The impact of the location, incidence and distribution of lung metastases in primary colorectal and renal cell cancer patients on prognosis: a retrospective observational study.

Background: Patients with distant metastases have an unfavourable prognosis, but patients with isolated pulmonary metastases should generally not be considered hopeless. Complete resection of metachronous and solitary metastases leads to prolonged survival; however, the influence of the location, distribution and bilaterality of pulmonary metastases needs to be investigated further. This article aimed to investigate the role of the distribution of lung metastases in primary colorectal and renal cell cancer patients on prognosis. Methods: We retrospectively investigated the prognosis of patients with pulmonary metastases and colorectal or renal cell carcinoma, defined as the survival time of patients with different metastases. The types of metastases were unilobar, multilobar, unilateral, bilateral, diffuse, synchronous, or metachronous. The secondary outcome of this study was differences in prognosis according to additional criteria. Results: Patients with metachronous metastases had significantly greater median survival than patients with synchronous metastases. There was a statistically significant difference in median survival between patients with unilateral (better survival) and patients with bilateral (worse survival) lung metastases. In patients with renal cell carcinoma, a statistically significant difference in median survival time was detected for patients with unilateral metastases. A significantly longer median survival time was observed in patients without diffuse metastases. A significantly greater median survival time was detected in patients with no thoracic nodal involvement. Moreover, there was no statistically significant difference in the median survival time for patients with colorectal versus renal cell carcinoma in general or for those with lung metastases. No statistically significant difference in median survival time was detected for patients according to single or multiple lung metastases, additional tumours or metastases during disease, the distance of residence from a specialized clinic in Coburg, sex, smoking or adipocytes, multimorbidity, immunosuppression or different cancer treatments. Conclusions: For a minority of patients, pulmonary resection is a chance for prolonged survival. The perioperative mortality rate after metastasectomy is less than five percent. Patients with metachronous and unilateral lung metastases should be evaluated for surgery. Patients with diffuse metastases or lymph node involvement have a significantly shorter median survival time. Decision-making should be interdisciplinary.

Comparison of outcomes of surgical and other invasive treatment modalities for malignant pleural effusion in patients with pleural carcinomatosis.

Background: Treatment modalities for malignant pleural effusion (MPE) are diverse. The objectives were to analyze actual clinical data from patients with MPE and pleural carcinomatosis and to compare the outcomes of different treatment modalities with regard to effectiveness, survival, morbidity, and mortality as well as the duration of hospitalization. Methods: Patients with pathologically proven pleural carcinomatosis or MPE from 2018 to 2020 were included in this retrospective-observational study with additional questionnaires. We identified four treatment modalities: (I) video-assisted thoracic surgery with pleurodesis (VATS, mechanical/chemical); (II) VATS with pleurodesis combined with indwelling pleural catheter (IPC) placement; (III) VATS (without pleurodesis) combined with IPC placement; and (IV) management with IPC placement alone. Results: We enrolled 91 patients aged 38-90 years who were treated by either VATS-pleurodesis (N=22), VATS-IPC placement (N=21), a combination of VATS with pleurodesis and IPC placement (N=22), or IPC placement alone (N=26). The mean survival time was 138.3 days. No significant differences were detected among treatment groups regarding the outcome of pleurodesis failure, either initially or later. Patients in the VATS-pleurodesis with IPC group experienced significantly more complications than those in the other treatment modality groups [odds ratio (OR): 3.288, P=0.026]. However, no statistically significant differences were observed regarding the type of adverse event and survival. Hypoalbuminemia, systemic therapy, and successful pleurodesis (P=0.008; P=0.011; P=0.044, respectively) were significantly correlated with survival. In multiple linear regression, hypoalbuminemia persisted as an independent predictor of survival (P=0.031). The type of intervention showed significant differences regarding the duration of hospitalization (P=0.017). IPC placement alone shortened the mean total hospitalization time by 7.9, 5.9, and 7.0 days compared to VATS-pleurodesis (P≤0.001), VATS-IPC placement (P=0.004), and VATS-pleurodesis with IPC placement (P≤0.001), respectively. Conclusions: The survival time was very short, and each treatment group had pros and cons. Therefore, decisions should be made on a case-by-case basis. The use of an IPC, even if the lung is not trapped, can significantly reduce the length of hospital stay. VATS is needed when histology is needed. The ideal method for treating recurrent MPE should be simple, effective, and inexpensive, with minimal disturbance to the patient.

Ability of 18F-FDG Positron Emission Tomography Radiomics and Machine Learning in Predicting KRAS Mutation Status in Therapy-Naive Lung Adenocarcinoma.

OBJECTIVE: Considering the essential role of KRAS mutation in NSCLC and the limited experience of PET radiomic features in KRAS mutation, a prediction model was built in our current analysis. Our model aims to evaluate the status of KRAS mutants in lung adenocarcinoma by combining PET radiomics and machine learning. METHOD: Patients were retrospectively selected from our database and screened from the NSCLC radiogenomic dataset from TCIA. The dataset was randomly divided into three subgroups. Two open-source software programs, 3D Slicer and Python, were used to segment lung tumours and extract radiomic features from 18F-FDG-PET images. Feature selection was performed by the Mann-Whitney U test, Spearman's rank correlation coefficient, and RFE. Logistic regression was used to build the prediction models. AUCs from ROCs were used to compare the predictive abilities of the models. Calibration plots were obtained to examine the agreements of observed and predictive values in the validation and testing groups. DCA curves were performed to check the clinical impact of the best model. Finally, a nomogram was obtained to present the selected model. RESULTS: One hundred and nineteen patients with lung adenocarcinoma were included in our study. The whole group was divided into three datasets: a training set (n = 96), a validation set (n = 11), and a testing set (n = 12). In total, 1781 radiomic features were extracted from PET images. One hundred sixty-three predictive models were established according to each original feature group and their combinations. After model comparison and selection, one model, including wHLH_fo_IR, wHLH_glrlm_SRHGLE, wHLH_glszm_SAHGLE, and smoking habits, was validated with the highest predictive value. The model obtained AUCs of 0.731 (95% CI: 0.619~0.843), 0.750 (95% CI: 0.248~1.000), and 0.750 (95% CI: 0.448~1.000) in the training set, the validation set and the testing set, respectively. Results from calibration plots in validation and testing groups indicated that there was no departure between observed and predictive values in the two datasets (p = 0.377 and 0.861, respectively). CONCLUSIONS: Our model combining 18F-FDG-PET radiomics and machine learning indicated a good predictive ability of KRAS status in lung adenocarcinoma. It may be a helpful non-invasive method to screen the KRAS mutation status of heterogenous lung adenocarcinoma before selected biopsy sampling.

Disseminated cancer cells detected by immunocytology in lymph nodes of NSCLC patients are highly prognostic and undergo parallel molecular evolution.

In melanoma, immunocytology (IC) after sentinel lymph node disaggregation not only enables better quantification of disseminated cancer cells (DCCs) than routine histopathology (HP) but also provides a unique opportunity to detect, isolate, and analyse these earliest harbingers of metachronous metastasis. Here, we explored lymph node IC in non-small cell lung cancer (NSCLC). For 122 NSCLC patients, 220 lymph nodes (LNs) were split in half and prepared for IC and HP. When both methods were compared, IC identified 22% positive patients as opposed to 4.5% by HP, revealing a much higher sensitivity of IC (p < 0.001). Assessment of all available 2,952 LNs of the same patients by HP uncovered additional patients escaping detection of lymphatic tumour spread by IC alone, consistent with the concept of skip metastasis. A combined lymph node status of IC and complete HP on a larger cohort of patients outperformed all risk factors in multivariable analysis for prognosis (p < 0.001; RR = 2.290; CI 1.407-3.728). Moreover, isolation of DCCs and single-cell molecular characterization revealed that (1) LN-DCCs differ from primary tumours in terms of copy number alterations and selected mutations and (2) critical alterations are acquired during colony formation within LNs. We conclude that LN-IC in NSCLC patients when combined with HP improves diagnostic precision, has the potential to reduce total workload, and facilitates molecular characterization of lymphatically spread cancer cells, which may become key for the selection and development of novel systemic therapies. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Standardized 18F-FDG PET/CT radiomic features provide information on PD-L1 expression status in treatment-naïve patients with non-small cell lung cancer.

PURPOSE: To study the relationship between standardized 18F-FDG PET/CT radiomic features and clinicopathological variables and programmed death ligand-1 (PD-L1) expression status in non-small cell lung cancer (NSCLC) patients. METHODS: 58 NSCLC patients with preoperative 18F-FDG PET/CT scans and postoperative results of PD-L1 expression were retrospectively analysed. A standardized, open-source software was used to extract 86 radiomic features from PET and low-dose CT images. Univariate analysis and multivariate logistic regression were used to find independent predictors of PD-L1 expression. The Area Under the Curve (AUC) of receiver operating characteristic (ROC) curve was used to compare the ability of variables and their combination in predicting PD-L1 expression. RESULTS: Multivariate logistic regression resulted in the PET radiomic feature GLRLM_LGRE (Odds Rate (OR): 0.300 vs 0.114, 95% confidence interval (CI): 0.096-0.931 vs 0.021-0.616, in NSCLC and adenocarcinoma respectively) and the CT radiomic feature GLZLM_SZE (OR: 3.338 vs 7.504, 95%CI: 1.074-10.375 vs 1.382-40.755, in NSCLC and adenocarcinoma respectively), being independent predictors of PD-L1 status. In NSCLC group, after adjusting for gender and histology, the PET radiomic feature GLRLM_LGRE (OR: 0.282, 95%CI: 0.085-0.936) remained an independent predictor for PD-L1 status. In the adenocarcinoma group, when adjusting for gender the PET radiomic feature GLRLM_LGRE (OR: 0.115, 95%CI: 0.021-0.631) and the CT radiomic feature GLZLM_SZE (OR: 7.343, 95%CI: 1.285-41.965) remained associated with PD-L1 expression. CONCLUSION: NSCLC and adenocarcinoma with PD-L1 expression show higher tumour heterogeneity. Heterogeneity-related 18F-FDG PET and CT radiomic features showed good ability to non-invasively predict PD-L1 expression.

[Surgical Treatment of Lung Cancer: How Has the Introduction of the 8th Edition of the TNM Classification Affected Guideline-Based Therapy?] / Ergeben sich durch die Einführung der 8. Auflage der TNM-Klassifikation Änderungen für eine leitliniengerechte, chirurgische Therapiestrategie des Lungenkarzinoms?

STUDY AIM: The 8th edition of the TNM classification combined with the latest update of the S3-guideline (by AWMF/Scientific Medical Societies in Germany) on prevention, diagnosis, therapy and follow-up of lung cancer led to several changes in staging and treatment of lung cancer. The aim of this study was to identify differences in the distribution of patients due to changes from the 7th to the 8th edition that affected staging. The influence on surgical therapy will be discussed by using the recommendations of the latest S3 guideline. METHODS: Prospective analysis of all primary cases at two thoracic surgical centres in the year 2016 and follow-up in March 2019. Comparison of the 7th edition of tumour classification for lung cancer with the 8th edition, focused on changes in tumour staging and its effects on the appropriate surgical therapy according to the latest S3 guideline. RESULTS: A total of 432 primary cases comprised the study population. According to the 8th edition, 82 patients (7th edition: n = 85) in stage I, 43 (n = 49) patients in stage II, 100 (n = 91) patients in stage III and 207 (n = 207) patients are assigned to stage IV. 81 changes (18.7%) were detected (77 upgrades vs. 4 downgrades). 63 patients (14.6%) exhibited a different graduation within the stages. 18 patients (4.1%) were classified in different tumour stages. As a result, fewer patients (n = 12; 2.8%) should have surgery according to the latest S3 guidelines. 290 patients (67.1%) were classified to new subgroups (IA1-3, IIIC and IVA/B). Two-year survival was significantly higher in IVA (25.2%) vs. IVB (13.0%) patients (p < 0.05). CONCLUSION: The 8th edition of the TNM-classification affords a higher level of differentiation. In this study, the new TNM classification led to a shift in the distribution, with a tendency to increase the tumour stage. This is mainly caused by changes in the T-descriptor and stage grouping. As a result, fewer patients in stage I - IIIA should have surgery according to the latest S3 guidelines. A significantly higher two-year survival rate was detected in stage IVA (M1a and M1b) compared to IVB and justifies the new differentiation due to the metastatic pattern.

Blast injures to the thorax.

One out of 10 of military casualties and 6-9 out of 10 civilian victims of terror incidents suffer pulmonary blast injuries when the attackers use explosives as weapon. No specific therapy exists for the primary, shock-wave injury to the lung. The treatment protocols are based on mechanical ventilation, intensive therapy and supportive care. Secondary and tertiary blast structural injuries to the thorax require damage control surgery, dominated by pleural space management (drainage) and haemorrhage control (thoracotomy if needed). Parenchyma resection of irreversibly destroyed lung is rarely needed, and non-anatomical resections are to be preferred. Delayed chest wall reconstruction follows haemodynamic stabilisation and completion of demarcation process. Blast injury to the chest requires a multidisciplinary approach, where the outcome is strongly influenced by the concomitant injuries.

[Modern Treatment Options for Postoperative Chylothorax: a Systematic Review]. / Systematische Übersichtsarbeit: moderne Behandlungsverfahren beim postoperativen Chylothorax.

BACKGROUND: Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis. MATERIAL AND METHODS: The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations. RESULTS: The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3 - 90%). Non-invasive or semi-invasive procedures are successful in 50 to 100% of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100%. The morbidity and mortality rate can reach values up to 25%. CONCLUSION: Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.

[Surgical Treatment of Pseudotumours of the Lung]. / Chirurgische Therapie von Pseudotumoren der Lunge.

INTRODUCTION: Pseudotumour of the lung is a collective term for various subentities. Some subgroups are considered to be intermediary malignant tumours. A pseudotumour is a rare condition, which makes it difficult to estimate its incidence and prevalence. METHODS: Retrospective analysis of all surgically treated patients between 2008 and 2015 diagnosed with a pseudotumour of the lung. The primary endpoint of this study was to estimate the rates of local recurrence and metastasis. Secondary endpoints were to determine the nomenclature, medical history, treatment, and the perioperative course. RESULTS: Out of 27 patients (10 females and 17 males) with a median age of 58 years, 19 patients (70%) had an inflammatory pseudotumour (IPT), and four patients (15%) had an inflammatory myofibroblastoma (IMT). Two patients had a pneumocytoma/histiocytoma. A preoperative pulmonary infection was present in 12 (44%) patients. The average tumour size was 2.1 cm (0.8 - 5.3 cm), with the lower pulmonary lobes being mostly affected (52%). One enucleation, 20 atypical wedge resections and six anatomical resections were performed. This was done in a minimally invasive procedure (VATS) in 48% of cases (13/27). R0 resection was achieved in 93% of cases (25/27). Complications occurred in seven (26%) patients. The difference between the duration of hospital stay (mean duration 8 days) after open resection and VATS was minimal (8.8 vs. 7.2 days). Patients were followed up over a period of 4 years, during which time only one patient developed a tumour recurrence, which led to the patient's death, although she had had a R0 resection of an IMT. CONCLUSIONS: The treatment of choice for pseudotumours of the lung is R0 resection, preferably with VATS. Most patients have a benign course of disease, although relapses are possible in some cases, especially in IMT. Follow-up monitoring is necessary for IMT. The application of a uniform nomenclature and classification would be a sensible approach.

Evaluation of the new TNM-staging system for thymic malignancies: impact on indication and survival.

BACKGROUND: The objective of this study is the evaluation of the Masaoka-Koga and the International Association for the Study of Lung Cancer (IASLC)/International Thymic Malignancy Interest Group (ITMIG) proposal for the new TNM-staging system on clinical implementation and prognosis of thymic malignancies. METHODS: A retrospective study of 76 patients who underwent surgery between January 2005 and December 2015 for thymoma. Kaplan-Meier survival analysis was used to determine overall and recurrence-free survival rates. RESULTS: Indication for surgery was primary mediastinal tumor (n = 55), pleural manifestation (n = 17), or mediastinal recurrence (n = 4) after surgery for thymoma. Early Masaoka-Koga stages I (n = 9) and II (n = 14) shifted to the new stage I (n = 23). Advanced stages III (Masaoka-Koga: n = 20; ITMIG/IASLC: n = 17) and IV (Masaoka-Koga: n = 33; ITMIG/IASLC: n = 35) remained nearly similar and were associated with higher levels of WHO stages. Within each staging system, the survival curves differed significantly with the best 5-year survival in early stages I and II (91%). Survival for stage IV (70 to 77%) was significantly better compared to stage III (49 to 54%). Early stages had a significant longer recurrence-free survival (86 to 90%) than advanced stages III and IV (55 to 56%). CONCLUSIONS: The proportion of patients with IASLC/ITMIG stage I increased remarkably, whereas the distribution in advanced stages III and IV was nearly similar. The new TNM-staging system presents a clinically useful and applicable system, which can be used for indication, stage-adapted therapy, and prediction of prognosis for overall and recurrence-free survival.

Short-term and long-term outcomes of intrathoracic vacuum therapy of empyema in debilitated patients.

BACKGROUND: This retrospective study analyzed the effectiveness of intrathoracic negative pressure therapy for debilitated patients with empyema and compared the short-term and long-term outcomes of three different intrapleural vacuum-assisted closure (VAC) techniques. METHODS: We investigated 43 consecutive (pre)septic patients with poor general condition (Karnofsky index ≤ 50 %) and multimorbidity (≥ 3 organ diseases) or immunosuppression, who had been treated for primary, postoperative, or recurrent pleural empyema with VAC in combination with open window thoracostomy (OWT-VAC) with minimally invasive technique (Mini-VAC), and instillation (Mini-VAC-Instill). RESULTS: The overall duration of intrathoracic vacuum therapy was 14 days (5-48 days). Vacuum duration in the Mini-VAC and Mini-VAC-Instill groups (12.4 ± 5.7 and 10.4 ± 5.4 days) was significantly shorter (p = 0.001) than in the group treated with open window thoracostomy (OWT)-VAC (20.3 ± 9.4 days). No major complication was related to intrathoracic VAC therapy. Chest wall closure rates were significantly higher in the Mini-VAC and Mini-VAC-Instill groups than in the OWT-VAC group (p = 0.034 and p = 0.026). Overall, the mean postoperative length of stay in hospital (LOS) was 21 days (median 18, 6-51 days). LOS was significantly shorter (p = 0.027) in the Mini-VAC-Instill group (15.1 ± 4.8) than in the other two groups (23.8 ± 12.3 and 22.7 ± 1.5). Overall, the 30-day and 60-day mortality rates were 4.7 % (2/43) and 9.3 % (4/43), and none of the deaths was related to infection. CONCLUSIONS: For debilitated patients, immediate minimally invasive intrathoracic vacuum therapy is a safe and viable alternative to OWT. Mini-VAC-Instill may have the fastest clearance and healing rates of empyema.

Immune Architecture of Colorectal Lung Metastases and Implications for Patient Survival.

BACKGROUND: Pulmonary metastases occur in 10-20% of patients with colorectal cancer and significantly influence long-term survival. In this study, the immunological architecture of colorectal lung in comparison to liver metastases and its impact on patient survival were examined. METHODS: Specimens of patients with colorectal lung and liver metastases were stained for HE, CD4, CD8, CD20, CD68 and CD45RO. Besides histomorphological evaluation, immunohistochemical stainings were analyzed for the respective cell numbers separately for tumor area, infiltrative margin and distant lung or liver stroma. These findings were correlated with clinical data and patient outcome. RESULTS: In colorectal lung (n = 69) in comparison to liver (n = 222) metastases, the immunological focus is located in the tumor region. A high CD4+ cell infiltration of this area is associated with prolonged survival of patients after resection of colorectal lung metastases [103 ± 33 (high) vs. 37 ± 6 months (low); p = 0.0246]. Patients who were treated with preoperative chemotherapy did not show differences in immune infiltrates compared to chemotherapy-naïve patients. CONCLUSION: Colorectal lung and liver metastases showed a distinct immunological architecture. A dense cell infiltration of colorectal lung metastases by CD4+ cells was related to prolonged patient survival. Preoperative chemotherapy did not influence cellular immune infiltrates.

[Review of evidence-based modern treatment for chylothorax]. / A chylothorax modern kezelésének bizonyítékalapú áttekintése.

Chylothorax is a multi-factorial complication, frequently of an operation or an accident, but rarely of a tumour. In the absence of prospective or randomised studies evidence-based treatment is normally based on personal experience, ideally in the possession of retrospective analyses using the "best practice" method. The aim of the authors was the review the up-to-date chylothorax treatments. They performed the PubMed database's "chylothorax" keyword search of the publications reported in the last ten years. They put emphasis on articles that included a comparative analysis of the various treatment options. During the critical analysis of the methods and recommendations, the authors relied on their own joint experience amounting to 39 years. The results showed that the success of the initial conservative treatment indicates a significant deviation depending on the etiology (3-90%). The success rate of non-invasive or semi-invasive interventions is between 50-100%, again depending on the etiology. The standard surgical treatment following an unsuccessful conservative treatment of an operable patient includes the fitting of a (thoracoscopic) knot to the ductus thoracicus, pleurodesis, insertion of a permanent chest drain or a pleuroperitoneal shunt. The success rate of these interventions is between 64-100%, with a morbidity index and mortality index exceeding 25%. Conservative treatment should be the first step, which should then be followed by a gradually increased aggressive therapy, during which the decisions should be made according to the patient's condition and the drain volume. Interventional radiology procedures are safe, successful and they can be offered concurrently with conservative or operative treatment, although they are available only in a few centres.

Radical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support.

BACKGROUND: Radical surgical resection of advanced thymic tumors invading either the heart or great vessels facing towards the heart is uncommonly performed because of the potential morbidity and mortality. To achieve a complete tumor resection, the use of cardiolpulmonary bypass (CPB) support might be necessary. METHODS: Retrospective analysis of the results in six patients, who underwent radical tumor resection with CBP support. RESULTS: Mean age was 46 years (27 to 66 years) and five patients were male. Tumor infiltration of the heart or the great vessels was evident in all patients. Five patients underwent induction therapy. Two patients were operated in complete cardioplegic arrest (antegrade cerebral perfusion: n = 1). Arterial cannulation of the ascending aorta (n = 5) or the femoral artery (n = 1) and venous cannulation of the right atrium (n = 4) or the femoral vein (n = 2) were performed. Resection of the left brachiocephalic vein (n = 6), resection of the superior caval vein (n = 2), the ascending aorta (n = 1) and the complete aortic arch with outgoing branches (n = 1) were performed. A macroscopic complete resection (R0/R1) was achieved in five patients, whereas one patient was resected incompletely (R2). In-hospital mortality was 0 %. Three (50 %) patients needed operative revision (hematothorax: n = 2, chylothorax: n = 1). All patients had a complicated postoperative course and developed respiratory insufficiency. CONCLUSIONS: Locally advanced thymoma/thymic carcinoma invading the heart or great vessels can be treated with radical surgical resection alongside with increased perioperative morbidity. The usage of CBP improves the chance of complete tumor resection in selected patients and might lead to a prolonged survival.

Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema.

OBJECTIVES: This prospective study is an evaluation of the mini-open vacuum-assisted closure with instillation (Mini-VAC-Instill) therapy for the treatment of complicated pleural empyema. METHODS: We investigated septic patients in poor general physical condition (Karnofsky index ≤50%) with multimorbidity and/or immunosuppression who were treated by minimally invasive intrathoracic VAC-Instill therapy without the insertion of an open-window thoracostomy (OWT) between December 2012 and November 2014. All patients underwent mini-thoracotomy with position of a tissue retractor, surgical debridement and local decortication. Surgery was followed by intrathoracic vacuum therapy including periodic instillation using antiseptics. The VAC dressings were changed under general anaesthesia and the chest wall was closed during the same hospital stay. All patients received systemic antibiotic therapy. RESULTS: Fifteen patients (13 males, median age: 71 years) underwent intrathoracic Mini-VAC-Instill dressings for the management of pleural empyema without bronchopleural fistula. The median length of vacuum therapy was 9 days (5-25 days) and the median number of VAC changes per patient was 1 (1-5). In-hospital mortality was 6.7% (n = 1) and was not related to Mini-VAC-Instill therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in 85.7% of surviving patients (12 of 14). After the follow-up at an average of 13.2 months (range, 3-25 months), we observed recurrence once, 21 days after discharge. Two patients died in the late postoperative period (Day 43 and Day 100 after discharge) of fulminant urosepsis and carcinoma-related multiorgan failure, respectively. Analysis of the follow-up interviews in the outpatient clinic showed a good quality of life and a subjectively good long-term aesthetic result. CONCLUSIONS: Mini-VAC-Instill therapy is an upgrade of Mini-VAC, which guarantees the advantage of an open treatment, including flushing but without OWT. This procedure is minimally invasive, highly compatible especially with patients in poor general condition and may be an alternative to the OWT in selected patients. Consequently, a very short course of therapy results in good patient acceptance.

Minimally Invasive Vacuum-Assisted Closure Therapy With Instillation (Mini-VAC-Instill) for Pleural Empyema.

Enthusiasm for minimally invasive thoracic surgery is increasing. Thoracoscopy plays a significant therapeutic role in the fibrinopurulent stage (stage II) of empyema, in which loculated fluid cannot often be adequately drained by chest tube alone. For some debilitated and septic patients, further procedures such as open-window thoracostomy (OWT) with daily wound care or vacuum-assisted closure (VAC) therapy are necessary. In the present article, we propose a new option of minimally invasive VAC therapy including a topical solution of the empyema without open-window thoracostomy (Mini-VAC-instill). Three patients who underwent surgery using this technique are also presented. The discussion is focused on the advantages and disadvantages of the approach.

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

OBJECTIVES: The effects of cisplatin on the lung parenchyma during hyperthermic intrathoracic chemotherapy perfusion have not been analysed in detail. The objective of this study was to evaluate both the concentration and depth of the penetration of cisplatin in human lung tissue after hyperthermic exposure under ex vivo conditions. METHODS: This experimental study was approved by the local ethics committee. Twelve patients underwent pulmonary wedge resections after elective thoracic lobectomies were performed (resected lobe), and the lung tissue (approximately 1-2 cm(3)) was incubated (in vitro) with cisplatin (0.05 mg/ml; 60 min, 42°C). Subsequent tissue beds (depth, 0.5 mm; median weight, 70-92 mg) were prepared from the outside to the middle, and the amount of cisplatin per tissue weight was analysed using atomic absorption spectrometry. Afterwards, the penetration of cisplatin depth was calculated and related to the different concentrations per tissue. RESULTS: Cisplatin penetrated into the human lung tissue after ex vivo hyperthermic exposure. The median amount of platinum [nmol cisplatin/g lung tissue] decreased significantly (P ≤ 0.05) depending on the penetration depth: 32 nmol/g (1 mm), 20 nmol/g (2 mm) and 6.8 nmol/g (4 mm). The calculated median concentrations of cisplatin (µg/ml) were 2.4 µg/ml (1 mm), 1.4 µg/ml (2 mm) and 0.5 µg/ml (4 mm), respectively. CONCLUSIONS: Under ex vivo hyperthermic conditions, cisplatin diffused into human lung tissue. The median penetration depth of the cisplatin was approximately 3-4 mm. The penetration of cisplatin into lung tissue may affect the local therapy of residual tumour cells on the lung surface using hyperthermic intrathoracic chemotherapy perfusion in patients with malignant pleural tumours.

Vacuum-assisted closure therapy in the management of lung abscess.

BACKGROUND: Despite significant advances in the treatment of thoracic infections, complex lung abscess remains a problem in modern thoracic surgery. We describe the novel application of vacuum-assisted closure for the treatment of a lung abscess. The technical details and preliminary results are reported. METHODS: After the initial failed conservative treatment of an abscess, minimally invasive surgical intervention was performed with vacuum-assisted closure. The vacuum sponges were inserted in the abscess cavity at the most proximal point to the pleural surface. The intercostal space of the chest wall above the entering place was secured by a soft tissue retractor. The level of suction was initially set to 100 mm Hg, with a maximum suction of 125 mm Hg. The sponge was changed once on the 3rd postoperative day. RESULTS: The abscess cavity was rapidly cleaned and decreased in size. The mini-thoracotomy could be closed on the 9th postoperative day. Closure of the cavity was simple, without any short- or long-term treatment failure. This technique reduced the trauma associated with the procedure. The patient was discharged on the 11th postoperative day. CONCLUSIONS: Vacuum-assisted closure systems should be considered for widespread use as an alternative option for the treatment of complicated pulmonary abscess in elderly, debilitated, immunocompromised patients after failed conservative treatment.

Minimally invasive epicardial left ventricular lead placement in a case of massive pleural adhesion.

BACKGROUND: In cases of intravenous placement failure of the left ventricular (LV) lead for cardiac resynchronisation therapy (CRT) and obliteration of the left pleural space, the alternative approach of transthoracic placement by video-assisted thoracoscopic surgery (VATS) is difficult and not commonly practiced. METHODS: Here, we present a simple technique for transthoracic introduction of an epicardial LV lead using a wound retractor (ALEXIS) in a patient with heart failure. This wound retractor enables atraumatic tissue retraction without rib spreading, an optimal direct view in the pleural space for surgical pleurolysis and a high degree of safety for the patient. RESULTS: No perioperative complications occurred. The tube drainage was removed on the second postoperative day, and the patient was discharged on the third postoperative day. CONCLUSIONS: The decided advantage of this new method is the lack of any need for rib spreading using a mechanical retractor. Especially in patients with a history of open-heart surgery (including internal mammary artery bypass grafting and/or revascularisation of the left lateral wall) or known pleural adhesions (e.g., pleuritis or lung operations), the described technique provides a rapid and save access with minimal surgical effort and greater safety.