Publications by authors named "Hans-Stefan Hofmann"

93 Publications

Exposure to cisplatin in the operating room during hyperthermic intrathoracic chemotherapy.

Int Arch Occup Environ Health 2021 Jun 30. Epub 2021 Jun 30.

Germany and Comprehensive Pneumology Center Munich, University Hospital, LMU Munich, Institute and Clinic for Occupational, Social and Environmental Medicine, Munich, Germany.

Purpose: Hyperthermic intrathoracic chemotherapy (HITOC) is an additive, intraoperative treatment for selected malignant pleural tumors. To improve local tumor control, the thoracic cavity is perfused with a cisplatin-containing solution after surgical cytoreduction. Since cisplatin is probably carcinogenic to humans, potential contamination of surfaces and pathways of exposure should be systematically investigated to enable risk assessments for medical staff and thus derive specific recommendations for occupational safety.

Methods: Wipe sampling was performed at pre-selected locations during and after ten HITOC procedures, including on the surgeon's gloves, for the quantitation of surface contaminations with cisplatin. After extraction of the samples with hydrochloric acid, platinum was determined as a marker for cisplatin by voltammetry.

Results: High median concentrations of cytostatic drugs were detected on the surgeons' (1.73 pg Cis-Pt/cm, IQR: 9.36 pg Cis-Pt/cm) and perfusionists' (0.69 pg Cis-Pt/cm, IQR: 1.73 pg Cis-Pt/cm) gloves. The display of the perfusion device showed partially elevated levels of cisplatin up to 4.92 pg Cis-Pt/cm and thus could represent an origin of cross-contamination. In contrast, cisplatin levels on the floor surfaces in the area of the surgeon and the perfusion device or in the endobronchial tube were relatively low.

Conclusion: With a correct use of personal protective equipment and careful handling, intraoperative HITOC appears to be safe to perform with a low risk of occupational exposure to cisplatin.
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http://dx.doi.org/10.1007/s00420-021-01738-3DOI Listing
June 2021

Nachwuchsakademie der DGT: Förderung von Forschungsnachwuchs in der Thoraxchirurgie.

Zentralbl Chir 2021 06 21;146(3):318. Epub 2021 Jun 21.

Universitätsmedizin Magdeburg, Klinik für Herz- und Thoraxchirurgie.

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http://dx.doi.org/10.1055/s-0037-1599669DOI Listing
June 2021

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults.

Interact Cardiovasc Thorac Surg 2021 May 17. Epub 2021 May 17.

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

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Objectives: Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered.

Methods: We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points.

Results: Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths.

Conclusions: Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.
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http://dx.doi.org/10.1093/icvts/ivab127DOI Listing
May 2021

Video-assisted pulmonary metastectomy is equivalent to thoracotomy regarding resection status and survival.

J Cardiothorac Surg 2021 Apr 15;16(1):84. Epub 2021 Apr 15.

Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.

Background: Surgical resection of pulmonary metastases leads to prolonged survival if strictly indicated. Usually, thoracotomy with manual palpation of the entire lung with lymph node dissection or sampling is performed. The aim of this study was to evaluate the role of video-assisted thoracoscopic surgery (VATS) in pulmonary metastectomy with curative intent.

Methods: In this study, all patients with suspected pulmonary metastasis (n = 483) who visited the Center for Thoracic Surgery in Regensburg, between January 2009 and December 2017 were analysed retrospectively.

Results: A total of 251 patients underwent metastectomy with curative intent. VATS was performed in 63 (25.1%) patients, 54 (85.7%) of whom had a solitary metastasis. Wedge resection was the most performed procedure in patients treated with VATS (82.5%, n = 52) and thoracotomy (72.3%, n = 136). Postoperative revisions were necessary in nine patients (4.8%), and one patient died of pulmonary embolism after thoracotomy (0.5%). Patients were discharged significantly faster after VATS than after thoracotomy (p < 0.001). Complete (R0) resection was achieved in 89% of patients. The median recurrence-free survival was 11 months (95% confidence interval 7.9-14.1). During follow-up, eight (12.7%) patients in the VATS group and 42 (22.3%) patients in the thoracotomy group experienced recurrence (p = 0.98). The median overall survival was 61 months (95% confidence interval 46.1-75.9), and there was no significant difference with regard to the surgical method used (p = 0.34).

Conclusions: VATS metastasectomy can be considered in patients with a solitary lung metastasis. An open surgical approach with palpation of the lung showed no advantage in terms of surgical outcome or survival.
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http://dx.doi.org/10.1186/s13019-021-01460-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048191PMC
April 2021

Classification and staging of thymoma.

J Thorac Dis 2020 Dec;12(12):7607-7612

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

The appropriate therapy and prognosis of patients with thymic malignancies is decisively influenced by the local extent and dissemination of the tumor. For this reason, a staging system that reflects these factors is essential. Mainly the Masaoka-Koga classification, which was introduced in 1994, has been applied for this purpose. The rarity of thymic malignancies makes it difficult not only to establish internationally standardized diagnostics and treatment, but also to progress staging. Besides, efforts were made to adapt the classification into a tumor-node-metastasis-based (TNM) system for standardization with the staging of other tumor entities. The 2017 published 8th edition of the TNM Classification of Malignant Tumors introduced several adjustments based on a proposal of the International Association for the Study of Lung Cancer (IASLC) and the International Thymic Malignancy Interest Group (ITMIG). Compared to the Masaoka-Koga classification, surgically good resectable tumor involvements like pericardium, mediastinal fat or mediastinal pleura have been shifted to lower stages. Thus, even more than in Masaoka-Koga classification, tumors are basically divided into completely resectable and thus surgically treatable tumors (stage I, II, IIIA) and advanced stages (stage IIIB, IVA and IVB) that require multimodal therapy.
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http://dx.doi.org/10.21037/jtd-2019-thym-01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797834PMC
December 2020

[Extended Resection of Locally Advanced Thymic Tumours in Stage III].

Zentralbl Chir 2021 Feb 23;146(1):119-125. Epub 2020 Jul 23.

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.

In the treatment of locally advanced thymic tumours, specific diagnostic testing is required, with a multimodal therapeutic approach consisting of surgery, radio- and/or chemotherapy. The complete resection of the tumour represents the most important prognostic factor with regard to recurrence-free and long-term survival. Local invasive growth of malignant thymic tumours into neighbouring mediastinal structures is classified as Masaoka-Koga stage III. Surgical resection can be performed primarily or after induction therapy, depending on the extent of the tumour. However, in some cases these tumours must be classified as non-resectable, so that only palliative radio-/chemotherapy remains as therapeutic option. TNM classification for malignant thymic tumours has been recently introduced. This resembles the established Masaoka-Koga classification in many aspects, but also includes some therapy-relevant changes. A differentiation is made between stages IIIA and IIIB, with the aim of assessing the resectability of advanced thymic tumours in a more differentiated manner and consequent planning of the therapy concept. Besides the thymus, thymoma, perithymic tissue, mediastinal pleura (stage I) or pericardium (stage II), all infiltrated structures should be removed "en bloc", if possible in stage III tumours. While the lung, brachiocephalic vessels or extrapericardial pulmonary vessels can still be resected and reconstructed if necessary, infiltration of the aorta or intrapericardial pulmonary vessels often limits macroscopically complete resection.
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http://dx.doi.org/10.1055/a-1192-6961DOI Listing
February 2021

Protocol of a retrospective, multicentre observational study on hyperthermic intrathoracic chemotherapy in Germany.

BMJ Open 2020 07 20;10(7):e041511. Epub 2020 Jul 20.

Department of Thoracic Surgery, Universitätsklinikum Regensburg, Regensburg, Bayern, Germany

Introduction: Objective of the 'German hyperthermic intrathoracic chemotherapy (HITOC) study' is to evaluate the HITOC as additional treatment after surgical cytoreduction for malignant pleural tumours. Even though HITOC is applied with increasing frequency, there is no standardised therapy protocol concerning the technique of HITOC, the selection as well as dosage of chemotherapeutic agents and perioperative management in order to provide a safe and comparable, standardised treatment regime.

Methods And Analysis: This trial is a retrospective, multicentre observational study, which is funded by the German Research Foundation. Approximately 300 patients will be included. Four departments of thoracic surgery, which are performing the most HITOC procedures in Germany, are contributing to this study: Center for Thoracic Surgery at the University Hospital Regensburg, Thoracic Clinic Heidelberg of the University of Heidelberg, Center for Thoracic Surgery of the Hospital University of Munich and the Department of Thoracic Surgery at the University Hospital Freiburg. All patients who underwent surgical cytoreduction and subsequent HITOC at one of the four centres between starting the HITOC programme in 2008 and December 2019 will be included. Information on the performed HITOC will be obtained, focusing on the technique as well as the applied perfusion solution including the chemotherapeutic agent. Furthermore, parameters of the patient's postoperative recovery will be analysed to determine 30-day morbidity and mortality.

Ethics And Dissemination: The approvals by the local ethics committee of the respective clinic and the three participating clinics have been obtained. The results will be presented in conferences and published in a peer-reviewed journal.

Trial Registration Number: German Clinical Trials Registry (DRKS00015012; Pre-results).
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http://dx.doi.org/10.1136/bmjopen-2020-041511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375498PMC
July 2020

[Surgical Treatment of Lung Cancer: How Has the Introduction of the 8th Edition of the TNM Classification Affected Guideline-Based Therapy?]

Zentralbl Chir 2020 Dec 6;145(6):589-596. Epub 2020 Jul 6.

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland.

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.
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http://dx.doi.org/10.1055/a-1164-7058DOI Listing
December 2020

[Five Years PLEURATUMOR Register of the German Society of Thoracic Surgery].

Zentralbl Chir 2021 Jun 6;146(3):321-328. Epub 2020 Jul 6.

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.

Background: Since 01.01.2015, the nationwide "PLEURATUMOR Register of the German Society of Thoracic Surgery (DGT)" has documented the most relevant parameters of patients with primary and secondary malignant pleural diseases receiving thoracic surgery in Germany. This online database is intended to record both primary and recurrent diseases. In particular, the registry focuses on the documentation of patients with pleural carcinosis, malignant pleural mesothelioma and tumours of the thymus with pleural dissemination.

Methods: A structured evaluation of all patients documented up to and including December 2019 was carried out.

Results: At this time, 33 departments participated in the PLEURATUMOR Register and 670 patients have been recorded. Of these patients, 522 data sets were complete and 516 patients received surgical treatment. Most patients were documented in 2017 (n = 135; 26.2%), and in 2019 (n = 72; 14%). With 317 listed patients (61.4%), pleural carcinosis was the most frequently reported pleural tumour, followed by malignant pleural mesothelioma (n = 175; 33.9%) and thymoma/thymic carcinoma with pleural metastases (n = 11; 2.1%). The majority of patients (n = 499; 96.7%) were treated because of an initial manifestation. The most frequently documented procedure was VATS-talcum pleurodesis (n = 204; 39.5%). In 69 patients (13.4%) hyperthermic intrathoracic chemotherapy was performed after cytoreductive surgery. Postoperative complications occurred in 107 patients (20.7%); in 35 cases (6.8%) surgical revision was necessary. The overall 30-day mortality was 8.3% (n = 43).

Conclusion: Due to the consistent data entry of the participating clinics, a representative dataset of pleural tumour diseases could be recorded. In the future, we hope for consistent continuation of data entry and the initiation of register-based studies.
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http://dx.doi.org/10.1055/a-1178-1355DOI Listing
June 2021

[Minimum volumes in surgical treatment of lung cancer : A survey of thoracic surgeons in Germany on the introduction of a minimum volume regulation for surgical treatment of lung cancer].

Chirurg 2020 Dec;91(12):1053-1061

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Deutschland.

Background: The Federal Joint Committee (G‑BA) is currently discussing the introduction of new minimum volume regulations (MVR) in Germany. The present study examined the current opinions of active thoracic surgeons regarding minimum volumes (MV) for the surgical treatment of lung cancer.

Methods: The participating centers for the online survey were identified on the basis of the thoracic surgery departments in the 2017 hospital directory (Federal Statistical Office), lung cancer centers (German Cancer Society), certified centers of excellence for thoracic surgery (German Society for Thoracic Surgery), hospitals with a focus on lung surgery and German university hospitals. They were asked about the potential effects of MVR on the quality of results and quality of care, economic aspects and the structure of care. Furthermore, a recommendation for MV was requested and possible provisions for exemption were evaluated.

Results: A total of 145 hospitals (response rate 85%) with 454 thoracic surgeons (response rate 54%) were surveyed. The results showed a high degree of approval for MV to improve the quality of results and 78.4% of the surgeons surveyed expected it to result in centralization of surgical care, although this would not lead to a deterioration in care according to 70.1% of the participants. Approximately 46.1% of the participants expected care to become more economical and 83.3% supported the introduction of an MVR, with the average recommended MV being 67 anatomical lung resections per center per year.

Conclusion: An MVR for the surgical treatment of lung cancer met with a high degree of approval among active thoracic surgeons. The MV that was called for (n = 67) was slightly below the prerequisite for primary surgical cases at a certified lung cancer center.
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http://dx.doi.org/10.1007/s00104-020-01185-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716896PMC
December 2020

Current status and evolution of robotic-assisted thoracic surgery in Germany-results from a nationwide survey.

J Thorac Dis 2019 Nov;11(11):4807-4815

Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany.

Background: Robot-assisted surgery has made a significant entry into surgical practice within Germany, including thoracic surgery. As no published data exists regarding robotic-assisted thoracic surgery (RATS), we conducted a survey to investigate its current status.

Methods: We performed a nationwide survey of all centers active in RATS, using a standardized questionnaire. The annual number of operations, mean duration of surgery, docking time, length of hospital stay(s), conversions, chest tube duration, the RATS program start date, robot system used, operating room capacity, and staplers and instruments used were recorded.

Results: Of the 22 centers contacted, 14 responded. In total, 786 RATS interventions were recorded. Most were anatomical lung resections, comprising 372 (bi-) lobectomies and 80 segmentectomies. During the study period, eight bronchoplastic procedures were performed robotically. There were 93 wedge lung resections, 148 thymectomies, 26 sympathectomies, and 59 other RATS procedures, and a single-center series of around 1,000 RATS thymectomies (excluded from statistical analysis). The average incision-suture time of the RATS lobectomy was 245 (range, 80-419) minutes, average residence time seven days. The conversion rate was 6.7% across all interventions, with significant inter-intervention differences. All surveyed centers plan to further expand RATS, with OR capacity being a frequent impediment. Five RATS interventions were performed in Germany in 2013, versus 320 in 2018.

Conclusions: Overall, RATS is becoming more established in everyday clinical practice in Germany. The number of operations, active centers, and trained RATS surgeons has increased steadily since 2013. A German-speaking operation course for entry into RATS already exists. Even extended resections can be carried out safely, and RATS has become standard procedure in some centers.
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http://dx.doi.org/10.21037/jtd.2019.10.48DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940261PMC
November 2019

Complicated chylous pericardial and thoracic effusion as the first clinical manifestation of thoracic lymphatic malformation.

Interact Cardiovasc Thorac Surg 2020 04;30(4):654-655

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

Lymphatic malformations are benign focal proliferations of lymphatic vessels with a congenital origin. We present a case of an 18-year-old patient with post-traumatic chylopericardium and recurrent left-sided chylothorax, who was unresponsive to a variety of therapeutic measures until he was diagnosed with a complicated thoracic lymphatic malformation.
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http://dx.doi.org/10.1093/icvts/ivz301DOI Listing
April 2020

[National Learning Objectives Catalogue in Surgery - General Part Defining Competences of Medical School Graduates in Surgery].

Zentralbl Chir 2019 Dec 16;144(6):573-579. Epub 2019 Dec 16.

Gründungsdekanat, Medizinische Fakultät der Universität Augsburg, Deutschland.

Competency-based medical education is needed in order to meet the requirements of medical care currently and in the future. The basis of this are activity-based learning objectives that are merged in competency-based catalogues. A basis for a core curriculum of undergraduate medical training is the National Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). Already in 2013, for surgery, the competencies which medical students should have achieved after completing the practical year (PJ) in relation to surgical diseases were defined in the special part of the National Catalogue of Learning Objectives in Surgery (NKLC). In the now amended general part of the NKLC, interdisciplinary competencies were defined and consented from all surgical disciplines, that are relevant for all surgical disciplines and that all representatives from the different surgical disciplines should incorporate in their surgical training. The complete NKLC is now available for faculties, teachers and students for trial (available online: https://www.dgch.de/index.php?id=190&L=528). The guiding principle for the entire development process was to make sure that students gain all competencies they need when starting to work as a medical doctor and therefor to increase patient safety.
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http://dx.doi.org/10.1055/a-1033-7769DOI Listing
December 2019

Surgical Cytoreduction and HITOC for Thymic Malignancies with Pleural Dissemination.

Thorac Cardiovasc Surg 2021 03 15;69(2):157-164. Epub 2019 Nov 15.

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

Background: Objective of this study was to assess postoperative morbidity and mortality as well as recurrence-free and overall survival in patients with thymic malignancies and pleural dissemination undergoing surgical cytoreduction and hyperthermic intrathoracic chemotherapy (HITOC).

Methods: Retrospective study between September 2008 and December 2017 with follow-up analysis in May 2018.

Results: A total of 29 patients (male:  = 17) with thymic malignancies and pleural spread (primary stage IVa:  = 11; pleural recurrence:  = 18) were included. Surgical cytoreduction was performed via pleurectomy/decortication (P/D;  = 11), extended P/D ( = 15), and extrapleural pneumonectomy (EPP;  = 3). These procedures resulted in 25 (86%) patients with macroscopically complete (R0/R1) resection. Intraoperative HITOC was performed for 60 minutes at 42°C either with cisplatin (100 mg/m body surface area [BSA]  = 8; 150 mg/m BSA  = 6; 175 mg/m BSA  = 1) or with a combination of cisplatin (175 mg/m BSA)/doxorubicin (65 mg;  = 14). Postoperative complications occurred in nine patients (31%). Cytoprotective therapy resulted in lower postoperative creatinine levels ( = 0.036), and there was no need for temporary dialysis in these patients. The 90-day mortality rate was 3.4%, as one patient developed multiple organ failure. While recurrence-free 5-year survival was 54%, an overall 5-year survival rate of 80.1% was observed. Survival depended on histological subtype ( = 0.01).

Conclusion: Surgical cytoreduction with HITOC is feasible in selected patients and offers encouraging survival rates. The application of cytoprotective agents appears to be effective for the prevention of postoperative renal insufficiency.
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http://dx.doi.org/10.1055/s-0039-1700883DOI Listing
March 2021

Adequate nephroprotection reduces renal complications after hyperthermic intrathoracic chemotherapy.

J Surg Oncol 2019 Dec 10;120(7):1220-1226. Epub 2019 Oct 10.

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

Background And Objectives: Hyperthermic intrathoracic chemotherapy (HITOC) is used for the treatment of malignant pleural tumors. Although HITOC proved to be safe, postoperative renal failure due to nephrotoxicity of intrapleural cisplatin remains a concern.

Methods: This single-center study was performed retrospectively in patients who underwent pleural tumor resection and HITOC between September 2008 and December 2018.

Results: A total of 84 patients (female n = 33; 39.3%) with malignant pleural tumors underwent surgical cytoreduction with subsequent HITOC (60 minutes; 42°C). During the study period, we gradually increased the dosage of cisplatin (100-150 mg/m BSA n = 36; 175 mg/m BSA n = 2) and finally added doxorubicin (cisplatin 175 mg/m BSA/doxorubicin 65 mg; n = 46). All patients had perioperative fluid balancing. The last 54 (64.3%) patients also received perioperative cytoprotection. Overall 29 patients (34.5%) experienced renal insufficiency. Despite higher cisplatin concentrations, patients with cytoprotection showed significantly lower postoperative serum creatinine levels after 1 week (P = .006) and at discharge (P = .020). Also, they showed less intermediate and severe renal insufficiencies (5.6% vs 13.3%).

Conclusions: Adequate perioperative fluid management and cytoprotection seem to be effective in protecting renal function. This allows the administration of higher intracavitary cisplatin doses without raising the rate of renal insufficiencies.
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http://dx.doi.org/10.1002/jso.25726DOI Listing
December 2019

[Expert Recommendation for the Implementation of Hyperthermic Intrathoracic Chemotherapy (HITOC) in Germany].

Zentralbl Chir 2020 Feb 10;145(1):89-98. Epub 2019 Jul 10.

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.

Introduction: During the last few years, hyperthermic intrathoracic chemotherapy (HITOC) has been performed in several departments for thoracic surgery in Germany. The objective of this expert recommendation is to provide elementary recommendations for a standardised HITOC treatment, which are based on clinical experiences and research data.

Methods: Between October and December 2018, a group of experts for thoracic surgery in five departments of thoracic surgery developed recommendations for the HITOC procedure in Germany. These experts were selected by the latest national survey for HITOC and had the most clinical experience with HITOC. All recommendations are based on clinical experience, the experts' research data and recent literature.

Results: All recommendations were evaluated by all participating departments in one consensus survey. Finally, a total of six main conclusions including a total of 17 recommendations were developed. For each recommendation, the strength of the consensus is presented in percentages. 100% agreement was established for nomenclature, technique, the chemotherapeutic agent, the perioperative management, the safety measures and the indications for HITOC. All experts recommended cisplatin as the first choice chemotherapeutic agent for HITOC. The dosage of cisplatin is specified in mg/m body surface area (BSA) and should be between 150 and 175 mg/m BSA. The volume of the perfusion fluid (approximately 4 - 5 l) seems to play a role for the concentration gradient of cisplatin and should therefore also be taken into account.

Conclusions: These expert recommendations provide a standardised and consistent implementation of the HITOC procedure. On this basis, postoperative complications associated to HITOC should be reduced and comparison of the results should be improved.
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http://dx.doi.org/10.1055/a-0934-7806DOI Listing
February 2020

[Recent Developments in the Regional Treatment of Peritoneal and Pleural Tumours (incl. HIPEC and HITOC)].

Zentralbl Chir 2019 Jun 5;144(3):235-241. Epub 2019 Jun 5.

Klinik für Thoraxchirurgie, Krankenhaus Barmherzige Bruder Regensburg, Regensburg, Germany.

The multimodal treatment of limited peritoneal metastases may improve prognosis in selected patients (pseudomyxoma peritonei, malignant peritoneal mesothelioma, colorectal, gastric and ovarian cancer) provided complete cytoreduction can be performed. Additive intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) is often performed. If the treatment is undertaken in experienced (and certified) centres, associated mortality is low. Intrapleural hyperthermic chemoperfusion (HITOC) can be performed in patients with pleural malignancies, mainly for malignant pleural mesothelioma or metastases from a thymoma. In single patients, pleural metastases from gastrointestinal malignancies might be an indication. Both therapies (HIPEC and HITOC) are complex and their exact role has to be defined within further prospective randomised trials.
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http://dx.doi.org/10.1055/a-0882-6545DOI Listing
June 2019

Combination Therapy of Pulmonary Arterial Hypertension with Vardenafil and Macitentan Assessed in a Human Ex Vivo Model.

Cardiovasc Drugs Ther 2019 06;33(3):287-295

Department of Thoracic Surgery, University of Regensburg Medical Center, Regensburg, Germany.

Purpose: Treatment of pulmonary arterial hypertension (PAH) by vasodilator drug monotherapy is often limited in its effectiveness. Combination therapy may help to improve treatment and to reduce drug toxicity. This study assessed the combination of the endothelin receptor antagonist macitentan and the phosphodiesterase-5 inhibitor vardenafil in a human ex vivo model.

Methods: Study patients did not suffer from PAH. Human pulmonary arteries (PA) and veins (PV) were harvested from resected pulmonary lobes. Contractile forces of blood vessel segments in the presence and absence of the vasodilator drugs macitentan, its main metabolite ACT-132577, and vardenafil were determined isometrically in an organ bath.

Results: Macitentan 1E-7 M was sufficient to significantly abate endothelin-1-induced vasoconstriction in PA. A concentration of 1E-6 M was required for significant effects of macitentan on PV and of ACT-132577 on both vessel types. Combination of 1E-7 M macitentan and 1E-6 M vardenafil inhibited sequential constriction with endothelin-1 and norepinephrine of PA significantly more than either compound alone. Effects of 3E-7 M and 1E-6 M macitentan and effects of all doses of ACT-132577 were not further enhanced by 1E-6 M vardenafil.

Conclusions: These data suggest that vasodilator effects of macitentan and vardenafil combined may surpass monotherapy in vivo if drug doses are adjusted properly. Vasodilation by the longer-acting metabolite ACT-132577 was not further enhanced by vardenafil.
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http://dx.doi.org/10.1007/s10557-019-06868-yDOI Listing
June 2019

Incidental thoracic findings in computed tomography scans before transcatheter aortic valve implantation.

Interact Cardiovasc Thorac Surg 2019 04;28(4):559-565

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

Objectives: Preoperative computed tomography (CT) scans for transcatheter aortic valve implantation (TAVI) are used routinely. In elderly high-risk patients, incidental radiographic findings are frequently reported. The aim of this study was to investigate the impact of auxiliary findings on the patients' mid-term survival, which might affect the treatment strategy.

Methods: Between March 2011 and April 2016, all radiological reports of contrast-enhanced CT scans of 976 patients scheduled for TAVI were analysed retrospectively for incidental thoracic findings including solitary pulmonary nodules (SPN) and thoracic lymphadenopathy (LAP). The minimum follow-up period was 1 year after TAVI.

Results: The median age of all patients was 79 years; 51.9% (n = 507) were women. Approximately 37% (n = 361) of patients showed 1 of the determined findings. An SPN ≥5 mm was diagnosed in 16.4% (n = 160) of patients. Four of them developed lung cancer and 2 nodules were identified as metastases during follow-up. In addition, 12% (n = 117) of the patients had thoracic LAP. Whereas SPN had no significant effect on the overall survival rate, evidence of LAP turned out to be a statistically significant factor regarding 4-year survival (P = 0.001; hazard ratio 1.66; 95% confidence internal 1.19-2.31).

Conclusions: SPN ≥5 mm were detected in 16.4% of patients scheduled for TAVI. Nevertheless, the incidence of lung cancer was low and the effect on survival in this high-risk group of patients was statistically not significant. In contrast, thoracic LAP had a significant negative effect on survival. It needs to be proven if the outcome of this cohort can be enhanced by further diagnostics and therapy.
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http://dx.doi.org/10.1093/icvts/ivy299DOI Listing
April 2019

[Non-Elective Thoracic Surgery in Patients with Respiratory Insufficiency During Support with Veno-Venous Extracorporeal Membrane Oxygenation].

Zentralbl Chir 2019 Feb 15;144(1):93-99. Epub 2018 Oct 15.

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Regensburg.

Introduction: Patients with severe respiratory failure and veno-venous extracorporeal membrane oxygenation (vv-ECMO) often require diagnostic or therapeutic thoracic surgery.

Methods: Retrospective analysis of prospectively collected data (Regensburg ECMO Registry) on all patients requiring vv-ECMO between December 2010 and December 2016 due to acute lung failure (ALF) with diagnostic or therapeutic thoracic surgery. Endpoints were the indications for thoracic surgery as well as postoperative morbidity and in-hospital mortality.

Results: A total of 418 patients (male n = 285, 68%, mean age 50.0 ± 16.5 years) with severe respiratory insufficiency refractory to conventional therapy required vv-ECMO. Indications for vv-ECMO were ALF due to pneumonia (59.8%), postoperative (18.7%), posttraumatic (9.8%), after chemotherapy (2.8%) and others (8.9%). Overall, in 24.4% (n = 102) of patients with vv-ECMO surgery was performed. Of these, 28.4% (n = 29) of patients required thoracic surgery. Primary indications for thoracic surgery were most frequently therapeutic due to hemothorax (n = 13; 44.8%), followed by carnifying pneumonia/pulmonary abscess (n = 5; 17.2%), pleural empyema (n = 3; 10.3%) and others (n = 3; 10.3%). In patients with interstitial lung disease of unknown origin (n = 5; 17.2%), diagnostic pulmonary biopsy was performed. For initial thoracic intervention thoracotomy was carried out in 93.1% (n = 27) of patients, whereas only two patients (6.9%) received thoracoscopy. At least one repeated thoracotomy was performed in 15 patients (51.7%) and nine patients (31.0%) underwent more than two surgeries. In-hospital mortality of patients with thoracic surgery (44.8%) was higher than in patients without thoracic surgery (35.7%; p = 0.326).

Conclusion: Thoracic surgery in patients with vv-ECMO warrants strict indications, because postoperative complications are common and surgical revision (58,6%) is often required. Therefore, ECMO therapy should only be carried out in specialised centers with thoracic surgery.
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http://dx.doi.org/10.1055/a-0721-1983DOI Listing
February 2019

Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation.

Ann Thorac Surg 2018 12 5;106(6):1668-1674. Epub 2018 Sep 5.

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

Background: Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are at risk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation.

Methods: A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications.

Results: The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n = 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n = 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p = 0.035) and hospital length of stay (58 ± 50 days; p = 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p = 0.013).

Conclusions: Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2018.07.020DOI Listing
December 2018

Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management.

J Thorac Dis 2018 Jun;10(6):3585-3594

Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.

Background: Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients.

Methods: Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime.

Results: The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 31.8 months; P=0.137).

Conclusions: N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).
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http://dx.doi.org/10.21037/jtd.2018.05.203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051831PMC
June 2018

Management of Spontaneous Pneumothorax and Postinterventional Pneumothorax: German S3-Guideline.

Zentralbl Chir 2018 Aug 24;143(S 01):S12-S43. Epub 2018 Jul 24.

Lungenklinik Köln-Merheim, Lehrstuhl Thoraxchirurgie der Universität Witten-Herdecke.

In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery (DGT), in co-operation with the German Society for Pulmonology (DGP), the German Radiological Society (DRG) and the German Society of Internal Medicine (DGIM) has developed an S3 guideline on spontaneous pneumothorax and postinterventional pneumothorax moderated by the German Association of Scientific Medical Societies (AWMF).

Method: Based on the source guideline of the British Thoracic Society (BTS2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to GRADE (A: "we recommend"/"we do not recommend", B: "we suggest"/"we do not suggest") were determined in three consensus conferences by the nominal group process.

Results: The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery (VATS). Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of postinterventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax.

Discussion: The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.
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http://dx.doi.org/10.1055/a-0588-4444DOI Listing
August 2018

Management of Spontaneous Pneumothorax and Post-Interventional Pneumothorax: German S3 Guideline.

Respiration 2019;97(4):370-402. Epub 2018 Jul 24.

Lungenklinik Köln-Merheim, Lehrstuhl Thoraxchirurgie der Universität Witten-Herdecke, Witten-Herdecke, Germany.

In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery, in co-operation with the German Society for Pulmonology, the German Radiological Society, and the German Society of Internal Medicine has developed an S3 guideline on spontaneous pneumothorax and post-interventional pneumothorax moderated by the German Association of Scientific Medical Societies.

Method: Based on the source guideline of the British Thoracic Society (2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to grade (A: "we recommend"/"we do not recommend," B: "we suggest"/"we do not suggest") were determined in 3 consensus conferences by the nominal group process.

Results: The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery. Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences, and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of post-interventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax.

Discussion: The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.
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http://dx.doi.org/10.1159/000490179DOI Listing
August 2020

[Comparison of the Masaoka-Koga Classification with the New TNM Staging of the IASLC/ITMIG for Thymoma and Thymic Carcinoma].

Zentralbl Chir 2018 Aug 18;143(S 01):S44-S50. Epub 2018 May 18.

Abteilung für Thoraxchirurgie, Universitätsklinikum Regensburg, Deutschland.

Background: The Masaoka-Koga classification describes the extent and spread of thymic epithelial malignancies. The objective of this study was to evaluate the Masaoka-Koga and the new TNM-staging system regarding differences in stage distributions, clinical implementation and therapeutic consequences.

Methods: Retrospective analysis of all patients who underwent surgery between January 2005 and December 2015 for thymoma/thymic carcinoma in two centres for thoracic surgery. The final tumour stages were determined on the basis of preoperative imaging, surgical reports and histological findings.

Results: A total of 118 patients (male 51%) with a mean age of 56 ± 14.8 years were included. Indications for surgery were primary mediastinal tumour (n = 97), pleura dissemination (n = 15) or mediastinal recurrence (n = 7). Radical tumour resection was performed in 92% of patients (n = 109) within one operation, whereas 8% of patients (n = 9) underwent two operations. Surgical revision was necessary in 12 patients (10.1%) and in-hospital mortality was 1.7% (n = 2). Early Masaoka-Koga stages I (n = 34) and II (n = 16) shifted to the new UICC stage I (T1: n = 58). Locally advanced stages (Masaoka-Koga stage III n = 22 vs. UICC stage IIIA + IIIB n = 20) and metastasised stages (Masaoka-Koga stage IV n = 36 vs. UICC stage IV n = 39) remained very similar.

Conclusions: The new TNM staging system gave rise to changes, especially in early stages (downstaging), but these had no therapeutic implications. Although advanced stages were very similar, the new TNM staging provides more clinically relevant differentiation.
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http://dx.doi.org/10.1055/a-0606-5603DOI Listing
August 2018

[Implementation of Hyperthermic Intrathoracic Chemotherapy (HITHOC) in Germany].

Zentralbl Chir 2018 Jun 12;143(3):301-306. Epub 2018 Mar 12.

Thoraxklinik, Thoraxchirurgie, Universität Heidelberg, Deutschland.

Introduction: For several years, hyperthermic intrathoracic chemotherapy (HITHOC) has been performed in a few departments for thoracic surgery in a multimodality treatment regime in addition to surgical cytoreduction. Specific data about HITHOC in Germany are still lacking.

Methods: Survey in written form to all departments of thoracic surgery in Germany. The objective is the evaluation of HITHOC with respect to number, indications, technique, perioperative protection measure and complications.

Results: A total of 116 departments of thoracic surgery were contacted, with a return rate of 43% (n = 50). HITHOC was not performed in 33 departments, due to lack of resources or experience (n = 17), missing efficacy of the procedure (n = 8) and fear of excessive complication rates (n = 3). Since 2008, a total of 343 HITHOC procedures have been performed in 17 departments. Eight departments have their own perfusion machine, whereas the remaining departments borrow the perfusion machine. Indications were malignant pleural mesothelioma in all departments (n = 17), thymoma with pleural spread (n = 11) and secondary pleural carcinosis (n = 7). The HITHOC was performed in nearly all departments after closing the chest (n = 16), with a temperature of 42 °C (n = 12) and for 60 minutes (n = 15). Cisplatin was always used, either alone (n = 9) or in combination (n = 8). In all the participating departments, the aims of the HITHOC were improvement in local tumor control and prolonged recurrence-free and overall survival. Relevant HITHOC-associated complications were low.

Conclusions: HITHOC is performed in at least 17 departments of thoracic surgery in Germany, and is widely standardised with protective measures and a low rate of complications. The aims of the HITHOC are improvement in local tumor control in pleural malignancies combined with prolonged overall survival and better quality of life.
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http://dx.doi.org/10.1055/a-0573-2419DOI Listing
June 2018

Reduced proliferation capacity of lung cells in chronic obstructive pulmonary disease.

Z Gerontol Geriatr 2019 May 22;52(3):249-255. Epub 2018 Feb 22.

Department Department of Thoracic Surgery, University Medical Centre Regensburg, Regensburg, Germany.

Background And Objectives: The prevalence of chronic obstructive pulmonary disease (COPD) and lung emphysema increases with age and both lung diseases are again risk factors for lung cancer. Since a reduced capacity of fibroblasts for proliferation is a good indicator of tissue aging, we studied the cell proliferation of lung fibroblasts from normal and tumor tissue of lung cancer patients depending on lung comorbidities.

Material And Methods: Fibroblasts were isolated from tumor and normal lung tissue of 40 lung cancer patients. Cumulative population doubling (CPD) was determined to assess the proliferation capacity, and the PCR technique was used to measure telomere lengths. Since many patients had previously been exposed to severe air pollution, we also studied the effect of air pollution particles on the fibroblast CPD in vitro.

Results: Fibroblasts from tumor and normal lung tissue had comparable CPDs; however, the CPD of fibroblasts from both tumor and normal lung tissue was significantly reduced in patients also suffering from COPD. This CPD reduction was highest in COPD patients who had already developed emphysema or were smokers. A significant correlation between CPD and telomere length was identified only for fibroblasts of non-COPD patients. Further studies also showed an adverse effect of air pollution particles on the CPD of lung fibroblasts.

Conclusion: Lung cells of COPD patients are characterized by accelerated senescence which must have been initiated prior to lung tumorigenesis and cannot depend on telomere shortening only. In addition to smoking as a known risk factor for COPD and lung cancer, air pollution particles could be another reason for the accelerated senescence of lung cells.
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http://dx.doi.org/10.1007/s00391-018-1377-9DOI Listing
May 2019

Burden between Undersupply and Overtreatment in the Care of Primary Spontaneous Pneumothorax.

Thorac Cardiovasc Surg 2018 10 31;66(7):575-582. Epub 2017 Dec 31.

Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.

Background: The optimal treatment of primary spontaneous pneumothorax (PSP) is still controversial. The purpose of this study was to analyze the incidence of recurrence, the recurrence-free time, and to identify risk factors for recurrence after PSP.

Methods: We performed a retrospective analysis of 135 patients with PSP who were treated either conservatively with a chest tube ( = 87) or surgically with video-assisted thoracoscopic surgery (VATS;  = 48) from January 2008 through December 2012.

Results: In this study, 101 (74.8%) male and 34 (25.2%) female patients were included with a mean age of 35.7 years. The indications for surgery included blebs/bullae in the radiological images ( = 20), persistent air leaks ( = 15), or the occupations/wishes of the patients ( = 13). A first ipsilateral recurrent pneumothorax (true recurrence) was observed in 31.1% of all patients (VATS: 6.25%, conservative: 44.8%). Including contralateral recurrence, the overall first recurrence rate was 41.3% (VATS: 14.6%, conservative: 57.5%). The recurrence-free time did not differ significantly between the treatment groups ( = 0.51), and most recurrences were observed within the first 6 months after PSP. Independent risk factors identified for the first recurrence were conservative therapy ( = 0.0001), the size of the PSP (conservative;  = 0.016), and a body mass index <17 (VATS; 0.022). The risk for second and third recurrences of PSP was 17.5 and 70%, respectively, for both treatment groups, but it was 100% after conservative therapy.

Conclusion: Surgery for PSP should be selected based on the risk factors and the patient's wishes to prevent first recurrences but also to avoid overtreatment. The treatment of first and subsequent PSP recurrences should be with surgery since conservative treatment is associated with a 100% recurrence rate.
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http://dx.doi.org/10.1055/s-0037-1609011DOI Listing
October 2018

[The Medical Examination - Between Desire and Reality - Analysis of Consensus Between the Second Part of the Medical Licensing Exam (IMPP) and the National Catalogue of Expertise-based Learning Goals in Surgery (NKLC)].

Zentralbl Chir 2017 Dec 13;142(6):614-621. Epub 2017 Dec 13.

Abteilung Medizinische Ausbildung und Ausbildungsforschung, Fakultät für Medizin und Gesundheitswissenschaften, Carl von Ossietzky-Universität, Oldenburg, Deutschland.

The working party of the German Society for Surgery (DGCH) on undergraduate surgical education has developed a national expertise-based catalogue of learning goals in surgery (NKLC). This study analyses the extent to which the questions of the German second medical licensing examination compiled by the IMPP are congruent with the NKLC and which thematic focus is emphasised. Firstly, a guideline and evaluation sheet were developed in order to achieve documentation of the individual examination questions of the second licensing examination with respect to the learning goals of the NKLC. In a retrospective analysis from autumn 2009 to autumn 2014, eleven licensing examinations in human medicine were screened independently by three different reviewers. In accordance with the guideline, the surgical questions were identified and subsequently matched to the learning goals of the NKLC. The analysis included the number of surgical learning goals as well as the number of surgical questions for each examination, learning goal, and different levels of expertise (LE). Thirteen reviewers from six surgical disciplines participated in the analysis. On average, reviewers agreed on the differentiation between surgical and non-surgical questions in 79.1% of all 3480 questions from 11 licensing examinations. For each examination (n = 320 questions), 98.8 ± 22.6 questions (min.: 69, max.: 150) were rated as surgical. For each surgical learning goal addressed, 2.2 ± 0.3 questions (min.: 1, max.: 16) were asked. For each examination, 23.5 ± 6.3 questions (min.: 11; max.: 31) referred to learning goals of LE 3, 52.5 ± 16.7 questions (min.: 34; max.: 94) addressed learning goals of LE 2 and 22.8 ± 7.7 questions (min.: 9; max.: 34) were related to learning goals of LE 1. 64 learning goals (27.8% of all learning goals of the NKLC) were not reflected in the examinations. With a total of 70 questions, the most frequently examined surgical topic was "disorders of the rheumatic spectrum". The number of surgical examination questions in the German second medical licensing examination seems to be sufficient. However, the questions seem to be unevenly distributed between different surgical areas of undergraduate education. In order to achieve a more homogenous representation of relevant surgical topics, improved alignment is needed between the state examination with existing catalogues of learning goals by the IMPP.
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http://dx.doi.org/10.1055/s-0043-119995DOI Listing
December 2017

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

World J Surg Oncol 2017 Dec 2;15(1):214. Epub 2017 Dec 2.

Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.

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.
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http://dx.doi.org/10.1186/s12957-017-1283-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712125PMC
December 2017
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