Thursday Afternoon, May 8, 1952

2:00 P.M. Scientific Session.

7. Localized Fibrous Mesothelioma of the Pleura.

O. Theron Clagett, John R. McDonald (by invitation) and

Herbert W. Schmidt, Rochester, Minn.

Localized fibrous mesotheliomas of the pleura are fibrogenic tumors of the thorax apparently originating from the pleura. This report concerns 24 such tumors which were surgically excised. The tumors were sufficiently cellular to suggest malignancy histologically, but there was no evidence of metastasis in our cases, although 4 lesions did recur locally. The tumors should not be confused with diffuse pleural mesotheliomas, which are definitely malignant. These fibrous mesotheliomas varied from 9 to 5,700 gin. in weight. In 16 of the 24 cases which we are reporting the outstanding symptoms that led the patient to consult a physician were swollen, painful joints. Duration of symptoms involving joints varied from four months to fifteen years. In 11 of these 16 cases clubbing of the fingers was present, and in 7 recurrent bouts of chills and fever occurred. The symptoms of arthritis and chills and fever were completely cured by removal of the tumor. In 4 cases pleural effusion was found.

The tumors were closely associated with the visceral pleura in 18 cases and with the parietal pleura in 6 cases. They may appear as intra-pleural tumors attached to the pleura by a narrow pedicle, intrapulmonary tumors or mediastinal tumors. The pathologic, clinical and surgical aspects of this interesting group of thoracic tumors will be discussed.

8. Resection of the Trachea for Carcinoma-Report of Two Cases.

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

Beverly Hills, Calif.

To our knowledge only eight cases of carcinoma of the trachea have been treated by resection. Consequently, two such cases are presented in detail and discussed.

One is a case of squamous cell carcinoma of the trachea which required total resection from the cricoid cartilage to one centimeter above the carina. Surgery was performed January, 1951.

The other case is one of adenocarcinoma which necessitated subtotal resection of the thoracic trachea. Surgery was performed on November 5, 1951.

Reconstruction was carried out in both cases with a stainless steel tube.

The surgical technique, immediate and other postoperative complications are discussed.

Both patients are alive and symptom free. Brief review of the methods of treatment is presented.

9. The Surgical Treatment of Carcinoma Involving the Hypopharynx, Larynx and Upper Esophagus.

Orville F. Grimes (by invitation) and H. Brodie Stephens,

San Francisco, Calif.

Malignant disease involving the hypopharynx, larynx and upper esophagus presents difficult surgical problems. Early extension to cervical lymph nodes complicates an already formidable operative procedure by necessitating their en bloc removal.

The experience gained from the surgical treatment of 15 patients with malignant disease involving the hypopharynx, larynx, upper esophagus with or without regional lymph node metastases is presented. Modifications of the original procedure described by Wookey have become necessary in order to resect greater areas of malignant involvement.

The indications and contraindications for surgical intervention, the prognosis of treated cases and the futility of the use of roentgen therapy in patients exhibiting advanced malignant disease in and about the hypo-pharynx are discussed.

10. A Consideration of Palliative Treatment with Direct Attacks upon Carcinoma of the Esophagus.

Mark M. Ravitch, Henry T. Bahnson (by invitation) and

Thomas N. P. Johns (by invitation), Baltimore, Md.

The results of extirpation of carcinoma of the esophagus, to date have been so discouraging as to raise serious question concerning the value of the direct attack. Palliative gastrostomy has been properly abandoned as unsatisfactory. Simple dilatation and the Souttar tube have a limited application. The prime requisite of any palliative procedure is the restoration and maintenance of oral feeding. A number of shunting techniques including esophagojejunostomy, intra- or antethoracic may be employed. These may be expected to carry a much lower mortality rate than resection and can be performed in poor risk patients with non-resectable tumors. Since the results of resection are so poor it is quite probable that a wider application of shunting procedures will result in a greater number of comfortable patient-months in a given group of patients at the possible expense of the loss of an occasional cure.

11. A Pathologic Study of Large Tissue Sections of Bronchogenic Carcinoma.

Edward J. McGrath and Edward A. Gall (by invitation),

Cincinnati, Ohio

This study includes 86 lungs with neoplasm subjected to large tissue sections, the blocks ranging up to 8 x 12 cm. cut at 10 to 15 microns thickness.

The possibility of multicentric origin is manifest in 31 of the above cases. This is characterized by multiple foci of preinvasive carcinoma and/or multiple histologic types in a single lesion. The study also includes an investigation of submucosal and peribronchial extension as well as microscopic penetration of adjacent lobes, and their surgical significance.

12. The Use of Streptokinase-Streptodornase (Varidase) in the Management of Early Postoperative Partial Pulmonary Resections.

C. Thomas Read (by invitation), Phoenix, Arizona

Previous experiences with SK-SD used within the thorax for purposes of lysing blood clots, exudates, and related coagula have shown these enzymes to be practical and frequently of considerable value in the management of certain thoracic problems. Other reports have dealt with their use relative to total lung resection, hemothorax, and em-pyema.

Since the enzymes uniquely lyse fibrinous deposits and nucleoprotein and may cause fistulae to become manifest, some hesitation has existed in the application of SK-SD to early postoperative partial lung resection case.

This report recounts our experience in the application of the enzymes in six instances of lobectomy and/or segmental resection. The diseases encountered at operation diagnosed histopathologically, were tuberculosis, coccidioidmycosis, and a granulomatous lesion possibly coccidioidomycosis.

The enzymes ‘were instilled through the usual indwelling drainage tubes into the operated hemithoraces on the third postoperative day (three cases), fourth day (one case), sixth day (one case), and the seventh day (one case). In addition one patient was reoperated and SK-SD was injected the next day.

The results were entirely satisfactory clinically and favorable from a roentgenological point of view. In no instance was there a chronic fistula created or evidence of a deleterious effect on the underlying disease process. All the wounds healed per primam and no leakage was manifest into or from the thoracotomy incisions. The cases have been followed from one to six months and their courses have not been altered in any way unfavorably.