Friday Afternoon, March 27, 1953

2:00 P.M. Scientific Session.

7. Localization of Radioactivity in the Lung and Thoracic Lymph Nodes.

J. Ray Bryant (by invitation) and Harold F. Berg (by invitation),

Louisville, Ky.

Localization of radioactive gold 198 in specific areas of the lung has been accomplished by instillation of a colloidal solution into terminal bronchi.

Localization of radioactive gold 198 in the lymphatic drainage chain of the lung has also been accomplished by several methods.

The methods used and results will be discussed. Diagrams showing the deposition of activity and photomicrographs showing the resulting histological changes will be presented.

The therapeutic implication of this new approach to tumor therapy will be discussed.

8. The Ability of the Pulmonary Vascular System to Influence the Spread of Tumor Emboli.

Edwin A. Lawrence, Donald B. Moore (by invitation) and

George I. Bernstein (by invitation), Indianapolis, Ind.

The capacity of the vascular system of the lung either to capture tumor emboli that reach it from the various peripheral venous systems or to permit them to pass on to the arterial blood is not understood. Although it is known that under certain experimental conditions tumor emboli will pass this barrier, the established diameter of pulmonary arteriovenous shunts in normal lungs (160-290 microns in the rabbit and up to 500 microns in the human) would suggest that they could do so with facility greater than ordinarily observed.

The purpose of this communication is to describe experimental procedures with a transplantable tumor in rabbits in which tumor emboli injected into a peripheral vein have been found to pass readily through the vascular bed of the lungs. At this stage in the study all control animals who grew tumor had it in the lungs at autopsy. But 65 percent of them also had tumor in organs, such as liver, kidney and skeletal muscle, that could have been reached only by emboli passing through the lungs.

In contrast to controls, animals that were heparinized at the time of injection sometimes had no tumor at all in the lungs at autopsy, but tumor elsewhere in the body, as in the liver and kidneys. Furthermore, the incidence of organ involvement other than the lung in the experimental group was significantly greater than in the control group.

The passage of tumor emboli through the lungs seems to be dependent upon these factors, at least: (i) character of the tumor suspension; (2) size of the individual tumor emboli; (3) diameter of the pulmonary arteriovenous communications and coagulability of the blood.

9. Bronchial Resection and Anastomosis.

Paul W. Gebauer, Honolulu, T.H.

This paper is a report of 14 instances of reparative bronchial surgery, without the use of dermal grafts or artificial prostheses. The patients have been followed for a period of from eight months to two years. There have been no deaths or serious complications. The procedure used most often was excision and anastomosis of main bronchi or of lobar bronchi.

There were 10 instances of healed tuberculous bronchostenosis, two of non-tuberculous bronchial deformity, and two of localized tumor excision. In each instance intact, functional, pulmonary tissue was salvaged, by surgical procedures on diseased bronchi, and the results indicate that the receptiveness of the tracheobronchial tree is comparable to that of the gastro-intestinal and vascular systems.

Brief case summaries are a means of portraying pre-operative studies and treatment. The operative technique is illustrated by a colored movie depicting an anastomosis of the right upper lobe bronchus following excision of a fibrous stenosis and segmental resection.

10. Bronchiolar ("Alveolar Cell") Carcinoma of the Lung.

Clifford F. Storey, K. P. Knudtson (by invitation) and

B. E. Lawrence (by invitation), St. Albans, N.Y.

Bronchiolar carcinoma has also been referred to as terminal bronchiolar carcinoma, alveolar cell carcinoma, pulmonary adenomatosis and other descriptive titles. A histologically similar infectious pulmonary disease of sheep is known as jaagsiekte. These pulmonary neoplasms are interesting, controversial and, while uncommon in comparison with bronchogenic carcinoma, they are not as rare as has been thought. The origin of these tumors and whether they arise multicentrically or from a single primary lesion is debatable. The relationship between so-called benign pulmonary adenomatosis and bronchiolar carcinoma is not a matter of universal agreement.

This report is based on a detailed study of 36 proved cases of bronchiolar carcinoma. Twenty-eight of these have died and complete postmortem examinations have been carried out in most instances. The eight surviving individuals, treated by surgical procedures varying from segmental resection to total pneumonectomy, are clinically free of disease from one to three years following operation.

Early in the course of this disease there are no characteristic signs or symptoms and no typical roentgenographic changes in the lungs. The early diagnosis usually is dependent upon examination of the excised specimen. The late symptoms are those of pulmonary malignancy in general and, in addition, many patients raise unusually large quantities of clear, watery sputum. There is often a terminal pneumonia. Advanced cases show either complete consolidation of a lobe or entire lung or multiple nodular infiltrations involving one or both lungs. These types are often found in combination.

The study of this series of patients and a review of the literature has convinced us that pulmonary adenomatosis and bronchiolar carcinoma are the same, varying only in degree of malignancy in different patients. Although still indefinite, available evidence indicates that they probably arise in the bronchioles. We could find no convincing evidence in the literature or in our material that these tumors are multi-centric in origin. It appears most probable that they arise from a single focus from which they may spread via the blood stream, the lymphatics or by bronchogenic dissemination.

Hope for patients with this disease lies in the prompt removal of early small suspicious pulmonary lesions of doubtful etiology. Because of the peculiar growth behavior and manner of spread of this neoplasm, conservative resection consisting of lobectomy or even segmental resection appears to be the most rational method of surgical management.

11. The Significance of Pulmonary Hypertension as a Cause of Death Following Pulmonary Resection.

W. E. Adams, John F. Perkins, Jr. (by invitation) and

Adolfo Flores (by invitation), Chicago, Ill.

It is well known that pneumonectomy in patients with advanced pathological changes in both lungs is attended by a considerable risk. What are the physiologic changes that lead to a fatal termination following operation in these cases?

Observations:

(1) When performed in stages, dogs may tolerate reduction in lung capacity by bronchial stenosis or lung resection to as little as 15 percent of normal;

(2) When capacity reduction is made more rapidly, most animals die within a few hours or days;

(3) Arterial blood O₂ saturation in dogs with only 15 percent of normal lung capacity remains within a few percent of a normal level. If oxygen is inhaled, the saturation becomes elevated to a normal level;

(4) Right ventricular and pulmonary arterial pressures become elevated to as much as twice that of normal and are sustained at that level when the lung capacity is reduced to as low as 15 percent;

(5) Pathological changes in the lungs of dogs that have expired following sudden reduction in lung capacity are those suggestive of cardiac failure.

Conclusions: Pulmonary hypertension is an important factor as a cause of death following pulmonary resection where advanced bilateral pathologic alterations exist preceding operation. If an operation that reduces pulmonary capacity by a considerable degree is necessary in a patient with pulmonary hypertension and can be performed in stages the risk may be materially reduced. Prevention of further reduction in pulmonary capacity due to retained secretions with resultant atelectasis and pneumonitis especially in patients with preoperative pulmonary hypertension is of paramount importance.

12. Prevention of Chest Wall Defects: Use of Tantalum and Steel Mesh.

Donald B. Effler, Cleveland, Ohio

Surgical treatment in malignant neoplasms of the chest wall requires extensive block excision of bony thorax and soft parts. Similar treatment may be necessary for benign tumors and chronic infectious granulomas. Certain lesions of the diaphragm also pose problems of reconstruction after radical excision. Defects of the chest wall following surgery or trauma pose a serious respiratory problem. Prevention of significant paradoxial motions attributable to elective surgery is mandatory and can be accomplished in most instances.

Methods of surgical reconstruction of chest wall defects are discussed and criticized. Previous attempts with prostheses and foreign material are listed and the methods described. The concept of inert metal in the form of mesh was described by Koontz in 1948. The role of mesh in establishing a firm chest wall is discussed and emphasis is placed on the essential difference between this and other commonly used prostheses.

Clinical experience is based on 20 cases where either tantalum or stainless steel mesh has been employed. The follow-up period varies from 4 years to 6 months. Selected cases are described to illustrate wide excision in chest wall neoplasm with a definitive procedure to prevent subsequent chest wall deformity. Six case histories will be presented to illustrate certain principles of surgical, therapy, chest wall reconstruction, primary closure and skin grafting if indicated.

There have been no complications or failures in this series that may be attributable to the use or mesh. In no instance was it necessary to remove the mesh. Definite advantages have been observed with the use of steel mesh as contrasted to tantalum; such advantages will be briefly discussed as well as the technique of insertion.