Wednesday Morning, April 18, 1951

9:00 A.M. Scientific Session.

22. Radical Pneumonectomy.

William G. Cahan (by invitation), William L. Watson and

John L. Pool, New York, N. Y.

Radical pneumonectomy is the excision en bloc of a lung containing cancer along with the lymph nodes present in the mediastinal, paratracheal, peribronchial, subcorynal and pre-esophageal areas. The purpose of this procedure is to remove as much cancer as possible and to attempt to standardize the operation for cancer of the lung.

The mediastinal-or paratracheal-dissection begins superiorly at the thoracic inlet, and its anatomical boundaries are different for the right and left thorax. The subcorynal dissection includes the lymph nodes that lie beneath the coryna and also those available from the inferior margin of the contralateral bronchus. The pre-esophageal nodes are excised beginning at the diaphragm.

At Memorial Hospital, New York City, there have been 25 radical pneumonectomies performed since March 1949. In eight of these, lymph nodes containing metastases were found beyond the limits of dissection usually employed for total pneumonectomy. Although the lymph nodes in the remaining cases often appeared grossly negative, it was not felt that this was a justification for allowing them to remain in situ, for in several instances of those found to be positive, that fact was established by microscopic study alone.

After many more radical pneumonectomies have been performed, more intelligence will be derived about the pathways of carcinomatous spread and the value of this procedure in enhancing the possibility of cure for cancer of the lung.

23. A Preliminary Report of 26 Cases of Pulmonary Resection With Pleurectomy.

Bert H. Cotton and John R. F. Penido (by invitation)

Beverly Hills, Calif.

A preliminary report of 26 cases of pulmonary resection in combination with pleurectomy includes a discussion of the indications, complications, technical problems and results.

Indications:

Pulmonary tuberculosis with tuberculous empyema......................................... 9 cases

Pulmonary tuberculosis with mixed empyema and broncho-

pleural fistula...................................................................................................... 2 cases

Bronchiectasis plus nonspecific empyema.......................................................... 1 case

Bronchiogenic carcinoma with cells in pleural effusion...................................... 5 cases

Endothelioma of the pleura................................................................................ 4 cases

Ruptured fungus cavities with empyema........................................................... 5 cases

Complications:

Two cases of pulmonary tuberculosis plus empyema developed bronchopleural fistula. These were controlled by cauterization of the bronchial stump with closure of the fistula.

Two cases developed immediate postoperative shortness of breath out of proportion to the usual pneumonectomy, which we felt was due to the hemidiaphragmectomy.

Technical Problems:

These problems are discussed in detail. Some of the more interesting were: 1. When malignant tumors involve the lung and pleura, we have found a hemidiaphragmectomy, accomplished with the pneumonectomy and pleurectomy, makes the operation more definitive for removal of all malignant implantations. 2. In one case of endotheli-oma, it was necessary to perform a pneumonectomy, pleurectomy, hemidiaphragmectomy, adrenalectomy and left nephrectomy. The patient was well for 14 months before he died of cerebral hemorrhage from hypertension. 3. We have found it advantageous to make a small opening in the pleura, through which all the fluid or purulent material is removed. The opening is then closed. Thus, the chance of widespread contamination, by inadvertently tearing the pleura during the dissection, is greatly reduced. 4. The pericardium was entered when necessary to secure the vessels.

Results:

The 17 cases due to infection were cured and able to return to work. In the nine cases, in which malignant cells were found in the pleural fluid, four postoperative deaths occurred. These were due to -coronary thrombosis one month following surgery-cerebral hemorrhage 14 months after surgery-two cases by metastases of the malignant process, six and eight months postoperatively.

Three cases or 60% of pleural extension due to carcinoma of the lung are alive and well. The follow-up interval is from three years to six months. Two cases or 50% of the endotheliomas are alive and well. One case has been followed two years; the other is a recent case of only two months.

Many apparently hopeless cases were helped by this combination of surgical procedures. Others have been apparently cured and rehabilitated. We feel the favorable results warrant further investigation.

24. The Management of the Patient With Inoperable Cancer of the Chest.

Richard H. Meade, Jr. and Richard A. Rasmussen,

Grand Rapids, Mich.

In considering the subject of cancer we are primarily concerned with the possibility of cure. At present most of the patients we see with cancer cannot be cured by our present methods of treatment. This admission of inadequacy does not release the physician from his responsibility for the care of the patient. He must do all that is in his power to help him. There are rare instances of patients with inoperable cancer within the chest who live a number of years in apparent health when all hope had been abandoned for them. There are a great many more whose tumors respond to radiotherapy, or to this in combination with other forms of treatment. Although these cases make up a pitifully small percentage of the total they are rays of sunshine in a very dark corner. Several cases of this type will be presented, and a general plan for the management of patients with inoperable cancer will be discussed.

25. Radio Active Isotopes in the Palliative Management of Carcinomatosis of the Pleura.

Edward M. Kent and Campbell Moses (by invitation)

Pittsburgh, Pa.

Preliminary studies have been conducted on the use of radio active isotopes as a palliative measure to control excessive pleural effusion occurring as a result of carcinomatosis of the pleura. For this purpose patients were chosen who had proven carcinoma with demonstrable evidence of carcinomatosis of the pleura. The primary carcinoma arose in a bronchus in the majority of the patients, however, in a few instances breast cancer was the primary lesion. Only those patients were selected for study who presented serious problems of management because of a rapidly forming pleural effusion which required frequently repeated aspirations. The studies conducted included (1) observations of the effectiveness of isotopes in reducing or controlling completely the formation of pleural effusion, (2) the rate of excretion of the isotopes, (3) the retention of radio activity in the pleural fluid, (4) microscopic observations of the effect of the agent on the surface implants in the pleural space.

The dosage of radio active isotopes employed has been selected by arbitrary means. In most instances, a single injection has been utilized but in a few patients a second treatment was administered. In each patient studied the rate of excretion of the isotope was determined.

The preliminary conclusions which have been made possible include: (1) Complete suppression of the pleural effusion in most patients studied. (2) Evidence of a favorable effect on the rate of formation of pleural fluid in the remaining patients of the series. (3) The absence of adverse effects of radio active isotopes on these patients. (4) The rate of excretion of radio active isotopes when injected into the pleural cavity as well as the retention of radio activity in the pleural space.

26. Identification of Regional Lymph Nodes in the Treatment of Bronchiogenic Carcinoma.

Joseph A. Weinberg, Long Beach, Calif.

A method is described which is designed to facilitate the identification of regional lymph nodes of the lung for their removal during the operation of radical pneumonectomy. The procedure is a further application of the method devised by the author for use in radical gastric resection, previously reported with E. M. Greaney.

A solution of pontamine sky blue dye and hyaluronidase is injected into the pulmonary parenchyma as soon as the thorax is opened. The dye is taken up by the regional lymph nodes, imparting to them a blue color which makes them more easily distinguishable than they would be in their natural state. Many nodes which would remain obscured, even with acquired dust pigmentation, become readily identifiable after being colored by the dye.

The technic has been used in 40 operations on the lung during the past two years, 27 of which were for bronchiogenic carcinoma. In the course of the study, stained nodes have been seen and removed from the hilum; along the phrenic nerve; under the arch of the aorta; along the azygos vein, superior vena cava and trachea; under the coryna; the beginning of the subclavian artery; and less frequently in other accessible situations. In two cases in which death occurred within eleven days after operation, autopsy revealed stained nodes in the opposite hemithorax.

This method is offered as a means of more nearly approaching the ideal of planned resection of the lymph nodes, a phase of the operation which is of fundamental importance in the surgical treatment of bronchiogenic carcinoma.

27. Pneumonectomy for Severe Irradiation Damage of Lung.

Martin Bergman (by invitation) and Evarts A. Graham,

St. Louis, Mo.

The structural alterations resulting from exposure of a lung to relatively large quantities of irradiation produce symptoms of cough, dyspnea, chest pain and hemoptysis. Pulmonary function becomes markedly compromised.

While there is no known nonoperative treatment of radiation damage of the lung, pneumonectomy in a unilateral case is an effective therapeutic procedure. Two patients with this disease were greatly benefited by pneumonectomy. Both acquired the condition because of too much irradiation following breast operations for carcinoma.

The study of the surgically removed lungs showed a greatly increased number of thick elastic fibers. This finding appears to be an important criterion for the histologic diagnosis of irradiation damage. On the other hand, the presence of hyaline membranes, reported by others in autopsy material, is probably an artefact not seen in surgically removed lungs.