Predictive value of a novel digital risk calculator to determine early patient outcomes after major surgery: a proof-of-concept pilot study.

BACKGROUND: A structured risk assessment of patients with validated and evidence-based tools can help to identify modifiable factors before major surgeries. The Protego Maxima trial investigated the value of a new digitized risk assessment tool that combines tools which can be easily used and implemented in the clinical workflow by doctors and qualified medical staff. The hypothesis was that the structured assessment and risk-grouping is predictive of short-term surgical quality reflected by complications and overall survival. METHODS: The Protego Maxima Trial was a prospective cohort analysis of patients undergoing major surgery (visceral, thoracic, urology, vascular and gynecologic surgeries) as key inclusion criterion and the absence of an acute or acute on chronically decompensated pulmo-cardiovascular decompensation. Patients were risk-scored with the software (The Prehab App) that includes a battery of evidence-based risk assessment tools that allow a structured risk assessment. The data were grouped to predefined high and low risk groups and aggregate and individual scores. The primary outcome was to validate the predictive value of the RAI score and the TUG for overall survival in the high and low risk groups. Secondary outcomes were surgical outcomes at 90-days after surgery (overall survival, Clavien-Dindo (CD) 1-5 (all complications), and CD 3-5 (major complications)). The study was carried out in accordance with the DIN ISO 14,155, and the medical device regulation (MDR) at Frankfurt University Hospital between March 2022 and January 2023. RESULTS: In total 267 patients were included in the intention to treat analysis. The mean age was 62.1 ± 12.4 years. Patients with a RAI score > 25 and/or a timed up and go (TUG) > 8 s had a higher risk for mortality at 90 days after surgery. The low-risk group predicted beneficial outcome and the high-risk group predicted adverse outcome in the ROC analysis (Area Under the Curve Receiver Operator Characteristics: AUROC > 0.800; p = 0.01). Risk groups (high vs. low) showed significant differences for 90-day survival (99.4% vs. 95.5%; p = 0.04) and major complications (16.4% vs. 32.4%; p < 0.001). CONCLUSION: The proof-of-concept trial showed that a risk assessment with 'The Prehab App' may be viable to estimate the preoperative risk for mortality and major complications before major surgeries. The overall performance in this initial set of data indicated a certain reliability of the scoring and risk grouping, especially of the RAI score and the TUG. A larger data set will be required to proof the generalizability of the risk scoring to every subgroup and may be fostered by artificial intelligence approaches. TRIAL REGISTRATION: Ethics number: 2021-483-MDR/MPDG-zuständig monocentric; The Federal Institute for Pharmaceuticals and Medical Devices/BfArM, reference number: 94.1.04-5660-13655; Eudamed: CIV-21-07-0307311; German Clinical Trial Registry: DRKS 00026985.

Lung Cancer Resection after Immunochemotherapy Versus Chemotherapy in Oligometastatic Nonsmall Cell Lung Cancer.

BACKGROUND: Neoadjuvant immunochemotherapy is currently being tested in pivotal trials for stage I to III nonsmall cell lung cancer (NSCLC). The impact of immunochemotherapy in patients with oligometastatic disease (OMD) remains undefined. This study aimed to compare the outcomes of radical treatment after the neoadjuvant course of immunochemotherapy versus chemotherapy. METHODS: We retrospectively analyzed patients with OMD who were treated with immunochemotherapy or chemotherapy combined with local ablation of metastases and radical primary tumor resection between 2017 and 2021. Group A included eight patients with immunochemotherapy; Group B included seven patients with chemotherapy. Descriptive statistical analysis included the characteristics of the patients, tumors, and outcomes. RESULTS: There was no difference in postoperative morbidity rates between the groups (p = 0.626). The 30-day mortality in both groups was 0%. The median overall survival for Group A was not reached, with a median follow-up time of 25 (range: 13-35) months; the median overall survival for Group B was 26 (range: 5-53) months. In Group A, all patients remained alive; in contrast, in Group B, four patients died (p = 0.026). There was no local thoracic recurrence in either group. In Group B, the recurrent disease was identified significantly more often (12.5 vs. 85.75%; p = 0.009). The rates of complete and major pathologic response were 37.5 and 0% in Group A and 42.85 and 14.25% in Group B, respectively. CONCLUSION: Despite the small patient number and short-term results, the progression-free and overall survival in patients with OMD after local therapy for metastases and primary tumor resection following a neoadjuvant course of immunochemotherapy might be promising compared with chemotherapy.

A Possible Distinct Molecular Subtype (Quintuple-Wildtype) of Metastatic Colorectal Cancer in First-Line Anti-EGFR Therapy with Cetuximab Plus FOLFIRI - Palliative Precision Therapy and a Multidisciplinary Treatment Approach: Interim Analysis of the IVOPAK II Trial with Early Results.

OBJECTIVE: The study aimed to prospectively evaluate a new molecular biomarker panel (KRAS, NRAS, BRAF, PIK3CA, and ERBB2) for palliative first-line treatment of colorectal cancer (CRC), including a multidisciplinary treatment approach. The rate of secondary metastasis resections was assessed. PATIENTS AND METHODS: A total of 40 patients with definitively nonresectable metastatic CRC were enrolled from 10 centers before the interim analysis (June 2019) of the IVOPAK II trial (Interdisciplinary Care with Quality Control in Palliative Treatment of Colorectal Cancer). After determination of 5 molecular biomarkers in the tumor (KRAS, exons 2-4; NRAS, exons 2-4; BRAF V600E; PIK3CA; and ERBB2), patients in the IVOPAK II study received FOLFIRI plus cetuximab for all-RAS/quintuple-wildtype disease and FOLFIRI plus bevacizumab in the case of RAS mutations. The current article presents the early description of the clinical outcome of the interim analysis of IVOPAK II comparing the all-RAS/quintuple-wildtype and RAS-mutations populations, including a multidisciplinary-treated case report of a quintuple-wildtype patient. RESULTS: The quintuple-wildtype population treated with FOLFIRI plus cetuximab in first-line exhibited a significantly higher response rate and enhanced early tumor shrinkage in the interim analysis than the RAS-mutations population, as well as a high rate of secondary metastatic resections. CONCLUSION: Initial results of this new biomarker panel (quintuple-wildtype) are promising for anti-EGFR therapy with cetuximab plus doublet chemotherapy (FOLFIRI) in first-line treatment of metastatic CRC. These results warrant confirmation with higher case numbers in the IVOPAK II trial.

Surgery for Pulmonary Metastases: Long-Term Survival in 281 Patients.

BACKGROUND: Despite weak evidence, pulmonary metastasectomy (PM) is widely performed with intent to improve patient survival. Our single-institution analysis aims to evaluate outcomes and to identify factors influencing survival of patients undergoing PM for metastases from wide range of primary tumors. MATERIALS AND METHODS: All patients undergoing curative-intent PM between 2008 and 2018 were retrospectively analyzed. The impact of factors related to primary tumor, metastases, and associated therapy on overall survival (OS) was evaluated using univariable and multivariable Cox proportional hazard models. Cutoff values of continuous variables were determined by a receiver operating characteristic analysis. RESULTS: In this study, 281 patients (178 male, median age 61 years) underwent PM. Two (0.7%) perioperative deaths and 23 (8.2%) major complications occurred. Median interval between the treatment of primary tumor and PM was 21 months. Median size of largest metastasis was 1.4 cm. After the median follow-up of 29 months, 134 patients (47.7%) had died. Five-year OS rate after first PM was 47.1%. Complete resection was achieved in 274 (97.5%) patients. Multivariable analysis identified genitourinary origin (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.15-0.60, p = 0.0008) as independent positive survival prognosticator; incomplete resection (HR: 3.53, 95% CI: 1.40-8.91, p = 0.0077) and age at PM of ≥66 years (HR: 1.97, 95% CI: 1.36-2.85, p = 0.0003) were negative prognosticators. CONCLUSION: The use of PM as a part of multimodal treatment is in selected population justified. Our analysis identified age, primary tumor origin, and completeness of resection as independent survival prognosticators.

Survival and Prognostic Analysis after Pulmonary Metastasectomy for Head and Neck Cancer.

BACKGROUND: There is no consensus on the value of pulmonary metastasectomy (PM) for head and neck cancer (HNC). The aim of our single-institution study was to evaluate outcomes and to examine factors influencing 5-year survival of patients undergoing resections for HNC lung metastases. METHODS: All HNC patients undergoing curative-intent PM between January 2008 and December 2018 were retrospectively analyzed. The impact of factors related to primary tumor, metastases, and associated therapy on patient survival was evaluated using the univariable Cox proportional hazard model. Cutoff values of continuous variables were determined by a receiver operating characteristic analysis. RESULTS: In total, 44 patients (32 males and 12 females, with a median age of 65 years) underwent PM for metastatic HNC. There was one perioperative death, and major complications occurred in 2 (4.5%) patients. The median interval between the treatment of primary tumor and PM was 19.4 months (range: 0-151 months). Median size of the largest resected pulmonary lesion was 1.3 cm (range: 0.3-6.9 cm). Mean follow-up was 21 months (range: 0-123 months), and 5-year overall survival (OS) rate after the first PM was 41%. Resection was complete (R0) in all patients. Larger size of pulmonary metastasis (≥1.4 cm; hazard ratio: 4.49; 95% confidence interval: 1.79-11.27) was a significantly negative prognostic factor. CONCLUSION: Despite the lack of randomized controlled trials, PM for HNC is a reasonable therapeutic option with favorable survival in a selected population. In patients with larger pulmonary lesions, shorter OS after PM is to be expected.

Negative Pressure Wound Therapy Combined With Instillation for Sternoclavicular Joint Infection.

BACKGROUND: There is no consensus on the management of spontaneous sternoclavicular joint infection (SCJI). Negative pressure wound therapy (NPWT) has been widely accepted for SCJI. We reviewed our experience with the management of this condition comparing NPWT alone and NPWT combined with instillation and dwell time. METHODS: We retrospectively analyzed the data of patients with spontaneous SCJI treated in our thoracic unit. RESULTS: From March 2008 to October 2019, 27 patients (21 men and 6 women) underwent NPWT combined with muscle flap transfer after necrosectomy and chest wall resection for SCJI. The median age was 57.1 years (range, 35 to 85). Depending on management, the patients were divided into two groups: 16 patients with NPWT in group 1, and 11 patients with NPWT combined with instillation and dwell time in group 2. The severity of SCJI, extent of chest wall resection, and type of muscle flap were not significantly different (P = .35, P = .858, P = .705, respectively). Median duration of hospital stay and NPWT were shorter in group 2 (30 vs 25 days, and 20 vs 16 days, respectively). The required wound dressing changes were significantly lower in group 2 (P = .008). Statistical trend to higher bacterial eradication in group 2 was noted (P = .093). Postoperative complications including SCJI recurrence, wound seroma, and dehiscence were not significantly different between groups (P = .269). CONCLUSIONS: The NPWT combined with instillation and dwell time appears a useful strategy in patients with SCJI, leading to higher incidence of bacterial eradication and shorter wound care.

Major Pathologic Response after Induction Therapy Has a Long-Term Impact on Survival and Tumor Recurrence in Stage IIIA/B Locally Advanced NSCLC.

BACKGROUND: Major pathologic response (MPR) determines favorable outcome in locally advanced non-small cell lung cancer after induction therapy (IT) followed by lung resection. The aim of this retrospective study was to identify the prognostic relevance of MPR in long-term interval. METHODS: In 55 patients, the survival rate according to MPR and non-MPR was estimated by Kaplan-Meier method and compared using log-rank, Breslow, and Tarone-Ware tests. RESULTS: The IT included chemoradiation with 50.4 Gy (range: 45-56.4 Gy) combined with platinum-based chemotherapy in 52 patients (94.5%) and platinum-based chemotherapy in 3 patients (5.5%). Perioperative morbidity and 30-day mortality were 36 and 3.6%, respectively. The estimated 5-year postoperative and progressive-free survivals were statistically significantly improved in MPR versus non-MPR with 53.5 versus 18% and 49.4 versus 18.5%, respectively. According to the log-rank, Breslow, and Tarone-Ware tests, the MPR demonstrates prognostic significance in early, long-term, and whole postoperative interval. CONCLUSION: MPR is associated with a robust correlation to long-term postoperative and recurrence-free survival improvement, and can potentially simplify the multidisciplinary debate and allow further stratification of adjuvant treatment in multimodality therapy.

Pulmonary metastasectomy for sarcoma-survival and prognostic analysis.

BACKGROUND: Pulmonary metastasectomy (PM) has commonly been performed in patients with controlled metastatic sarcoma. We reviewed our single-institution experience with pulmonary resections for sarcoma to analyse clinical outcome and to identify prognostic factors associated with patient survival. METHODS: All sarcoma patients undergoing curative intent PM between 2008 and 2014 were retrospectively analysed. Factors related to primary tumour, metastases, applied therapy, systematic inflammation and preoperative nutritional condition, associated with survival after PM were evaluated using the univariable Cox proportional hazard model. Cut-off values of continuous variables were determined by a receiver operating characteristic (ROC) analysis. RESULTS: In total, 33 patients (19 male and 14 female, median age 55 years) underwent PM for metastatic sarcoma. There were no perioperative deaths; major complications occurred in 5 (15.2%) patients. The median interval between the treatment of primary tumour and PM was 16 months (range, 0-171 months). The median size of the largest pulmonary lesion was 1.3 cm. Mean follow-up was 37 months (range, 1-100 months) and the 5-year overall survival (OS) rate after first PM was 40.4%. Resection was complete (R0) in 31 (93.9%) patients. In univariable analysis, a shorter interoperative interval [<30 months, hazard ratio (HR) 5.05, 95% confidence interval (CI): 1.15-22.19] and grade 3 (G3) sarcoma (HR 3.52, 95% CI: 1.01-12.25) were significant negative prognosticators. CONCLUSIONS: Despite the lack of randomized controlled trials PM for sarcomatous disease is a reasonable therapeutic option with acceptable survival in a selected patient population. In sarcoma patients with a shorter interoperative interval and G3 tumour, shorter survival after PM can be expected.

Combined recurrent laryngeal nerve monitoring and one-lung ventilation using the EZ-Blocker and an electromyographic endotracheal tube.

BACKGROUND: Intraoperative neuromuscular monitoring (IONM) is a widespread procedure to identify and protect the recurrent laryngeal nerve (RLN) during thyroid surgery. However, for left thoracic surgery with high risk of RLN injury, both reliable recurrent laryngeal nerve monitoring and one-lung ventilation could interfere. METHODS: In this prospective study, a new method for IONM during one-lung ventilation combining RLN monitoring with an electromyographic (EMG) endotracheal tube (ETT) and lung separation using the EZ-Blocker (EZB) is described and its clinical feasibility and effectiveness were assessed. RESULTS: A total of 14 patients undergoing left upper lobe surgery and left upper mediastinal lymph node dissection were enrolled. The EZB was introduced and positioned without any problems and sufficient lung collapse was achieved in all patients. No tracheobronchial injuries or immediate complications occurred. A stable EMG signal was present in all patients and no RLN palsy and no negative side effects of the NIM EMG ETT or the EZB were observed postoperatively. CONCLUSIONS: The described method is technically feasible, easy to apply and save. It provides both reliable IONM and independent lung separation for optimal surgical exposure. The combined use of the EZB and the NIM EMG ETT might reduce the risk for RLN palsy and impaired lung separation during left thoracic surgery with high risk for RLN injury.

Sternal resection and reconstruction for secondary malignancies.

BACKGROUND: Limited data on sternal and/or anterior chest wall resections for secondary malignancies exist. The purpose of this study was to examine the perioperative outcomes and postoperative overall survival (OS) in patients who underwent sternal and/or anterior chest wall resections for secondary sternal tumors (SSTs). METHODS: A retrospective analysis of all patients who underwent resection of SSTs at single institution between 2000 and 2016 has been performed. OS was estimated using the Kaplan-Meier method. RESULTS: Ten patients underwent sternal and/or anterior chest wall resection for SSTs with curative (70%) or palliative (30%) intent. Two (20%) patients underwent complete and 8 (80%) partial sternal and/or anterior chest wall resection. There were no perioperative deaths, major complications occurred in 3 (30%) patients. Tumor resection was complete (R0) in 5 (50%) patients. The 5-year OS rate was 40%. No OS difference in R0 vs. R1 resections was observed. CONCLUSIONS: Sternal and/or anterior chest wall resections for SSTs can be performed with low morbidity and mortality. Complete SST resection does not assure favorable OS. Sternal resections can be considered palliative treatment option in patients with stable stage IV disease with isolated sternal involvement.

Pathologic complete response after induction therapy-the role of surgery in stage IIIA/B locally advanced non-small cell lung cancer.

BACKGROUND: Pathologic complete response (pCR) is dominant prognostic factor determining favorable outcome in locally advanced non-small cell lung cancer (NSCLC) after induction therapy (IT). There is no non-operative diagnostics that adequately estimates the pCR. Aim of this retrospective study was to assess the correlation between clinical and pathological factors in patients with pCR. METHODS: Twenty-five patients with pCR after curative lung resection following IT were assessed using univariate and multivariate Cox regression and descriptive analysis. The survival rate was estimated by Kaplan-Meier method. RESULTS: The IT included chemoradiation with median doses of 50.4 Gy (range, 45-59.4 Gy) combined with platinum-based chemotherapy in 23 patients (92%) and induction platinum-based chemotherapy in 2 patients (8%). Clinical tumor stage before IT was IIIA in 21, IIIB in 4 patients. Mean interval between IT and surgery was 8.1±3.0 weeks. Perioperative morbidity and 30-day mortality was 32% and 4%, respectively. There was no significant correlation of pCR and different clinical and pathological factors. The estimated 5-year long-term survival (LTS) and progressive-free survival (PFS) was 57% and 54%, respectively. The median LTS and PFS was not reached. CONCLUSIONS: pCR in patients with locally advanced NSCLC following IT is an independent prognostic factor, without correlation with pathological and clinical factors. Non-operative accurate assessment of pCR is currently impossible. Surgical resection enables secure identification of pCR and might improve the patient stratification for additive therapy.

[Lung Resection after Definitive and Neo-Adjuvant Chemoradiation for Stage IIIA/B Locally Advanced Non-Small Cell Lung Cancer: a Retrospective Analysis]. / Lungenresektion nach definitiver und neoadjuvanter Radiochemotherapie im Stadium IIIA/B des lokal fortgeschrittenen nicht kleinzelligen Lungenkarzinoms: eine retrospektive Analyse.

BACKGROUND: The outcomes of so called "salvage" resections after definitive chemoradiation vs. curative resections after neoadjuvant chemoradiation therapy (IT-resection) in patients with stage IIIA/B locally advanced non-small cell lung cancer have rarely been compared. The aim of our study was to compare perioperative results, postoperative and recurrence-free survival and to identify relevant prognostic survival factors for both therapy strategies. PATIENTS AND METHODS: Between June 2008 and May 2017, 43 patients underwent pulmonary resection following induction therapy (group 1) and 14 patients underwent salvage resection after definitive chemoradiation (group 2). Retrospective analysis was performed of demographic factors, tumour stage and location, initial therapy, preoperative regression status, perioperative morbidity and mortality, postoperative and recurrence-free survival. RESULTS: In group 2, significantly higher radiation dose was applied (p < 0.001) and the interval between chemoradiation and lung resection was significantly longer (p = 0.02). In addition, significantly higher perioperative blood loss and more frequent blood transfusions were noted (p = 0.003 and 0.005, respectively). Perioperative morbidity and mortality were statistically comparable in the two groups (p = 0.72 and 0.395, respectively). Postoperative 5 year survival in group 1 was 55%, in group 2 48% (log-rank p = 0.353). Five year recurrence-free survival in group 1 was 53%, in group 2 42% (log-rank p = 0.180). Diffuse metastasis occurred mostly in group 2, whereas in group 1 oligometastasis was more frequently noted. CONCLUSION: Postoperative outcome after salvage resection seems statistically comparable to results following curative resection after induction therapy. Diffuse distant metastasis is frequently noted. Careful patient selection is required.

[Videothoracoscopic Sympathetic Clipping in a Patient With Azygos Lobe. Intraoperative Management to Avoid Potential Complications]. / Videothorakoskopisches Sympathikus-Clipping bei einem Patienten mit Lobus venae azygos. Intraoperatives Management zur Vermeidung von potenziellen Komplikationen.

INTRODUCTION: Sympathetic clipping in the presence of an azygos lobe is a rare combination. Anatomical relations between the sympathetic trunk and the mesoazygos impede surgical handling and can be associated with potential complications. INDICATION: We report the case of a 25-year old woman with grade III palmoplantar and axillary hyperhidrosis with azygos lobe incidentally found on preoperative chest X-ray. METHOD: Our intraoperative video shows a step-by-step approach to the sympathetic trunk in the presence of the azygos lobe, involving thoracoscopic looping and precise clip application onto the sympathetic trunk. Video-assisted reposition and expansion of the accessory lobe to avoid potential complications have been demonstrated. CONCLUSION: Videothoracoscopic sympathetic clipping in patients with lobus azygos is technically challenging. Potential complications can be avoided by coordinated surgical management.

Long-Term Survival after Salvage Surgery for Local Failure after Definitive Chemoradiation Therapy for Locally Advanced Non-small Cell Lung Cancer.

BACKGROUND: The incidence of local failure and residual tumor after definitive chemoradiation therapy (dCRT) for locally advanced non-small-cell lung cancer remains high, irrespective of applied radiation dose (>59 Gy). So-called salvage surgery has been suggested as a feasible treatment option after failure of definitive chemoradiation for locally advanced non-small cell lung cancer (NSCLC). Experience with salvage lung surgery (SLS) is limited, and long-term survival is rarely reported. Patient selection criteria for surgical lung salvage are not defined. The aim of this study was to assess postoperative survival and perioperative morbidity/mortality to identify prognostic factors and to define patient selection criteria. PATIENTS AND METHODS: Records of 13 consecutive patients with locally advanced NSCLC, who underwent SLS at a single institution between March 2011 and November 2016, were reviewed. Descriptive statistics were applied for patient characteristics and surgical and oncological outcome. Survival rates were calculated using the Kaplan-Meier method and were compared with the long-rank test. RESULTS: All patients initially received curative-intent definitive chemoradiation with median radiation doses of 66 Gy (range 59.4-72) and concurrent platinum-based chemotherapy. Clinical tumor stage before definitive chemoradiation was IIIA in 9, IIIB in 3, IV in 1 patients. Median interval between definitive chemoradiation and salvage surgery was 6.7 months. Perioperative morbidity and 30-days-mortality was 38% and 7.7%, respectively. The median postoperative survival and estimated 5-year survival rate were 29.7 months and 46%, respectively. CONCLUSION: SLS in patients with locally advanced non-small cell lung surgery following dCRT is feasible, prolongs long-term survival and allows local tumor control. Selection criteria remain undefined and patients should be considered surgical candidates during multidisciplinary team conference.

Forty-Two Years' Experience with Pulmonary Resections of Metastases from Colorectal Cancer.

Background Pulmonary metastasectomy is a commonly performed surgery in patients with controlled metastatic colorectal cancer (CRC). We reviewed our long-term single institution experience with lung resections for colorectal metastases to assess the factors influencing patient survival. Materials and Methods A cohort of 220 patients (138 men and 82 women; median age, 59 years) who underwent complete pulmonary metastasectomy for CRC with curative intent between 1972 and 2014 was retrospectively analyzed. The impact of factors related to primary tumor, metastases, and associated therapy on patient survival was assessed. Results Two postoperative inhospital deaths occurred. The median interoperative interval was 26 months. The overall 5-year survival rate after pulmonary metastasectomy was 49.4%. In univariable analysis, bilateral pulmonary metastases (log rank p = 0.02), multiple metastases (log rank p = 0.005), and stage IV UICC (the International Union Against Cancer) CRC at the time of initial presentation (log rank p = 0.008) were significantly associated with poor outcome. Multivariable Cox analysis demonstrated that stage IV CRC (p = 0.02) and multiple metastases (p = 0.0019) were statistically significant predictors of survival after the pulmonary metastasectomy. There was no significant difference in survival between patients with high versus low preoperative carcinoembryonic antigen serum level (p = 0.149), high versus low preoperative carbohydrate antigen 19-9 serum level (p = 0.291), and primary tumor location in rectum versus colon (p = 0.845). Conclusion Patients with unilateral metastasis and stages I to III primary tumor benefited most from pulmonary metastasectomy for CRC.

Should salvage surgery be considered for local recurrence after definitive chemoradiation in locally advanced non-small cell lung cancer?

BACKGROUND: Incidence of local relapse after definitive chemoradiation (>59 Gy) for locally advanced non-small-cell lung cancer (NSCLC) is high, irrespective of high dose radiation applied. Experience with salvage lung resections in patients with locally relapsed NSCLC after definitive chemoradiation is limited. We present our series of salvage lung resections for local NSCLC relapse after curative-intent chemoradiation for locally advanced tumor. METHODS: Nine consecutive patients with local tumor recurrence or persistence following definitive chemoradiation were reviewed. Kaplan-Meier analysis was used to assess patient survival. RESULTS: All patients received definitive radiation (median dose 66.2 Gy) with concurrent chemotherapy. Tumor stage prior to chemoradiation was IIIA in 8 patients and IV in 1. In 4 patients tumor invaded the chest wall, in 2 the spine and in 1 the aorta. Median interval between chemoradiation and salvage resection was 30.2 weeks. Nine patients underwent 9 resections (6 lobectomies, 1 bilobectomy, 1 pneumonectomy and 1 bi-segmentectomy). One death occurred on the 12th postoperative day. Median overall survival was 23 months; postoperative 3-year survival was 47 %. Median progression-free survival was 21 months. CONCLUSION: Salvage lung resection for locally recurrent or persisted NSCLC in selected patients with locally advanced NSCLC following definitive chemoradiation is a worthwhile treatment option.

Combined Clagett procedure, negative pressure therapy, and thoracomyoplasty for treatment of late-onset postpneumonectomy empyema necessitatis.

Late-onset post-pneumonectomy empyema necessitatis can occur many years after the surgery and is a life-threatening condition. A 58-year-old male presented with empyema necessitatis 18 years after undergoing pneumonectomy. He was successfully treated with a modified two-stage Clagett procedure and ambulatory negative pressure as the bridge between the stages. The 72-month follow-up was uneventful. The complete obliteration of the rigid and wide residual postpneumonectomy cavity was necessary to avoid re-recurrence of the infection.

Is salvage surgery for recurrent non-small-cell lung cancer after definitive non-operative therapy associated with reasonable survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether salvage pulmonary resection is possible and worthwhile for patients with recurrence of non-small-cell lung cancer (NSCLC) after prior definitive non-operative therapy. A total of nine reports were identified using the reported search, of which four represented the best available evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All studies were retrospective. In total, 48 pulmonary salvage resections were performed in 47 patients after prior definitive radiation, chemoradiation or stereotactic body radiation therapy, of which 28 were lobectomies (including 1 sleeve lobectomy), 12 pneumonectomies, 4 bilobectomies and 4 sublobar resections (2 segmentectomies and 2 wedge resections). Postoperative complications ranged from 0 to 58% (mean from four studies 42.5%). Only one study reported any mortality (4%), the other three had zero mortality. Median postoperative survival was reported in two studies and ranged from 9 to 30 months. Experience with salvage lung resection for locally recurrent NSCLC, after prior definitive non-surgical treatment, remains limited. Therefore, this analysis was based on only 48 resections in 47 patients from four retrospective studies. Nevertheless, the published data suggest that salvage lung surgery for recurrent, previously non-operatively managed non-small-cell lung cancer is a worthwhile treatment option with good survival, acceptable morbidity and low mortality.

Spontaneous Pneumothorax due to Ectopic Deciduosis: A Case Report.

This report presents a 20-week pregnant 38-year-old woman with right-sided pneumothorax due to pulmonary deciduosis. Initial pleural drainage was ineffective. Video-assisted thoracoscopy revealed areas of consolidation within the lung parenchyma. A wedge resection with partial pleurectomy was performed. Histopathological examination showed subpleural decidual implants. The patient made a full recovery and was discharged on day 5. Videoscopic inspection of the lung parenchyma and pleura with resection of decidual foci is the recommended treatment for pneumothorax in pregnant women with pleuropulmonary deciduosis in whom classical pleural drainage is ineffective.