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Cardiac and pulmonary physiologic assessment is necessary for risk stratification before any lung resection. It may uncover hidden health issues, which can be addressed first to make patients fit for surgery. It allows for the surgeon to estimate the patient's risk for major complications and at the same time for the patient to understand the procedural risks and give informed consent or even reject surgery. Recommended work-up for both to cardiac risk evaluation and preoperative pulmonary function test algorithms are based on guidelines formulated by the ERS/ESTS and ACCP 1 3 4.Basic pulmonary function tests consist of spirometry, blood gas analysis and measurement of diffusion capacity (DLCO); followed by cardiopulmonary exercise testing (CPET) which estimates or measures the patient's oxygen consumption, and split function tests such as perfusion scintigraphy. Clinical assessment of both the patient's overall status and pulmonary function allows for an adequate assessment of overall operative risk. Pulmonary function tests are affected by multiple variables and as such prone to error. It is advisable to always question the validity of every work-up and to repeat any test if necessary.

Background and objectives It is unclear how much additional perioperative risk a sleeve lobectomy could pose in comparison to lobectomy. The objective of this analysis was to compare the complication rate, 30-day mortality, and overall survival between lobectomy and sleeve lobectomy without prior neoadjuvant treatment in non-small-cell lung cancer (NSCLC). Methods This is a retrospective study using our prospective database for quality assurance in our hospital. Inclusion criteria for our study was a completed lobectomy or sleeve lobectomy for primary treatment of NSCLC. Results In 506 patients, the tumor was treated by means of standard lobectomy. In 252 patients with central tumor localization, sleeve lobectomy was performed. Postoperative complications occurred in n:148 (29.24%) patients of the lobectomy group and in n = 76 (30.15%) of the sleeve group. The mortality rate difference between the two groups was statistically significant and favored the lobectomy group (0.78% vs. 4.76%, p = .007). Five year survival was 69.97% for the lobectomy and 65.59% for the sleeve group (p = .829). Conclusion Sleeve lobectomy for primary surgical treatment of NSCLC has comparable perioperative complications with lobectomy. Sleeve lobectomy does not seem to negatively influence survival. Postoperative mortality was higher in the sleeve group.

Die Lungen- und Thoraxsonographie ist neben der Computertomographie und der Labordiagnostik eine weitere Untersuchungsmodalitat bei der COVID-19-Erkrankung. Sie eignet sich zur Erweiterung der klinisch-korperlichen Untersuchung, weil sie sensitiv die Lungenoberflache untersuchen kann. Diese verandert sich in den Sonogrammen mit bislang haufig beschriebenen Mustern bei Patienten mit COVID-19-Pneumonie und im Krankheitsverlauf. Deutsche Fachgesellschaften der klinischen Akut‑, Notfall- und Intensivmedizin sowie der Bildgebung, die mit der Versorgung von Patienten mit SARS-CoV-2-Infektion und der COVID-19-Erkrankung befasst sind, haben unter der Fuhrung der Deutschen Gesellschaft Interdisziplinare Notfall- und Akutmedizin e. V. (DGINA) Empfehlungen zur Lungen- und Thoraxsonographie abgestimmt. Das Dokument wurde uber einen transparenten Prozess durch eine Expertengruppe und Delegierte der Fachgesellschaften erstellt. Quellen der ersten internationalen 200 Fallanalysen wurden zusammengefasst. Bislang haufig beschriebene thoraxsonographische Muster werden vorgestellt. Anhand von Fallbeispielen und multimedialen Inhalten soll das Dokument die Anwender unterstutzen und Qualitatsmerkmale und das Potenzial der Thorax- und Lungensonographie aufzeigen. Die Deutsche Gesellschaft fur Ultraschall in der Medizin e. V. (DEGUM) fuhrt dazu eine Multizenterstudie durch (Studienkoordination TU Munchen).

Prevention of bronchial complications after airway surgery must be our primary goal. Understanding bronchial and anastomotic healing is the first step to success. This can be improved by standardizing operating technique (bronchial closure and end-to-end anastomosis) as well as postoperative care. Bronchopleural fistula after pneumonectomy still remains a feared complication with a high mortality rate. Especially after sleeve resection interpretation of endobronchial healing and postoperative measures of care with the help of an algorithm, may avoid anastomotic insufficiency and therefore reduced the secondary pneumonectomy rate.

Introduction Sleeve resection is an established oncological operative treatment for centrally located tumors with reduced complications compared to pneumonectomy. In cases of neoadjuvant chemoradiotherapy, the optimal timing of surgery for bronchial anastomotic healing has not been adequately explored. Materials and methods Between 2006 and 2017, 584 tracheobronchial sleeve resections were retrospectively analyzed. We selected all patients (n = 88) after sleeve lobectomy or sleeve bilobectomy for lung cancer with fully completed neoadjuvant chemoradiotherapy. Bronchial healing was assessed by bronchoscopy on the 7th postoperative day using our earlier published classification from grades 1 to 5. Results The median interval to surgery was 50 days (interquartile range 46-53, mean 50.03 ± 3.72). Mean anastomotic grade was 2.05 ± 1.03 and in 29.5% of the patients a critical anastomosis (grade ≥3) was documented. Anastomotic healing showed optimal results (bronchoscopic grade mean value: 1.5 ± 0.70) between the 6th and 8th postchemoradiotherapy week (P = .001). All patients operated before (bronchoscopic grade mean value: 2.3 ± 1.02) or after the above period (bronchoscopic grade mean value: 2.5 ± 1.15) had an increased ratio of anastomotic healing complications. Conclusion It is safer to perform sleeve-resections for non-small cell lung cancer after neoadjuvant trimodal treatment between the 6th and 8th week of completion of chemoradiotherapy.

Background Preoperative radiotherapy and/or chemotherapy of lung cancer in patients with locally advanced disease is an option in multimodal treatment. Sleeve lobectomy has an important part in decreasing complications and sparing lung function. We present our experience in a large cohort of patients after sleeve lobectomy with or without neoadjuvant treatment and standardized assessment of bronchial anastomotic healing. Methods The data used for this study were collected in a prospective database in our hospital. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day and thereafter only when necessary, using a standardized scoring system. From 2006 to 2017, we performed 501 sleeve lobectomies representing 19% of all lung cancer resections. A total of 365 of patients had no preoperative treatment (73%), 41 had neoadjuvant chemotherapy (8%), and 95 had radiochemotherapy (19%). Results Using our scoring system of the bronchial anastomosis from 1 (excellent) to 5 (insufficient), we found the anastomosis was worse than grade 2 after no treatment, chemotherapy, or radiochemotherapy in 17%, 10%, and 30%, respectively (P = .002). The rate of anastomotic insufficiency was equally low after no pretreatment and chemotherapy (2.7% and 2.4%) and rose to 10.4% after radiotherapy (P = .002). Similarly, the risk for pulmonary complications was higher after radiochemotherapy (39%) compared with no pretreatment (29%) or chemotherapy (27%), respectively (P = .382). Conclusions Neoadjuvant radiotherapy is associated with worse wound healing of the anastomosis after sleeve lobectomy in lung cancer. There seems to be a higher risk for anastomotic insufficiency and complications.

The therapy of severely injured patients is demanding and promising only in an interdisciplinary context. From a thoracic surgical perspective, the blunt chest trauma is in the foreground; as it is the 2nd leading cause of death after traumatic brain injury. The first step is to identify the potentially life-threatening injury and its treatment (airway obstruction, prevention of gas exchange, tension pneumothorax, serious bleeding complications in lung-/vascular injuries). Pneumothorax or tension pneumothorax is present in 20% of all polytrauma patients and 50% of all patients with severe chest trauma. In most cases, the use of a chest tube is sufficient in the acute phase (90%). For complex injuries with persistent thoracic haemorrhage and haemodynamic instability of the patient or pleural fistulization with increasing skin emphysema, surgical treatment should be performed at an early interval. Nevertheless, emergency thoracotomy is rarely required at this early stage.

Due to the demographic change prevailing in Germany, the age pyramid is shifting more and more upwards. According to the WHO, a patient over the age of 75 is considered to be old. Whether or not and to what extent an old patient can tolerate thoracic surgery purely based on his age and comorbidities remains unclear. Under most circumstances the surgeon's experience seems to be crucial in this decision. PATIENTS AND METHODS: The data analysis included data from 01. 2016-01. 2018 based on the German Thorax Register (Project ID: 2017-03), which was set up under the patronage of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the German Society for Thoracic Surgery (DGT). A total of 1357 patients were included, 658 patients had histologically proven lung cancer stage I-II. These were divided into three groups according to their age; group I ( 65 years), group II (65- ≤ 75) years and group III ( 75 years). We were able to show that group III had essentially no increased postoperative complication rates (all = 48.00 %; group I = 40.90 %; group II = 53.00 %; group III = 52.90 %) and even performed better than group II (65 to ≤ 75) regarding pulmonary complications. (postoperative pneumonia group II = 19.20 %, group III = 12.90 %) The mortality was lowest in patients who were operated on in centers of the German Thorax Register (all = 1.70 %, group I = 1.90 %; group II = 1.70 %; group III = 1.30 %), compared to national german average. (all = 1.99 %; group I = 1.23 %; group II = 2.18 %; group III = 3.78 %) In particular, patients of group III showed the greatest difference. Furthermore, we saw that the majority of anatomical resections performed in centers of the German Thorax Register were resected by VATS (Video-assisted Thoracoscopic Surgery) as opposed to patients operated on in hospitals not affiliated with the German Thorax Register. DISCUSSION: Considering these results, the question arises whether in Germany all old patients were treated according to current guidelines. Although there is a certain selection bias in group III, operative candidates fit for surgery are operated in the centers of the German Thorax Register. Our results permit us to conclude that this group of patients should be given optimal surgical therapy when indicated. Age alone should not be the sole determining factor in decision-making regarding thoracic surgery.Durch den in Deutschland herrschenden demografischen Wandel verschiebt sich die Alterspyramide immer mehr nach oben. Als älter gilt laut WHO ein Mensch zwischen dem 61. und dem 75. Lebensjahr. Als alt werden Menschen ab 76 Jahren bezeichnet. Für die Beantwortung der Frage, ob und in welchem Ausmaß ein alter Patient aufgrund seiner Komorbiditäten thoraxchirurgisch operabel ist, gibt es bislang keine systematische Klassifizierung. In den meisten Fällen scheint für diese Entscheidung die Erfahrung und Einschätzung des Operateurs ausschlaggebend zu sein. PATIENTEN UND METHODEN: Die Datenanalyse erfolgte im Zeitraum von 01. 2016–01. 2018 anhand der Daten des Deutschen Thoraxregisters (Projekt-ID:2017–03), das unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) aufgebaut wurde. Insgesamt wurden 1357 Patienten eingeschlossen, von denen 658 ein histologisch nachgewiesenes Lungenkarzinom im Stadium I-II hatten. Diese wurden in drei Gruppen unterteilt; Gruppe I ( 65 Jahre), Gruppe II (65– ≤ 75 Jahre) und Gruppe III ( 75 Jahre).Wir konnten zeigen, dass Gruppe III, die der 75-jährigen Patienten, im Wesentlichen keine erhöhten postoperativen Komplikationsraten hatten (Alle = 48,00 %; Gr. I = 40,90 %; Gr. II = 53,00 %; Gr. III = 52,90 %) und sogar bei einigen speziellen Komplikationen besser abschnitt, als die Gruppe der 65 bis ≤ 75-jährigen Patienten. (z. B. postoperative Pneumonie Gruppe II = 19,20 %, Gruppe III = 12,90 %).Die Mortalität lag bei den Patienten der Gruppen I–III, die in Zentren des Deutschen Thoraxregisters operiert wurden (Alle = 1,70 %, Gr. I = 1,90 %; Gr. II = 1,70 %; Gr. III = 1,30 %), insgesamt niedriger als im bundesdeutschen Durchschnitt (Alle = 1,99 %; Gr. I = 1,23 %; Gr. II = 2,18 %; Gr. III = 3,78 %). Insbesondere die alten Patienten der Gruppe III wiesen hierbei den größten Unterschied auf.Weiterhin konnten wir feststellen, dass im Gegensatz zu anderen deutschen Zentren und Kliniken, der größte Teil der anatomischen Resektionen in den Zentren des Deutschen Thoraxregisters minimalinvasiv per VATS (Video-assisted Thoracoscopic Surgery) durchgeführt wurde. DISKUSSION: Auf Grundlage dieser Erhebungen stellte sich uns die Frage, ob die alten Patienten der Gruppe III ( 75jährigen) in Deutschland in der Regel einer leitliniengerechten Therapie zugeführt wurden. Zwar gibt es eine Selektion der Patienten in Gruppe III in den Zentren des Deutschen Thoraxregisters, dennoch ist unser Appell, dass nach Abwägung der individuellen Risiken und nach objektiven Kriterien auch diese Patientengruppe deutschlandweit der onkologischen Therapie der Wahl (Goldstandard) zugeführt werden sollte. Hierunter verstehen wir unbedingt die anatomische Resektion mit einem minimal invasiven Zugang per VATS. Das Risiko einer postoperativen Komplikation auf Grund des Alters darf nicht die alleinige Entscheidungsgrundlage gegen eine Resektion sein.

Lung and chest ultrasound are further examination modalities in addition to computed tomography and laboratory diagnostics in patients with COVID-19. It extends the clinical-physical examination because it can examine lung surface sensitively. Lung surface pattern changes have been found in sonograms of patients with COVID-19 pneumonia and during the course of the disease. German specialist societies of clinical acute, emergency and intensive care medicine as well as imaging, which are concerned with the care of patients with SARS-CoV‑2 infection and COVID-19, have coordinated recommendations for lung and thorax sonography. This document has been created within a transparent process, led by the German Society of Interdisciplinary Emergency and Acute Medicine e. V. (DGINA), and worked out by an expert panel and delegates from the societies. Sources of the first 200 cases were summarized. Typical thorax sonographic findings are presented. International sources or standards that were available in PubMed until May 24, 2020 were included. Using case studies and multimedia content, the document is intended to not only support users but also demonstrate quality features and the potential of chest and lung sonography. The German Society for Ultrasound in Medicine (DEGUM) is carrying out a multicenter study (study coordination at the TU Munich).Die Lungen- und Thoraxsonographie ist neben der Computertomographie und der Labordiagnostik eine weitere Untersuchungsmodalität bei der COVID-19-Erkrankung. Sie eignet sich zur Erweiterung der klinisch-körperlichen Untersuchung, weil sie sensitiv die Lungenoberfläche untersuchen kann. Diese verändert sich in den Sonogrammen mit bislang häufig beschriebenen Mustern bei Patienten mit COVID-19-Pneumonie und im Krankheitsverlauf. Deutsche Fachgesellschaften der klinischen Akut‑, Notfall- und Intensivmedizin sowie der Bildgebung, die mit der Versorgung von Patienten mit SARS-CoV-2-Infektion und der COVID-19-Erkrankung befasst sind, haben unter der Führung der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin e. V. (DGINA) Empfehlungen zur Lungen- und Thoraxsonographie abgestimmt. Das Dokument wurde über einen transparenten Prozess durch eine Expertengruppe und Delegierte der Fachgesellschaften erstellt. Quellen der ersten internationalen 200 Fallanalysen wurden zusammengefasst. Bislang häufig beschriebene thoraxsonographische Muster werden vorgestellt. Anhand von Fallbeispielen und multimedialen Inhalten soll das Dokument die Anwender unterstützen und Qualitätsmerkmale und das Potenzial der Thorax- und Lungensonographie aufzeigen. Die Deutsche Gesellschaft für Ultraschall in der Medizin e. V. (DEGUM) führt dazu eine Multizenterstudie durch (Studienkoordination TU München).

The therapy of severely injured patients is demanding and promising only in an interdisciplinary context. From a thoracic surgical perspective, the blunt chest trauma is in the foreground; as it is the 2nd leading cause of death after traumatic brain injury. The first step is to identify the potentially life-threatening injury and its treatment (airway obstruction, prevention of gas exchange, tension pneumothorax, serious bleeding complications in lung-/vascular injuries). Pneumothorax or tension pneumothorax is present in 20% of all polytrauma patients and 50% of all patients with severe chest trauma. In most cases, the use of a chest tube is sufficient in the acute phase (90%). For complex injuries with persistent thoracic haemorrhage and haemodynamic instability of the patient or pleural fistulization with increasing skin emphysema, surgical treatment should be performed at an early interval. Nevertheless, emergency thoracotomy is rarely required at this early stage.Häufig sind thorakale Verletzungen Begleitverletzungen im Rahmen eines Polytraumas. Die Therapie polytraumatisierter Patienten ist anspruchsvoll und nur im interdisziplinären Kontext erfolgversprechend. Aus thoraxchirurgischer Sicht steht dabei das stumpfe Thoraxtrauma im Vordergrund.

Anatomical lung resection for curative treatment of a tumour disease is the most common selective procedure in oncological thoracic surgery. The goal of the working group of the German Thoracic Surgery Society (DGT) was to achieve a consensus on the perioperative management of selective oncological lung resection procedures.The assigned group of the DGT designed and conducted two electronic rounds of questions in all major thoracic and lung centres. Consensus was considered as a rate of ≥ 75%. After statistical analysis of the results, an expert meeting took place and a final Delphi process poll was used in order to reach consensus for controversial topics.Fourteen questions on the perioperative management of anatomical oncological lung resections were proposed and voted on. A consensus was reached for the following topics: preoperative infectiological screening, extended respiratory diagnostics for impaired lung function, use of a cardiac risk assessment score, postoperative monitoring, prophylaxis for venous thromboembolism, control bronchoscopy after sleeve resections or pneumonectomy, blood gas test before discharge from the hospital. No consensus was reached for the following topics: preoperative endobronchial microbiological diagnostics, pleural rinsing, standardised clinical chemistry blood test postoperatively.Our manuscript depicts the results of a Delphi process in 2018/2019 involving experts of the German Thoracic Surgery Society from high volume departments certified for thoracic surgery and/or lung cancer surgery. In general, a very high rate of consensus was documented for the majority of the topics concerning the perioperative management of oncological anatomical selective lung resection procedures. The most important topic for which no consensus could be reached was preoperative endobronchial microbiological diagnostic testing.Die anatomische Lungenresektion zur kurativen Behandlung einer malignen Grunderkrankung ist die am häufigsten durchgeführte elektive Operation in der onkologischen Thoraxchirurgie. Ziel dieses Projektes war die Erarbeitung eines Konsenses bez. der am häufigsten gestellten Fragen zum Thema perioperatives Management für elektive onkologische Lungenresektionen.Die Arbeitsgruppe erarbeitete 2 elektronische Delphi-Fragerunden. Als Konsens wurde eine Übereinstimmung in ≥ 75% definiert. Nach der statistischen Auswertung der Ergebnisse der elektronischen Fragerunde erfolgte eine Expertenkonferenz, die in einer finalen Delphi-Abstimmung versucht hat, weiteren Konsens über strittige Themen zu erreichen.14 Fragen bez. des perioperativen Managements für elektive onkologische Lungenresektionen konnten formuliert und abgestimmt werden. Konsens konnte für folgende Themen erreicht werden: präoperatives infektiologisches Screening, erweiterte lungenfunktionelle Diagnostik bei eingeschränkter Lungenfunktion, Verwendung eines validierten Cardiac-Risk-Assessment-Algorithmus, Überwachung des Patienten postoperativ, Thromboembolieprophylaxe, Kontrollbronchoskopie nach Bronchusmanschettenresektionen oder nach Pneumonektomie sowie Blutgasanalyse vor Entlassung. Für folgende Themen konnte kein Konsens erreicht werden: präoperative endobronchiale mikrobiologische Diagnostik, Spülung der Thoraxhöhle, standardisierte laborchemische Untersuchungen postoperativ.Die vorliegende Arbeit fasste die Ergebnisse eines Delphi-Prozesses zusammen, der 2018/2019 mit Experten aus zertifizierten Kliniken oder hochvolumigen thoraxchirurgischen Einheiten geführt wurde. Insgesamt zeigte sich eine sehr hohe Konsensrate bez. des perioperativen Managements bei onkologischen anatomischen selektiven Lungenresektionen. Die präoperative mikrobiologische endobronchiale Diagnostik war der Hauptpunkt, wo ein Konsens nicht erreicht werden konnte.

Zusammenfassung Einführung Nicht kleinzellige Lungenkarzinome (engl. non-small cell lung cancer = NSCLC) im Stadium III und ihre mögliche multimodale Therapie stellen eine Herausforderung für die behandelnden Onkologen, Thoraxchirurgen und Strahlentherapeuten dar. Ziel dieser retrospektiven Studie war die Analyse und Evaluation des Therapiealgorithmus unserer Klinik bei Patienten mit NSCLC im Stadium III (intention to treat). Es sollte ermittelt werden, ob sich ein aggressives Therapieregime mit primärer trimodaler Therapie (Hochdosisradiochemotherapie und Resektion) unabhängig von einem „multilevel“-N2- oder „single-level“-N3-Status: Diese Resultate wurden anschließend mit einem historischen Kollektiv unserer Patienten verglichen, die eine alleinige simultane Radio-/Chemotherapie erhielten (= bimodale Therapie). Material und Methoden 156 Patienten wurden in dem Erhebungszeitraum mit einem NSCLC Stadium III diagnostiziert und einer trimodalen Therapie zugeführt. Das mediane Alter war 71 Jahre, 103 Patienten (60%) waren männlich, 53 (34%) waren weiblich. In der Gruppe mit bimodaler Therapie konnten 102 Patienten ausgewertet werden. Ergebnisse Nach radiologischem Restaging und Überprüfung der funktionellen Resektabilität konnten 90 Patienten (57,7%) aus der trimodalen Therapiegruppe einer sekundären Resektion zugeführt werden. Hierbei wurden 37 (41,1%) Lobektomien/Bilobektomien, 37 (41,1%) Sleeve-Lobektomien, 13 (14,4%) Pneumonektomien und 3 (3,3%) Segmentektomien (bei schwerer lungenfunktioneller Einschränkung) durchgeführt. Das mediane Überleben in der trimodalen Therapiegruppe betrug 535 Tage, in der bimodalen Therapiegruppe hingegen 388 Tage, der Unterschied war statistisch nicht signifikant (p = 0,1377). Abschließend wurde eine Analyse der 5-Jahres-Überlebensrate nach tatsächlicher Therapie durchgeführt („as-treated trimodally“ vs. „as-treated bimodally“). Hier betrug das mediane Überleben 807 Tage für Patienten, die eine trimodale Therapie erhielten, 427 Tage für Patienten die eine bimodale Therapie erhielten. Schlussfolgerung Eine hochdosierte neoadjuvante Radiochemotherapie gefolgt von einer sekundären Resektion stellt weiterhin eine wertvolle Option für selektionierte Patienten in der Behandlung des NSCLC im Stadium III dar. Diese retrospektive Analyse konnte jedoch einen statistisch signifikanten Überlebensvorteil für die „intention-to-treat-trimodally“-Patienten nicht nachweisen.

ZusammenfassungDie Erhebung klinischer Behandlungsdaten in Registerdatenbanken hat seit Jahren einen hohen Stellenwert in der Versorgungsforschung. Hierdurch kann bspw. eine kritische Prüfung der Sicherheit, Wirksamkeit und Wirtschaftlichkeit klinischer Behandlungskonzepte an großen Untersuchungskollektiven erfolgen. Die erhobenen Erkenntnisse aus der Registerforschung entsprechen der tatsächlichen Patientenklientel und dem Versorgungsalltag der teilnehmenden Kliniken. Sie sind nicht durch strenge Einschlusskriterien oder realitätsferne Rahmenbedingungen klinischer prospektiver Studien beschränkt. Durch die Implementierung des Deutschen Thoraxregisters wurde erstmalig die Möglichkeit geschaffen, die interdisziplinäre Betreuung (Thoraxchirurgie, Anästhesiologie, Intensivmedizin, Schmerztherapie) von Patienten mit operativen Eingriffen am Thorax ganzheitlich in einer Datenbank zu erfassen und auszuwerten. Unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) wurde ein ursprünglich rein thoraxchirurgisches Register des Klinikums der Universität Witten/Herdecke-Köln in enger Kooperation mit dem Universitätsklinikum Freiburg erweitert. Nach Ausarbeitung eines umfangreichen Datenschutzkonzepts und Abschluss der Pilotphase wurde das Deutsche Thoraxregister als erstes perioperatives, interdisziplinäres Behandlungsregister im Januar 2016 offiziell implementiert. Neben der reinen Registerforschung, profitieren die teilnehmenden Kliniken vor allem durch die „benchmarking“-Funktionen. Das „benchmarking“, also der Vergleich der Behandlungsqualität verschiedener Kliniken, erlaubt es, individuelle Profile, Stärken und Schwächen im nationalen Vergleich zu identifizieren und eigene Fortschritte über mehrere Jahre zu verfolgen. Das Eingabe- und Benchmarkportal ist jederzeit online verfügbar (www.thoraxregister.de). Seit Oktober 2016 wurde das Teilnehmerspektrum erweitert, sodass sämtliche Kliniken mit mindestens 50 thoraxchirurgischen Eingriffen im Jahr teilnahmeberechtigt sind.

Traditionelle Organisationsstrukturen eigenen sich nur einschrankt, um in einem volatilen Umfeld den Erfolg eines Unternehmens langfristig zu sichern. Die strategische Steuerung ist hierbei besonders von den sich verandernden Umweltbedingungen betroffen. Wie schafft es ein Unternehmen in Zeiten von VUCA mit einer zukunftsgerichteten Organisationsstruktur, Unsicherheit und Komplexitat zu meistern und zielfuhrend fur den Erfolg einzusetzen ohne strategische oder auch normative Ziele aus den Augen zu verlieren?

The advantages of a bronchial sleeve resection are well established. A clear majority of reported cases are of upper lobe sleeve resection. Reimplantation of the upper lobe bronchus after a lower sleeve lobectomy or bilobectomy (the so-called Y-sleeve resection) is infrequent. Related technical peculiarities are the main issues. We present our experience and results in this setting.Between 1989 and 2015, we performed 28 Y-sleeve resections of the left lower lobe (n = 18) or right middle and lower lobes (n = 10). The lung-sparing reconstructive operation was performed for non-small-cell lung cancer in 23 cases, for bronchial carcinoid tumour in 4 cases and for a cystic adenoid carcinoma in 1 case. Anastomotic reconstruction was performed by interrupted 4-0 absorbable sutures (monofilament material).All the resections were complete (R0). Postoperative mortality was 3.6%. The rate of major complications was 10.7% (1 myocardial infarction, 1 anastomotic stenosis requiring dilatation and 1 anastomotic fistula). Among the 23 patients with non-small-cell lung cancer (18 men and 5 women; mean age 58 ± 12 years), 8 were Stage I, 9 were Stage II and 6 were Stage IIIa. At a mean follow-up of 46 months, the recurrence rate was 32%. There were 2 loco-regional recurrences. No endobronchial or perianastomotic recurrence occurred. The 3- and 5-year overall and disease-free survival rates of patients with non-small-cell lung cancer were 76.3% and 55.1% and 68.7% and 62.9%, respectively.A Y-sleeve resection with reimplantation of the upper load bronchus is a technically feasible and oncologically adequate operation.

Background: The aim of this study was to compare the perioperative outcome of patients receiving anatomic segmentectomy either by open surgery or video-assisted thoracoscopic surgery (VATS). To assess the short-term morbidity of the procedure itself, lung cancer patients in all stages as well as patients with pulmonary metastases and benign lesions scheduled for segmental resection were enrolled in this study. Methods: A retrospective analysis of prospectively collected data on 445 consecutive patients that underwent segmentectomy either by VATS (n=233) or thoracotomy (n=212) was performed. A propensity-matched analysis was conducted based on age, gender, smoking history, histology, tumor size, forced expiratory volume in 1 second (FEV1) and history of previous pulmonary resections. The matched sample included two groups of 140 patients each. Results: Both study groups were comparable with respect to age, gender, smoking history, diagnosis, tumor size, pulmonary function and history of previous pulmonary resections. VATS segmentectomy was associated with decreased length of stay (7.4 vs . 9.5 days, P vs . 5.9 days, P=0.012) and severe postoperative complications (1.4% vs . 7.1%, P=0.018). Conclusions: VATS segmentectomy is safe and effective for the treatment of benign and malignant pulmonary lesions. Compared with open thoracotomy, it is associated with shorter hospitalization time and decreased number of severe complications. The preservation of functional lung tissue, combined with a minimally invasive approach, make VATS segmentectomy highly suitable for patients with reduced pulmonary function or severe comorbidities.

Der Anteil der durchgefuhrten Manschettenresektion bei Patienten mit einem Lungenkarzinom liegt in Deutschland zwischen 3,1 % und 27,7 % aller anatomischen Resektionen. Die Anastomoseninsuffizienz nach Manschettenresektion ist eine schwerwiegende Komplikation. Eine aufgrund dieser erfolgende sekundare Pneumonektomie weist eine hohe Morbiditat und Mortalitat (30 % bis 80 %) auf und sollte daher dringend vermieden werden. Es ist in diesem Zusammenhang von Bedeutung, fur die Manschettenresektion einen einheitlichen Standard in Bezug auf die Technik und das postoperative Vorgehen zu etablieren. Der Zeitpunkt und die Interpretation der postoperativen Kontrolle der bronchialen Anastomose sind bislang nicht definiert. In dieser Arbeit werden die Grundlagen der bronchialen Wundheilung und die Interpretation der Anastomose mit der 5-Punkte-Klassifikation beschrieben. Ziel ist es ein standardisiertes Vorgehen nach einer Manschettenresektion mit einem Interpretations- und Behandlungsalgorithmus vorzustellen. Wie diese Unterteilung erfolgt und welche Masnahmen daraus abgeleitet wurden, wird hier beschrieben und anhand von klinischen Beispielen erlautert.

Hintergrund: Die haufigste Langzeitkomplikation nach einer Tracheotomie ist die benigne Trachealstenose, welche mit einer Inzidenz von bis zu 20 % beschrieben ist. Typischerweise tritt die Stenose nach Dekanulierung im Rahmen der sekundaren Wundheilung auf. In dieser Studie wurde uberpruft, ob der chirurgische Verschluss des Tracheostomas die Stenoserate reduziert. Methode: Anhand der klinischen Datenbank unserer Abteilung wurde eine retrospektive Analyse von 401 chirurgischen Tracheostomata durchgefuhrt. Erfasst wurden die Indikation zur Tracheotomie, der klinische Verlauf nach Stomaanlage sowie auftretende Komplikationen. Ergebnisse: 155 Patienten konnten erfolgreich dekanuliert werden. Bei 92 der dekanulierten Patienten wurde das Tracheostoma chirurgisch verschlossen, bei 63 erfolgte der Verschluss spontan durch Wundheilung. Nach Dekanulierung kam es bei 3 % (n = 3) der chirurgisch verschlossenen und bei 22 % (n = 14) der spontan durch sekundare Wundheilung verschlossenen Tracheostomata zu symptomatischen Trachealstenosen (p Schlussfolgerung: Bei einem Verschluss des Tracheostomas durch sekundare Wundheilung wurden haufig symptomatische Trachealstenosen beobachtet. Dagegen konnte in der Patientengruppe, welche einen chirurgischen Verschluss des Tracheostomas erhielt, das Auftreten symptomatischer Trachealstenosen signifikant reduziert werden.

Bronchial sleeve resection is the treatment of choice for centrally located lung cancer, even in patients with normal lung function. The objective is to preserve lung tissue and avoid both pneumonectomy and its complications related, in terms of long-term survival and quality of life. As our experience in minimally invasive surgery increases, we have modified technological aspects to adapt to the new situation. This article focuses on these new technical aspects and literature data on bronchial sleeve resection.Die Bronchusmanschettenresektion ist auch bei Patienten mit normaler Lungenfunktion ein Standardverfahren zur Resektion von Lungentumoren in zentraler Lage. Ziel dieser Methode ist es, parenchymerhaltend zu operieren und dadurch die Pneumonektomie und deren Komplikationen in Bezug auf Langzeitüberleben und Lebensqualität zu vermeiden. Mit dem Fortschreiten der minimalinvasiven Thoraxchirurgie befindet sich auch diese Operationstechnik im Wandel. Diese Arbeit setzt den Fokus auf die neuen Aspekte der Bronchusmanschettenresektion, bezugnehmend auf die Literatur.

The collection of clinical treatment data in registry databases is an important aspect of health services research. It allows for a critical evaluation of the safety, efficacy and cost-effectiveness of clinical treatment concepts in large patient populations. The findings of registry research represent real-world patients and treatment structures as they are not limited by strict inclusion criteria or unrealistic conditions as applied in prospective clinical trials. The implementation of the German Thorax Registry has enabled the collection and analysis of data on the interdisciplinary care (thoracic surgery, anaesthesiology, intensive care, pain management) of patients undergoing thoracic surgery. Under the auspices of the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Thoracic Surgery, a registry of the Hospital of the University Witten/Herdecke-Cologne, purely surgical at first, was expanded in close cooperation with the University Hospital of Freiburg. After a comprehensive data protection concept was drafted and a test phase completed, the German Thorax Registry was officially launched in January 2016. Most notably, participating hospitals profit from the registry's "benchmarking" services. "Benchmarking", i.e. the comparison of treatment quality between different hospitals, enables participants to identify individual profiles, strengths and weaknesses on a nation-wide level and follow their own progress over the course of several years. An online database for data entry and benchmarking is always accessible (www.thoraxregister.de). In October 2016, the spectrum of participants was expanded to include all hospitals performing at least 50 thoracic operations a year.Die Erhebung klinischer Behandlungsdaten in Registerdatenbanken hat seit Jahren einen hohen Stellenwert in der Versorgungsforschung. Hierdurch kann bspw. eine kritische Prüfung der Sicherheit, Wirksamkeit und Wirtschaftlichkeit klinischer Behandlungskonzepte an großen Untersuchungskollektiven erfolgen. Die erhobenen Erkenntnisse aus der Registerforschung entsprechen der tatsächlichen Patientenklientel und dem Versorgungsalltag der teilnehmenden Kliniken. Sie sind nicht durch strenge Einschlusskriterien oder realitätsferne Rahmenbedingungen klinischer prospektiver Studien beschränkt. Durch die Implementierung des Deutschen Thoraxregisters wurde erstmalig die Möglichkeit geschaffen, die interdisziplinäre Betreuung (Thoraxchirurgie, Anästhesiologie, Intensivmedizin, Schmerztherapie) von Patienten mit operativen Eingriffen am Thorax ganzheitlich in einer Datenbank zu erfassen und auszuwerten. Unter der Schirmherrschaft der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Gesellschaft für Thoraxchirurgie (DGT) wurde ein ursprünglich rein thoraxchirurgisches Register des Klinikums der Universität Witten/Herdecke-Köln in enger Kooperation mit dem Universitätsklinikum Freiburg erweitert. Nach Ausarbeitung eines umfangreichen Datenschutzkonzepts und Abschluss der Pilotphase wurde das Deutsche Thoraxregister als erstes perioperatives, interdisziplinäres Behandlungsregister im Januar 2016 offiziell implementiert. Neben der reinen Registerforschung, profitieren die teilnehmenden Kliniken vor allem durch die „benchmarking“-Funktionen. Das „benchmarking“, also der Vergleich der Behandlungsqualität verschiedener Kliniken, erlaubt es, individuelle Profile, Stärken und Schwächen im nationalen Vergleich zu identifizieren und eigene Fortschritte über mehrere Jahre zu verfolgen. Das Eingabe- und Benchmarkportal ist jederzeit online verfügbar (www.thoraxregister.de). Seit Oktober 2016 wurde das Teilnehmerspektrum erweitert, sodass sämtliche Kliniken mit mindestens 50 thoraxchirurgischen Eingriffen im Jahr teilnahmeberechtigt sind.

Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

Das nicht-kleinzellige Lungenkarzinom ist eine der haufigsten Krebserkrankungen weltweit und damit auch eine der haufigsten krebsbedingten Todesursachen. Bei Erstdiagnose haben bereits rund 40 % aller Patienten Fernmetastasen (Tumorstadium UICC IV) und werden mit einer palliativen systemischen Chemotherapie und/oder Tyrosinkinase-Inhibition behandelt. Eine kleine Gruppe dieser Patienten weist jedoch nur eine einzige Fernmetastase auf. Diese kann synchron oder erst metachron auftreten und intrathorakal oder extrathorakal liegen. Im Gegensatz zu multiplen Metastasen, die Ausdruck einer diffusen systemischen Erkrankung sind und dementsprechend einer systemischen Therapie bedurfen, kann man das Auftreten singularer Metastasen als noch begrenzte Erkrankung auffassen. Durch lokale Exzision der Metastasen und des Primartumors haben die Patienten eine Chance auf Heilung. Eine Resektion des Primartumors und der singularen Metastase kann die Uberlebenswahrscheinlichkeit in vielen Fallen deutlich verbessern.

Introduction The aim of this study was to determine whether preoperative elevated serum C-reactive protein (CRP) is an independent risk factor of postoperative morbidity and mortality after pulmonary resection for lung cancer. Material and methods A retrospective analysis of prospectively collected data on 1414 consecutive patients that underwent an anatomic resection for lung cancer was performed. Patients’ characteristics, operative procedures and the postoperative outcome were assessed with a standardised data entry form. Univariate and multivariate analyses were conducted to identify factors that affect morbidity and mortality. Results Postoperative complications occurred in 35.5% of the patients. The mortality rate was 3.2%. Patients with preoperative C-reactive protein above 40 mg/l showed more overall complications and a higher mortality than patients below this limit. Patients with a CRP level between 3 mg/l and 40 mg/l had no significant increase in morbidity and mortality compared to patients with values ​​below the detection limit ( Conclusions Preoperative serum C-reactive protein level is an independent and significant indicator for elevated morbidity and mortality after pulmonary resection. We propose the evaluation of CRP levels as a preoperative diagnostic modality of risk assessment in addition to standardised functional testing.

Introduction: Phospatidylinositol-3-kinases (PI3K) play an important role in various cell processes. Oncogenic mutations in the PIK3CA gene, which codes for the catalytic subunit, have been identified in various malignancies and activate the PI3K/AKT/mTOR pathway, which is a critical driver of tumorigenesis. Methods: We tested 41 tumor samples with known KRAS, BRAF, and EGFR mutation status for the occurrence of mutations in the PIK3CA gene, using a pyrosequencing assay. Results: Pyrosequencing revealed 2 mutations (4.9%) in the PIK3CA gene, one in exon 9 and the other in exon 20. Both mutations have not been identified yet in lung tumor tissue. Discussion: The screening of our small patient cohort by pyrosequencing identified 2 mutations (4.9%) in PIK3CA, one in exon 9 (Q546H) and the other in exon 20 (M1043T). Both mutations have not been described in lung tumors yet and seem to be rather uncommon mutations. Future screening of large patient cohorts with pyrosequencing may contribute to the detection of more mutations in lung cancer because of the low limit of detections of this method and may contribute to a better understanding of the interaction of mutations and tumorigenesis.

Background: Thoracotomy leads to chronic neuropathic pain in up to 50% of patients and is responsible for an impaired quality of life. Intercostal nerve injury has been suggested to be responsible for this pain. In the present study the impact of paravertebral intercostal neurectomy on post thoracotomy pain was assessed. Methods: In this single center parallel-group randomized controlled trial patients underwent muscle sparing anterolateral thoracotomy and anatomical lung resection for lung cancer. A subcostal approach was used for thoracotomy with single paravertebral neurectomy being performed at the beginning of the procedure at the level of the retracted intercostal space. For documentation of neuropathic pain the Leeds Assessment Score for Neuropathic Symptoms and Signs (LANSS) was used postoperatively. The primary endpoint was defined as LANSS ≥12 points on day 120. In addition, the numeric pain rating scale (NRS) was used to score pain intensity. Results: Out of 172 patients initially randomized 161 patients were investigated following intraoperative and postoperative drop-out criteria. All patients required anatomical lung resection via thoracotomy. Five patients were lost for follow up. For the remaining 156 patients there was no difference between the two groups with regard to LANSS ≥12: 26.6 % in patients with neurectomy and 28.8% in control-subjects (P=0.78). In addition, the NSR score at day 120 did not differ significantly at rest and during activity between the two groups (at rest: 21.7% vs . 15.8% P=0.439; activity: 24.5% vs . 21.9% P=0.735). Conclusions: Neurectomy was not shown to reduce the post thoracotomy pain syndrome in patients with anatomical lung resection following anterolateral muscle sparing thoracotomy.

Objective Ischemia and infection of the distal part of the tracheobronchial anastomosis are the leading causes of bronchial anastomotic leakage with a high morbidity and mortality. To improve interpretation of healing of the anastomosis and the consequences, we have developed a classification scheme that allows quality control and defines early and standardized treatment of complications. Patients and Method We conducted a retrospective analysis of the records of 202 patients treated in our institution between January 1, 2006 and December 31, 2010 after sleeve lobectomy. All patients received prophylactic inhalation with tobramycin 80 mg twice a day. Neoadjuvant treatment was given in 21% of the patients. Routine bronchoscopy on day 7 was performed with classification of the anastomosis as follows: X, unknown; 1, healing well with no fibrin deposits; 2, focal fibrin deposits and superficial (mucosal) necrosis; 3, circular fibrin deposits, superficial (mucosal) necrosis, and/or ischemia of the distal mucosa; 4, transmural necrosis with instability of the anastomosis; and 5, perforation, necrosis of the anastomosis, and insufficiency. Results The anastomosis was graded as satisfactory (1 and 2) in 86% of the patients. In 14%, it was regarded as critical (≥3-5) leading to systemic antibiotic treatment and control bronchoscopy. The overall 30-day mortality was 1%. Conclusions Quality control of the tracheobronchial anastomosis comprised bronchoscopy performed before patients were dismissed. Inasmuch As postoperative bronchoscopy is not always performed by the operating surgeon, this classification is an aid to improve the description of endobronchial healing and to commence treatment of critical bronchial healing.

Small-cell lung cancer (SCLC) is an aggressive lung tumor subtype with poor prognosis(1-3). We sequenced 29 SCLC exomes, 2 genomes and 15 transcriptomes and found an extremely high mutation rate of 7.4 +/- 1 protein-changing mutations per million base pairs. Therefore, we conducted integrated analyses of the various data sets to identify pathogenetically relevant mutated genes. In all cases, we found evidence for inactivation of TP53 and RB1 and identified recurrent mutations in the CREBBP, EP300 and MLL genes that encode histone modifiers. Furthermore, we observed mutations in PTEN, SLIT2 and EPHA7, as well as focal amplifications of the FGFR1 tyrosine kinase gene. Finally, we detected many of the alterations found in humans in SCLC tumors from Tp53 and Rb1 double knockout mice(4). Our study implicates histone modification as a major feature of SCLC, reveals potentially therapeutically tractable genomic alterations and provides a generalizable framework for the identification of biologically relevant genes in the context of high mutational background.

Die Therapie des Lungenkarzinoms wird stadienabhangig durchgefuhrt. Zum primaren Staging dienen u.a. das Computertomogramm (CT) des Thorax mit Oberbauch, die Bronchoskopie, das Positronenemissionstomogramm (PET)-CT oder Ganzkorper-Magnetresonanztomogramm (MRT), das MRT des Schadels oder Knochenszintigramm und die Sonographie des Abdomens. Bei Patienten mit Lungenrundherden (cT1–2 N0 M0) entsprechend einem operablen Befund ohne mediastinale Lymphknotenveranderungen und ohne systemische Zeichen der Tumorerkrankung genugt ein eingeschranktes Staging (CT des Thorax mit Oberbauch, Bronchoskopie). Nichtkleinzellige Lungenkarzinome im Stadium I–IIB werden primar reseziert. Parenchymsparenden Eingriffe bei den in der Regel funktionell eingeschrankten Patienten ist in Hinsicht auf postoperative Morbiditat und Langzeituberleben der Vorzug zu geben. Die Indikation zur adjuvanten Chemotherapie in fruhen Tumorstadien ist fur die Stadien II und IIIA gesichert. Die 5-Jahres-Uberlebensraten erreichen je nach Stadium 40–80%. Sollte im primaren Staging der Verdacht auf mediastinale Lymphknotenmetastasen bestehen (Lymphknotenquerdurchmesser > 1 cm oder positiver PET-Befund), ist eine histologische Sicherung notwendig. Bei histologischem Nachweis mediastinaler Lymphknotenmetastasen konnen eine neoadjuvante Chemotherapie, Operation und Radiotherapie bzw. eine Radiochemotherapie mit Operation durchgefuhrt werden. Mit diesem trimodalen Ansatz wird ein 5-Jahres-Uberleben von etwa 20–40% erreicht. Im Fall von ausgedehnten mediastinalen Lymphknotenmetastasen besteht in der Regel keine primare Resektabilitat. Die primare kombinierte Radiochemotherapie wird empfohlen. Die sekundare Resektion kann in erfahrenen Zentren gepruft werden. Bei einer definierten Infiltration des Mediastinums (T4) oder der oberen Thoraxapertur (Pancoast-Tumoren) bzw. bei solitaren Fernmetastasen (Hirn, Nebenniere) jeweils ohne mediastinale Lymphknotenmetastasen kann durch angepasste Konzepte aus Radiatio, Chemotherapie und Operation behandelt werden (5-Jahres-Uberlebensrate 10–40%). Im Idealfall werden die diagnostische und die therapeutische Strategie bei Patienten mit Lungenkarzinomen durch eine interdisziplinare Besprechung festgelegt.

BACKGROUND: In this study the histological examination of pulmonary nodules and a comparison of the number of pre-, intra- and post-operative lung metastases in patients with a previous history of malignant disease were assessed. PATIENTS AND METHODS: Between 1998 and 2003 we operated on 276 patients with suspected lung metastases. The histology of the primary tumour, the number of preoperatively diagnosed nodules, the number of lesions removed during surgery and the number of histologically confirmed metastases of 276 patients are presented. RESULTS: In 276 patients a resection was performed. 161 of the patients were men (58.1 %). The median age was 62 years (range: 21 - 86 years). In 110 cases a left-sided thoracotomy was performed (39.8 %), in another 110 cases a right-sided thoracotomy was performed and in 56 cases we perfomed a bilateral thoracotomy (20.4 %). In 15.2 % the histology of the resected nodules was benign. In 8.6 % of the cases the histological examination showed a primary lung cancer in stage I, in 74.4 % of the cases the histology confirmed a metastasis of the primary cancer. CONCLUSIONS: Solitary pulmonary nodules in patients with a previous history of malignant disease should always be resected for histological examination. Multiple pulmonary nodules should be histologically reappraised if there is any doubt about the entity.

Objective: Sleeve resections were introduced to preserve lung function in patients with limited pulmonary reserve. Ischaemia and infection of the distal part of the anastomosis is the leading cause of bronchial anastomotic leakage. We have learned from our experience in lung transplantation that inhalation with Tobramycin W helps prevent anastomotic insufficiency. We would like to present our experience in patients with tracheobronchial sleeve and prophylactic Tobramycin W inhalation. Patients and methods: Retrospective analysis of 114 patient records, between 01.01.2005 and 31.12.2006, where a bronchial anastomosis (patients with tracheal resection were excluded) was performed. All patients received Tobramycin W inhalation (2 80 mg) for 7 days. Data analysed were; length of chest tube drainage in days, complications, morbidity and hospital mortality. Results: In 694 patients, an anatomic resection was performed. Of these, 114 (16%) were sleeve resections and 63 (9%) pneumonectomies. In 21 women and 93 men, between 25 and 84 years old, sleeve lobectomy was performed 104 times and carinal resection 10 times. A preoperative neoadjuvant therapy had been given in 26%. Radical (R0) resection was possible in 94%. The duration of the operation was between 83 and 225 min (median: 127 min). Chest tubes were removed on average after 6 days. Patients were discharged after 11 days. The rate of bronchial anastomotic leakage was 4.4%. There were two patients with postoperative respiratory insufficiency and mechanical ventilation, two patients with technical failure required early correction of the suture and one patient with a necrosis of the anastomosis. Thirtydayhospitalmortalitywas2.6%(3/114).Conclusions:Increasingexperiencewithsleeveresectionhasreducedtherateofpneumonectomybelow 10%, although a number of the patients had received neoadjuvant therapy and the carinal resection rate of necrosis and infection of the anastomosis was low. We therefore recommend use of local antibiotic inhalation after sleeve resection. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

When a lung tumor arises in segment 6, the close anatomical relationship to the middle lobe bronchus may make a lower bilobectomy necessary. Sleeve lobectomy may be an alternative. These procedures were compared retrospectively in 36 patients operated on between January 2005 and December 2006 with non-small-cell lung cancer (stage I-IIIB) of the right lower lobe. Sleeve lobectomy was performed in 21 patients and bilobectomy in 15 (41%). Preoperative lung function was comparable in both groups. Radical resection was achieved in 34/36 patients. Operation time was 121 min for sleeve lobectomy and 144 min for bilobectomy. Chest tubes were removed after 5 days in both groups. Postoperative lung function was better after sleeve lobectomy than bilobectomy (forced expiratory volume in 1st sec: 78% vs. 69%). Preservation of the middle lobe by sleeve lobectomy is feasible. There was no evidence that this resection was less radical, and complication rates were similar in both groups.

Objective. In diffuse parenchymal lung diseases, the evolution of pulmonary fibrosis is often devastating and may result in death. In this study the role of CCL18 as a biomarker of disease activity in idiopathic interstitial pneumonias (IIPs) and systemic sclerosis (SSc) with lung involvement was evaluated. Methods. CCL18 was assessed in supernatants of cultured bronchoalveolar lavage (BAL) cells as well as BAL fluid and serum samples from 43 patients with IIPs, 12 patients with SSc, and 23 healthy control subjects. Concentrations of CCL18 were measured by enzyme-linked immunosorbent assay, and expression of CCL18 was assessed by flow cytometry. Results. CCL18 concentrations were statistically significantly increased in all patients with fibrotic lung diseases. Spontaneous CCL18 production by BAL cells was negatively correlated with total lung capacity and the diffusion capacity for carbon monoxide, whereas there was a positive correlation of CCL18 concentrations with BAL neutrophil and eosinophil cell counts. Flow cytometry revealed an increase in the percentage of CCL18-positive alveolar macrophages and an increase in the CCL18 fluorescence intensity per cell in patients with fibrotic lung diseases. In a cohort of patients who were followed up for at least 6 months (n 40), a close negative correlation was observed between changes in the predicted total lung capacity and changes in CCL18 serum concentrations. Conclusion. These findings suggest that CCL18 production by BAL cells and serum CCL18 concentrations reflect pulmonary fibrotic activity in patients with IIPs and those with SSc. Monitoring changes in CCL18 production might be an extraordinarily useful tool in clinical practice and in studies aimed at evaluating new approaches for treatment of fibrotic lung diseases.

Introduction Spontaneous regression of cancer is defined as a complete or partial, temporary or permanent disappearance of tumor in the absence of specific therapy. With only a few cases reported, spontaneous regression is extremely rare in primary lung cancer. Regarding spontaneous regression in lung cancer, recent investigations revealed the role of immunological mechanisms, thus indicating potential treatment options by specific immunotherapy in the future. Case presentation A 76-year-old Caucasian man with progressive dyspnea presented to our hospital. A computed tomography scan revealed a tumor mass in the upper lobe of his right lung and enlarged mediastinal lymph nodes. A biopsy of a paratracheal lymph node by mediastinoscopy disclosed metastatic lung cancer. By immunohistochemical findings the tumor was classified as large cell carcinoma. Diagnosed with clinical stage IIIA non-small cell lung cancer, a neoadjuvant therapy concept was indicated. However, before starting chemoradiation, a computed tomography scan showed a regression of both the tumor mass in the upper lobe of his right lung and the mediastinal lymphadenopathy. As a repeated computed tomography scan showed further regression, we agreed with our patient to perform routine follow-up instead of starting therapy. To date, no relapse has been reported. Conclusions Given the circumstances that regression started after the biopsy and involved both the tumor in the upper lobe of his right lung and the mediastinal lymph node metastases, an immune response is a reasonable explanation for the observed spontaneous regression in this case.

We characterized genome alterations in 1255 clinically annotated lung tumors of all histological subgroups to identify genetically defined and clinically relevant subtypes. More than 55% of all cases had at least one oncogenic genome alteration potentially amenable to specific therapeutic intervention, including several personalized treatment approaches that are already in clinical evaluation. Marked differences in the pattern of genomic alterations existed between and within histological subtypes, thus challenging the original histomorphological diagnosis. Immunohistochemical studies confirmed many of these reassigned subtypes. The reassignment eliminated almost all cases of large cell carcinomas, some of which had therapeutically relevant alterations. Prospective testing of our genomics-based diagnostic algorithm in 5145 lung cancer patients enabled a genome-based diagnosis in 3863 (75%) patients, confirmed the feasibility of rational reassignments of large cell lung cancer, and led to improvement in overall survival in patients with EGFR-mutant or ALK-rearranged cancers. Thus, our findings provide support for broad implementation of genome-based diagnosis of lung cancer.

EGFR mutations were previously found in patients suffering from peritoneal mesothelioma but have not yet been described in pleural mesothelioma. The aim of the present study was the identification of EGFR mutations in patients suffering from pleural mesothelioma. Pleural mesothelioma tissue from 31 patients was used to analyze possible mutations in the EGFR gene comprising the exons 18-21 with the codons 719, 768, 790, 858 + 861, 731 + 734, 785, 797 + 801, 831, and 868 with pyro-sequencing. The results indicate that 31 pleural mesothelioma patients show a wild-type EGFR gene when analyzing the codons D19, 768, 790, 858 + 861, 731 + 734, 785, 797 + 801, 831, and 868, whereas 2 patients have a mutation in the EGFR gene in codon 719. Sanger sequencing of the EGFR codon 785 was used for the determination of a polymorphism in the sequencing of tumor-free patients and pleural mesothelioma patients with a distribution of a wild-type homozygous sequence with guanine, a wild-type heterozygous sequence having guanine and adenine, a wild-type homozygous sequence with adenine, and a wild-type heterozygous sequence with adenine and guanine. Next, the identification of less EGFR mutations in the EGFR gene of the pleural mesothelioma an up to this time unknown polymorphism in the EGFR gene was identified which could be wrongly interpreted as a mutation.