[Thoracic lymphatic system-principles, characteristics and advice for the practice]. / Das thorakale Lymphsystem ­ Grundlagen, Besonderheiten und Hinweise für die Praxis.

The lymphatic system of the lungs is complex. To maintain an effective gas exchange there is a need for a dense lymphatic network. The alveolae have no lymphatic vessels. There is no segment-specific lymph drainage. For both lungs there are fixed bronchopulmonary lymph nodes but the number and size of the lymph nodes are variable. There are seven mediastinal lymph node chains that vary in extent, each of which acts as an independent functional unit. The accurate assessment of the nodal status needs a simple reproducible nodal map. The division into compartments or zones makes this easier. Mediastinal lymph node metastases without involvement of bronchopulmonary lymph nodes are possible. The development mechanism of this skip metastasizing is multifactorial.

[The technique of thoracic lymph node dissection]. / Technik der thorakalen Lymphknotendissektion.

Systematic mediastinal, hilar and interlobar lymph node dissection is required in the S3 guidelines for the treatment of operable lung cancer. The lymph node involvement is considered one of the key prognostic factors. The type of lymph node resection is repeatedly the subject of controversially discussion. Lymph node dissection is essential for staging, prognosis, survival and recurrence rate. It should be standardized as a compartmental dissection with en bloc resection of lymph nodes including surrounding fat and connective tissue. Thus, exact knowledge of the anatomy of the thoracic organs with their peculiarities and high anatomical variability is necessary.

[Rationale of thoracic lymph node dissection in pulmonary metastasectomy]. / Die Rationale der thorakalen Lymphknotendissektion in der pulmonalen Metastasenchirurgie.

The goal of metastasectomy is a R0 resection. Depending of the tumor entity the prevalence of lymph node metastases in pulmonary metastasectomy can be up to 45%; however, systematic lymph node dissection is not yet established as a fixed component of metastasectomy. Although there is a high prevalence of lymph node metastases and the increase in the prevalence with a higher number of lung metastases, it remains unclear if a systematic lymph node dissection should be part of pulmonary metastasectomy. For this reason, the goal of this review was to evaluate the rationale of systematic lymph node dissection in pulmonary metastasectomy based on the currently available literature. Furthermore, it was investigated whether patients with additional thoracic lymph node metastases should be excluded per se from pulmonary metastasectomy, even though positive lymph node metastases might be associated with a lower but nevertheless good long-term survival after resection.

[Treatment of chylothorax]. / Therapie des Chylothorax.

Chylothorax is an infrequent but important form of pleural effusion. The most common causes are of postoperative and neoplastic origin. No prospective or randomized trials have been performed to evaluate the available treatment options for chylothorax. The basic principles of conservative treatment include drainage of the effusion and dietary measures. Chylothorax is typically treated conservatively. In the case of failure of conservative treatment, interventional radiological or surgical procedures are applied. Untreated chylothorax has a high morbidity and mortality.

[Thoracic inflammatory pseudotumors : A rare differential diagnosis]. / Thorakale inflammatorische Pseudotumoren : Eine seltene Differenzialdiagnose.

BACKGROUND: Inflammatory pseudotumors are a rare and in the main benign tumor entity but infiltrative growth, recurrence and metastases are described. Generally, a complete resection is needed to exclude lung cancer. This study analyzed our data and experiences with this rare tumor entity. MATERIAL AND METHODS: We performed a retrospective study of all our patients who had been operated on between 2002 and 2016 in our institution for an inflammatory pseudotumor of the lungs. The extent of resection, morbidity, mortality and long-term results were analyzed. RESULTS: Altogether, in this period 13 patients were operatively treated (5 women and 8 men). The median age was 52 years (range 34-74 years). A reoperation was carried out in one patient for recurrence after enucleation of the tumor in another hospital. In no case could lung cancer be excluded prior to complete resection. In total, 11 pulmonary, 1 tracheal and 1 chest wall pseudotumor could be resected by thoracotomy (9×) and thoracoscopy (3×) and 1 by ventral chest wall resection. In eight patients the resections were performed by standard resection (wedge resection or anatomic resection) and five times by extended resection. In all cases a R0 resection was achieved. Due to one case of postoperative pneumonia the morbidity and mortality rates were 7.7% and 0%, respectively. CONCLUSION: The differential diagnosis between inflammatory pseudotumors and lung cancer cannot be definitely made preoperatively. For an exact diagnosis by the pathologist a complete histological preparation is needed. Due to infiltrative growth and recurrence, extended resection can be necessary for a R0 resection. This can be achieved with low morbidity and mortality. Important is an en bloc R0 resection, which is associated with good long-term results.

[Surgical therapy of malignant pleural mesothelioma]. / Chirurgische Therapie des malignen Pleuramesothelioms.

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor disease, which rapidly leads to death if untreated. In Germany the incidence of newly occurring disease is expected to reach a peak in the coming 5 years. An R0 resection for MPM is technically impossible; therefore, the aim of surgical procedures is to achieve the maximum amount of cytoreduction. There are two established surgical techniques for treatment of MPM, extrapleural pneumonectomy and tumor pleurectomy with decortication. The type and extent of surgery are currently controversially discussed. Within multimodal therapy concepts including cytoreductive surgery, long-term remission is possible in selected patients. When choosing the appropriate surgical therapy the high incidence of recurrence has to be borne in mind.

[Liver and lung metastases of colorectal cancer. Long-term survival and prognostic factors]. / Leber- und Lungenmetastasen des kolorektalen Karzinoms. Langzeitüberleben und Prognosefaktoren.

INTRODUCTION: The resection of liver and lung metastases from colorectal cancer has not yet been completely investigated. The aim of this study was to investigate the overall survival and prognostic factors for patients with liver and lung metastases from colorectal cancer. METHODS: A retrospective review of a prospective database of 52 patients with liver and lung metastases from colorectal cancer, undergoing metastasectomy with curative intent from 1999-2009 at a single institution was carried out. RESULTS: The mean overall survival (OS) was 64 months. For synchronous liver and lung metastases the mean overall survival was 63 months (5-year survival 54 %) and for metachronous liver and lung metastases 74 months (5-year survival 58 %, p = 0.451). A poor prognostic outcome was observed in cases of localization of the primary tumor in the rectum (OS 81 vs. 38 months, p = 0.004), with multiple lung metastases (≥ 2 metastases, OS 74 vs. 59 months, p = 0.032) and with disease progression after premetastasectomy chemotherapy (OS 74 vs. 63 vs. 15 months, p < 0.001). No influence on overall survival was detected for bilateral lung metastases, thoracic lymph node metastases, disease recurrence and disease-free interval < 36 months. CONCLUSION: Metastasectomy for liver and lung metastases of colorectal cancer is associated with a good overall survival in selected cases. Patients with liver and lung metastases should not be routinely excluded from metastasectomy and patients with thoracic lymph node metastases should also not be routinely excluded. Negative prognostic factors for survival are localization of the tumor in the rectum, multiple metastases and disease progression after premetastasectomy chemotherapy. Patients with disease progression after premetastasectomy chemotherapy should be excluded from metastasectomy.

[Multimodal Treatment of Non-Small Cell Lung Cancer with Cerebral Metastases]. / Multimodale Therapie des zerebral metastasierten nicht kleinzelligen Lungenkarzinoms.

BACKGROUND: The role of surgical treatment of lung cancer with brain metastases remains controversial. The aim of this study was to determine the long-term outcome and to identify potential prognostic factors in patients with cerebral metastatic non-small cell lung cancer (NSCLC). METHODS: The data of patients who underwent a resection of oligometastatic NSCLC with brain metastases from January 1999 to December 2012 were investigated retrospectively at a single institution. Multimodal treatment included resection or radiation surgery of the brain metastases at first, followed by systemic chemotherapy and the surgical treatment of the lung cancer finally. Survival, potential prognostic factors, response to chemotherapy as well as morbidity and mortality were investigated. RESULTS: A total of 105 patients with primary NSCLC and brain metastases was identified. Out of these, 26 patients (18 males, 8 females) were included in the study. Morbidity and mortality rates were 15 and 0 %, respectively. Lobectomies were performed in 15 patients, pneumonectomy in 5 and sleeve lobectomy in 6 patients, respectively. The brain metastases were treated individually by resection (n = 12), stereotactic radiotherapy (n = 11) or whole brain radiotherapy in several combinations. Histological response to chemotherapy was proven in 9.1 %. The 2-year survival rate was 50 % (median survival [MS], 26 months). There were no significant differences of the survival depending on the patients' age, gender, presence of lymph node metastases, number of the brain metastases, type of chemotherapy or response to chemotherapy. Adenocarcinoma as histology of the primary tumour showed a significantly better survival compared to squamous cell carcinoma (MS: 26 vs. 8 months; p = 0.034). Treatment of the brain metastases without any additional whole brain radiation was associated with inferior survival compared to patients with whole brain radiation (mean survival: 17 vs. 73 months; p = 0.005). CONCLUSION: Long-term survival is achievable in highly selected patients with NSCLC and cerebral metastasis by multimodal treatment including resection of the primary lung cancer. Patients with squamous cell carcinoma should be selected carefully for multimodal treatment. Treatment of the brain metastases without whole brain radiation should be avoided.

[Intraoperative bleeding during thoracic surgery : avoidance strategies and surgical treatment concepts]. / Intraoperative Blutungen in der Thoraxchirurgie : Vermeidungsstrategien und chirurgische Therapiekonzepte.

BACKGROUND: As a direct result of the thoracic anatomy, heavy bleeding is possible during nearly all central resections in thoracic surgery. OBJECTIVE: Description of the incidence of intraoperative bleeding including avoidance strategies and treatment concepts. Presentation of special anatomical features of pulmonary arteries. MATERIAL AND METHODS: A literature search was performed in Pubmed, medline and by manual searching. Publications from the last 60 years were analyzed and the results are summarized in a structured review. RESULTS: Little data is available on the incidence of intraoperative bleeding during thoracic surgery. Most data were collected retrospectively. For mediastinoscopy the incidence of severe bleeding is 0.2 %, for minimally invasive anatomical resections the incidence of intraoperative bleeding is 4.7 % and for open surgery 5 %. Bleeding from the central pulmonary artery can take a dramatic course and requires rapid and targeted therapy. DISCUSSION: Knowledge of the anatomical topographic details, the structure, the course and the specific features of the vessels of the lungs is essential to prevent and treat bleeding. Avoidance strategies include techniques of proximal and distal vessel control, intrapericardial preparation and sharp preparation in general. Techniques of forward-looking preparation and well-prepared exit strategies in case of bleeding have to be part of the training in thoracic surgery.

[Surgical therapy of lung metastases]. / Chirurgische Therapie von Lungenmetastasen.

Surgical treatment of lung metastases from extrathoracic malignancies is an established procedure. Pulmonary metastases are common. Generally, lung metastases are located peripherally and are asymptomatic. Involvement of the bronchial system or infiltration of the chest wall can be symptomatic. The indications for resection are an interdisciplinary decision. Metastasectomy can be with curative or palliative intent. Prerequisitess for pulmonary metastasectomy are primary tumor under control, the absence of extrathoracic metastases, the lack of other promising treatment options, the possibility for complete resection and low perioperative risk. Extra-anatomic resections are common. Perioperative morbidity and mortality is low. A cure is possible in selected patients.

[Malignant pleural mesothelioma: comparison of radical pleurectomy und extrapleural pneumonectomy]. / Malignes Pleuramesotheliom: Radikale Pleurektomie und extrapleurale Pneumonektomie im Vergleich.

The role of surgical resection per se and the type of surgery in the management of multimodality treated malignant pleural mesothelioma remains controversial. Patient selection for either extrapleural pneumonectomy or radical pleurectomy depends not only on the cardiopulmonary status of the patient, tumor stage and intraoperative findings but is also strongly influenced by surgeons' preference, experience and philosophy. The aim of this review is to compare extrapleural pneumonectomy and radical pleurectomy with regard to surgical technique, morbidity, mortality and survival.

[Pneumonectomy: an alternative to sleeve resection in lung cancer patients?]. / Pneumonektomie: Eine Alternative zur Manschettenresektion beim Lungenkarzinom?

Lung cancer is localized in the upper lobes in more than half of the cases. The risk of tumor infiltration of centrally located structures, such as bronchi and vessels are enhanced due to the anatomic topography. Pneumonectomy competes with sleeve resection for the surgical resection of centrally located tumors. The present review deals with the question if pneumonectomy should be considered as an alternative to sleeve resection for the treatment of lung cancer. Primary pneumonectomy does not provide any advantage even in advanced nodal disease. Extended lymph node dissection is not a contraindication for sleeve resections. Local recurrence rate is lower after sleeve resections despite the same radicality for both surgical treatment options. Mortality and morbidity rates are significantly lower for sleeve resections. Sleeve resections are associated with prolonged survival and better quality of life even in elderly patients.

[Pneumothorax, what kind of therapy is necessary? A clinical overview]. / Pneumothorax, welche Therapie ist notwendig? Ein klinischer Überblick.

Pneumothorax is defined as the accumulation of air in the pleural space. A distinction is made between a primary (idiopathic) spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP) as well as between iatrogenic pneumothorax and traumatic pneumothorax. Primary spontaneous pneumothorax (PSP) occurs mainly in otherwise healthy people (mainly tall and thin young men) without any clinical sign of lung disease. In contrast, secondary pneumothorax (SSP) mostly occurs in patients with diagnosed and clinically manifested lung disease and is most frequent in older subjects (> 50 years). Smokers have a higher risk of developing pneumothorax. Most pneumothorax cases require a therapeutic intervention using thorax drainage. Observation alone is recommended for only those few patients suffering from pneumothorax without clinical symptoms. Although simple needle aspiration is often recommended as a first-line treatment, our clinical experience shows no advantage for most of the patients. All patients with symptomatic pneumothorax should be treated with immediate intercostal tube drainage. In the surgical therapy of pneumothorax, VATS (video-assisted thoracic surgery) is the current effective standard treatment. Open posterolateral thoracotomy is the recommend approach rather than the minimally invasive procedure in patient with serious illness or complications. The aim of both interventions is to reduce the recurrence rate of pneumothorax as much as possible.

[Intrathoracic injuries]. / Intrathorakale Verletzungen.

Severe intrathoracic injuries are uncommon but immediately life-threatening. These injuries are mostly associated with polytrauma. After stabilization of polytraumatized patients imaging is a prerequisite for treatment and operation planning. The assessment warrants an interdisciplinary approach primarily between the specialties of anesthesia, trauma surgery and thoracic surgery and further specialties should be involved depending on the injury pattern. This article gives an overview about the current management of the most important intrathoracic injuries.

[Diagnostic assessment and treatment concepts for thoracic trauma]. / Diagnostik und Behandlungskonzepte beim Thoraxtrauma.

Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. An appropriate structured network of surgical centers guarantees sufficient and efficient care of patients with severe chest trauma. In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.

Sleeve resections for the treatment of non-small cell lung cancer.

Parenchyma-sparing sleeve lobectomies were originally developed as a surgical strategy for patients not fit for a pneumonectomy, because of impaired pulmonary function. As promising short- and long-term results were demonstrated, sleeve lobectomy was accepted as an alternative surgical procedure to pneumonectomy. Nowadays, sleeve resections are associated with prolonged long-term survival and better quality of life, compared to pneumonectomy. Therefore, sleeve resections should be performed for centrally located non-small cell lung cancer (NSCLC) whenever technically, anatomically and oncologically possible. In this review, we discuss the current status of sleeve resections in the management of NSCLC.

Pneumonectomy vs. sleeve resection for non-small cell lung carcinoma in the elderly: analysis of short-term and long-term results.

BACKGROUND: Aim of the study was to assess the short- and long-term results of sleeve resections and pneumonectomies for centrally located non-small cell lung cancer (NSCLC) in a cohort of elderly patients. METHODS: We retrospectively reviewed our prospective database of all patients aged ≥ 70 years who underwent sleeve resection (SL group) or pneumonectomy (PN group) for NSCLC between January 1999 and December 2005. Patients' characteristics, morbidity, mortality and survival were analyzed and compared between groups. RESULTS: Sixty patients qualified for the analysis, of whom 31 underwent sleeve resection and 29 had pneumonectomy. Both groups were statistically equivalent with regard to age (73.6 ± 2.4 vs. 74.2 ± 3.6 years), sex, comorbidities, histology, completeness of resection and stage. Presurgical FEV1 was higher in the PN group ( P = 0.02). There were no statistical differences in the morbidity rate (SL: 41.9%, PN: 44.8%), mortality rate (SL: 6.5%, PN: 10.3%), local recurrence (SL: 3.2%, PN: 0%) or distant metastases (SL: 19.4%, PN: 24.1%). The loss of FEV1 was higher in the PN group (27.3%) compared to the SL group (12.0%; P = 0.001). Overall 5-year survival and mean survival for SL patients was 59% and 51.9 months compared to 0% and 30.1 months for the PN patients ( P = 0.038). In patients with stage N2 disease, the type of surgery showed a trend to prolonged long-term survival favoring sleeve resection ( P = 0.096). CONCLUSION: In specialized centers both pneumonectomy and sleeve resection can be performed with acceptable mortality and morbidity rates in elderly patients with centrally located NSCLC. In elderly patients with anatomically suitable NSCLC, sleeve resections offer better functional results and long-term survival irrespective of nodal status.

A 30-year-old woman with only right-sided asthma?

Centrally located endobronchial tumors present diagnostic and therapeutic challenges. We report the case of a 30-year-old woman presenting with nonspecific respiratory symptoms and wheezing, who was initially diagnosed with asthma, but eventually was found to have a non-secreting typical carcinoid tumor of the right main bronchus. Surgical management with isolated resection of the right main bronchus allowed us to avoid any parenchymal loss. This case is an instructive example showing that not every wheeze is asthma, especially if the wheezing is unilateral. The excellent long-term outcome of our patient highlights the fact that for central carcinoids, parenchyma-saving resection together with systematic lymphadenectomy should be considered the standard surgical procedure.