Search

Copyright of WISTA Wirtschaft und Statistik is the property of Statistisches Bundesamt and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: Epidemiological studies have shown contradictory results regarding the time trend of end-stage renal disease (ESRD) in people with diabetes. This study aims to analyze the incidence of ESRD, defined as chronic renal replacement therapy (RRT), to investigate time trends among people with and without diabetes in Germany and to examine whether these patterns differ by age and sex.Research Design and Methods: The data were sourced from nationwide data pooled from two German branches of statutory health insurances covering ∼25 million inhabitants. We estimated age- and sex-standardized incidence rates (IRs) for chronic RRT among people with and without diabetes in 2010-2016 and the corresponding relative risks. Time trends were analyzed using Poisson regression.Results: We identified 73,638 people with a first chronic RRT (male 60.0%, diabetes 60.6%, mean age 71.3 years). The IR of chronic RRT among people with diabetes (114.1 per 100,000 person-years [95% CI 110.0-117.2]) was almost six times higher than among people without diabetes (19.6 [19.4-19.8]). A consistent decline in IR was observed among people with diabetes (3% annual reduction, P < 0.0001) for both sexes and all age classes. In contrast, no consistent change of IR was identified in people without diabetes. Only among women aged <40 years (P = 0.0003) and people aged ≥80 years (P < 0.0001) did this IR decrease significantly.Conclusions: Incidence of chronic RRT remained significantly higher among people with diabetes. The IR decreased significantly in people with diabetes independent of age and sex. Time trends were inconsistent in people without diabetes. [ABSTRACT FROM AUTHOR]

Introduction: During the COVID-19 pandemic, worldwide over 600,000 human beings died due to the cause of the disease. In order to deescalate the transmission rate and to avoid crush loading the countries medical health systems social distancing, face masks, and lockdowns have been considered essential by the majority of governments. Whereas some countries have highly reduced or completely stopped otorhinolaryngological procedures, other countries have continued selected surgeries. The objective of this study was to analyze procedures and outcomes of continuing semielective and emergency surgeries during the COVID-19 pandemic. Methods: Retrospective analysis of n = 750 patients who received semi-elective or emergency surgery between March 26 and June 16, 2020, in the Otolaryngology Department of the Friedrich-Alexander-University of Erlangen-Nürnberg. All patients were screened for COVID symptoms and swabbed for SARS-CoV-2 prior to surgery. Results: Of the n = 750 patients, n = 699 patients received semielective surgery and n = 51 emergency surgery. For 27 patients, the swab result could not be awaited due to a life-threatening condition. In these cases, surgery was performed in full protective equipment. No patient was tested positive during or after the surgery (follow-up 45 to 127 days). No member of the medical personnel showed symptoms or was tested positive after contact with patients. Due to the continuation of surgeries, patients' lives were saved and improvement of long-term quality-of-life and outcomes is anticipated. Conclusions: Continuing selected otorhinolaryngological surgeries is crucial for patients' health, survival, and long-time quality of life, yet, the protection of the medical personnel has to be granted. [ABSTRACT FROM AUTHOR]

Background. We aimed to examine the epidemiology and mortality risk of patients with incident end-stage renal disease (ESRD) in diabetic and non-diabetic individuals and to determine differences between sexes.Methods. We used the claims data of a statutory health insurance company. Patients aged 30 years and older who started dialysis or had pre-emptive kidney transplantation between 1 April 2006 and 7 October 2008 were included. We estimated incidence rates of ESRD according to diabetes status, sex and age as well as relative and attributable risks due to diabetes. Using Cox regression, we studied survival and estimated time-dependent hazard ratios (HR).Results. We included 623 patients with incident ESRD (n = 254 had diabetes); 477 (76.6%) were male, and the mean age was 66.5 years. Standardized to the German population, incidences of ESRD in patients with and without diabetes were 157.9 and 25.6 per 100 000 person-years respectively (6.2-fold increased risk). The impact of diabetes on mortality was time-dependent. Diabetics had an increased mortality risk after the first year. An interaction of diabetes with time (per additional year of follow-up) was found in the whole population (HR 2.01, 95% CI 1.21–3.33) and in females (HR 3.27, 95% CI 1.03–10.39); however, males did not reach statistical significance (HR 1.78, 95% CI 0.99–3.18). The fixed baseline effect of diabetes in these models was non-significant (HR ~ 0.7–0.8).Conclusions. Diabetes is an important risk factor for ESRD. We provide further evidence that the impact of diabetes on survival after ESRD is time-dependent and that differences between sexes might exist. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To estimate the impact of diabetes on the mortality of patients with incident renal replacement therapy (RRT). Methods: We assessed the mortality of 544 incident RRT patients aged ≥30 years between 2002 and 2009 (57.9% men, mean age 70.3 years, 49.6% patients with diabetes) by analyzing the data of all dialysis centers covering a German region. We compared the estimated time-dependent hazard ratios of patients with and without diabetes by using the Cox proportional-hazards regression model. Results: Overall, 319 patients had died (158 diabetic), approximately 50% after 3 years. Up to about 3 years, the mortality rate was lower in diabetic than in nondiabetic patients. Thereafter, the survival curves crossed (interaction diabetes×time, p =0.002; adjusted hazard ratios for diabetes: baseline, 0.66; year 1, 0.84; year 2, 1.05; year 3, 1.33; year 4, 1.68). The results were similar in men and women; however, the interaction of diabetes and time was significant only in men (p =0.004). Further significant risk factors of mortality were age, sex, initial central venous catheter, cardiovascular disease, and malignancy. Conclusions: In this population-based study, the influence of diabetes was time-dependent, with a lower mortality in diabetic versus non-diabetic patients in the first three years but a higher mortality in these patients after 3 years. Results were similar in men and women. [Copyright &y& Elsevier]

Introduction: During the COVID-19 pandemic, worldwide over 600,000 human beings died due to the cause of the disease. In order to deescalate the transmission rate and to avoid crush loading the countries medical health systems social distancing, face masks, and lockdowns have been considered essential by the majority of governments. Whereas some countries have highly reduced or completely stopped otorhinolaryngological procedures, other countries have continued selected surgeries. The objective of this study was to analyze procedures and outcomes of continuing semielective and emergency surgeries during the COVID-19 pandemic., Methods: Retrospective analysis of n = 750 patients who received semi-elective or emergency surgery between March 26 and June 16, 2020, in the Otolaryngology Department of the Friedrich-Alexander-University of Erlangen-Nürnberg. All patients were screened for COVID symptoms and swabbed for SARS-CoV-2 prior to surgery., Results: Of the n = 750 patients, n = 699 patients received semielective surgery and n = 51 emergency surgery. For 27 patients, the swab result could not be awaited due to a life-threatening condition. In these cases, surgery was performed in full protective equipment. No patient was tested positive during or after the surgery (follow-up 45 to 127 days). No member of the medical personnel showed symptoms or was tested positive after contact with patients. Due to the continuation of surgeries, patients' lives were saved and improvement of long-term quality-of-life and outcomes is anticipated., Conclusions: Continuing selected otorhinolaryngological surgeries is crucial for patients' health, survival, and long-time quality of life, yet, the protection of the medical personnel has to be granted.

Aims/hypothesis: Data on trends of end-stage renal disease among people with diabetes are lacking. We analysed the incidence of end-stage renal disease, defined as renal replacement therapy, among people with and without diabetes, and the corresponding relative risk. Moreover, we investigated time trends for the period 2002-2016., Methods: In this retrospective population-based study we analysed data from one dialysis centre of a region in Germany covering a population of about 310,000 inhabitants. We estimated the age- and sex-standardised incidence rates for chronic renal replacement therapy among adults with and without diabetes and the corresponding relative risks. The time trend was analysed using Poisson regression models., Results: Between 2002 and 2016, 1107 people (61.2% male; mean age 71.6 years; 48.7% with diabetes) had a first renal replacement therapy. During the study period, the incidence rate in the population with diabetes varied from 93.6 (95% CI 50.4, 136.7) in 2002 to 140.5 (95% CI 80.6, 200.4) in 2016 per 100,000 person-years. In the population without diabetes the incidence rate was substantially lower and reached 17.3 (95% CI 10.9, 23.6) in 2002 and 24.6 (95% CI 17.5, 31.7) in 2009. The relative risk comparing people with and without diabetes was 3.57 (95% CI 3.09, 4.13). No significant change in the incidence rates was found during the observation period, either in the population with or in the population without diabetes, and thus the relative risk also remained constant., Conclusions/interpretation: People with diabetes have a higher risk of needing renal replacement therapy than those without diabetes, a fact that remained constant over a time period of 15 years.

Transcutaneous ultrasound (TCUS) is an accepted diagnostic method in salivary gland diseases. However, sparse data are available on the use of transoral ultrasound (TOUS) in sialadenopathies. One hundred five patients presenting with various obstructive sialadenopathies were examined using TOUS and TCUS. Ultrasound findings were validated by direct visualization in subsequent sialendoscopy examinations. By TOUS, but not by TCUS, all patients with sialolithiasis (70/105) could be identified and virtually all concrements, even very small ones, were detected and distinguished from artifacts. Ductal stenoses (16/105) could be correctly differentiated from sialoliths, and exceptional insights into the delicate anatomy of parotid duct stenoses were gained. TOUS provided detailed information on other space-occupying lesions (14/105) and circumvented the method-related diagnostic weaknesses of TCUS. As a valuable tool in the diagnosis of obstructive sialadenopathies, TOUS seems superior to TCUS in pathologies involving the distal parotid duct, the submandibular duct system and the floor of the mouth., (Copyright © 2019 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To investigate epidemiological features and symptoms of sialolithiasis and their implications for diagnosis and management., Study Design: Retrospective cohort study., Methods: Retrospective analysis on 2,322 patients with sialolithiasis, between 1987 and 2009. The statistical significance between two sample distributions was computed using analysis of variance Student t test for two-tailed distribution., Results: A total of 2,959 calculi were identified by means of ultrasound. Of those, 80.4% were located in the submandibular duct system (53% hilar/proximal, 37% distal, 10% intraparenchymal) and 19.6% were parotid stones (83% in Stensen's duct, 17% intraparenchymal). Sialoliths had been discovered beforehand in the submandibular gland (P = 0.00024; t test). Symptoms, measured from first visit, lasted on average 26 months (range: 1 day-30 years). The main group suffered from swelling (50.3%), followed by painful swelling (41.6%) and pain (3.1%). Multiple stones were found in 16.9% of patients (18.1% in the submandibular gland; 14.3% in the parotid). Average stone diameter in the submandibular gland was 8.3 mm (range 1-35 mm), and the stones were in Lustmann group II (46%). In the parotid gland, the average diameter was 6.4 mm (range 1-31 mm), and 51% were in Lustmann group I., Conclusion: Nowadays, epidemiologic features and clinical manifestations of sialolithiasis play an important role, assisting not only in diagnosis but also in determining appropriate treatment. Due to their location and smaller diameter, parotid stones in some cases can only be treated using a mini-invasive endoscopic technique. Submandibular stones more often require a combined approach., Level of Evidence: 4, (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective/hypothesis: The ideal extent of surgical intervention for benign parotid tumors remains a matter of controversy. The aim of the study was to trace the development of surgical therapy in a large cohort, explore its changes in a single institution specializing in salivary gland pathologies over the last 12 years, and determine the extent to which a possible shift in the surgical therapy of parotid benign tumors toward less radical methods was correlated with a change in the incidence of facial palsy and Frey's syndrome., Study Design: Retrospective clinical study., Methods: A retrospective evaluation of the records for all patients treated for benign parotid tumors between 2000 and 2012 at a tertiary referral center was carried out. Surgical methods were classified into four groups: extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy, and complete parotidectomy., Results: A total of 1,624 patients were included in the study. Our analysis demonstrated an increase in the total number of parotidectomies for benign lesions from 71 (2000) to 184 (2012), mostly due to the increase in extracapsular dissections (from 9 to 123). Increased performance of less radical surgery was associated with a significantly decreased incidence of temporary and permanent facial palsies (from 22.8% to 9% and 9.8% to 5.9%, respectively) and Frey's syndrome (from 11.3% to 1.6%)., Conclusions: One of the most controversial issues in the treatment of benign parotid tumors is the best therapeutic approach to be taken in such patients. Our study showed that increased performance of less radical surgery was associated with better functional outcomes., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

This article describes new relationships between the age-specific incidence of, the prevalence of and mortality from a chronic disease. We express these relationships in terms of an ordinary differential equation and form the methodological basis for a novel approach to estimating incidences from age-specific prevalence data. We examine practical aspects of the relationships and a comparison with a known stochastic method in a simulation study. Finally, we apply the novel method to a data set of renal replacement therapy recorded from patients with chronic kidney failure in a region of Germany with approximately 310,000 inhabitants from 2002 to 2010., (Copyright © 2012 John Wiley & Sons, Ltd.)

Background: With the development of imaging techniques in diagnostics of head and neck carcinomas, especially computed tomography and ultrasonogaphy, one might expect that the incidence of occult metastases would be reduced. The aim of this study was to determine the rate of occult metastases in a large population cohort and explore its changes with improvement of imaging techniques over the last 30 years., Methods: All patients between 1980 and 2010 with head and neck carcinoma and cN0 neck status were retrospectively evaluated. Six hundred thirty-six patients with cN0 neck who received an elective neck dissection as part of a definitive surgical treatment were included., Results: The overall rate of occult metastases was 24.8% (158/636). The rate was 26.5% (80/302) between 1980 and 1995 and 23.4% (78/334) between 1995 and 2010. Only pT1-2 glottic carcinomas had an occult metastases rate of less than 10%. All other pT1-2 carcinomas had an incidence of occult metastases between 19.1% and 42.5%. pT3-4 tumors showed an occult metastases rate of 24.5-53.3%., Conclusion: The occult metastases rate showed only a marginal improvement over the last 30 years and is still above the 20% margin. All but pT1-2 glottic carcinomas should be considered for elective treatment of the neck., (Copyright © 2012 Wiley Periodicals, Inc.)

Objectives: Markov chain models are frequently used to study the clinical course of chronic diseases. The aim of this article is to adopt statistical methods to describe the time dynamics of chronically ill patients when 2 kinds of data sets--fully and partially observable data are available., Model: We propose a 6-state continuous-time Markov chain model for the progression of chronic kidney disease (CKD), where little is known about the transitions between the disease stages. States 1 to 3 of the model correspond to stages III to V of chronic kidney disease in the Kidney Disease Outcomes Quality Initiative (KDOQI) CKD classification. States 4 and 5 relate to dialysis and transplantation (renal replacement therapy), respectively. Death is the (absorbing) state 6., Methods and Data: The model can be investigated and identified using Kolmogorov's forward equations and the methods of survival analysis. Age dependency, covariates in the form of the Cox regression, and unobservable risks of transition (frailties) can be included in the model. We applied our model to a data set consisting of all 2097 patients from all renal centers in a region in North Rhine-Westphalia (Germany) in 2005-2010., Results: We compared transitions and relative risks to the few data published and found them to be reasonable. For example, patients with diabetes had a significantly higher risk for disease progression compared with patients without diabetes., Conclusions: In summary, modeling may help to quantify disease progression and its predictors when only partially observable prospective data are available.

In veterinary medicine, there is an ongoing need for students, educators, and veterinarians to exchange the latest knowledge in their respective fields and to learn about unusual cases, emerging diseases, and treatment. Networking among veterinary faculties is developing rapidly, but conferences and meetings can be difficult to attend because of time limitations and travel costs. The current study examines acceptance of synchronous online conferences, seminars, meetings, and lectures by veterinarians and students. First, an online survey on the use of communication technology in veterinary medicine was made available for 15 weeks to every German-speaking veterinary university and via professional journals and an online veterinary forum. A total of 1,776 persons (620 veterinarians and 1,156 students) participated. Most reported using the Internet at least once per day; more than half reported using instant messengers. Most participants used the Internet for communication, but less than half used Skype. Second, to test the spectrum of tools for online conferences, a variety of "virtual classroom" systems (netucate systems iLinc, Adobe Acrobat Connect Pro, Cisco WebEx, Skype) were used to deliver student lectures, veterinary continuing-education courses, and academic conferences at the University of Veterinary Medicine, Hannover (TiHo). Of 591 participants in 63 online events, 99.4% rated the virtual events as enjoyable, 96.1% found them useful, and 92.4% said that they learned a lot. Participants noted that the courses were not tied to a certain place, and thus saved time and travel costs. Online conference systems thus offer new opportunities to provide information in veterinary medicine.

Objective: To determine whether unique patterns of care are evolving in the United States compared with Germany in endoscopic management of chronic sialadenitis., Design: Comparison of consecutive series of patients., Setting: Academic tertiary salivary referral centers in Germany and the United States., Patients: A total of 446 patients having chronic sialadenitis treated with salivary endoscopy., Main Outcome Measures: To compare practice patterns and outcomes at each location, databases tracking patients having chronic sialadenitis treated with salivary endoscopy were searched for the following variables: age, sex, involved gland, radiographic studies, endoscopic findings, endoscopic-related complications, gland preservation rate, patient symptom control, and techniques for managing salivary stones and intraductal scar tissue., Results: Significantly more patients in the US cohort had chronic sialadenitis of the parotid gland (P = .03) and multiple gland involvement (P < .001). Salivary endoscopy was regularly performed using local anesthesia in Germany and using general anesthesia in the United States (P < .001). Endoscopic-related complication rates were higher (10.9% vs 1.6%) and gland preservation rates lower (85.9% vs 98.4%) among US patients; however, patients with intact glands demonstrated similar rates of symptom control at both centers (92.7% in the United States vs 85.3% in Germany) at the last follow-up visit. The lower rate of gland preservation in the United States is largely because of lack of access to lithotripsy for larger salivary stones., Conclusions: Different patterns of care are emerging in the endoscopic management of chronic sialadenitis in the United States compared with Germany, where these techniques were largely developed. Nevertheless, patients with chronic sialadenitis at both locations who undergo endoscopic gland-preserving therapy have high rates of gland preservation and symptom control.

Background: This study was conducted to estimate incidences of renal replacement therapy (RRT) in the diabetic and non-diabetic populations in Germany, as well as relative and attributable risks of RRT due to diabetes., Methods: Using the data of a regional dialysis centre (region population of 310 000), we assessed all incident RRT patients aged 30 years or older in 2002-08. We estimated sex- and age-specific and -standardized incidences of RRT in the diabetic and non-diabetic populations, which were estimated by applying diabetes prevalences from a population-based study, and relative and attributable risks due to diabetes., Results: Of all subjects with incident RRT (n = 544), 49.6% had diabetes. Fifty-eight percent were male, mean age (SD) was 70.3 years (11.4 years). Incidences per 100 000 person-years (standardized to the 2004 German population) in the diabetic and the non-diabetic populations were 213.7 [95% confidence interval (95% CI), 159.5-267.8] and 26.9 (95% CI, 22.5-31.3) in men and 130.2 (95% CI, 65.6-194.9) and 16.4 (95% CI, 13.5-19.3) in women, respectively. Standardized relative risks were 7.9 (5.9-10.8) in men and 8.0 (4.7-13.5) in women. There was a significant interaction between age and diabetes, with lower relative risks in higher ages. Attributable risks among diabetic individuals were 0.87 in men and women, and population-attributable risks were 0.41 and 0.35 in men and women, respectively., Conclusions: In this population-based study in a German region, we found the relative risk of RRT in the estimated adult diabetic population to be 8-fold increased compared with the non-diabetic population. A high proportion of the RRT risk can be attributed to diabetes in the diabetic as well as in the whole population.

Objectives/hypothesis: To determine the incidence of major and minor complications and their impact on patients' comfort after parotid surgery in benign disease., Study Design: Retrospective., Methods: Four hundred ninety-two patients were included. Total parotidectomy (TP) was performed in 65.8%, superficial parotidectomy (SP) in 27.2%, and partial superficial parotidectomy (PSP) in 7.0%. Patients were interviewed using a self-designed questionnaire. Incidence of complications was evaluated depending on the extent of surgery and intensity of complaints. To ascertain the impact of morbidity on their daily lives, patients were asked to estimate it according to a visual analog scale., Results: Frey's syndrome occurred in 63.4%, and temporary facial nerve palsy in 32.7% of all cases. Both rates were significantly reduced after PSP. Permanent facial nerve paresis was observed in 2.3% of the cases, but in no case after PSP. Perception of patients and their scores reflected these results. Scores regarding Frey's syndrome and facial nerve paresis showed a significant positive correlation with extent of surgery. The recurrence rate was 2.2%; no recurrences were noted after PSP. Scores of perceived general condition indicated an excellent state., Conclusions: The incidence of complications was reduced after PSP compared to SP or TP. Patient scores, which represent their perception of these complications, reflected these data and may be an additional instrument to measure outcome. These data suggest that less invasive operative techniques should be considered in case of a benign disease.

Objectives/hypothesis: The desirable extent of surgical intervention for benign parotid tumors remains a matter of controversy. Superficial or total parotidectomy as a standard procedure is often said to be the gold standard; however, with it the risk of intraoperative damage to the facial nerve cannot be ignored. For some time now, extracapsular dissection without exposure of the main trunk of the facial nerve has been favored as an alternative for the treatment of discrete parotid tumors. Data on the incidence of facial nerve lesions and other acute postoperative complications of extracapsular dissection have been lacking until now., Study Design: Retrospective analysis., Methods: We performed a retrospective analysis of the data from patients in whom extracapsular dissection of a benign parotid tumor had been performed under facial nerve monitoring and as a primary intervention in our department between 2000 and 2008., Results: A total of 934 patients were operated on for a newly diagnosed benign tumor of the parotid gland. Three hundred seventy-seven patients (40%) underwent extracapsular dissection as a primary intervention. The most common postoperative complication was hypoesthesia of the cheek or the earlobe, as reported by 38 patients (10%). Eighteen patients (5%) developed a seroma and 13 patients (3%) a hematoma. A salivary fistula formed in eight patients (2%). Secondary bleeding occurred in three patients (0.8%). In 346 patients (92%) facial nerve function was normal (House-Brackmann grade I) in the immediate postoperative period, whereas 23 patients (6%) showed temporary facial nerve paresis (House-Brackmann grade II or III) and eight patients (2%) developed permanent facial nerve paresis (seven patients House-Brackmann grade II, one patient House-Brackmann grade III)., Conclusions: Extracapsular dissection of benign parotid tumors is associated with a low rate of postoperative complications, a fact that is confirmed by the available literature. We therefore recommend that use of this technique always be considered as a means of treating benign parotid tumors as conservatively, that is, as uninvasively, as possible.

Objective: Olfactory neuroblastoma constitutes a rare and, in clinical terms, biologically variable tumor of the nasal cavity, paranasal sinuses, and the base of the skull and presents a challenge to a modern multidisciplinary therapy. Generally acknowledged prognostic factors and a standard therapy fail to exist., Methods: Between 1975 and 2000 we diagnosed and treated 26 patients with an olfactory neuroblastoma. According to Kadish's classification, 1 patient (4%) showed stage A, 16 patients (53%) stage B, and 11 cases (43%) stage C. Hyams grading was established in 81% of all cases. Fifty-two percent were thus classified as low-grade and 48% as high-grade tumors. Surgical therapy was performed on 23 patients (88.5%), surgery being the exclusive form of therapy (monotherapy) in 5 of these patients. Combined therapy was carried out in 18 cases (surgery, radiotherapy, chemotherapy)., Results: Currently, 16 of 26 treated patients (61.5%) are alive. The disease-specific 10- and 15-year survival determined according to Kaplan-Meier is 76.2%. Fifteen-year survival amounts to 86.7% for smaller tumors (Kadish A/B) and 63.6% for advanced tumors (Kadish C). Seven (26.9%) of the overall group of treated patients developed a recurrence. Salvage therapy was successful in 60% (3 of 5 patients). Fifteen-year survival following salvage therapy amounts to 60%. Patients with high-grade tumors exhibit a significantly reduced 10-year survival (40%) compared to patients with low-grade tumors (100%)., Conclusions: The therapy of olfactory neuroblastoma calls for an interdisciplinary multimodal therapeutic strategy, particularly in the case of advanced tumors. Tumor staging and histopathologic grading according to Hyams are important factors for survival and prognosis. Aggressive salvage therapy can lead to a distinct improvement of long-term survival.