Objective: Primary complex and repetetive congenital cardiac procedures are the most common cause of phrenic nerve injury. Unilateral diaphragm paralysis may produce a 50% loss of pulmonary function and is a significant cause of complicated weaning from postoperative mechanical ventilation.

BACKGROUND AND OBJECTIVE:The overall prognosis of patients with stage IIIA non-small-cell lung cancer is unfavourable (median survival time 12 months). Tolerance to and efficacity of a multimodal neoadjuvant treatment was assessed in a prospective study.PATIENTS AND METHODS:25 patients (median age 59 [37-69] years), with histologically confirmed mediastinal lymph node metastases, underwent chemotherapy. Immediately after two cycles with carboplatin/Ifosfamid (dimethoate)/etoposide they received hyperfractionated accelerated radiotherapy (45 Gy; 2 x 1.5 Gy daily) with simultaneous administration of carboplatin and vindesine. This was followed by tumour resection.RESULTS:After conclusion of the neoadjuvant treatment 19 of 25 patients (76%) had a remission. Of the 20 operated patients complete resection (R0) was possible in 17 (85%) and 14 of the 20 patients with resection (70%) had histologically demonstrated marked tumour regression. Critical toxicity consisted of pneumonitis and bronchial stump problems. Median survival time of all patients was 24.8 months and for patients with R0 resection 35.9 months.CONCLUSION:Neoadjuvant multimodal treatment of stage IIIA non-small-cell lung cancer can achieve prolongation in survival time. The place of radiotherapy or radiotherapy with chemotherapy in such a treatment concept will need to be defined in a randomized study.

Objective: Tracheobronchial lesions are rare emergencies and sequence of blunt or open chest trauma. Some lesions however, especially in the trachea, represent rare complications following endotracheal intubation, also in cardiac patients. Iatrogenous lesions demand diagnostic evaluation immediately. Prognosis may be well following treatment in time.

Objective: Multimodality approaches are increasingly employed to improve prognosis in surgically treated NSCLC stage III. Risk and benefit of preoperative chemotherapy or combined radiochemotherapy on surgical morbidity, mortality and survival are still a matter of debate.

Hintergrund: Multimodale Therapiekonzepte werden zunehmend eingesetzt, um die Prognose des NSCLC im Stadium III zu optimieren. Allerdings ist der Stellenwert einer zusätzlichen präoperativen Radiochemotherapie, nach neoadjuvanter Chemotherapie, und deren Einfluss auf die chirurgische Morbidität, Letalität und das Überleben bis dato nicht überzeugend gesichert. Methoden: Im Jahre 1995–2003 wurde eine multizentrische prospektiv randomisierte Phase-III-Studie durchgeführt, die im Studienarm A die Therapiesequenz Chemotherapie – komb. Radiochemotherapie – Operation versus Chemotherapie – Operation – Radiotherapie im Studienarm B vergleichend untersuchte. Zur Klärung des chirurgischen Risikos und des Überlebens erfolgte eine finale Auswertung der Studiendaten. Ergebnisse: 297 von 525 Patienten (56%) wurden operiert, 143 (54%) in Arm A und 154 (59%) in Arm B; davon waren 182 (61%) Patienten im Stadium IIIB. Eine R0-Resektion konnte 119 Patienten im Arm A (83%) und 119 Patienten im Arm B (77%) erreicht werden. In der Analyse der Morbidität war die Bronchusstumpf-Insuffizienz häufiger im Arm A (5,6% vs. 2,6%), die Rate an Pneumonien nahezu ausgeglichen (7,0% vs. 6,5%), ebenso die anderen Komplikationen. Die operative Letalität betrug 4,9% im Arm A vs. 2,7% im Arm B. Das 5-Jahres-Überleben der R0-operierten Patienten war 38% vs. 20% aller Patienten, mit einem medianen Follow-up von 60 Monaten; einzelne R0-operierte Subgruppen erreichten ein 5-Jahres-Überleben von 42% bzw. 46%. Schlussfolgerung: In beiden Studienarmen konnte nach neoadjuvanter Therapie eine vergleichbare Anzahl an Patienten operiert werden, auch im Stadium IIIB. Die bimodale Induktionstherapie ist überzeugend im Hinblick auf eine höhere R0-Resektions-Rate, aber mit einer höheren Komplikationsrate belastet. Die Überlebensrate in beiden Studienarmen ist nicht signifikant unterschiedlich. Detaillierte Analysen nach chirurgischer Therapie und Vorteile der einzelnen Studienarme werden dargestellt.

We report on an extremely rare case of pulmonary mucinous cystadenocarcinoma. A 29-year-old male patient was admitted because of progressive enlargement of a right lower lobe mass over a period of 10 years. Right lower lobectomy was performed after a malignant mucinous cystadenocarcinoma was diagnosed by intraoperative frozen section. PET and CT scans did not detect metastatic disease. This case is the youngest patient reported so far with a malignant pulmonary mucinous cystadenocarcinoma and highlights the importance of close follow-up of indeterminate pulmonary nodules in patients with unremarkable history.

Objective: We sought to examine our management and the outcomes of cardiothoracic procedures after heart and heart lung transplantation.Methods: We performed a retrospective review of cardiothoracic surgical procedures carried out between 1990 and 2004 in patients who had previously undergone heart or heart-lung transplantation at our institution.Results: Twenty-one out of 340 patients (6.2%) were identified. Cardiothoracic surgery was performed 44.4 +/- 33 months (range 1 - 115 months) after transplantation. Predominant types Of Surgery were coronary artery bypass grafting due to allograft vasculopathy (n = 5), aortic surgery due to acute dissection (n = 3), biventricular assist device implantation due to acute rejection (n = 1), tricuspid valve repair (n = 1), multiple cardiac surgical procedures including coronary artery bypass grafting, retransplantation, and tricuspid valve replacement (n = 2), explantation of a functionless heterotopic transplanted heart (n = 1). Lung surgery was performed in six patients due to pneumonia (n = 2), primary lung carcinoma (n = 3), lung torsion following heart-lung transplantation (n = 1). All patients underwent either lobectomy or segmental lung resection. Single lung retransplantation (n = 2) after prior heart-lung transplantation due to bronchiolitis obliterans was performed. In one patient a pneumonectomy (n = 1) due to severe chronic rejection of the contralateral lung was performed. Six subsequent deaths after cardiothoracic procedures were recorded after 1, 4, 78, 163, 205, and 730 days, respectively. Causes of death were advanced carcinoma (n = 1), multi-organ failure due to sepsis (n = 2), sudden heart death (n = 2), and advanced heart failure (n = 1). Fifteen out of 21 patients having undergone cardiothoracic procedures (71.4%) survived the observation period of 56.6 +/- 34 months (range 1 - 114).Conclusions: Reasons for cardiothoracic procedures after prior heart or heart-lung transplantation were allograft vasculopathy, aortic dissections years after transplantation, chronic rejection, and either lung infections or malignancies. Surgical repair can be performed with an acceptable operative risk and good long-term survival rates.

To evaluate the impact of preoperative simultaneous hyperfractionated (hf)RTCT plus surgery compared to surgery plus postoperative radiotherapy, both after neoadjuvant chemotherapy, on resectability, tumor control, survival and toxicity. After stratification according to center and stage (IIIA vs IIIB, mediastinoscopy obligatory) all patients had 3 cycles Cisplatin/Etoposide (PE). In arm A, PE was followed by hfRT (45 Gy, 2 × 1.5 Gy/d) with concurrent Carboplatin/Vindesin (d 1, 8, 15), then surgery and, if no or R1/2 resection, additional hfRT (24 Gy, 2 × 1.5 Gy/d) was given. In arm B, PE was followed by surgery and postoperative RT (54 Gy or, if no or R1/2 resection, 68.4 Gy, 1.8 Gy/d). From 10/95 to 8/03 558 patients were randomized; 33 (6%) were ineligible. Patient characteristics (arm A/arm B): male 83/83.1%, female 17/16.9%; age (median) 59/59 yrs; PS 0 86.6/87.2%; PS 1 13.4/12.8%; stage IIIA 31/35%, stage IIIB 69/65%; squamous cell carcinoma 57/61%; adenocarcinoma 30/30%. After a median follow-up of 52 months, 3year rates for overall survival (OS) and progression -free survival (PFS) (arm A/arm B) were 26.2/ 24.6% and 17.8/19.9% (n.s.). Complete and partial remission rates (CR/PR), R0-resection rates, median OS and PFS are shown in table 1. Grade 3/4 esophagites was more frequent in arm A (19% in arm A vs. 3% in arm B, p = 0.0001) whereas the incidence of pneumonitis grade 3/4 was higher in arm B (1% in arm A vs. 6% in arm B, p = 0.004). There was no difference in treatment-related mortality (arm A 5.8% vs. arm B 5.1%). After neoadjuvant chemotherapy, no advantage for either preoperative simultaneous hfRTCT plus surgery or surgery plus postoperative radiotherapy concerning PFS and OS could be shown, with different toxicity-patterns in both arms.

Lung resection remains the therapy of choice offering the greatest potential for cure in non-spread lung cancer. Prognostic importance of lymph-node involvement has been underlined by several studies. So, exploration of the mediastinum is of major importance for defining the therapeutic strategy in a possibly curative setting. Pre-resectional exploration of the mediastinal lymph-nodal status is mandatory to define tumour stage exactly and establish specific therapy. Cervical mediastinoscopy is the primary diagnostic procedure and remains the gold standard in invasive surgical staging. Complementary, parasternal mediastinoscopy, extended mediastinoscopy, and video-assisted thoracoscopy may be performed. These techniques allow accurate assessment of mediastinal lymph-node involvement, resulting in an appropriate judgement as to resectability and possible treatment options. Different techniques are established for intraoperative exploration and staging. In terms of curative surgery of lung cancer we demand accurate staging which is achieved by systematic and complete Lymph-node dissection. So, individually and dependent on primary tumour site, accurate mediastinal staging of Lung cancer should be performed in combination with definitive lung resection.

7004 Background: In the neoadjuvant treatment setting of stage III NSCLC the additional impact of hfRT/CT after preoperative CT on resectability and survival is open to conjecture. Methods: In a phase III trial patients [pts] with stage III NSCLC (invasive mediastinal staging obligatory) were stratified (center; stage, IIIA vs IIIB) and then randomized to (arm A) 3 cycles P 55 mg/m2 (d 1+4) / E 100 mg/m2 (d 1–4), followed by hfRT (45 Gy; 2 x 1.5 Gy/d) with concurrent Carboplatin 100 mg/m2 / Vindesin 3 mg (d 1, 8, 15), then surgery and, if no or R1/2-resection, additional hfRT (24 Gy; 2 x 1.5 Gy/d) versus (arm B) 3 cycles of PE followed by surgery and then RT (1.8 Gy/d) with 54 Gy or, if no or R1/2-resection, 68.4 Gy. The primary (secondary) study endpoint was progression free survival [PFS] (survival [S]). With 500 pts. evaluable an improvement of median PFS (S) from 10 to 14 (17 to 23) months [mo]; 3 y.-rate from 8 to 17 (23 to 34) % could be detected. Results: 558 pts. were randomized (10/95–07/03); 32 (6%) were ineligible. On december 1st, 2003 median follow up was 46 mo with outcome data available for 481 pts. Patient characteristics were well balanced between arm A (245 pts.) and arm B (236 pts): male 82%/83%, female 18%/17%; PS 0 86%/87%; PS 1 14%/13%; age 59/59 ys. [median]; stage IIIA 31%/34%; stage IIIB 69%/66%. Whilst the rate of grade 3/4-esophagitis was significantly different between treatment arms (15%/4%, p < 0.001), there was no significant difference for the response rate after induction (52%/47%; p = 0.35), the proportion of patients with complete tumor resection (111/245, 45% /118/236, 50%; p = 0.30), the treatment related mortality rate (5,6%/5,3%), nor for PFS (median, 10/10 mo; 3 y.-rate, 17%/18%; p = 0.37, log-rank) or S (median, 15/17 mo; 3 y.-rate, 24%/23%; p = 0.89, log-rank). Conclusions: In this trial the addition of hfRT/CT to PE prior to planned surgery had no impact on PFS or S but contributed to significantly higher rates of grade 3/4 esophagitis. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Lilly

Objective: Multi-modality approaches are increasingly employed to improve prognosis in surgically treated stage III non-small cell lung cancer (NSCLC). Risk and benefit of the preoperative therapeutic chemotherapy or combined radiochemotherapy on surgical morbidity and mortality are still a matter of debate. Methods: In 1995, a national phase III trial was started to compare (arm A) preoperative chemotherapy followed by twice-daily chemoradiation and consecutive surgery, with (arm B) preoperative chemotherapy alone followed by surgery and consecutive radiotherapy. An interim analysis with 277 patients was performed to assess surgical risk and complication rates. Results: Of the 385 patients, 273 (71%) underwent thoracotomy, 130 (73%) in arm A and 143 (69%) in arm B. Of the 273 patients undergoing thoracotomy, 168 had stage 11113 disease. Complete resection (R0) was achieved in 212 patients (78%), 104 in arm A (80%) and 108 in arm B (76%) (P = n.s.). There was no difference in the proportion of complex resections between treatment arms (41% in arm A; 48% in arm B). Whilst bronchial stump insufficiency (3.8 vs 2.1%) and bleeding requiring re-thoracotomy (1.5 vs 0.7%) prevailed slightly in arm A, the occurrence of pneumonia divided similar on both treatment arms (4.6 vs 4.9%). Surgical mortality reached 6.1% in arm A (8/130) and 5.6% in arm B (6/143) (P=n.s.). Conclusions: In both treatment arms, a similar percentage of patients could be forwarded to surgery, even in stage IIIB disease. Bimodality induction seems to be superior with regard to resection rates (R0) (n.s.), but was associated with a higher complication rate, especially bronchial stump insufficiency. (C) 2004 Elsevier B.V. All rights reserved.

Die Lungentransplantation ist heutzutage weltweit als Therapie des finalen Lungenversagens anerkannt. Frühere Probleme bei der Indikationsstellung und Technik der Transplantationsverfahren, Organkonservierung sowie Differenzialdiagnostik und -therapie der Transplantatabstoßung und Infektion konnten durch klinische und experimentelle Studien weiter geklärt und damit die Ergebnisse deutlich verbessert werden. Heute werden im Register der „International Society of Heart and Lung Transplantation“ (ISHLT) 1-Jahres- und 5-Jahres-Überlebensraten von 75 und 50% (alle lungentransplantierten Patienten) berichtet; in der Analyse des alterbezogenen Überlebens erreichen Patienten in der Altersgruppe 50–64 Jahre respektive 75 und 42%.

Das extraossäre Osteosarkom ist ein sehr seltener,maligner Tumor. Es ist wenig über die Behandlung diesesKrankheitsbildes bekannt. Wir berichten über eine 72-jährigePatientin, die mit dem 4. Rezidiv eines extraossärenOsteosarkoms der rechten Mamma lokalchirurgisch behandelt wurde,und legen das postoperative onkologische Konzept dar.

An 85-year-old patient suffered from progressive deterioration (NYHA III) for several months. Cardiac disease was suspected. Echocardiography as well as a CT scan of the heart revealed a heart tumor to be the cause. Tumor staging was negative. After transvenous biopsy, the diagnosis of a Burkitt lymphoma could be established. Due to the advanced age of the patient, the intended surgical therapy was turned down and the patient was treated with 6 courses of a potentially therapeutic chemotherapy (CHOP scheme), which was well tolerated by the patient. The following CT scan showed a complete remission of the tumor. Six months after chemotherapy the patient is in NYHA stage I.

Wir berichten über einen 85-jährigen Patienten, bei dem aufgrund einer Leistungsminderung (NYHA III) eine kardiologische Diagnostik erfolgte und mittels Echokardiographie und Cardio-CT ein Herztumor als Ursache diagnostiziert wurde. Die endgültige Diagnose eines Burkitt-Lymphoms konnte jedoch erst durch eine Biopsie gestellt werden. Aufgrund des fortgeschrittenen Alters des Patienten wurde auf die angestrebte chirurgische Therapie verzichtet und der Patient mit 6Zyklen einer potentiell kurativen Chemotherapie (CHOP-Schema) behandelt. Diese Therapie hat der Patient gut toleriert. Mittels Cardio-CT konnte eine komplette Remission des Tumors nachgewiesen werden, der Patient befindet sich 6Monate nach Chemotherapie im NYHA-StadiumI.

Abstract. In this communication, we will present a very rare case of the coexistence of non-Hodgkin's lymphoma (NHL; low malignant lymphocytic lymphoma of the B-cell type) and a non-small-cell lung carcinoma (NSCLC). A patient with a 15-year history of NHL developed a generalized relapse of the lymphoma with an additional tumor mass in the left lower lobe of the lung. Bronchoscopy showed the evidence of the NHL. Due to non-responding chemotherapy on the lung tumor, the coexistence of a second malignancy was histologically proved in a second bronchoscopy. Resection of the lung tumor with complex lobectomy and lymphadenectomy was performed. After that, chemotherapy with four cycles of carboplatin supplemented with taxol was induced. The patient was discharged from the hospital with a stable remission of both tumor diseases. Restaging after six months showed no evidence of a tumor relapse. This is a very rare case of the coexistence of NHL and NSCLC; we will discuss the difficulty of diagnostic and treatment of both tumor diseases.

Purpose: The aim of this prospective study was to assess the prognostic impact of serum tumor markers (Cyfra21-1, carcinoembryonic antigen, neuron-specific enolase, squamous cell carcinoma-antigen and TPAcyk) in patients with non-small cell lung cancer (NSCLC) receiving complete resection. Methods: Sixty-seven patients with histologically proven NSCLC and complete resection of stage I-IIIA disease were included. The scrum levels of all markers were measured using commercially available immunoassays. Results: With a median follow-up of 86 months for surviving patients, those with initial Cyfra21-1 serum levels higher than 3.57 ng/ml had a significantly worse prognosis (P=0.014). The remaining serum tumor markers showed no prognostic impact. In a Cox regression model, Cyfra21-1 proved to be an independent prognostic factor for both overall survival and disease-free interval. In addition, Cyfra21-1 sustained as an independent prognostic factor in completely resected stage I/II disease. Conclusions: With a cut-off value of 3.57 ng/ml, Cyfra 21-1 was an independent prognostic factor for survival in NSCLC-patients with complete resection. Further evaluation is needed, particularly in stage I/II disease. When the prognostic impact is confirmed with larger patient numbers this may contribute to the identification of stratification variables for future treatment approaches of NSCLC. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.