after macroscopic complete resection. The addition of chemotherapy significantly prolonged the time to tumor recurrence or progression.

Hybrid (Digital/Water Seal) Chest Drainage System - An Innovative Device for Patients with Anticipated Air Leaks

BACKGROUND

To date, several chest drainage systems are available, such as digital drainage systems (DDS) and traditional systems with continuous suction or water seal. However, none of these systems were yet shown to be favorable in the treatment of complex situations such as persistent air leaks or residual spaces. We present in-vitro as well as clinical data of a novel hybrid drainage system consisting of an optimized digital drainage system (ODDS) and an underwater seal drainage system (UWSD).

METHODS

For in-vitro analysis, a DDS and an ODDS were connected to a pleural cavity simulator. Different air leaks were produced and data on intrapleural pressure and air flow were analyzed. Furthermore, we tested the hybrid drainage system in 10 patients with potential air leaks after pulmonary surgery.

RESULTS

In in-vitro analysis, we could show, that with advanced pump technology, pressure fluctuations caused by the drainage system when trying to maintain a set pressure level in patients with airleaks were much smaller when using an ODDS and could even be eliminated when using a fluid collection canister with sufficient buffer capacity. This minimized air leak boosts caused by the drainage system. Optimizing the auto-pressure regulation algorithms also led to a reduced airflow through the fistula and promoted rest. Switching to a passive UWSD also reduced the amount of airflow. Clinical application of the hybrid drainage system yielded promising results.

CONCLUSION

The novel hybrid drainage system shows promising results in the treatment of patients with complex clinical situations such as persistent air leaks.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

[Resection of Solitary Lung Metastasis of Urinary Tract Transitional Cell Cancer Can Prolong Survival in Selected Patients]

There are only a few small published studies on pulmonary metastasectomy for urinary tract transitional cell carcinoma (TCC). In this study, we examined the long-term outcome and the prognostic survival factors associated with pulmonary metastasectomy of urinary tract TCC, as based on our centre's 20-year experience. Between 2000 and 2020, curative pulmonary metastasectomy was performed in 18 patients (14 males and 4 females). Clinical, demographical and surgical data were retrospectively analysed. The disease-free interval between treatment of the primary tumour and pulmonary metastasectomy ranged from one to 48 months. Survival analysis was conducted with the Kaplan-Meier method and log-rank test. The 3- and 5-year survival rates were 84.7% and 52.9%, respectively. Resection of solitary metastases was a positive and independent factor for survival (p = 0.04). Pulmonary metastasectomy of urinary tract TCC is associated with a favourable outcome and solitary metastasis is associated with long-term survival. Surgical resection of solitary pulmonary metastasis and repeated lung metastasectomy by pulmonary recurrence from a urinary tract TCC is feasible in selected patients.

[Robotic Diaphragm Plication]

Acquired unilateral hemidiaphragm elevation is characterised by dyspnoea, which is typically aggravated when lying down, bending over or during swimming. The most common causes are idiopathic or due to injury to the phrenic nerve during cervical or cardio-thoracic surgery. To date, surgical diaphragm plication remains the only effective treatment. The aim of the procedure is to plicate the diaphragm to restore its tension and thus improve breathing mechanics, increase the available space for the lung and reduce compression from abdominal organs. In the past, various techniques using open and minimally invasive approaches have been described. Robot-assisted thoracoscopic diaphragm plication combines the advantages of a minimally invasive approach with excellent visualisation and freedom of movement. It was shown to be a safe technique which is easy to establish and can significantly improve pulmonary function.

Outcome of Repeated Resection of Pulmonary Metastases for Renal Cell Cancer

BACKGROUND

To date, many studies investigated results and prognostic factors of pulmonary metastasectomy (PM) in renal cell cancer (RCC). However, reports concerning repeated resection for patients with recurrent pulmonary metastases (RPM) are limited. In this study, we analyzed safety, efficacy, and prognostic factors for survival after PM focusing on RPM for RCC.

PATIENTS AND METHODS

Clinical, operative, and follow-up data of patients who underwent PM or RPM for RCC in our institution were retrospectively collected and correlated with each other from January 2005 to December 2019.

RESULTS

Altogether 154 oncological pulmonary resections in curative intention as PM or RPM were performed in 82 and 26 patients. Postoperative complications were similar in both groups (n = 22 [26.8%] vs. 4 [15.4%], p = 0.2). Zero mortality was documented up to the 30th postoperative day. RPM was not associated with decreased 5-year-survival compared with PM (66.2 vs. 57,9%, p = 0.5). Patients who underwent RPM for recurrent lung metastases had a better overall survival in comparison with the other treatments including chemotherapy, radiotherapy, immunotherapy, and best supportive care (p = 0.04). In the multivariate analysis, disease-free survival was identified as an independent prognostic factor for survival (hazard ratio: 0.969, 0.941-0.999, p = 0.04).

CONCLUSION

RPM is a safe and feasible procedure. The resection of recurrent lung metastases shows to prolong survival in comparison with the other therapeutic options for selected patients with RCC.

Surgery for thoracic oligoprogression in metastatic renal cell cancer in the era of new systemic therapies

Background

Novel systemic therapies have improved response rates and survival in metastatic renal cell cancer (mRCC) and are considered standard of care for this entity. However, complete remission (CR) is rare and often oligoprogression is observed. Here, we analyse the role of surgery for oligoprogressive lesions in mRCC.

Methods

We retrospectively analyzed all patients who underwent surgery for thoracic oligoprogressive lesions of mRCC after receiving systemic therapy including immunotherapy, tyrosine kinase inhibitors (TKI), and/or multikinase inhibitors at our institution between 2007 and 2021 regarding treatment modalities, progression-free survival (PFS) and overall survival (OS).

Results

Ten patients with oligoprogressive mRCC were included. The median interval between nephrectomy and oligoprogression was 65 months (range, 16-167). Median PFS after surgery for oligoprogression was 10 months (range, 2-29) and median OS after resection 24 months (range, 2-73). In 4 patients, CR was achieved of whom three showed no progression at last follow-up (PFS median 15 months, range, 10-29). In 6 patients, removal of the progressive site resulted in stable disease (SD) for a median of 4 months (range, 2-29), before 4 of them progressed.

Conclusions

In selected cases, surgery can lead to sustained disease control in patients with oligoprogressive mRCC after systemic treatment including immunotherapy and novel treatment agents.

Surgical cytoreduction and hyperthermic intrathoracic chemotherapy for thymic tumours with pleural spread is effective on survival: results from the multicentre German HITOC-study

OBJECTIVES

Cytoreductive surgery and hyperthermic intrathoracic chemotherapy (HITOC) is effective on survival for patients with pleural metastatic thymic tumours.

METHODS

Multicentre, retrospective analysis of patients with stage IVa thymic tumours treated with surgical resection and HITOC. Primary end-point was overall survival, secondary end-points were recurrence-/progression-free survival and morbidity/mortality.

RESULTS

A total of n = 58 patients (thymoma n = 42, thymic carcinoma n = 15, atypical carcinoid of the thymus n = 1) were included, who had primary pleural metastases (n = 50; 86%) or pleural recurrence (n = 8; 14%). Lung-preserving resection (n = 56; 97%) was the preferred approach. Macroscopically complete tumour resection was achieved in n = 49 patients (85%). HITOC was performed with cisplatin alone (n = 38; 66%) or in combination with doxorubicin (n = 20; 34%). Almost half of the patients (n = 28; 48%) received high-dose cisplatin > 125 mg/m2 body surface area. Surgical revision was required in eight (14%) patients. In-hospital mortality rate was 2%. During follow-up tumour recurrence/progression was evident in n = 31 (53%) patients. Median follow-up time was 59 months. The 1-, 3-, and 5-year survival rates were 95%, 83%, and 77%, respectively. Recurrence/progression free survival rates were 89%, 54%, and 44%, respectively. Patients with thymoma had significantly better survival compared to patients with thymic carcinoma (p-value ≤0.001).

CONCLUSIONS

Promising survival rates in patients with pleural metastatic stage IVa in thymoma (94%) and even in thymic carcinoma (41%) were achieved. Surgical resection and HITOC is safe and effective for treatment of patients with pleural metastatic thymic tumours stage IVa.

CLINICAL REGISTRATION NUMBER

DRKS-ID DRKS00015012.

Independent risk factors for an increased incidence of thromboembolism after lung transplantation

BACKGROUND

Thromboembolism (TE) after lung transplantation (LTX) is associated with increased morbidity and mortality. The aim of this study is to analyze the incidence and outcome of venous and arterial thromboembolic complications and to identify independent risk factors.

PATIENTS AND METHODS

We retrospectively analyzed the medical records of 221 patients who underwent LTX at our institution between 2002 and 2021. Statistical analysis was performed using SPSS and GraphPad software.

RESULTS

74 LTX recipients (33%) developed TE. The 30-days incidence and 12-months incidence were 12% and 23%, respectively. Nearly half of the patients (48%) developed pulmonary embolism, 10% ischemic stroke. Arterial hypertension (p = 0.006), a body mass index (BMI) > 30 (p = 0.006) and diabetes mellitus (p = 0.041) were independent predictors for TE. Moreover, a BMI of > 25 at the time of transplantation was associated with an increased risk for TE (43% vs. 32%, p = 0.035). At the time of LTX, 65% of the patients were older than 55 years. An age > 55 years also correlated with the incidence of TE (p = 0.037) and these patients had reduced overall post-transplant survival when the event occurred within the first postoperative year (59% vs. 72%, p = 0.028).

CONCLUSIONS

The incidence of TE after LTX is high, especially in lung transplant recipients with a BMI > 25 and an age > 55 years as well as cardiovascular risk factors closely associated with the metabolic syndrome. As these patients comprise a growing recipient fraction, intensified research should focus on the risks and benefits of regular screening or a prolonged TE prophylaxis in these patients. Trial registration number DKRS: 00021501.

Should cardiovascular comorbidities be a contraindication for pulmonary metastasectomy?

BACKGROUND

Limited information is available about the impact of cardiovascular comorbidities (CVC) on the postoperative course of patients undergoing pulmonary metastasectomy (PM). In this study, we aim to compare the postoperative morbidity, mortality, and the long-term survival of patients with and without CVC undergoing PM.

METHODS

A retrospective monocentric study was conducted including 760 patients who underwent PM in curative intention. Patients were divided into two groups depending on the presence of CVC.

RESULTS

The data from 164 patients with CVC (21.6%) and 596 patients without CVC (78.4%) were investigated. In both groups, zero in-hospital-mortality and limited 30-day mortality was detected. Postoperative complications occurred more often in patients with CVC (N=47, 28.7% vs. N=122, 20.5%, P=0.02). However, most of them were minor (N=37, 22.6% vs. N=93, 15.6%, P=0.03). The presence of multiple CVC (N=18 patients, 40% vs. N=28, 23.9%, P=0.04) and reduced left ventricular function (N=5, 62.5% vs. N=42, 27.1%, P=0.03) were identified as risk factors for postoperative morbidity. Patients with CVC showed reduced overall survival (5-year survival rate: 75.8% vs. 68%, P=0.03). In the multivariate analysis lobectomy [hazard ratio (HR) 0.3, 95% confidence interval (CI): 0.1-0.8, P=0.02] and general vascular comorbidities (HR 2.1, 95% CI: 1.1-3.9, P=0.01) were identified as independent negative prognostic factors.

CONCLUSIONS

Resection of pulmonary metastases can be performed safely in selected patients with stable CVC. The presence of CVC in patients undergoing PM is associated with reduced overall survival compared to patients without CVC in the long term follow up. However, a prolonged 5-year survival rate of 68% could be achieved.

Study Protocol for a Randomised Controlled Trial on Pulmonary Metastasectomy vs. Standard of Care in Colorectal Cancer Patients With ≥ 3 Lung Metastases (PUCC-Trial)

This is a multicentre prospective randomised controlled trial for patients with 3 or more resectable pulmonary metastases from colorectal carcinoma. The study investigates the effects of pulmonary metastasectomy in addition to standard medical treatment in comparison to standard medical treatment plus possible local ablative measures such as SBRT. This trial is intended to demonstrate an overall survival difference in the group undergoing pulmonary metastasectomy. Further secondary and exploratory endpoints include quality of life (EORTC QLQ-C30, QLQ-CR29 and QLQ-LC29 questionnaires), progression-free survival and impact of mutational status. Due to the heterogeneity and complexity of the disease and treatment trajectories in metastasised colorectal cancer, well powered trials have been very challenging to design and execute. The goal of this study is to create a setting which allows treatment as close to the real life conditions as possible but under well standardised conditions. Based on previous trials, in which patient recruitment in the given setting hindered successful study completion, we decided to (1) restrict inclusion to patients with 3 or more metastases (since in case of lesser, surgery will probably be the preferred option) and (2) allow for real world standard of care (SOC) treatment options before and after randomisation including watchful waiting (as opposed to a predefined treatment protocol) and (3) possibility that patient can receive SOC externally (to reduce patient burden). Moreover, we chose to stipulate 12 weeks of systemic treatment prior to possible resection to further standardize treatment response and disease course over a certain period of time. Hence, included patients will be in the disease state of oligopersistence rather than primary oligometastatic. The trial was registered in the German Clinical Trials Register (DRKS-No.: DRKS00024727).

Lung Resections for Elderly Patients with Lung Metastases: A Comparative Study of the Postoperative Complications and Overall Survival

Background: Pulmonary metastasectomy (PM) is an established treatment option for selected patients with stage IV solid tumors. The aim of this study was to investigate the feasibility of and survival rate in PM for elderly patients. Methods: We retrospectively analyzed all of the patients who underwent PM with curative intention at our institution. The patients were categorized into two groups: the elderly group (≥70 years old) and the non-elderly group (<70 years old). Results: The elderly group consisted of 222 patients versus 538 patients in the non-elderly group. The median number of resected metastases was 2 ± 3 in the elderly group and 4 ± 5 in the non-elderly group (p < 0.01). No difference in the rate of postoperative complications was observed between the two groups (p = 0.3). The median length of hospital stay in each group was comparable (10 ± 5 vs. 10 ± 4.3 days, p = 0.3). The 5-year survival rate was 67% in the elderly group and 78% in the non-elderly group (p = 0.117). In the univariate analysis, COPD was associated with poor survival in the elderly group (p = 0.002). Conclusion: The resection of pulmonary metastases in elderly patients is safe, is not associated with increased risks of postoperative complication, and the survival benefit is not reduced in selected patients.

CD26-inhibition correlates with the absence of chronic lung allograft dysfunction and decreases fibroblast activity in vitro

Objective

Chronic lung allograft dysfunction (CLAD) limits the survival after lung transplantation (Tx). CLAD is characterized by progressive fibrosis of small airways and lung parenchyma. No effective therapy is available that reverses or prevents CLAD. CD26 is a molecule with enzymatic activity also playing a key role in the progression of fibrotic diseases. Here, we analyzed the inhibitory effect of CD26 on fibroblast activity in vitro and the role of CD26-inhibition on allograft rejection in lung transplant patients.

Methods

Profibrogenic mRNA and protein levels were analyzed in vitro on the CD26-expressing fibroblast cell line Wi-38 using RT-qPCR and Western blot. CD26 was inhibited by Vildagliptin. Migration and proliferation activity of activated fibroblasts were analyzed by Incucyte® and Celltiter-Glo®. Characteristics of patients undergoing lung Tx between 2004 and 2021 were reviewed. Lung biopsies were analyzed by immunohistochemistry (IHC) for CD26.

Results

In vitro, the expression of profibrogenic genes (αSMA, FAPα, IGFBP7, Collagen 3 and Fibronectin) was significantly reduced in activated lung fibroblasts by Vildagliptin treatment. Also, migration and proliferation activity were attenuated by Vildagliptin. In 221 patients analyzed, CLAD was absent in 34 patients treated with the CD26-inhibitor Sitagliptin vs. an incidence of 18% in patients without Sitagliptin intake (p=0.02). Five-year survival in patients on Sitagliptin was significantly improved vs. patients without CD26-inhibitor intake (80% vs. 58%, p=0.006). Likewise, the incidence of acute cellular rejection (ACR) was significantly reduced in patients on Sitagliptin (7% vs. 35%, p=0.01). IHC of patient lung biopsies showed expression of CD26 in perifibrotic areas of CLAD lesions. Additional clinical data from University Hospital Zurich and from University Hospital Padua confirmed the finding that Sitagliptin intake correlated with the absence of acute and chronic allograft rejection.

Conclusion

CD26-inhibition attenuates key pro-fibrotic mediators and fibroblast activity in vitro. Impressively, patients on CD26-inhibitor did not show any CLAD. Moreover, ACR was significantly reduced. Gliptins which are in routine clinical use for the treatment of type II diabetes therefore seem to have great potential to be repurposed for a novel clinical application against lung allograft rejection.

Enhanced AC133-specific CAR T cell therapy induces durable remissions in mice with metastatic small cell lung cancer

Metastatic small cell lung cancer (SCLC) is not curable. While SCLC is initially sensitive to chemotherapy, remissions are short-lived. The relapse is induced by chemotherapy-selected tumor stem cells, which express the AC133 epitope of the CD133 stem cell marker. We studied the effectiveness of AC133-specific CAR T cells post-chemotherapy using human primary SCLC and an orthotopic xenograft mouse model. AC133-specific CAR T cells migrated to SCLC tumor lesions, reduced the tumor burden, and prolonged survival in a humanized orthotopic SCLC model, but were not able to entirely eliminate tumors. We identified CD73 and PD-L1 as immune-escape mechanisms and combined PD-1-inhibition and CD73-inhibition with CAR T cell treatment. This triple-immunotherapy induced cures in 25% of the mice, without signs of graft-versus-host disease or bone marrow failure. AC133⁺ cancer stem cells and PD-L1⁺CD73⁺ myeloid cells were detectable in primary human SCLC tissues, suggesting that patients may benefit from the triple-immunotherapy. We conclude that the combination of AC133-specific CAR T cells, anti-PD-1-antibody and CD73-inhibitor specifically eliminates chemo-resistant tumor stem cells, overcomes SCLC-mediated T cell inhibition, and might induce long-term complete remission in an otherwise incurable disease.

Cycling‐induced recurrent spontaneous pneumomediastinum and pneumopericardium in a young female patient

We present an exceptional case of recurrent cycling‐induced spontaneous pneumomediastinum and pneumopericardium in a female patient without any trauma. Radiological and endoscopic examinations were carried out to exclude other differential diagnoses. Decision for in‐hospital observation and conservative treatment was made. No symptoms were reported 12 months after return to sports activity.

Lung Abscess and Recurrent Empyema After Infection With Mycoplasma hominis: A Case Report and Review of the Literature

Mycoplasma hominis is a rarely identified cause of respiratory infection that can cause significant morbidity and mortality in immunocompromised patients. It is often missed due to the difficult detection of the organism with routine laboratory methods.

We present the case of a 63-year-old male with a history of lymphoma who was transferred to our hospital with recurrent right-sided empyema and lung abscess in the right lower lobe. Advanced microbiological analysis finally revealed infection with M hominis. Despite appropriate antibiotic treatment, prolonged drainage as well as repeated surgery, which eventually resulted in right lower bilobectomy, were necessary for clinical improvement of our patient.

Infection with M hominis may be more prevalent than previously indicated and can cause severe morbidity and mortality in thoracic surgery patients. Due to the diagnostic challenge, the appropriate antimicrobial treatment is often delayed. Inherent resistance to macrolides and inactivity of cell wall-active agents potentially complicate empiric antibiotic therapy. A review of the currently available literature enables a better understanding of the diagnostic difficulties and importance of this infection.

[Surgery for Thoracic Malignancies during the COVID-19 Pandemic: a Case-control Study Investigating the Risk for Postoperative Complications]

BACKGROUND

The COVID-19 pandemic led to a major disturbance in the health care system. Many elective operations were postponed, including surgical oncology cases. Besides the need to contain hospital resources, this was also due to concerns about the safety to perform surgery during the pandemic and the impact of perioperative infections on postoperative outcomes. In this study we investigate the safety of surgery for thoracic malignancies during the COVID-19 pandemic.

METHODS

We retrospectively analysed the outcome of surgery for thoracic malignancies during the first, second and third waves of the COVID-19 pandemic (from 01.01. to 30.04.2020 and from 01.01. to 30.04.2021). As a control group we included the patients who received thoracic oncology surgeries during the same period in the last 2 years before the onset of the pandemic. The primary outcome was the rate of postoperative complications.

RESULTS

236 operations were included in the pandemic group and 227 operations in the control group. There was no statistically significant difference in the rate of postoperative minor complications (16.1% vs. 18.5%, p = 0.5395) or major complications (12.2% vs. 10.13 %, p = 0.5563). The risk to develop postoperative pulmonary complications was not higher in the pandemic group (odds ratio 1.193, 95% CI 0.6515-2.203, p = 0.8232). There were 5 cases with COVID-19 infection after the operation in the pandemic group. There was no difference in the rate of postoperative mortalities (2 (0.85%) vs. 1 (0.44%), p > 0.9999) There was no COVID-19 related mortality.

CONCLUSION

Maintaining oncologic thoracic surgery during the COVID-19 pandemic is safe, feasible and not associated with increased risks of postoperative complications or mortalities.

Early assessment of circulating tumor DNA after curative-intent resection predicts tumor recurrence in early-stage and locally advanced non-small-cell lung cancer

Circulating tumor DNA (ctDNA) has demonstrated great potential as a noninvasive biomarker to assess minimal residual disease (MRD) and profile tumor genotypes in patients with non‐small‐cell lung cancer (NSCLC). However, little is known about its dynamics during and after tumor resection, or its potential for predicting clinical outcomes. Here, we applied a targeted‐capture high‐throughput sequencing approach to profile ctDNA at various disease milestones and assessed its predictive value in patients with early‐stage and locally advanced NSCLC. We prospectively enrolled 33 consecutive patients with stage IA to IIIB NSCLC undergoing curative‐intent tumor resection (median follow‐up: 26.2 months). From 21 patients, we serially collected 96 plasma samples before surgery, during surgery, 1–2 weeks postsurgery, and during follow‐up. Deep next‐generation sequencing using unique molecular identifiers was performed to identify and quantify tumor‐specific mutations in ctDNA. Twelve patients (57%) had detectable mutations in ctDNA before tumor resection. Both ctDNA detection rates and ctDNA concentrations were significantly higher in plasma obtained during surgery compared with presurgical specimens (57% versus 19% ctDNA detection rate, and 12.47 versus 6.64 ng·mL⁻¹, respectively). Four patients (19%) remained ctDNA‐positive at 1–2 weeks after surgery, with all of them (100%) experiencing disease progression at later time points. In contrast, only 4 out of 12 ctDNA‐negative patients (33%) after surgery experienced relapse during follow‐up. Positive ctDNA in early postoperative plasma samples was associated with shorter progression‐free survival (P = 0.013) and overall survival (P = 0.004). Our findings suggest that, in early‐stage and locally advanced NSCLC, intraoperative plasma sampling results in high ctDNA detection rates and that ctDNA positivity early after resection identifies patients at risk for relapse.

Surgical Morbidity and Lung Function Changes After Laser-Assisted Pulmonary Metastasectomy: A Prospective Bicentric Study

Objective: The surgical resection of pulmonary metastases is associated with a survival benefit in selected patients. The use of laser devices for pulmonary metastasectomy (PM) is believed to facilitate the complete resection of metastases while preserving a maximum of healthy parenchyma. This is a prospective study to evaluate surgical outcome including the changes of lung function after laser–assisted surgery (LAS).

Methods: A total of 77 operations in 61 patients in which PM was carried out in a curative intent were analyzed. A 1.320 nm diode-pumped Nd: YAG-Laser was used for resection of the metastases. Surgical and clinical data were collected using a standardized form and postoperative lung function changes 3 and 6 months after surgery were assessed using whole body plethysmography and diffusion capacity for carbon monoxide (DLCO). Size and distance of metastases to the pleural surface were measured radiologically.

Results: A median of two metastases were resected per operation (range 1–13). The median duration of postoperative air leak was 1 day (range 0–11). LAS associated postoperative minor and major complications were observed in 4 (5%) cases and 1 (1%) case, respectively; there were no mortalities. The analysis of perioperative lung function showed that mean VC 3 months after surgery was reduced by 11 %, FEV1 by 11% and median DLCO by 11% (all p < 0.0001). There was almost no recovery of lung function between 3 and 6 months in the whole cohort. Patients with two or less metastases showed a recovery of lung function after 3 months regarding DLCO (p = 0.003). Decline of DLCO in the whole cohort correlated with the number of resected metastases at 3 months (r = 0.45, p = 0.006) and at 6 months (r = 0.42, p = 0.02) as well as depth of metastases in the parenchyma at 6 months (r = 0.48, p = 0.001).

Conclusions: LAS is a safe and effective method for PM even for higher numbers of metastases, with short duration of postoperative air leak and little morbidity. Number and depth, but not size of metastases affect lung function changes after resection.

Reconstruction of the Mediastinum and Tracheopexy for Tracheomalacia in Straight Back Syndrome

Tracheomalacia in straight back syndrome results from chronic compression of the trachea and the mainstem bronchi mainly because of decreased mediastinal diameter. The mainstay of correction is the increase of mediastinal space and the restoration of the tracheal lumen and stability. Owing to the great variability of the manifestation of this disease, individualized approaches are required. We describe our approach in a 36-year-old woman with straight back syndrome associated severe tracheobronchomalacia with reconstruction of the proximal aorta, brachiocephalic artery, sternoplasty, and anterior tracheopexy, which resulted in successful treatment of the condition.

[Surgical Therapy for Lung Cancer: Why it Should be Performed in High Volume Centres]

Data on surgical lung cancer cases were extracted from the German Federal Statistics on Diagnosis-related groups (DRG) and a possible association between hospital volume and surgical mortality was explored. All treatment cases documented between 2005 and 2015 with the main diagnosis of lung cancer (International Classification of Disease code C34) and the German Operations and Procedure Key (OPS) codes 5-323 to 5-328 for anatomical lung resections were analysed. The treatment cases were assigned to hospital groups, defined according to the number of procedures performed per year. The total number of anatomical lung resections for the diagnosis of lung cancer increased by 24 % from 9376 resections in 2005 to 11,614 resections in 2015. In 2015, 57 % of anatomical lung resections in patients with lung cancer were performed in 47 high volume centres (hospitals with ≥ 75 resections/year); the remaining 43 % of the resections were distributed among 271 hospitals performing fewer than 75 resections per year. In hospitals performing fewer than 25 procedures/year, hospital mortality was almost twice as high as in large centres with ≥ 75 resections per year (5.7 vs. 3.0 %, mean value 2005 to 2015). In summary, our data indicate that a small number of high-volume hospitals perform the major part of lung resections of lung cancer in Germany with better survival as compared to low-volume hospitals. Based on current nationwide data a clear association between hospital volume and surgical mortality could be demonstrated.

Regional versus systemic analgesia in video-assisted thoracoscopic lobectomy: a retrospective analysis

Background

The optimal perioperative analgesic strategy in video-assisted thoracic surgery (VATS) for anatomic lung resections remains an open issue. Regional analgesic concepts as thoracic paravertebral or epidural analgesia were used as systemic opioid application. We hypothesized that regional anesthesia would provide improved analgesia compared to systemic analgesia with parenteral opioids in VATS lobectomy and would be associated with a lower incidence of pulmonary complications.

Methods

The study was approved by the local ethics committee (AZ 99/15) and registered (germanctr.de; DRKS00007529, 10th June 2015). A retrospective analysis of anesthetic and surgical records between July 2014 und February 2016 in a single university hospital with 103 who underwent VATS lobectomy. Comparison of regional anesthesia (i.e. thoracic paravertebral blockade (group TPVB) or thoracic epidural anesthesia (group TEA)) with a systemic opioid application (i.e. patient controlled analgesia (group PCA)). The primary endpoint was the postoperative pain level measured by Visual Analog Scale (VAS) at rest and during coughing during 120 h. Secondary endpoints were postoperative pulmonary complications (i.e. atelectasis, pneumonia), hemodynamic variables and postoperative nausea and vomiting (PONV).

Results

Mean VAS values in rest or during coughing were measured below 3.5 in all groups showing effective analgesic therapy throughout the observation period. The VAS values at rest were comparable between all groups, VAS level during coughing in patients with PCA was higher but comparable except after 8–16 h postoperatively (PCA vs. TEA; p < 0.004). There were no significant differences on secondary endpoints. Intraoperative Sufentanil consumption was significantly higher for patients without regional anesthesia (p < 0.0001 vs. TPVB and vs. TEA). The morphine equivalence postoperatively applicated until POD 5 was comparable in all groups (mean ± SD in mg: 32 ± 29 (TPVB), 30 ± 27 (TEA), 36 ± 30 (PCA); p = 0.6046).

Conclusions

Analgesia with TEA, TPVB and PCA provided a comparable and effective pain relief after VATS anatomic resection without side effects. Our results indicate that PCA for VATS lobectomy may be a sufficient alternative compared to regional analgesia.

Trial registration

The study was registered (germanctr.de; DRKS00007529; 10th June, 2015).

Morbidity, mortality and long-term outcome of lung cancer resections performed in palliative intent

Background

Surgery is seldom used for palliation in advanced lung cancer and the published data on this issue are very limited. We aimed to assess the results of palliative lung resections and identify criteria to guide surgical therapy in this situation.

Methods

This is a retrospective single-institution analysis of patients with palliative intended lung cancer resection. Survival analysis was performed by Kaplan-Meier method, log-rank test and Cox proportional hazards regression at a statistical significance level of P=0.05.

Results

Forty-eight patients received palliative intended lung resections (31 lobectomies, 4 bilobectomies, 13 pneumonectomies) with acceptable rates of severe complications (Clavien-Dindo >IIIa 29%) and 30-day mortality (4%). The most frequent indications were infection and hemoptysis. The median survival for the entire group was 12 months (95% CI: 6.9-17.1 months). Due to unexpectedly favorable histopathologic tumor stage, a switch to curative treatment in 17 completely resected patients resulted in a 2-year survival rate of 46%. In a subgroup of 20 patients with favorable prognostic factors as identified by uni- and multivariable analysis, a median survival of 26 months was observed.

Conclusions

In well selected patients with lung cancer, resection in palliative intent can offer symptom relief and even a survival benefit with acceptable morbidity and low mortality. Prognostic factors were identified and can be used to guide operative treatment. Due to the low specificity of CT and FDG-PET/CT in the presence of inflammation or centrally located lung tumors, a large proportion of patients with lung resection in palliative intent experience a down-staging and frequently also a switch from palliative to curative treatment with additional survival benefit. Factors like expected complete resection, a squamous cell type and the ability to receive adjuvant therapy are useful to support the decision to perform palliative tumor resection.

Pulmonary laser-assisted metastasectomy is associated with prolonged survival in patients with colorectal cancer

Background

Pulmonary metastases develop in 10-15% of patients with colorectal cancer. Surgical metastasectomy currently provides the only hope for a cure for these patients. The aim of this study was to analyze the expanding role of pulmonary metastasectomy in the context of laser-assisted surgery (LAS) vs. non-laser-assisted surgery (NLAS).

Methods

We performed a single-center retrospective analysis of 204 patients who underwent curative pulmonary metastasectomy for colorectal cancer between 01/2005 and 12/2016. The main endpoint was survival. The Kaplan-Meier method was applied for statistical analysis and survival rates were compared with the log rank test.

Results

Median follow-up was 53 months. A total of 267 metastases were resected in 154 operations in the NLAS group (median: 1) vs. 438 metastases in 122 operations in the LAS group (median: 5; P<0.0001). The interval between treatment of the primary tumor and the first pulmonary metastasectomy was significantly shorter in the LAS group (19 vs. 32 months; P=0.008). Anatomical resections were significantly reduced using LAS, 8% vs. 23% respectively. Despite more negative predictors in the LAS group, there was no statistically significant difference in overall disease-specific 5-year survival (70% LAS vs. 58% NLAS; P=0.18).

Conclusions

Survival after pulmonary metastasectomy has previously been shown to correlate with a low number of metastases and a longer disease-free interval. However, with the tissue-saving LAS technique complete resectability can be achieved in patients with more metastases and long-term survival is possible for selected patients.

[Expert Recommendation for the Implementation of Hyperthermic Intrathoracic Chemotherapy (HITOC) in Germany]

INTRODUCTION

During the last few years, hyperthermic intrathoracic chemotherapy (HITOC) has been performed in several departments for thoracic surgery in Germany. The objective of this expert recommendation is to provide elementary recommendations for a standardised HITOC treatment, which are based on clinical experiences and research data.

METHODS

Between October and December 2018, a group of experts for thoracic surgery in five departments of thoracic surgery developed recommendations for the HITOC procedure in Germany. These experts were selected by the latest national survey for HITOC and had the most clinical experience with HITOC. All recommendations are based on clinical experience, the experts' research data and recent literature.

RESULTS

All recommendations were evaluated by all participating departments in one consensus survey. Finally, a total of six main conclusions including a total of 17 recommendations were developed. For each recommendation, the strength of the consensus is presented in percentages. 100% agreement was established for nomenclature, technique, the chemotherapeutic agent, the perioperative management, the safety measures and the indications for HITOC. All experts recommended cisplatin as the first choice chemotherapeutic agent for HITOC. The dosage of cisplatin is specified in mg/m² body surface area (BSA) and should be between 150 and 175 mg/m² BSA. The volume of the perfusion fluid (approximately 4 - 5 l) seems to play a role for the concentration gradient of cisplatin and should therefore also be taken into account.

CONCLUSIONS

These expert recommendations provide a standardised and consistent implementation of the HITOC procedure. On this basis, postoperative complications associated to HITOC should be reduced and comparison of the results should be improved.

[Postoperative Haemothorax Following Thoracic Surgery]

Postoperative haemothorax following thoracic surgery is a rare complication, but associated with a high mortality. In the literature, this complication occurs in 0.6 to 4.6% of patients and with a mortality of 5.1 to 17.8%. In minor cases, chest tube placement, application of fresh frozen plasma (FFP) or transfusion can be sufficient to control the situation. In severe cases, re-thoracotomy is mandatory. The most frequent origin of bleeding is a bronchial or intercostal vessel (21 and 16%) or the area of pleural adhesions that were separated (10.5%). The pulmonal artery or vein were the origin of bleeding in 16% of cases while in most cases (37%) active bleeding could no longer be detected. A positive effect on postoperative outcome is observed after an early reoperation.

Pulmonary metastasectomy for thyroid cancer as salvage therapy for radioactive iodine-refractory metastases

OBJECTIVES

Distant metastasis arising from thyroid cancer is rare but has been associated with significantly reduced long-term survival, especially when refractory to radioactive iodine ablation. We provide one of the largest studies worldwide reporting the outcome after salvage pulmonary metastasectomy for this entity, aiming to identify prognostic factors and to analyse surgical indication.

METHODS

We retrospectively analysed the medical records of 43 patients who had undergone pulmonary metastasectomy for radioactive iodine-refractory thyroid cancer from 1985 to 2016.

RESULTS

The median follow-up period was 77 (95% confidence interval 41-113) months. Twenty-three (53%) patients were alive at the time of analysis. The majority of tumours were follicular thyroid cancer by histology, with 23% identified as Hurthle cell subtype. Five- and 10-year disease-specific (DS) survival was 84% and 59%, respectively. Thirty-one (72%) patients underwent R0-resection with a 5- and 10-year DS survival of 100% and 77%, respectively. This was significantly reduced to 62% and 22% (P = 0.013) in case of incomplete resection, respectively. Ten years after R0-metastasectomy, 17 (55%) patients were recurrence-free. Systematic mediastinal lymphadenectomy was performed in 16 (37%) patients and was associated with improved long-term DS survival (10 years 88% vs 46%, P = 0.034). Moreover, a reduction of > 80% in serum thyroglobulin levels post-metastasectomy correlates with better long-term DS survival (10 years 81% vs 36%, P = 0.007).

CONCLUSIONS

Pulmonary metastasectomy is associated with good survival for selected patients with radioactive iodine-refractory metastases of differentiated thyroid cancer, especially if R0-resection can be achieved. Moreover, it is worth considering whether a significant reduction of tumour load, as indicated by thyroglobulin serum levels, seems possible.

[Surgical Therapy for Lung Cancer: Why it Should be Performed in High Volume Centres]

Data on surgical lung cancer cases were extracted from the German Federal Statistics on Diagnosis-related groups (DRG) and a possible association between hospital volume and surgical mortality was explored. All treatment cases documented between 2005 and 2015 with the main diagnosis of lung cancer (International Classification of Disease code C34) and the German Operations and Procedure Key (OPS) codes 5-323 to 5-328 for anatomical lung resections were analysed. The treatment cases were assigned to hospital groups, defined according to the number of procedures performed per year. The total number of anatomical lung resections for the diagnosis of lung cancer increased by 24% from 9376 resections in 2005 to 11,614 resections in 2015. In 2015, 57% of anatomical lung resections in patients with lung cancer were performed in 47 high volume centres (hospitals with ≥ 75 resections/year); the remaining 43% of the resections were distributed among 271 hospitals performing fewer than 75 resections per year. In hospitals performing fewer than 25 procedures/year, hospital mortality was almost twice as high as in large centres with ≥ 75 resections per year (5.7 vs. 3.0%, mean value 2005 to 2015). In summary, our data indicate that a small number of high-volume hospitals perform the major part of lung resections of lung cancer in Germany with better survival as compared to low-volume hospitals. Based on current nationwide data a clear association between hospital volume and surgical mortality could be demonstrated.

Pedicled and free flaps for intrathoracic fistula management

OBJECTIVES

Intrathoracic fistulae are among the potential sequelae of radiation therapy, empyema and abscess clearance and surgical tumour resections. Interdisciplinary plastic-reconstructive flap surgery is a helpful tool for the successful treatment of intrathoracic fistulae.

METHODS

From February 2006 to April 2016, 13 patients (3 females and 10 males) underwent flap surgery for bronchial (n = 5), tracheal (n = 2), oesophageal (n = 2), post-pneumonectomy bronchopleural fistula (n = 2), tracheo-oesophageal (n = 1), gastrobronchial (n = 1) and oesophagobronchial (n = 1) fistulae. Patient characteristics, identified pathogenic micro-organisms, treatment and decision criteria, long-term outcome and postoperative complications were evaluated by analysing patient charts and surgical reports.

RESULTS

The mean age of the 13 patients who underwent reconstructive surgery was 55.5 years (range: 42-66 years). The median follow-up time was 31.4 months (range: 2-96 months). American Society of Anaesthesiologists classification was II for 1 patient, III for 8 patients and IV for 4 patients. In total, 18 flaps were performed (7 latissimus dorsi pedicled flaps, 7 pectoralis major pedicled flaps, 2 rectus abdominis myocutaneous flaps, 1 free temporo-parietal fascia flap and 1 intercostal muscle flap). A second flap was indicated in 5 cases (38.5%) due to fistula recurrence; of these, 1 patient developed a bronchial fistula after successful reconstruction of a gastrobronchial fistula. Eight of the 13 patients (61.5%) were evaluated postoperatively at regular intervals for at least 1 year and showed no signs of fistula recurrence.

CONCLUSIONS

Our study showed that plastic-reconstructive flap surgery, although associated with significant morbidity and mortality, can be a life-saving tool for intrathoracic fistula reconstruction.

Clinical Trial Registration

DRKS00010447.

Intraoperative detection of circulating tumor cells in pulmonary venous blood during metastasectomy for colorectal lung metastases

Circulating tumor cells (CTC) have been studied extensively in various tumor types and are a well-established prognosticator in colorectal cancer (CRC). This is the first study to isolate CTC directly from the tumor outflow in secondary lung tumors. For this purpose in 24 patients with CRC who underwent pulmonary metastasectomy in curative intent blood was drawn intraoperatively from the pulmonary vein (tumor outflow). In 22 samples CTC-enumeration was performed using CellSieve-microfilters and immunohistochemical- and Giemsa-staining. Additionally 10 blood samples were analyzed using the CellSearch-System. We could isolate more CTC in pulmonary venous blood (total 41, range 0-15) than in samples taken from the periphery at the same time (total 6, range 0-5, p = 0.09). Tumor positive lymph nodes correlated with presence of CTC in pulmonary venous blood as in all cases CTC were present (p = 0.006). Our findings suggest a tumor cell release from pulmonary metastases in CRC and a correlation of CTC isolated from the tumor outflow with established negative prognostic markers in metastasized CRC. The presented data warrant further investigations regarding the significance of local tumor compartments when analyzing circulating markers and the possibility of tumor cell shedding from secondary lung tumors.

Prognostic value of lymph node ratio after induction therapy in stage IIIA/N2 non-small cell lung cancer: a monocentric clinical study

Background

The optimal treatment modalities for patients with stage IIIA N2 non-small cell lung cancer (NSCLC) are still a matter of debate. To provide best outcome and to avoid unnecessary treatment patient selection for surgical therapy is crucial. In addition to mediastinal downstaging the lymph node ratio (LNR) has been suggested as a prognosticator in this patient group.

Methods

We retrospectively reviewed clinical and histopathologic data of 78 patients with stage IIIA N2 NSCLC, who underwent induction therapy with two cycles of platinum-based chemotherapy for intended surgery at our clinic between 2009 and 2016. To evaluate the prognostic value of the LNR the cut off was set at 0.33 as reported in prior literature.

Results

The median follow-up time was 30.1 months. In multivariate analysis mediastinal down staging was associated with a longer overall survival (OS): 52.2 (range, 5.9-89.7) months for ypN0 versus 24.6 (4.4-84.2) months for ypN1/2 (HR, 2.76; 95% CI, 1.07-7.1, P=0.0348). LNR ≤0.33 was linked to a better OS of 39.3 (range, 5.9-89.7) months compared to 14.7 (range, 4.4-66.2) months for a LNR >0.33 in univariate analysis (P=0.037). In multivariate analysis a statistical trend could be observed (HR, 2.82; 95% CI, 0.98-8.14, P=0.1). In patients with persistent lymph node involvement the LNR could also identify a subgroup of patients with a favorable prognosis (30.1 vs. 14.7 months, P=0.145).

Conclusions

Mediastinal downstaging remains the best prognosticator in stage IIIA N2 NSCLC after induction therapy. However, using the LNR in patients with persistent mediastinal lymph node metastasis a subgroup with a favorable prognosis could be identified. The LNR could aid in finding the best treatment modalities for these patients.

Mucinous cystadenocarcinoma arising from mucinous cystadenoma of the lung: case report and review of the literature

Mucinous cystadenoma is a benign tumor commonly found in the pancreas, the ovaries or the appendix. Only very few cases of these tumors originating from the lungs have been reported worldwide, with even less cases describing malignant transformation. We present the case of a 58-year-old woman with a history of recurrent pulmonary infections who underwent left upper lobectomy for lung abscess and was initially diagnosed with pulmonary mucinous cystadenoma (PMCA). Upon thorough immunohistochemical workup, especially due to carcinoembryonic antigen (CEA) positivity, intramucinous singlet cells were eventually diagnostic for invasive carcinoma, in this case a mucinous cystadenocarcinoma arising from a PCMA. PMCA is a rare benign tumor whose potential for malignant transformation has not yet been fully understood. Due to the low number of cases further studies are needed to evaluate if there is a benefit of complete oncologic resection, provided the general condition of the patient allows it. A review of the currently available literature serves to better understand the clinical, radiological and histological features of this rare tumor.