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.

[Scientific Activity in German Thoracic Surgery, as Measured in Publication Output]

Thoracic surgery in Germany is primarily provided in non-university centres with a clinical focus and less at university hospitals. The extent to which scientific activity can be achieved within these different structures is investigated on the basis of publication output.A PubMed analysis was carried out for selected authors (leader in thoracic surgery in Germany) between Jan 2012 to Dec 2021. University hospitals, DKG-certified lung cancer centres (DKG: German Cancer Society) and DGT-certified thoracic centres (DGT: German Society for Thoracic Surgery) were included.An analysis of n = 54 non-university centres (DKG certificate n = 50 and/or DGT certificate n = 22) and n = 36 university hospitals (n = 9 autonomous clinic/department) was performed. A total of n = 2414 publications were identified, with original papers (n = 1776; 74%) and publications focussing on thoracic surgery (n = 1501; 62%) being found most frequently. The publication performance of the non-university centres was n = 599 publications (11/centre) and thus significantly lower than that of the university hospitals (n = 902; 25/clinic; p ≤ 0.001). Significantly higher publication output was confirmed for autonomous (n = 560; 62/clinic) compared to non-autonomous university thoracic surgery (n = 342; 13/clinic; p = 0.003). A 10-year trend was recorded, with almost doubling of publication output from n = 105 (university: n = 63) to n = 203 (university: n = 124) publications/year. The cumulative impact factors (IF) resulted in 2845 IF (52.7 IF/clinic) for non-university centres, 6361 IF (235.6 IF/clinic) for non-autonomous and 2931 IF (325.7 IF/clinic) for autonomous university thoracic surgery.Scientific activities have increased in non-university centres, but above all in university thoracic surgery. These positive developments are in acute danger due to the upcoming political changes (Hospital Structure Act, minimum volumes). Structural changes such as independent university thoracic surgery or cooperation models with non-university centres could offer solutions.

[Modern Perioperative Care Concepts in Thoracic Surgery: Enhanced Recovery After Thoracic Surgery (ERATS)]

In modern perioperative care concepts, multimodal ERAS (Enhanced Recovery After Surgery) is a multimodal perioperative treatment concept for improving postoperative recovery of surgical patients after an operation. This is managed by the so-called ERAS Society and through which hospitals can also be officially certified. The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team. In 2019, ERAS guidelines were published for the first time by the European Society of Thoracic Surgery (ESTS), in cooperation with the ERAS Society, for specific lung resection procedures, and these identified a total of 45 graduated recommendations or Enhanced Recovery Pathways (ERP). The implementation of ERAS concepts in thoracic surgery (ERATS = Enhanced Recovery After Thoracic Surgery) is intended to establish standardised perioperative procedures based on study results and/or expert recommendations. These recommendations take into account organisational aspects as well as thoracic surgical and anaesthesiological procedures, with the overriding goal of creating a structured treatment plan tailored to the patient. All these measures should result in a multimodal overall concept, which should primarily lead to an improved outcome after elective thoracic surgery and secondarily to shorter hospital stays with correspondingly lower costs.This review article describes basic ERAS principles and provides a compact presentation of the most important European ERAS recommendations from the authors' point of view, together with typical obstacles to the implementation of the corresponding ERATS program in German thoracic surgery.

[Rare cause of necrotizing pneumonia : A case report]

A 29-year-old Indian patient was admitted to the authors' pulmonary clinic with cough and fever. Community-acquired pneumonia was initially suspected. Various antibiotic therapies were administered, which did not lead to any clinical improvement. Despite detailed diagnostics, no pathogen was found. Computed tomography showed rapidly progressive pneumonia in the left upper lobe. Since the infection could not be managed conservatively, upper lobe resection was performed. Histologically, an amoebic abscess was found to be the cause of the infection. Since cerebral and hepatic abscesses were also found, hematogenous dissemination may be assumed.

The Excretion of Cisplatin after Hyperthermic Intrathoracic Chemotherapy

Hyperthermic intrathoracic chemotherapy (HITOC) is an additional intraoperative treatment option within the multimodality therapy of pleural malignancies. A chemotherapy perfusion with high-dose cisplatin is performed over a period of 60 min after surgical cytoreduction to improve local tumour control through the eradication of residual tumour cells. Although HITOC is increasingly used, there is only little scientific evidence about the necessary safety measures after HITOC. Therefore, the objective of this study was an analysis of cisplatin excretion via various body fluids after HITOC, with the aim of providing recommendations on occupational health and safety. Five patients undergoing HITOC were included. Before and after the HITOC, as well as during the following days, serum, urine, and bronchial secretion, as well as pleural effusion, were sampled. The platinum levels in the samples were measured using ICP-MS (inductively coupled plasma-mass spectrometry). Immediately after the HITOC, the mean levels of cisplatin increased dramatically in the serum (from 0.79 to 1349 µg/L), urine (from 3.48 to 10,528 µg/g creatinine), and bronchial secretion (from 0.11 to 156 µg/L). Thereafter, the cisplatin levels dropped to 133 µg/L in the serum and 994 µg/g creatinine in the urine within nine days after the HITOC. The AUC ratio shows 59% of the cisplatin being excreted via the urine after 48 h. The sampling of pleural effusion started 24 h after the HITOC, and the cisplatin levels decreased from 618 to 93 µg/L within nine days. Although the cisplatin levels in the body fluids of HITOC patients are much lower compared to patients receiving intravenous chemotherapy, a significant amount of cisplatin is excreted via these body fluids. Consequently, safety precautions must be implemented in the post-HITOC care of patients to avoid occupational exposure to cisplatin.

Intraoperative Contrast-Enhanced Ultrasonography (Io-CEUS) in Minimally Invasive Thoracic Surgery for Characterization of Pulmonary Tumours: A Clinical Feasibility Study

BACKGROUND

The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery.

METHODS

In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs.

RESULTS

In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5-4.5 cm) and a mean distance to the lung surface of 2.0 cm (0-6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3).

CONCLUSIONS

The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.

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.

Intraoperative ultrasound in minimally invasive thoracic surgery for the detection of pulmonary tumors: First intrathoracic application of TE9 and laparoscopic probe Lap 13-4cs (Mindray)

AIM

To apply intraoperative ultrasound (IO-US) for the first time using a laparascopic probe to detect malignancy-susceptible solitary pulmonary nodules (SPN) and assess macrovascularization using color-coded doppler sonography or power doppler. Description of technical feasibility.

METHODS

Technical description on intrathoracic endoscopic ultrasound. A positive ethics vote from the local ethics committee and written patient consent were available. Intraoperative ultrasound was performed using a laparascopic probe (Lap 13-4cs, Mindray) on the T9 ultrasound machine (Mindray, China). B-scan was used to detect the SPN. Color-coded doppler sonography (CCS) and power doppler were used to assess macrovascularization. Primary end point was the description of the technical performance of the Io-US. Secondary endpoints were the functions of Io-US in characterizing SPN.

RESULTS

Io-US was successfully applied using (n = 2) cases in video-assisted thoracic surgery. All SPN were successfully detected intraoperatively with the intrathoracically placed laparascopy probe using B-mode and examined using CCS or power Doppler (100%). Resection was sonography-guided with marking of the tumor area in all cases without complications. Histological workup revealed malignancy in both cases.

CONCLUSION

Intrathoracic application of laparascopically guided Io-US was technically feasible. In addition to B-mode detection, Io-US using power doppler and color-coded doppler sonography provided initial evidence for characterization of SPN based on macrovascularization.

The Treatment of Malignant Pleural Effusion With Permanent Indwelling Pleural Catheters

BACKGROUND

40 000 to 60 000 people develop malignant pleural effusion (MPE) in Germany each year. The most common causes are lung cancer and breast cancer. Patients with pleural carcinomatosis have a median survival time of four months.

METHODS

We investigated the current health services situation regarding treatment with indwelling pleural catheters (IPC) versus talc pleurodesis (TP) in Germany based on registry data from the Federal Statistical Office, the Pleural Tumor Registry of the German Society for Thoracic Surgery, and the IPC registry of the ewimed GmbH company. In addition, we conducted a selective literature review on IPC and TP.

RESULTS

The symptoms of dyspnea and thoracic pressure determine the need for therapy in MPE. Both TP and IPC are effective treatment options for MPE. Both therapeutic procedures are considered equally effective with respect to the relief of dyspnea, post-interventional quality of life, and complication rates. TP yields a higher rate of successful pleurodesis than IPC (relative risk: 1.56; 95% confidence interval: [1.26; 1.92]; p < 0.0001), while patients who receive an IPC stay in the hospital for a shorter time than those who undergo TP (a difference of slightly more than two days). The survival of patients with MPE is not affected by which of the two local therapeutic procedures is chosen.

CONCLUSION

The indication for either IPC or TP needs to be determined individually for each patient on the basis of his or her general condition, symptoms, clinical situation ("trapped lung"), and prognosis.

[Case-based learning in thoracic surgery : A comparison between online and face-to-face teaching]

BACKGROUND

In modern medical education, traditional face-to-face teaching is increasingly being supplemented by innovative teaching methods, such as case-based learning or e‑learning.

AIM OF THE WORK

Design and evaluation of a new course concept in thoracic surgery to motivate students and at the same time find ways to relieve the medical staff in their teaching activities.

MATERIAL AND METHODS

All students of the third clinical semester at the University of Regensburg completed a case-based course on the topic of pulmonary nodules in the summer semester 2016 and winter semester 2016/2017 as part of the practical course in thoracic surgery. This involved a moderated face-to-face seminar for one group of students and a purely online event for the other group. The knowledge gain and the subjective learning experience of the students were evaluated via questionnaires.

RESULTS

A total of 190 students took part in the courses, 88 in the face-to-face course and 102 in the online course. Although both groups recorded a significant increase in knowledge as a result of the course intervention, the students in the face-to-face course showed significantly higher subjective satisfaction compared to their peers in the online course.

CONCLUSION

Case-based learning was shown to be a promising concept in thoracic surgery education, although establishing online learning procedures proved to be more challenging than presence-based teaching.

Entwicklung der akademischen Thoraxchirurgie in Deutschland

Die Thoraxchirurgie ist in Deutschland vornehmlich an außeruniversitären thoraxchirurgischen Kliniken abgebildet und nur an verhältnismäßig wenigen Universitätskliniken klinisch als eigenständige Abteilung oder Klinik und wissenschaftlich als W2- oder W3-Professur etabliert. Infolgedessen ist die Gewinnung von fachärztlichem Nachwuchs und insbesondere die Generierung von akademisch tätigen Thoraxchirurgen als Kontaktpersonen für Forschende aus den unterschiedlichen Bereichen der Lebens- und Ingenieurwissenschaften sowie für die Weiterentwicklung des Fachgebiets Thoraxchirurgie deutlich schwieriger als in anderen chirurgischen Fächern. In den medizinischen Fakultäten stehen die Lehre, Forschung und Patientenversorgung gleichberechtigt nebeneinander. Für die Übernahme dieser Aufgaben durch Thoraxchirurgen werden Konzepte zum Ausbau und der Förderung der akademischen Thoraxchirurgie in der deutschen Hochschulmedizin benötigt. Ein strukturiertes Curriculum Akademische Thoraxchirurgie kann zusätzlich zu Mentorenprogrammen, Fördermöglichkeiten und zusätzlichen Freiräumen für die Forschung bzw. Lehre die akademische Karriere in der Thoraxchirurgie unterstützen.

Preservation of Adrenoceptor and Endothelin Receptor Mediated Vasoconstriction and of Endothelium-Dependent Relaxation after Cold Storage of Explanted Blood Vessels for ex vivo Analyses

INTRODUCTION

Adrenoceptor and endothelin (ET) receptor-mediated vasoconstriction as well as endothelium-dependent vasodilation of human saphenous veins were compared before and after 20 h of cold storage.

METHODS

Contractile responses to potassium chloride (KCl), norepinephrine (NE), and ET-1 as well as vasodilator responses to acetylcholine (ACh) were evaluated.

RESULTS

Storage in HEPES-supplemented Dulbecco's modified Eagle's medium (HDMEM) diminished KCl induced contractile forces to 71% (p = 0.002) and NE induced contractions to 80% (p = 0.037), in contrast to HEPES-supplemented Krebs-Henseleit solution (HKH) and TiProtec solution. KCl-normalized NE contractions were not affected by storage. NE EC50 values were slightly lower (7.1E-8 vs. 7.5E-8, p = 0.019) after storage in HKH, with no changes after storage in the other solutions. Endothelium-dependent responses to ACh were not affected by storage. ET-1 induced contractions were attenuated after storage in HDMEM (77%, p = 0.002), HKH (75%, p = 0.020), and TiProtec (73%, p = 0.010) with no changes in normalized constrictions. ET-1 EC50 values were not affected by storage.

CONCLUSION

Loss of contractility after storage in HDMEM may reflect the lower content of dextrose. There was no specific attenuation of adrenoceptor, ET-receptor, or ACh receptor mediated signal transduction after storage in any of the media. HKH or TiProtec are equally suitable cold storage solutions for ex vivo measurements.

Postoperative outcome after palliative treatment of malignant pleural effusion

BACKGROUND

The objective of this nationwide, registry-based study was to compare the two most frequently used procedures for the palliative treatment of a malignant pleural effusion (MPE) and to evaluate differentiated indications for these two procedures.

METHODS

This was a retrospective observational study based on data of the "PLEURATUMOR" registry of the German Society for Thoracic Surgery. Patients who were documented in the period from January 2015 to November 2021 and had video-assisted thoracic surgery (VATS) talc pleurodesis or implantation of an indwelling pleural catheter (IPC) were included.

RESULTS

A total of 543 patients were evaluated. The majority suffered from secondary pleural carcinomatosis (n = 402; 74%). VATS talc pleurodesis (n = 361; 66.5%) was performed about twice as often as IPC implantation (n = 182; 33.5%). The duration of surgery was significantly shorter in IPC-patients with 30 min compared to VATS talc pleurodesis (38 min; p = 0.000). Postoperative complication rate was 11.8% overall and slightly higher after VATS talc pleurodesis (n = 49; 13.6%) than after IPC implantation (n = 15; 8.2%). After VATS talc pleurodesis patients were hospitalized significantly longer compared to the IPC group (6 vs. 3.5 days; p = 0.000). There was no significant difference in postoperative wound infections between the groups (p = 0.10). The 30-day mortality was 7.9% (n = 41).

CONCLUSION

The implantation of an IPC can significantly shorten the duration of surgery and the hospital stay. For this reason, the procedure should be matched with the patient's expectations preoperatively and the use of an IPC should be considered not only in the case of a trapped lung.

Exposure to cisplatin in the operating room during hyperthermic intrathoracic chemotherapy

PURPOSE

Hyperthermic intrathoracic chemotherapy (HITOC) is an additive, intraoperative treatment for selected malignant pleural tumors. To improve local tumor control, the thoracic cavity is perfused with a cisplatin-containing solution after surgical cytoreduction. Since cisplatin is probably carcinogenic to humans, potential contamination of surfaces and pathways of exposure should be systematically investigated to enable risk assessments for medical staff and thus derive specific recommendations for occupational safety.

METHODS

Wipe sampling was performed at pre-selected locations during and after ten HITOC procedures, including on the surgeon's gloves, for the quantitation of surface contaminations with cisplatin. After extraction of the samples with hydrochloric acid, platinum was determined as a marker for cisplatin by voltammetry.

RESULTS

High median concentrations of cytostatic drugs were detected on the surgeons' (1.73 pg Cis-Pt/cm2, IQR: 9.36 pg Cis-Pt/cm2) and perfusionists' (0.69 pg Cis-Pt/cm2, IQR: 1.73 pg Cis-Pt/cm2) gloves. The display of the perfusion device showed partially elevated levels of cisplatin up to 4.92 pg Cis-Pt/cm2 and thus could represent an origin of cross-contamination. In contrast, cisplatin levels on the floor surfaces in the area of the surgeon and the perfusion device or in the endobronchial tube were relatively low.

CONCLUSION

With a correct use of personal protective equipment and careful handling, intraoperative HITOC appears to be safe to perform with a low risk of occupational exposure to cisplatin.

Evaluation of Surgical Therapy in Advanced Thymic Tumors

A complete resection of thymic tumors is known to be the most important prognostic factor, but it is often difficult to perform, especially in advanced stages. In this study, 73 patients with advanced thymic tumors of UICC stages III and IV who underwent radical resection were examined retrospectively. The primary endpoint was defined as the postoperative resection status. Secondary endpoints included postoperative morbidity, mortality, recurrence/progression-free, and overall survival. In total, 31.5% of patients were assigned to stage IIIa, 9.6% to stage IIIb, 47.9% to stage IVa, and 11% to stage IVb. In stages III a R0 resection was achieved in 53.3% of patients. In stages IV a R0/R1 resection was documented in 76.7% of patients. Surgical revision was necessary in 17.8% of patients. In-hospital mortality was 2.7%. Median recurrence/progression-free interval was 43 months (p = 0.19) with an overall survival of 79 months. The 5-year survival rate was 61.3%, respectively. Median survival after R2 resection was 25 months, significantly shorter than after R0 or R1 resection (115 months; p = 0.004). Advanced thymic tumors can be resected with an acceptable risk of complications and low mortality. In stage III as well as in stage IV the promising survival rates are dependent on the resection-status.

["Tissue Handling" in Thoracic Surgery - Results of a Delphi Expert Consensus Conference of the German Society for Thoracic Surgery]

BACKGROUND

The aim of this working group of the German Society for Thoracic Surgery (DGT) was to develop an expert consensus based on the Delphi method to define "tissue handling" and depict intraoperative handling of specific anatomical structures during thoracic surgery.

METHODS

Invited experts (thoracic surgery specialists; n = 93) completed two consecutive rounds of electronic Delphi questions on four main topics: transection of lung parenchyma, dissection/separation of pulmonary vessels, angioplasty/vascular anastomoses, and bronchus settling closure/plasty/anastomosis. Consensus was set at ≥ 75% agreement. At the subsequent expert conference, the results of the Delphi surveys were discussed and TED voting was used to try to reach consensus.

RESULTS

In each case, 66 (71%) answers were given in the first round of questions and 33 (35%) in the second round. Disputed questions were evaluated again by a final vote at the expert conference (54 participants; average participation 55%). The term "tissue handling" includes all procedures for dissection, transection, sealing, and reconstruction of various autologous tissues in the context of thoracic surgery (100% consensus). Similarly, the term "angioplasty expansion" was defined with a 97% consensus. Consensus was reached mainly for the technique of transecting the lung parenchyma using stapling suture devices, the recommendation of covering anastomoses as well as bronchial stump after pretreatment (> 75%).

CONCLUSIONS

This expert consensus describes for the first time the concept of tissue handling in thoracic surgery. Furthermore, this Delphi process led to a comprehensive current inventory of different intraoperative procedures in German thoracic surgery with derived consensual recommendations for tissue handling of lung parenchyma, vessels and bronchial structures.

Assessment of concentration and penetration depth of cisplatin in human lung tissue after decortication and hyperthermic exposure

Background

Hyperthermic perfusion of the pleural cavity with cisplatin after pleurectomy/decortication is an additional therapeutic option to reduce local relapse of malignant pleural tumours. Although there are data on the clinical effect, only little is known about the local impact on human lung tissue by cisplatin. The objective of this experimental study is to evaluate both the concentration and the penetration depth of cisplatin in human lung tissue after normothermic and hyperthermic exposure under ex-vivo-in-vitro conditions.

Methods

This study was approved by the local ethics committee. In total, 46 patients underwent elective lobectomy and wedge resections were taken from the resected lobes. A decortication of the visceral pleura was performed under ex-vivo conditions, and the tissue samples were incubated with cisplatin (c =0.05 mg/mL) at 37, 42 or 45 °C for 60 minutes. Then the mass concentration of platinum was measured with flameless atomic absorption spectroscopy and then converted into cisplatin concentration. In addition, the current data were compared with previous data of our working group (42 °C, without decortication).

Results

The overall maximum penetration depth was 7.5 mm due to limitations of our methods. The functional maximum penetration depth did not vary with temperature (P=0.243) but by decortication (P<0.001). The cisplatin concentration decreased with increasing penetration depth (P<0.001). An increase of temperature showed no effect on the cisplatin concentration in decorticated tissue samples (P=0.985). However, decortication at 42 °C significantly increased the cisplatin concentration in comparison to not decorticated tissue samples (P=0.005).

Conclusions

Decortication of the visceral pleura increases the cisplatin concentration in the lung tissue. Therefore, it possibly reduces the likelihood of a local relapse. An increase of temperature did not show any effect.

Hyperthermic intrathoracic chemotherapy (HITHOC): narrative review of the current literature, recommendations and future studies

Although the method of hyperthermic intrathoracic chemotherapy (HITHOC) after cytoreductive surgery is known for more than 20 years now, the interest of the scientific community has been growing especially in recent years with annually increasing numbers of publications. The feasibility and safety of HITHOC has already been demonstrated. The primary objective now is to reach a consent about the optimal implementation and standardization of the procedure. In the international clinical practice of HITHOC the parameters of temperature, duration, type and number of chemotherapeutic agents vary, making a comparison of the short- and long-term results difficult. For about ten years, the combination of surgical cytoreduction and HITHOC has been performed more routinely in several departments of thoracic surgery in Germany, especially in university hospitals. Recently, a group of experts for thoracic surgery of five departments of thoracic surgery elaborated recommendations for the HITHOC procedure in Germany. These recommendations represent a standardized and consistent implementation of HITHOC. Through this, postoperative complications associated to HITHOC should be reduced and a better comparison of the results should be enabled. This article is intended to give a brief overview of the literature, current recommendations in the implementation of HITHOC and also aims to show future perspectives of this procedure.

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults

 

OBJECTIVES

Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered.

METHODS

We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points.

RESULTS

Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths.

CONCLUSIONS

Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.

Video-assisted pulmonary metastectomy is equivalent to thoracotomy regarding resection status and survival

Background

Surgical resection of pulmonary metastases leads to prolonged survival if strictly indicated. Usually, thoracotomy with manual palpation of the entire lung with lymph node dissection or sampling is performed. The aim of this study was to evaluate the role of video-assisted thoracoscopic surgery (VATS) in pulmonary metastectomy with curative intent.

Methods

In this study, all patients with suspected pulmonary metastasis (n = 483) who visited the Center for Thoracic Surgery in Regensburg, between January 2009 and December 2017 were analysed retrospectively.

Results

A total of 251 patients underwent metastectomy with curative intent. VATS was performed in 63 (25.1%) patients, 54 (85.7%) of whom had a solitary metastasis. Wedge resection was the most performed procedure in patients treated with VATS (82.5%, n = 52) and thoracotomy (72.3%, n = 136). Postoperative revisions were necessary in nine patients (4.8%), and one patient died of pulmonary embolism after thoracotomy (0.5%). Patients were discharged significantly faster after VATS than after thoracotomy (p < 0.001). Complete (R0) resection was achieved in 89% of patients. The median recurrence-free survival was 11 months (95% confidence interval 7.9–14.1). During follow-up, eight (12.7%) patients in the VATS group and 42 (22.3%) patients in the thoracotomy group experienced recurrence (p = 0.98). The median overall survival was 61 months (95% confidence interval 46.1–75.9), and there was no significant difference with regard to the surgical method used (p = 0.34).

Conclusions

VATS metastasectomy can be considered in patients with a solitary lung metastasis. An open surgical approach with palpation of the lung showed no advantage in terms of surgical outcome or survival.

[Organ Bath Experiments on Human Pulmonary Vessels: Assessment of Drug Efficacy for Treatment of Pulmonary Arterial Hypertension]

Various vasodilator medications are used in the treatment of pulmonary arterial hypertension (PAH), such as endothelin receptor antagonists (ERA) or phosphodiesterase-5-(PDE-5-)inhibitors. In a human ex vivo model, we investigated whether the combination of two substance classes could achieve a higher effect or - without loss of vasodilatation - a lower dosage of the individual substances might be sufficient. We established an ex vivo organ bath model to evaluate the dose-dependent effects of ERA and PDE-5-inhibitors on pulmonary vessels harvested from patients who underwent surgery (lung resection/transplantation). We compared the combined use of both substance classes with administration of one class of drugs alone. Due to the limitations of the experimental design, it is not possible to extrapolate our results to the conditions in vivo. Nevertheless, organ bath proved to be helpful in evaluating the dose-dependent effects of ERA and PDE-5 inhibitors, which is not practical in everyday clinical practice. In this setting, the effectiveness of the combination therapy and the potential for dose reduction depended on the concentrations used and on the influence of previous illnesses on blood vessel function. This article describes the most important results of our experimental investigations and suggestions for future projects.

Evaluation of the combination of endothelin receptor antagonists (ERA) and phosphodiesterase-5 inhibitors for the treatment of pulmonary arterial hypertension (PAH) in pathologic human pulmonary arteries in an ex-vivo organ bath model

PURPOSE

Medical combination therapy of pulmonary arterial hypertension (PAH) may alleviate the drawbacks of monotherapy by avoiding drug tolerance and by increasing effectiveness, as shown by the combination of ambrisentan and tadalafil (AMBITION trial). The present ex-vivo study evaluated the combination of the endothelin receptor antagonists (ERA) macitentan and bosentan with the phosphodiesterase-5 (PDE-5) inhibitor vardenafil in pulmonary arteries from patients suffering from terminal lung disease as a model of PAH.

METHODS

Segments of the pulmonary vessels were excised from resected lungs of patients requiring lung transplantation (LTX). Contraction of pulmonary arteries (PA) was elicited by consecutive dose-response curves of endothelin-1 (ET-1) followed by norepinephrine (NE) to allow inhibition by different pathways. Forces were measured isometrically in an organ bath in the presence and absence of ERA and PDE-5 inhibitors and their combination.

RESULTS

PA of 38 patients were examined between October 2016 and November 2019. Bosentan (1E-7 M) and macitentan (1E-8 M, 3E-8 M, 1E-7 M) inhibited ET-1 induced contractions, whereas vardenafil (1E-6 M, 3E-6 M, 1E-5 M) inhibited only the NE induced part of the contractions. Vardenafil enhanced bosentan-induced inhibition of vasoconstriction in a dose-dependent fashion. Combination effects exceeded single bosentan at 3E-6 M and 1E-5 M vardenafil, and they exceeded single vardenafil at the lower vardenafil concentrations. Macitentan showed a more pronounced inhibition than bosentan regardless of the lower concentrations. Accordingly, combination effects with vardenafil resembled those of macitentan alone.

CONCLUSIONS

Macitentan and bosentan were potent antagonists of vasoconstriction in PA of LTX patients. The benefit of drug combinations was demonstrated at selected concentrations only owing to a narrow therapeutic range of vardenafil in this ex-vivo model. These results suggest the utility of drug combinations other than the established pair of ambrisentan and tadalafil in PAH treatment but also make a case for a further assessment of vasodilator properties of drugs complementing ERA.

[Minimum volumes in surgical treatment of lung cancer : A survey of thoracic surgeons in Germany on the introduction of a minimum volume regulation for surgical treatment of lung cancer]

BACKGROUND

The Federal Joint Committee (G‑BA) is currently discussing the introduction of new minimum volume regulations (MVR) in Germany. The present study examined the current opinions of active thoracic surgeons regarding minimum volumes (MV) for the surgical treatment of lung cancer.

METHODS

The participating centers for the online survey were identified on the basis of the thoracic surgery departments in the 2017 hospital directory (Federal Statistical Office), lung cancer centers (German Cancer Society), certified centers of excellence for thoracic surgery (German Society for Thoracic Surgery), hospitals with a focus on lung surgery and German university hospitals. They were asked about the potential effects of MVR on the quality of results and quality of care, economic aspects and the structure of care. Furthermore, a recommendation for MV was requested and possible provisions for exemption were evaluated.

RESULTS

A total of 145 hospitals (response rate 85%) with 454 thoracic surgeons (response rate 54%) were surveyed. The results showed a high degree of approval for MV to improve the quality of results and 78.4% of the surgeons surveyed expected it to result in centralization of surgical care, although this would not lead to a deterioration in care according to 70.1% of the participants. Approximately 46.1% of the participants expected care to become more economical and 83.3% supported the introduction of an MVR, with the average recommended MV being 67 anatomical lung resections per center per year.

CONCLUSION

An MVR for the surgical treatment of lung cancer met with a high degree of approval among active thoracic surgeons. The MV that was called for (n = 67) was slightly below the prerequisite for primary surgical cases at a certified lung cancer center.

Classification and staging of thymoma

The appropriate therapy and prognosis of patients with thymic malignancies is decisively influenced by the local extent and dissemination of the tumor. For this reason, a staging system that reflects these factors is essential. Mainly the Masaoka-Koga classification, which was introduced in 1994, has been applied for this purpose. The rarity of thymic malignancies makes it difficult not only to establish internationally standardized diagnostics and treatment, but also to progress staging. Besides, efforts were made to adapt the classification into a tumor-node-metastasis-based (TNM) system for standardization with the staging of other tumor entities. The 2017 published 8th edition of the TNM Classification of Malignant Tumors introduced several adjustments based on a proposal of the International Association for the Study of Lung Cancer (IASLC) and the International Thymic Malignancy Interest Group (ITMIG). Compared to the Masaoka-Koga classification, surgically good resectable tumor involvements like pericardium, mediastinal fat or mediastinal pleura have been shifted to lower stages. Thus, even more than in Masaoka-Koga classification, tumors are basically divided into completely resectable and thus surgically treatable tumors (stage I, II, IIIA) and advanced stages (stage IIIB, IVA and IVB) that require multimodal therapy.

[Extended Resection of Locally Advanced Thymic Tumours in Stage III]

In the treatment of locally advanced thymic tumours, specific diagnostic testing is required, with a multimodal therapeutic approach consisting of surgery, radio- and/or chemotherapy. The complete resection of the tumour represents the most important prognostic factor with regard to recurrence-free and long-term survival. Local invasive growth of malignant thymic tumours into neighbouring mediastinal structures is classified as Masaoka-Koga stage III. Surgical resection can be performed primarily or after induction therapy, depending on the extent of the tumour. However, in some cases these tumours must be classified as non-resectable, so that only palliative radio-/chemotherapy remains as therapeutic option. TNM classification for malignant thymic tumours has been recently introduced. This resembles the established Masaoka-Koga classification in many aspects, but also includes some therapy-relevant changes. A differentiation is made between stages IIIA and IIIB, with the aim of assessing the resectability of advanced thymic tumours in a more differentiated manner and consequent planning of the therapy concept. Besides the thymus, thymoma, perithymic tissue, mediastinal pleura (stage I) or pericardium (stage II), all infiltrated structures should be removed "en bloc", if possible in stage III tumours. While the lung, brachiocephalic vessels or extrapericardial pulmonary vessels can still be resected and reconstructed if necessary, infiltration of the aorta or intrapericardial pulmonary vessels often limits macroscopically complete resection.

Protocol of a retrospective, multicentre observational study on hyperthermic intrathoracic chemotherapy in Germany

INTRODUCTION

Objective of the 'German hyperthermic intrathoracic chemotherapy (HITOC) study' is to evaluate the HITOC as additional treatment after surgical cytoreduction for malignant pleural tumours. Even though HITOC is applied with increasing frequency, there is no standardised therapy protocol concerning the technique of HITOC, the selection as well as dosage of chemotherapeutic agents and perioperative management in order to provide a safe and comparable, standardised treatment regime.

METHODS AND ANALYSIS

This trial is a retrospective, multicentre observational study, which is funded by the German Research Foundation. Approximately 300 patients will be included. Four departments of thoracic surgery, which are performing the most HITOC procedures in Germany, are contributing to this study: Center for Thoracic Surgery at the University Hospital Regensburg, Thoracic Clinic Heidelberg of the University of Heidelberg, Center for Thoracic Surgery of the Hospital University of Munich and the Department of Thoracic Surgery at the University Hospital Freiburg. All patients who underwent surgical cytoreduction and subsequent HITOC at one of the four centres between starting the HITOC programme in 2008 and December 2019 will be included. Information on the performed HITOC will be obtained, focusing on the technique as well as the applied perfusion solution including the chemotherapeutic agent. Furthermore, parameters of the patient's postoperative recovery will be analysed to determine 30-day morbidity and mortality.

ETHICS AND DISSEMINATION

The approvals by the local ethics committee of the respective clinic and the three participating clinics have been obtained. The results will be presented in conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00015012; Pre-results).

[Surgical Treatment of Lung Cancer: How Has the Introduction of the 8th Edition of the TNM Classification Affected Guideline-Based Therapy?]

STUDY AIM

The 8th edition of the TNM classification combined with the latest update of the S3-guideline (by AWMF/Scientific Medical Societies in Germany) on prevention, diagnosis, therapy and follow-up of lung cancer led to several changes in staging and treatment of lung cancer. The aim of this study was to identify differences in the distribution of patients due to changes from the 7th to the 8th edition that affected staging. The influence on surgical therapy will be discussed by using the recommendations of the latest S3 guideline.

METHODS

Prospective analysis of all primary cases at two thoracic surgical centres in the year 2016 and follow-up in March 2019. Comparison of the 7th edition of tumour classification for lung cancer with the 8th edition, focused on changes in tumour staging and its effects on the appropriate surgical therapy according to the latest S3 guideline.

RESULTS

A total of 432 primary cases comprised the study population. According to the 8th edition, 82 patients (7th edition: n = 85) in stage I, 43 (n = 49) patients in stage II, 100 (n = 91) patients in stage III and 207 (n = 207) patients are assigned to stage IV. 81 changes (18.7%) were detected (77 upgrades vs. 4 downgrades). 63 patients (14.6%) exhibited a different graduation within the stages. 18 patients (4.1%) were classified in different tumour stages. As a result, fewer patients (n = 12; 2.8%) should have surgery according to the latest S3 guidelines. 290 patients (67.1%) were classified to new subgroups (IA1-3, IIIC and IVA/B). Two-year survival was significantly higher in IVA (25.2%) vs. IVB (13.0%) patients (p < 0.05).

CONCLUSION

The 8th edition of the TNM-classification affords a higher level of differentiation. In this study, the new TNM classification led to a shift in the distribution, with a tendency to increase the tumour stage. This is mainly caused by changes in the T-descriptor and stage grouping. As a result, fewer patients in stage I - IIIA should have surgery according to the latest S3 guidelines. A significantly higher two-year survival rate was detected in stage IVA (M1a and M1b) compared to IVB and justifies the new differentiation due to the metastatic pattern.

[Five Years PLEURATUMOR Register of the German Society of Thoracic Surgery]

BACKGROUND

Since 01.01.2015, the nationwide "PLEURATUMOR Register of the German Society of Thoracic Surgery (DGT)" has documented the most relevant parameters of patients with primary and secondary malignant pleural diseases receiving thoracic surgery in Germany. This online database is intended to record both primary and recurrent diseases. In particular, the registry focuses on the documentation of patients with pleural carcinosis, malignant pleural mesothelioma and tumours of the thymus with pleural dissemination.

METHODS

A structured evaluation of all patients documented up to and including December 2019 was carried out.

RESULTS

At this time, 33 departments participated in the PLEURATUMOR Register and 670 patients have been recorded. Of these patients, 522 data sets were complete and 516 patients received surgical treatment. Most patients were documented in 2017 (n = 135; 26.2%), and in 2019 (n = 72; 14%). With 317 listed patients (61.4%), pleural carcinosis was the most frequently reported pleural tumour, followed by malignant pleural mesothelioma (n = 175; 33.9%) and thymoma/thymic carcinoma with pleural metastases (n = 11; 2.1%). The majority of patients (n = 499; 96.7%) were treated because of an initial manifestation. The most frequently documented procedure was VATS-talcum pleurodesis (n = 204; 39.5%). In 69 patients (13.4%) hyperthermic intrathoracic chemotherapy was performed after cytoreductive surgery. Postoperative complications occurred in 107 patients (20.7%); in 35 cases (6.8%) surgical revision was necessary. The overall 30-day mortality was 8.3% (n = 43).

CONCLUSION

Due to the consistent data entry of the participating clinics, a representative dataset of pleural tumour diseases could be recorded. In the future, we hope for consistent continuation of data entry and the initiation of register-based studies.

Complicated chylous pericardial and thoracic effusion as the first clinical manifestation of thoracic lymphatic malformation

Lymphatic malformations are benign focal proliferations of lymphatic vessels with a congenital origin. We present a case of an 18-year-old patient with post-traumatic chylopericardium and recurrent left-sided chylothorax, who was unresponsive to a variety of therapeutic measures until he was diagnosed with a complicated thoracic lymphatic malformation.

Surgical Cytoreduction and HITOC for Thymic Malignancies with Pleural Dissemination

BACKGROUND

Objective of this study was to assess postoperative morbidity and mortality as well as recurrence-free and overall survival in patients with thymic malignancies and pleural dissemination undergoing surgical cytoreduction and hyperthermic intrathoracic chemotherapy (HITOC).

METHODS

Retrospective study between September 2008 and December 2017 with follow-up analysis in May 2018.

RESULTS

A total of 29 patients (male: n = 17) with thymic malignancies and pleural spread (primary stage IVa: n = 11; pleural recurrence: n = 18) were included. Surgical cytoreduction was performed via pleurectomy/decortication (P/D; n = 11), extended P/D (n = 15), and extrapleural pneumonectomy (EPP; n = 3). These procedures resulted in 25 (86%) patients with macroscopically complete (R0/R1) resection. Intraoperative HITOC was performed for 60 minutes at 42°C either with cisplatin (100 mg/m² body surface area [BSA] n = 8; 150 mg/m² BSA n = 6; 175 mg/m² BSA n = 1) or with a combination of cisplatin (175 mg/m² BSA)/doxorubicin (65 mg; n = 14). Postoperative complications occurred in nine patients (31%). Cytoprotective therapy resulted in lower postoperative creatinine levels (p = 0.036), and there was no need for temporary dialysis in these patients. The 90-day mortality rate was 3.4%, as one patient developed multiple organ failure. While recurrence-free 5-year survival was 54%, an overall 5-year survival rate of 80.1% was observed. Survival depended on histological subtype (p = 0.01).

CONCLUSION

Surgical cytoreduction with HITOC is feasible in selected patients and offers encouraging survival rates. The application of cytoprotective agents appears to be effective for the prevention of postoperative renal insufficiency.

Adequate nephroprotection reduces renal complications after hyperthermic intrathoracic chemotherapy

BACKGROUND AND OBJECTIVES

Hyperthermic intrathoracic chemotherapy (HITOC) is used for the treatment of malignant pleural tumors. Although HITOC proved to be safe, postoperative renal failure due to nephrotoxicity of intrapleural cisplatin remains a concern.

METHODS

This single-center study was performed retrospectively in patients who underwent pleural tumor resection and HITOC between September 2008 and December 2018.

RESULTS

A total of 84 patients (female n = 33; 39.3%) with malignant pleural tumors underwent surgical cytoreduction with subsequent HITOC (60 minutes; 42°C). During the study period, we gradually increased the dosage of cisplatin (100-150 mg/m² BSA n = 36; 175 mg/m² BSA n = 2) and finally added doxorubicin (cisplatin 175 mg/m² BSA/doxorubicin 65 mg; n = 46). All patients had perioperative fluid balancing. The last 54 (64.3%) patients also received perioperative cytoprotection. Overall 29 patients (34.5%) experienced renal insufficiency. Despite higher cisplatin concentrations, patients with cytoprotection showed significantly lower postoperative serum creatinine levels after 1 week (P = .006) and at discharge (P = .020). Also, they showed less intermediate and severe renal insufficiencies (5.6% vs 13.3%).

CONCLUSIONS

Adequate perioperative fluid management and cytoprotection seem to be effective in protecting renal function. This allows the administration of higher intracavitary cisplatin doses without raising the rate of renal insufficiencies.

[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.

[Hyperthermic intrathoracic chemotherapy in thoracic surgery]

In regional chemotherapy of the pleural space a differentiation is made between intrapleural hyperthermic perfusion (IHP) and hyperthermic intrathoracic chemotherapy (HITOC). The HITOC in particular is carried out as an additive procedure after surgical cytoreduction of the pleural tumor manifestation. The main indications are for malignant pleural mesothelioma and thymoma with pleural spread (stage IVa), whereas treatment of secondary pleural carcinomatosis is indicated only in selected patients suitable for resection followed by HITOC. Cisplatin is the standard chemotherapeutic agent and a concentration of 150-175 mg/m² body surface area is recommended. Postoperative, HITOC-related complications (e.g. renal insufficiency) can be minimized by an adapted perioperative management. Safety measures should be accomplished adhered to for the protection of personnel. The aim of HITOC is to achieve a better local tumor control with a corresponding longer recurrence-free and overall survival.

[Surgical treatment of tracheoarterial fistulas]

BACKGROUND

A tracheoarterial fistula (TAF) is an uncommon but life-threatening complication after tracheostomy. Only an immediate and targeted treatment provides a chance to survive.

OBJECTIVE

Surgical treatment of TAF.

METHODS

Selective review of the literature and case description.

RESULTS

A TAF leads to an acute bleeding complication with displacement of the respiratory tract. The mortality rate is nearly 100% without a surgical intervention. In the literature various interventional and surgical treatment procedures are described. Rapid control of bleeding via manual compression and overinflation of the tracheal cuff are the most important steps of treatment. Subsequent emergency surgery with ligation or resection of the TAF and covering of the tracheal lesion should be performed. Extracorporeal membrane oxygenation (ECMO) and a heart-lung machine can sometimes be necessary.

CONCLUSION

Despite all treatment options the mortality rate of TAF remains high. The critical steps are a quick diagnosis of TAF, securing the airway and immediate bleeding control.

Incidental thoracic findings in computed tomography scans before transcatheter aortic valve implantation

OBJECTIVES

Preoperative computed tomography (CT) scans for transcatheter aortic valve implantation (TAVI) are used routinely. In elderly high-risk patients, incidental radiographic findings are frequently reported. The aim of this study was to investigate the impact of auxiliary findings on the patients' mid-term survival, which might affect the treatment strategy.

METHODS

Between March 2011 and April 2016, all radiological reports of contrast-enhanced CT scans of 976 patients scheduled for TAVI were analysed retrospectively for incidental thoracic findings including solitary pulmonary nodules (SPN) and thoracic lymphadenopathy (LAP). The minimum follow-up period was 1 year after TAVI.

RESULTS

The median age of all patients was 79 years; 51.9% (n = 507) were women. Approximately 37% (n = 361) of patients showed 1 of the determined findings. An SPN ≥5 mm was diagnosed in 16.4% (n = 160) of patients. Four of them developed lung cancer and 2 nodules were identified as metastases during follow-up. In addition, 12% (n = 117) of the patients had thoracic LAP. Whereas SPN had no significant effect on the overall survival rate, evidence of LAP turned out to be a statistically significant factor regarding 4-year survival (P = 0.001; hazard ratio 1.66; 95% confidence internal 1.19-2.31).

CONCLUSIONS

SPN ≥5 mm were detected in 16.4% of patients scheduled for TAVI. Nevertheless, the incidence of lung cancer was low and the effect on survival in this high-risk group of patients was statistically not significant. In contrast, thoracic LAP had a significant negative effect on survival. It needs to be proven if the outcome of this cohort can be enhanced by further diagnostics and therapy.

[Non-Elective Thoracic Surgery in Patients with Respiratory Insufficiency During Support with Veno-Venous Extracorporeal Membrane Oxygenation]

INTRODUCTION

Patients with severe respiratory failure and veno-venous extracorporeal membrane oxygenation (vv-ECMO) often require diagnostic or therapeutic thoracic surgery.

METHODS

Retrospective analysis of prospectively collected data (Regensburg ECMO Registry) on all patients requiring vv-ECMO between December 2010 and December 2016 due to acute lung failure (ALF) with diagnostic or therapeutic thoracic surgery. Endpoints were the indications for thoracic surgery as well as postoperative morbidity and in-hospital mortality.

RESULTS

A total of 418 patients (male n = 285, 68%, mean age 50.0 ± 16.5 years) with severe respiratory insufficiency refractory to conventional therapy required vv-ECMO. Indications for vv-ECMO were ALF due to pneumonia (59.8%), postoperative (18.7%), posttraumatic (9.8%), after chemotherapy (2.8%) and others (8.9%). Overall, in 24.4% (n = 102) of patients with vv-ECMO surgery was performed. Of these, 28.4% (n = 29) of patients required thoracic surgery. Primary indications for thoracic surgery were most frequently therapeutic due to hemothorax (n = 13; 44.8%), followed by carnifying pneumonia/pulmonary abscess (n = 5; 17.2%), pleural empyema (n = 3; 10.3%) and others (n = 3; 10.3%). In patients with interstitial lung disease of unknown origin (n = 5; 17.2%), diagnostic pulmonary biopsy was performed. For initial thoracic intervention thoracotomy was carried out in 93.1% (n = 27) of patients, whereas only two patients (6.9%) received thoracoscopy. At least one repeated thoracotomy was performed in 15 patients (51.7%) and nine patients (31.0%) underwent more than two surgeries. In-hospital mortality of patients with thoracic surgery (44.8%) was higher than in patients without thoracic surgery (35.7%; p = 0.326).

CONCLUSION

Thoracic surgery in patients with vv-ECMO warrants strict indications, because postoperative complications are common and surgical revision (58,6%) is often required. Therefore, ECMO therapy should only be carried out in specialised centers with thoracic surgery.

[Influence of primary lymph node status of colorectal cancer on the development of pulmonary metastases and thoracic lymph node metastases]

BACKGROUND

The lungs are the second most common organ site for metastases in patients with colorectal cancer (CRC). Lymph node metastasis of CRC represents a prognostic factor for survival.

OBJECTIVE

The present study investigated the influence of CRC lymph node metastasis on lung metastasis, in particular thoracic lymph node metastasis.

MATERIAL AND METHODS

A retrospective analysis of 88 patients (n = 56 male) with curative resection of lung metastases of CRC was performed. Primary endpoint: influence of lymph node status of CRC on lung metastases. Secondary endpoints: disease-free survival and overall survival. Statistical evaluation was carried out with SPSS.

RESULTS

In 48 patients a positive lymph node status of CRC and in 9 patients an N+ status of lung metastases were determined. The lymph node status of the CRC significantly affected the incidence of synchronous metastases (p = 0.03), disease-free interval until formation of metachronous lung metastases (p = 0.012) and the overall survival of patients with CRC (p = 0.048). The 5‑year survival rate for CRC patients with lung metastases was 48.7% after pulmonary metastasectomy. Thoracic lymph node involvement also significantly affected survival (p = 0.001).

CONCLUSION

Screening for pulmonary metastases should be included in the staging and follow-up of all patients with CRC, especially in patients with a positive lymph node status of the CRC.

Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation

BACKGROUND

Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are at risk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation.

METHODS

A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications.

RESULTS

The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n = 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n = 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p = 0.035) and hospital length of stay (58 ± 50 days; p = 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p = 0.013).

CONCLUSIONS

Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.

Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management

Background

Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients.

Methods

Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime.

Results

The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 vs. 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 vs. 31.8 months; P=0.137).

Conclusions

N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).

[Comparison of the Masaoka-Koga Classification with the New TNM Staging of the IASLC/ITMIG for Thymoma and Thymic Carcinoma]

BACKGROUND

The Masaoka-Koga classification describes the extent and spread of thymic epithelial malignancies. The objective of this study was to evaluate the Masaoka-Koga and the new TNM-staging system regarding differences in stage distributions, clinical implementation and therapeutic consequences.

METHODS

Retrospective analysis of all patients who underwent surgery between January 2005 and December 2015 for thymoma/thymic carcinoma in two centres for thoracic surgery. The final tumour stages were determined on the basis of preoperative imaging, surgical reports and histological findings.

RESULTS

A total of 118 patients (male 51%) with a mean age of 56 ± 14.8 years were included. Indications for surgery were primary mediastinal tumour (n = 97), pleura dissemination (n = 15) or mediastinal recurrence (n = 7). Radical tumour resection was performed in 92% of patients (n = 109) within one operation, whereas 8% of patients (n = 9) underwent two operations. Surgical revision was necessary in 12 patients (10.1%) and in-hospital mortality was 1.7% (n = 2). Early Masaoka-Koga stages I (n = 34) and II (n = 16) shifted to the new UICC stage I (T1: n = 58). Locally advanced stages (Masaoka-Koga stage III n = 22 vs. UICC stage IIIA + IIIB n = 20) and metastasised stages (Masaoka-Koga stage IV n = 36 vs. UICC stage IV n = 39) remained very similar.

CONCLUSIONS

The new TNM staging system gave rise to changes, especially in early stages (downstaging), but these had no therapeutic implications. Although advanced stages were very similar, the new TNM staging provides more clinically relevant differentiation.

ICU Readmission after Cardiac Surgery-Still a Matter of Concern?

BACKGROUND

Despite improvements in diagnostics and perioperative care, readmission to intensive care unit (ICU) after cardiac surgery is still a severe drawback for patients with considerable morbidity, mortality, and costs. Aim of this retrospective analysis was to disentangle independent risk factors for ICU readmission.

MATERIAL AND METHODS

Between 01/2004 and 12/2012, 336 out of 9,555 (3.5%) patients undergoing cardiac surgery at the Department of Cardiothoracic Surgery in Regensburg (Germany) were readmitted to ICU. A matched-pair analysis (readmission vs control group) was conducted, matching for gender, age, and surgical procedure. Operations included coronary artery bypass grafting, valve reconstruction/replacement, aortic surgery, combined procedures, and others. Mean follow-up was 6.2 ± 2.3 years.

RESULTS

Median age of the readmitted patients was 71 years (65; 76), and the majority was male (67.9%). Median logistic Euroscore as a parameter for perioperative risk was significantly higher as compared with the control group (5.8 vs 5.2, p = 0.045) as was the prevalence of comorbidities including hypertension, chronic obstructive pulmonary disease, prior myocardial infarction, stroke, and PAOD. Most common reasons for readmission were cardiopulmonary instability (27.4%), respiratory failure (20.8%), and surgery for deep sternal infection (8.6%). Twenty-one percent required more than one readmission. Overall mortality was significantly higher in readmitted patients (21.1 vs 12.5%).

CONCLUSIONS

In conclusion, readmission to the ICU after cardiac surgery is a rare complication that is still associated with excessive mortality. Establishment of an intermediate care unit proved to be an excellent means to reduce ICU stay without endangering post-surgery patients and significantly reduced the ICU readmission rate.

[Implementation of Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Germany]

INTRODUCTION

For several years, hyperthermic intrathoracic chemotherapy (HITHOC) has been performed in a few departments for thoracic surgery in a multimodality treatment regime in addition to surgical cytoreduction. Specific data about HITHOC in Germany are still lacking.

METHODS

Survey in written form to all departments of thoracic surgery in Germany. The objective is the evaluation of HITHOC with respect to number, indications, technique, perioperative protection measure and complications.

RESULTS

A total of 116 departments of thoracic surgery were contacted, with a return rate of 43% (n = 50). HITHOC was not performed in 33 departments, due to lack of resources or experience (n = 17), missing efficacy of the procedure (n = 8) and fear of excessive complication rates (n = 3). Since 2008, a total of 343 HITHOC procedures have been performed in 17 departments. Eight departments have their own perfusion machine, whereas the remaining departments borrow the perfusion machine. Indications were malignant pleural mesothelioma in all departments (n = 17), thymoma with pleural spread (n = 11) and secondary pleural carcinosis (n = 7). The HITHOC was performed in nearly all departments after closing the chest (n = 16), with a temperature of 42 °C (n = 12) and for 60 minutes (n = 15). Cisplatin was always used, either alone (n = 9) or in combination (n = 8). In all the participating departments, the aims of the HITHOC were improvement in local tumor control and prolonged recurrence-free and overall survival. Relevant HITHOC-associated complications were low.

CONCLUSIONS

HITHOC is performed in at least 17 departments of thoracic surgery in Germany, and is widely standardised with protective measures and a low rate of complications. The aims of the HITHOC are improvement in local tumor control in pleural malignancies combined with prolonged overall survival and better quality of life.