Molekularpathologie in der Behandlung des Lungenkarzinoms – interdisziplinärer Blick auf die thoraxchirurgische Bedeutung

ZusammenfassungDie Therapie des Lungenkarzinoms wurde in den letzten Jahren zunehmend durch die Etablierung tumorspezifisch zielgerichteter Pharmaka und immunmodulatorischer Ansätze ergänzt und hat dadurch rasant an Komplexität gewonnen. Bessere Überlebensdaten und Erkenntnisse über andere Nebenwirkungensspektren und Rezidivcharakteristika begleiten diese Entwicklung. Dem Kliniker verlangt diese Entwicklung eine stete Wachsamkeit in der Stratifizierung der Behandlungsoptionen ab. Dieser Artikel gibt einen Überblick über die klinisch aktuell relevanten Ansätze der „targeted therapies“ in der Behandlung des Lungenkarzinoms und stellt Verbindungen zur Thoraxchirurgie dar. Mit der Darstellung der Optionen einer zielgerichteter Therapie wird beantwortet, welche Rolle sie in der adjuvanten Therapie bei nachgewiesener Mutation des Epidermal-growth-factor-Rezeptors (EGFR) spielen, wann eine Salvage-Operation infrage kommt und wie durch die „targeted therapies“ in Einzelfällen ein kuratives Therapiekonzept erarbeitet werden kann. Jedes Lungenkarzinom verlangt ab dem frühestmöglichen Zeitpunkt in der Diagnosefindung nach einer molekularen Analyse auf therapierelevante Mutationsmuster. Interdisziplinäre Konzepte können individualisiert das Langzeitüberleben des Patienten gewährleisten.

Managing the Salvage, Removal, Preservation and Re-Installation of Tilted Wellhead Platform

This paper describes the planning, offshore execution and technology involved in the intact salvage, removal, preservation and relocation of a Wellhead Drilling Platform (WHP) which was tilted during drilling operation in the "X" field. The field development plan consists of a WHP tied-back to a Floating, Production, Storage & Offloading (FPSO), anchored at 700 m away from the WHP. The oil field is located 110 km from shore and at water depth of 57 m. The Project Management Team (PMT) had completed the installation of the WHP, unfortunately mishap was happened when the WHP experienced tilting during drilling operation. The platform tilted/leaned two (2) degrees towards the drilling rig. The strategy adopted by the PMT was to rig-down and move out the affected rig; immediately salvage the newly installed 1,300MT WHP's topside. The work was executed under the crisis management envelop with the aim to save the rig and platform from total loss i.e., to avoid the platform topples into the sea and subsequently hits the rig. The salvage operation employed unique processes, procedures, and technology to safe hold the tilted platform by Anchor Handling Tugs (AHTs) and pipelay barge; rig-down and move out the drilling rig, reinstatement of lifting lug/pad eyes which had previously removed after completion of topside installation and finally removal of topside from the tilted jacket. The topside then transported to the fabrication yard, where there the topside had been preserved on the transportation barge for a period of five (5) months while waiting for the new jacket to be fabricated and installed. The re-development of the affected offshore facilities from the incident involved installation of new jacket at 150 m away from the tilted jacket location, re-installation of the topside to the new installed four (4) legged jacket, re-routing the previous installed infield pipelines (8" Liquid, 16" Wet Gas and 12’ Export Gas pipeline from FPSO) and tied-in to the new platform. The planning, innovation and execution has resulted in a significant cost containment and managed to avoid major disaster; subsequently safeguard Company's reputation. The salvage of the topside and rejuvenation of the pipelines have managed to avoid the reconstruction of the topside module which potentially could lead to non-cost recovery of huge amount of additional cost (in USD millions) and managed to avoid any Loss of Primary Containment (LOPC) by taken all the necessary precautions.

A Unique Salvage Operation Strategy: Implantation of the Ulnar Total Elbow Component to the Radius to Overcome Large Ulnar Bone Defect Caused by Infection After Total Elbow Arthroplasty

ABSTRACT The elbow joints of patients with rheumatoid arthritis (RA) are often destroyed, and total elbow arthroplasty (TEA) is one treatment for these patients. However, patients with RA tend to develop surgical site infections due to immunosuppression. Once an implant is infected, reoperation may be difficult because of the risk of reinfection. In such patients, the infected site must be debrided thoroughly, although this might reduce the bone scaffold needed for re-TEA. We used a unique method to manage a large ulnar bone defect and an infected implant. The patient with RA had undergone TEA 15 years earlier. Etanercept was initiated to control disease activity; however, this treatment led to infection of the elbow prosthesis. Several surgical debridements were performed to eradicate the bacteria, which improved the symptoms of infection. However, most of the proximal ulna was lost, and it seemed impossible to fix the prosthesis using the remaining small ulna after debridement. Therefore, we planned to implant the ulnar component into the radius as a salvage technique. With this procedure, we provided the patient with elbow mobility and eradicated the infection. This is an alternative method for restoring function in an elbow with a massive bone defect in the ulna.

Methodology of Using Terrain Passability Maps for Planning the Movement of Troops and Navigation of Unmanned Ground Vehicles

The determination of the route of movement is a key factor which enables navigation. In this article, the authors present the methodology of using different resolution terrain passability maps to generate graphs, which allow for the determination of the optimal route between two points. The routes are generated with the use of two commonly used pathfinding algorithms: Dijkstra’s and A-star. The proposed methodology allows for the determination of routes in various variants—a more secure route that avoids all terrain obstacles with a wide curve, or a shorter route, which is, however, more difficult to pass. In order to achieve that, two functions that modify the value of the index of passability (IOP), which is assigned to the primary fields that the passability map consists of, have been used. These functions have a β parameter that augments or reduces the impact of the applied function on IOP values. The paper also shows the possibilities of implementation of the methodology for the movement of single vehicles or unmanned ground vehicles (UGVs) by using detailed maps as well as for determining routes for large military operational units moving in a 1 km wide corridor. The obtained results show that the change in β value causes the change of a course of the route as expected and that Dijkstra’s algorithm is more stable and slightly faster than A-star. The area of application of the presented methodology is very wide because, except for planning the movement of unmanned ground vehicles or military units of different sizes, it can be used in crisis management, where the possibility of reaching the area outside the road network can be of key importance for the success of the salvage operation.

Salvage-Laryngektomie nach primärer Radio- und Radiochemotherapie

Zusammenfassung Hintergrund Das rezidivierende und residuelle Larynxkarzinom nach organerhaltender Radio- bzw. Radiochemotherapie ist mit einer schlechten Prognose verbunden. Die Salvage-Operation stellt in diesen Fällen die wichtigste therapeutische Option dar. Ziel der Arbeit Erfasst wurden die Rate an Rezidiv- und Residualtumoren sowie die Überlebensraten und die Komplikationsrate nach Salvage-Chirurgie des Kehlkopfs an dem akademischen Tumorzentrum der Autor(inn)en. Material und Methoden Retrospektiv wurden alle Patienten untersucht, bei denen zwischen 2001 und 2019 eine Salvage-Operation aufgrund eines Tumorresiduums oder Rezidivs nach primärer nichtchirurgischer Therapie erfolgt war. Ergebnisse Es wurden 33 Salvage-Operationen durchgeführt. Die Defektrekonstruktion erfolgte in 30,3 % der Fälle (n = 10) mittels freier und in 15,2 % (n = 5) mittels regionaler Lappenplastik. Ein Patient hat sowohl eine freie als auch gleichzeitig eine gestielte Lappenplastik erhalten. Das Gesamtüberleben nach einem, 2 und 5 Jahren betrug 68,7 %; 47,9 % bzw. 24,2 %, das krankheitsfreie Überleben 81,6 %; 47,8 % bzw. 24,2 % bei insgesamt 48,5 % (n = 16) postoperativen Tumorrezidiven. Das krankheitsfreie Überleben war signifikant kürzer bei Tumorausdehnung im bzw. auf den Hypopharynx (p = 0,041). Postoperativ entwickelten 72,7 % der Patienten eine pharyngokutane Fistel unabhängig von einer simultanen Defektrekonstruktion. Nur 24 % der der aufgetretenen Fisteln mussten operativ therapiert werden. Der Krankenhausaufenthalt betrug 28,0 ± 16,1 Tage. Schlussfolgerung Die Salvage-Laryngektomie ist mit vielen, aber beherrschbaren Komplikationen und einer hohen Morbidität verbunden. In Anbetracht der behandelten fortgeschrittenen Tumorkategorien und der Gesamtsituation des Patienten sind respektable onkologische Ergebnisse zu erreichen.

High-Energy Blast Injury Requiring Transradial Amputation with Associated Essex Lopresti and Terrible Triad Injuries of the Elbow: A Rare Presentation

Case. Blast injuries to the upper extremity can be devastating and emotionally stressful injuries. We describe a case of a high-energy blast injury to an upper extremity from an explosive. The transfer of energy caused severe soft tissue/bony damage to the hand, but also led to associated Essex Lopresti and terrible triad injuries. The patient required emergent transradial amputation by hand surgery as well as definitive fixation by our orthopaedic team. Conclusion. We describe a unique salvage operation that established forearm pronosupination, elbow flexion, and proper prosthetic fitting. We feel that describing our technique could help others in treating this injury if encountered.