Stage IIIA non-small cell lung cancer (NSCLC) consists of a heterogeneous group of disease, ranging from small T1a tumours with ipsilateral mediastinal lymph node involvement over T3 tumours with chest wall invasion, up to T4 tumours with mediastinal invasion with or without positive hilar lymph nodes. Based on this heterogeneity, treatment approaches as well as prognosis are very dependent on specific subgroups. Therapy recommendations should be based on multidisciplinary case discussions in high volume centres including medical and radiation oncologists, pneumologists and experienced thoracic surgeons specialized in thoracic cancer surgery. Recommendations may differ from standards in highly selected cases.Therefore, independent of age, in medically fit (operable) patients with resectable stage IIIA tumours, an aggressive approach in a curative setting is key to obtain good overall survival rates. Moreover, maintaining quality of life is essential. In this narrative review the different aspects of all the subgroups of stage IIIA NSCLC and their heterogeneity as well as the variety of treatment modalities, their combined treatment approaches and survival rates are discussed. Again, the reported 5-year survival rates, ranging from 5% in patients with bulky N2 disease, up to 50% for patients with superior sulcus tumours with hilar lymph node disease, reflect the heterogeneity of stage IIIA NSCLC.

Patients who have undergone previous pneumonectomy may develop new or second primary cancers, secondary cancers (metastases) or even recurrent malignant disease in the remaining single lung. It is a common misbelief that additional pulmonary resection in a single lung is not feasible. These cases should not be deemed unresectable solely due to the fact of new lesions in the remaining lung after contralateral pneumonectomy. Individual treatment approaches should be based on a multidisciplinary case discussion in specialized centers with high patient volume following meticulous preoperative evaluation and cardiopulmonary assessment. In patients with sufficient cardiopulmonary reserves, an aggressive approach with limited sublobar resection (segmentectomy or wedge resection) can be beneficial and provide good functional and oncological outcome as well as maintenance of quality of life. In this narrative review the evaluation, the management as well as the outcome of additional pulmonary resection after contralateral pneumonectomy with benefits of using extracorporeal membrane oxygenation (ECMO) during these surgical procedures is discussed. In addition, a patient that we encountered in our clinical work is dissected in further detail. This case elucidates numerous critical considerations that the interdisciplinary team must make and the challenging decision-making process in balancing feasibility, individual risks and expected benefits. The surgical methodology employed and the outcomes are also highlighted.

Background: Pulmonary arteriovenous malformations (PAVM) are abnormal direct connections between arteries and veins of the pulmonary circulatory system. In the majority of cases, they are of congenital origin and patients present with dyspnea, epistaxis or hemoptysis as the most common clinical symptoms.Before surgical treatment is considered, patients should be discussed interdisciplinary with angiologists and interventional radiologists regarding evaluation of embolotherapy. In case of unsuccessful embolotherapy, in case of complications (e.g., bleeding due to rupture of lesions), or in patients with contraindication for embolization such as untreatable contrast allergy, surgical resection of the pulmonary lesion is indicated. The former gold standard of open thoracotomy as treatment of PAVM has been mostly replaced by interventional embolization since the late 1980s. In recent years, less invasive approaches such as multi-or uniportal videoassisted thoracic surgeries (VATS) developed, have improved and have been shown to be safe and feasible treatment options, when surgery is necessary.Methods: Between October 2015 and August 2019 five patients suffering from PAVM or its complications underwent a uniportal lung-sparing VATS resection at our department. Four out of the five patients have been successfully treated with a sublobar resection (segmentectomy of one or two lung segments). In another patient, an extended vascular malformation between the superior phrenic artery and the inferior pulmonary vein was approached via wedge resection of the affected lung in a first step and embolization of the subphrenic part in a second step as decided in an interdisciplinary setting before treatment.Results: The median hospital stay was 4 days (range, 2-5 days) and, in all surgically treated patients, the postoperative course was uneventful. Only one of the five patients who suffered from hereditary hemorrhagic telangiectasia showed recurrence of the disease in the form of new vascular malformations in other lobes on CT scan 9 months after surgery, although so far asymptomatic. All other patients had an uneventful longtime course (median follow-up: 17 months; range, 5-52 months). Conclusions:The uniportal VATS technique is one of the least invasive approaches in thoracic surgery: It allows not only for lung-sparing anatomical lung resections in the form of segmentectomies, but is also associated with very low morbidity and complication rates. Therefore, uniportal VATS is an excellent therapeutic option in selected cases in which primary interventional measures fail or complications of PAVM occur.