[Significance of pulmonary lymph node metastases in locally advanced non-small cell lung cancer]. / Bedeutung der pulmonalen Lymphknotenmetastasierung bei lokal fortgeschrittenen, nicht-kleinzelligen Bronchialkarzinomen.

BACKGROUND: The locally advanced (T3 - 4) non-small cell lung cancer with pulmonary lymph node metastases (N1) is a mixture of different subgroups of disease with varying pattern of tumor extension and long-term survival rates. PATIENTS AND METHODS: We retrospectively reviewed hospital records and follow-up data of 181 patients operated on between 1990 and 1995 with pathological stage IIIA-pT3N1 and IIIB-pT4N1. Median age was 62 years (range 34 - 80). RESULTS: The operative mortality was 3.7 %. The analysis was carried out on the 181 hospital survivors. The operative procedure was a pneumonectomy in 110 cases (60.8 %) and a lobectomy/bilobectomy in 71 (39.26 %). The pathological stage according to the UICC TNM-Classification of 1997 was T3N1 in 128 (70.7 %) and T4N1 in 53 (29.3 %). We observed a metastatic involvement of the hilar, interlobar and lobar lymph nodes in 44 (24.3 %), 17 (9.4 %), and 27 (14.9 %) patients, respectively, whereas a direct infiltration in 93 patients (51.4 %). The actuarial overall 3-, 5- and 10-year survival rates for N1 hilar was 23 %, 13 % and 8 %, for N1 interlobar was 18 %, 6 % and 0 %, for N1 lobar was 48 %, 37 % and 22 %, and for N1 direct was 32 %, 27 % and 21 %, respectively. The involvement of hilar lymph nodes correlates with a worse prognosis (p =.0366). CONCLUSIONS: Metastases to the hilar lymph nodes in locally advanced NSCLC can be considered an initial N2-disease and should be treated correspondingly. Lymph node involvement by direct invasion is associated with a relatively more favourable prognosis for the patients.

Completion pneumonectomy: current indications, complications, and results.

OBJECTIVE: Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when done in patients with benign disease. We review our 9 years of experience with this operation to evaluate the postoperative outcome and long-term results of various indications. METHODS: Between January 1990 and December 1998, 66 consecutive patients underwent completion pneumonectomy (6.8% of all pneumonectomies), and their cases were retrospectively reviewed. The indication was benign disease in 17 patients and malignant disease in 49 patients. In patients with malignant indications there were 14 local recurrences, 4 second primary tumors, 5 metastatic diseases, and 26 indications because of incomplete initial resection. RESULTS: There were no intraoperative deaths, and the postoperative mortality rate was 7.6%. Complications were encountered in 32 (53%) patients, without any significant difference between benign indication (71%) and malignant indication (47%; P =.0923). Bronchopleural fistula was encountered in 5 (7.6%) patients, and empyema was encountered in 7 (11%) patients. The actuarial 5-year survival was 57% for all patients, 65% for those with benign indications, and 54% for those with malignant indications (60% for local recurrence, 50% for second primary tumor, and 56% for incomplete resection), without any difference between benign and malignant indications (P =.9478). CONCLUSIONS: Completion pneumonectomy can be performed with acceptable mortality and morbidity, even in patients with benign disease. Patients with preoperative infection can be managed with bronchial stump covering and adequate postoperative drainage. Although complications are common, they can successfully be managed with a proper understanding of them.

Prognostically orientated multimodality treatment including surgery for selected patients of small-cell lung cancer patients stages IB to IIIB: long-term results of a phase II trial.

Following mediastinoscopy, a prognostically orientated multimodality approach was chosen in selected small-cell lung cancer (SCLC) patients with hyperfractionated accelerated chemoradiotherapy (Hf-RTx) and definitive surgery (S). Stage IB/IIA patients had four cycles of cisplatin/etoposide (PE) and surgery. Stage IIB/IIIA patients had three cycles PE followed by one cycle concurrent chemoradiation including Hf-RTx and surgery. Most stage IIIB patients were not planned for surgery and had CTx followed by sequential RTx or one cycle concurrent CTx/RTx. Of 46 consecutive patients (stage IB six, IIA two, IIB/IIIA 22, IIIB 16) 43 (94%) showed an objective response. Twenty-three of patients (72%) planned for inclusion of S were completely resected (R0) (IB 6/6, IIA 2/2, IIB/IIIA 13/22, IIIB 2/2). Overall toxicity was acceptable--one patient died of septicaemia, no perioperative deaths occurred. Median follow-up of patients alive (n = 21) is 52 months (30+ - 75+). Median survival and 5-year survival rate of all patients are 36 months and 46%, in R0 patients 68 months and 63% (R0-IIB/IIIA/IIIB: not yet reached and 67%). This multimodality treatment including surgery proved highly effective with 100% local control and remarkable long-term survival after complete resection, even in locally advanced SCLC stages IIB/IIIA patients.

Video-assisted thoracoscopy in the treatment of pleural empyema: stage-based management and outcome.

OBJECTIVE: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. METHODS: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8-82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. RESULTS: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7. 1 days (range, 4-140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. CONCLUSIONS: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice.

Preoperative chemotherapy followed by concurrent chemoradiation therapy based on hyperfractionated accelerated radiotherapy and definitive surgery in locally advanced non-small-cell lung cancer: mature results of a phase II trial.

PURPOSE: To evaluate the feasibility and efficacy of an intensive multimodality approach with combination chemotherapy, hyperfractionated accelerated chemoradiotherapy, and definitive surgery in prognostically unfavorable subgroups of locally advanced non-small-cell lung cancer stages IIIA and IIIB (LAD-NSCLC). PATIENTS AND METHODS: Following staging, including mediastinoscopy, 94 patients with inoperable LAD-NSCLC were treated preoperatively with chemotherapy (three courses of split-dose cisplatin and etoposide [PE]) followed by concurrent chemoradiotherapy (one course of PE combined with 45 Gy hyperfractionated accelerated radiotherapy). After repeat mediastinoscopy, patients underwent surgery 4 weeks postradiation. RESULTS: Of 94 consecutive patients (52 stage IIIA [> or = two lymph node levels involved] and 42 stage IIIB [no pleural effusion, no supraclavicular nodes]), 62 (66%) completed induction and underwent surgery. Complete resection (R0) was achieved in 50 (53% of all patients) and pathologic complete response (PCR) in 24 (26%). After a median follow-up of 43 months, the median survival time was 20 months for IIIA, 18 months for IIIB, and 42 months for R0 patients. Calculated survival rates at 4 years were 31%, 26%, and 46%. Two patients died of sepsis preoperatively and four died postoperatively of pleural empyema (n = 1), stump insufficiency (n = 2), and cardiac failure (n = 1). Other toxicities were acceptable-mainly hematologic during chemotherapy or chemoradiotherapy and esophagitis during chemoradiotherapy. CONCLUSION: This intensive multimodality treatment is feasible and demonstrates high efficacy in prognostically unfavorable LAD-NSCLC subgroups with high R0 rates and improved long-term survival compared with historical controls

Clinical evaluation of a new bifurcated dynamic airway stent: a 5-year experience with 135 patients.

The Dynamic stent, a bifurcated airway prosthesis facilitating coughing, was clinically evaluated. The stents were inserted bronchoscopically in 135 patients (84 male, 51 female, age 12-90 years, mean 59 years) suffering from compression stenoses, strictures or malacias of the central airways, or tracheo-esophageal fistulas. Extrinsic compression from malignant and semi-malignant tumors was the leading indication for stenting (47.4%), followed by esophago-airway fistulas (22.2%) and post-intubation stenoses (14%). Stent insertion turned out to be very easy and could be performed without complications. The Dynamic stent was well tolerated and gave immediate relief of dyspnea in most cases. Follow-up data, three months after the last implantation revealed that at least 24 patients were still alive with a stent in place and free of complaints. In 27 cases, the stent had been removed after response to treatment. One of these patients received a second in order to seal a fistula, two months after removal of the first one. 85 patients, 79 with malignant, 6 with non-malignant diseases had died, with a mean survival time of 123 days (0 to 611 days). Complications directly attributable to the stent were rare. Two patients who had received the stent to counteract severe tracheal compression from aortic abnormalities died from arrosion and hemoptysis. There were no other severe complications. Cephalad migration occurred in 4/136 inserted stents. The Dynamic stent can be considered feasible, effective, and comparitively safe.

[Indications and results of para-sternal mediastinoscopy in tumors of the anterior mediastinum]. / Indikation und Ergebnisse der parasternalen Mediastinoskopie bei Tumoren im vorderen Mediastinum.

From January 1990 to December 1995 79 patients with mediastinal lesions were seen for parasternal mediastinoscopy at the Ruhrlandklinik Essen. Diagnosis was achieved in 91.1%. In 7 cases (8.9%) the diagnosis was not established. Six intraoperative complications occurred following mediastinoscopy: minor bleeding in five instances from the internal mammary vessels and one significant bleeding by injuring the V. cava. Postoperative minor wound infections occurred in five patients. Two pneumothoraces had to be managed by chest tube drainage. One patient with metastatic lung cancer died of respiratory failure.

[Principles of lung volume reduction]. / Prinzipien der Lungenvolumenreduktion.

Lung volume reduction (LVR) is a new surgical approach designed to relieve shortness of breath and to improve exercise tolerance in patients with severe lung emphysema. Selection of patients for LVR is based on history, clinical investigation, chest X-ray studies, CT scan, lung perfusion scan, lung function testing, and blood gas analysis. Selection criteria are severe emphysema (FEV1 20-35% pred., TLC > 120% pred., RV > 250% pred.), dyspnea despite optimized medical therapy, abstinence from smoking, acceptable nutritional status and rehabilitation potential. Patients with a uniform pattern of lung destruction benefit far less than those with a more localised pattern (> 30% on chest X-ray or CT scan) with the remaining lung being quite normal and a reduced perfusion of only the damaged areas. Prior to the final decision for LVR, all patients are enrolled in a supervised rehabilitation programme of 4 weeks duration. Some patients benefit so much that LVR can be postponed. The surgical approach of choice is a median sternotomy for bilateral LVR when the upper lobes are the target areas and a bilateral thoracotomy if the lower lobes are mainly affected. When a bilateral procedure is contraindicated, a unilateral approach may be an option. It is not yet clear whether an approach by thoracoscopy allows adequate surgical removal of all affected areas and whether the morbidity is lower. Laser ablation is a further therapeutic option but is much less effective than the surgical resection. Reinforcement of sutures using bovine pericardium strips reduces the chance of a prolonged air leak but is expensive. The results from our institution in 57 patients 1 month after LVR surgery showed the following improvement in dyspnea was a consistent finding in 88% of patients, the 6-min walking distance increased on average by 150 m, the FEV1 by 0.3 1 for unilateral LVR and 0.5 1 for bilateral LVR. The mean PaO2 in ambient air increased 6 mmHg after unilateral and 8 mmHg after bilateral LVR. There was also a significant improvement in respiratory muscle function and a reduction in respiratory drive. A significant improvement in quality of life was documented in 83% of the patients. Major hospital complications are prolonged air leak, pneumonia, and myocardial failure. Three cases of a delayed pneumothorax were observed. Early hospital mortality (< 30 days) was 1.7% and 90 days mortality 3.4%. Few follow-up data are available beyond 1 year, and the long-term benefit of LVR surgery therefore remains to be defined.

[Functional results of surgical lung volume reduction in severe pulmonary edema]. / Funktionelle Ergebnisse der chirurgischen Lungenvolumenreduktion beim schweren Lungenemphysem.

BASIC PROBLEM AND OBJECTIVE OF THE STUDY: Lung volume reduction (LVR) is a new surgical approach designed to relieve shortness of breath and improve exercise tolerance in patients with severe lung emphysema. The aim of this study was to analyse changes of lung function, gas exchange, exercise tolerance and degree of dyspnoea one and 3 months after LVR. PATIENTS AND METHODS: Seventeen patients (15 men and two women; mean age 53 [38-68] years) with severe emphysema (six with alpha 1-PI deficiency) underwent unilateral (n = 14) or bilateral (n = 3) LVR surgery. One week before and one and 3 months after surgery pulmonary function tests, arterial blood gas analysis at rest breathing room air, 6-minute walking distance and dyspnoea score (Medical Research Council Scale) were determined. RESULTS: There was a significant increase in forced expiratory vital capacity after one second (FEV1, P < 0.001), and a significant decrease in total lung capacity (TLC, P < 0.0001) and residual volume (RV, P < 0.0001). The mean increase in FEV1 was 39% and in PaO2 9%. The mean decrease in TLC was 20%, in RV 26% (P < 0.001; both comparisons), and in paCO2 4% (not significant). The mean 6-minute walking distance increased by 96% from 229 to 405 meters (P < 0.0001). The mean dyspnoea score on a five point scale (0-4 points) decreased by 52% from 3.4 to 1.6. With the exception of the improved inspiratory vital capacity the postoperative results at one and 3 months after LVR did not differ significantly. All patients were alive 3 months postoperatively. CONCLUSIONS: In patients with severe emphysema surgical LVR shows significantly improved pulmonary function, gas exchange, dyspnoea and walking distance as assessed one and three months postoperatively. The early mortality seems to be low.

Transsternal transpericardial operations in the treatment of bronchopleural fistulas after pneumonectomy.

Between 1972 and 1993, 19 patients (15 males and 4 females) with bronchopleural fistulae and pleural empyema after pneumonectomy were treated with transsternal transpericardial operations and closure of the fistula. The underlying malignant disease was a non-small cell carcinoma in 12, a malignant epithelial mesothelioma in two, and an atypical carcinoid tumor in one case. One patient each presented with tuberculosis, chest trauma, and lung destroyed by bronchiectasis. Fistulas affected the right bronchial stump in 17, and the left in 2, cases after pneumonectomy. The time between pneumonectomy and transsternal transpericardial operation ranged between 1 month and 4 years. All patients were submitted to drainage and irrigation of the empyema cavity (2-4 weeks). In 16 patients a long bronchial stump was sutured or stapled, in three cases resection of a short stump with the distal trachea was followed by anastomosis of the trachea and left main stem bronchus. Irrigation of the pneumonectomy cavity was continued in all patients for 2 weeks. Transsternal transpericardial operation was successful in 15 patients. Two patients died in the first 30 days, of renal or respiratory failure without fistula recurrence. In two cases the fistula recurred; definitive healing was achieved using a great omentum flap and endoscopic application of fibrin glue and bone spongiosa. Transsternal transpericardial management of bronchus stump fistula after pneumonectomy is highly effective and offers advantages over the direct approach through the infected empyema cavity.

Development of a new insertion technique and a new device for the placement of bifurcated airway stents.

We developed a new insertion technique and designed a forceps device for the placement of bifurcated airway stents; 131 of 142 endoscopically placed tracheobronchial Y-stents were inserted with a forceps and a laryngoscope. For the last 52 stent implantations we used the new stent forceps. It was determined to be a simple and safe method without major complications. In 11 cases alternative techniques had to be used. Technique and device are described in detail.

Theoretical and experimental basis for the development of a dynamic airway stent.

Three major problems are currently associated with airway stents: mucostasis, formation of granulation tissue, and migration. We wanted to determine whether these problems could be solved by a different stent design. Based on theoretical considerations of an idealized trachea, we developed a dynamic bifurcation stent made of silicone which incorporates horseshoe-shaped steel struts. A flexible posterior membrane enables dynamic compression during cough, whilst the clasps maintain the airway lumen in the face of external compression. The design of the stent cast was based upon computed tomographic (CT)-scan studies of the central airways. Its complex shape provides a smoother distribution of pressure on the mucosa; thereby, lowering the stimulus for granulation formation. The bronchial limbs saddle on the carina, preventing displacement. The mechanical behaviours of the new stent and two commercially available stents were compared in an ex-vivo model, utilizing freshly excised tracheae and new visualization techniques. Dynamic (artificial coughs) and static loads (simulating tumour compression or pleural pressures) were applied on excised human tracheae with different stents. Our dynamic stent preserved effective compression of the posterior membrane in response to cough, and also provided lumen stability against extrinsic compression. In comparison, the two commercially available stents did not provide both functions equally well. In conclusion, our newly designed dynamic bifurcation stent shows characteristics which should prove useful in avoiding problems currently associated with airway stents.

Three years experience with a new balloon catheter for the management of haemoptysis.

For the management of severe haemoptysis we have developed a double-lumen, bronchus-blocking catheter that can be introduced through the working channel of a standard fibrebronchoscope. We wondered whether this catheter would be suitable to control pulmonary haemorrhage in clinical practice. Over a period of 36 months, 30 of these catheters were used in 27 patients with moderate and massive pulmonary bleeding from various lesions. Underlying diseases were: malignancies (11), vascular deformities (5), tuberculosis (4), silicosis (2), carcinoids (2), silicosis (2), endometriosis (1), bronchiectasis (1). In 26 cases, the transbronchoscopic balloon tamponade was successful. In one patient, tumour growth close to the carina prevented securing of the balloon and double-lumen tube intubation was required. There were only minor complications attributable to the balloon. With the catheter in place for up to seven days, patients underwent surgery, received radiation, chemotherapy, drug treatment or bronchial arterial embolization. In conclusion, we found this double-lumen, bronchus-blocking device safe and the technique practicable to control pulmonary haemorrhage.

Omentopexy and muscle transposition: two alternative methods in the treatment of pleural empyema and mediastinitis.

From March 1987 to March 1993, 64 patients with chronic empyema and mediastinitis were treated with omentum and thoracic muscle transposition. There were 36 male and 28 female patients, age range 29 to 76 years. 31 patients suffered from chronic empyema and bronchopleural fistula after lung surgery, 18 patients had chronic empyema after pulmonary inflammatory disease, and 15 patients developed a mediastinitis with or without pleural empyema after cardiac surgery or irradiation of the chest wall. The pedicled omentum was used in 33, the thoracic muscles latissimus dorsi, pectoralis major, serratus anterior, and trapezius either alone or combined in 31 cases. There were no perioperative deaths. Bronchopleural fistulas and infected spaces were successfully closed in 61 patients (95.3%). Postoperative CT scan, angiography, bronchoscopy, and lung function tests demonstrate the efficacy of both surgical methods. Omentum pedicle and thoracic muscle flaps supply excellent vascularised tissue to fill infected pleural space and mediastinum, particularly in patients with limited cardiopulmonary function.

[Surgery of locally advanced non-small-cell bronchial cancer after intensive preoperative chemo-/radiotherapy]. / Chirurgie des lokal fortgeschrittenen nicht-kleinzelligen Bronchialcarcinoms nach intensiver präoperativer Chemo-/Strahlentherapie.

From March 1991 to June 1993 50 patients with local advanced NSCLC (mediastinoscopy obligatory) have been entered into an ongoing trial with preoperative chemotherapy and simultaneous chemo-/radiotherapy, followed by re-mediastinoscopy and surgery. Clinical response rates after chemotherapy amounted to 66.8% after chemo/radiotherapy 77.5%, no severe toxicity was observed. 36 patients ultimately underwent operation, 29 with a curative, 5 with a palliative resection and 2 with an explorative thoracotomy. Pathological complete remission rates of the primary tumor were found in 11 (32.3%), R0-resection in 18 (52.9%) and R1-resection in 5 (14.7%) cases. Sterilisation rates of mediastinal nodes were found in 86.3% of N2 tumors and 66.6% of N3 tumors. Median survival time ranged between 21 months for stage III a and 16 months for III b disease. This intensive preoperative neoadjuvant treatment is tolerable and effective, the requirements for a randomised comparative trial was met.

Sequential bilateral lung transplantation for pulmonary alveolar microlithiasis.

Lung transplantation has been successfully used in the treatment of patients with end-stage pulmonary disease and adequate cardiac function. We report about a 32-year-old man with pulmonary alveolar microlithiasis who underwent sequential bilateral lung transplantation. Preoperative hemodynamic studies revealed severe pulmonary hypertension; the right ventricular ejection fraction was 0.27. Eighteen months postoperatively, he continues to do well with normalized pulmonary and cardiac function and without clinical or histopathologic signs of graft rejection.

[The current role of thoracoplasty in treatment of chronic pleural empyema]. / Die heutige Rolle der Thorakoplastik zur Behandlung des chronischen Pleuraempyems.

To demonstrate the indication for surgery, the preoperative and postoperative course, and to assess the influence of thoracoplasty on respiratory physiology, the data of patients subjected to thoracoplasty during the past 30 years at our hospital were evaluated. Final assessment was performed separately for patients with and without preceding pulmonary resection. In 21 cases there was an unspecific empyema of the pleura and in 6 cases a specific one; in 14 cases there was also a concomitant bronchopleural fistula. After a washing-out period of 92 days (24-283) and after surgery had been unsuccessful in 9 patients, standard thoracoplasty was performed, complemented by a "jalousie" ("Venetian blind") plasty after Heller. Postoperative lethality was 11.1%. 5 patients developed pleuro-cutaneous fistulas that healed by local treatment; in one patient, a small residual cavity remained that required an additional plasty for correction. In 94% of the patients who had been operated upon, scoliosis occurred convex to the thoracoplasty; this was more marked in patients in whom lung resection had been performed than in patients without resection. Restrictive ventilatory disorders were seen in the lung function of 55% of the patients, whereas mixed restrictive-obstructive disorders occurred in 45%. Ergospirometry resulted under load besides in an increased respiratory minute volume (AMV), in a proportionate dead space of the AMV which was significantly higher than preoperatively. Despite the considerable functional and aesthetic consequences resulting therefrom, thoracoplasty still has its justification in refractory pleura empyemas as an ultimate means of cleaning up.

[Endobronchial prosthesis: experience report]. / Endobronchiale Prothesen--ein Erfahrungsbericht.

Between January 1988 and December 1990 a total of 84 endobronchial prosthesis were implanted in 55 patients at the Ruhrlandklinik, Essen. Bronchial carcinoma (33/55) was the leading indication for placing an endoluminal stent. Since the technique of implantation seldom leads to serious complications, non-malignant tracheobronchial stenosis and malacia play an increasing role in airway stenting. Implantation was usually performed under general anaesthesia and through rigid tube bronchoscopes with enlarged diameters. Most frequently a flexible silicone stent (Dumon) was used, Montgomery (5/84), Gianturco (5/84), Orlowski (4/84) and Strecker stents were also implanted. The respiratory gain was greatest in central stenosis, 79/84 stents were positioned into trachea or main stem bronchus. Permanent and temporary stenting were performed with success. Dislocation and hemoptysis seldom occur, mucus plugging and incrustation were more frequent complications.