Monday Afternoon, April 25,1955

2:00 P.M. Executive Session. (Limited to Active and Senior Members).

3:00 P.M. Scientific Session: REGULAR PROGRAM.

Remarks by the President, Edward S. Welles, Saranac Lake, N. Y.

28. Lower Esophageal Web.

Walter F. Bugden and J. Ernest Delmonico (by invitation),

Syracuse, N. Y.

Intermittent dysphagia caused by a smooth web or diaphragm in the lower esophagus at or near the esophago-gastric junction is described. Two adult male cases with surgical correction are presented. This entity is generally unrecognized by the roentgenologist and endoscopist for reasons that will be described. Both cases were "missed" at previous examinations. Schatzki described 5 cases in 1953 which he called "lower esophageal ring", only one of whish was treated surgically by esoph-agoplasty. Ingelfinger and Kramer described 6 cases in 1953 which they call "contractile lower esophageal ring". One was treated surgically by esophageal resection.

The etiological considerations will be discussed. Radiologically the findings are typical when proper maneuvers are made, but the diagnosis can be easily missed. The sparse number of reports in the literature indicates that the diagnosis is probably being overlooked by both roentgenologists and endoscopists. The esophagus must be distended with heavy barium above and below the defect to bring out the "web" on the roentgenograms.

The two cases we are reporting were explored and a lower esophageal web found. The lesion was not palpable externally but was clearly demonstrated with the esophagus opened longitudinally. Several diagrams demonstrate the method used for local esophagoplasty. Both cases are greatly improved and very grateful for the return to normal swallowing after many years of dysphagia and subternal distress.

29. Lymphoma of the Lung and Pleura.

Willard Van Hazel and Robert J. Jensik (by invitation), Chicago, Ill.

The occurrence of lymphoma in the chest has usually been thought of as media-stinal in anatomic location with typical roentgen appearance and characteristic symptomatology and bronchoscopic features. In recent years isolated case reports of pulmonary lymphomas have appeared in the literature. Our present study consists of a group of twelve cases, which have for a common denominator a diagnosis of lymphoma but which was primarily pulmonary or pleural in location and varied considerably as to roentgen appearance and symtomatology.

The lesions were either asymptomatic, or varied from occasional cough, episodes of hemoptysis, to dyspnea or toxemia. The clinical histories appear in the complete report. Seven of the cases had X-ray evidence of pulmonary pathology, either as a solitary mass (four), a large dense mass in two (one of which had cavitation) and a bilateral diffuse nodulation in one. Four of the remaining five had recurrent pleural fluid and one had a large mass in each pleural space.

Bronchoscopy failed to give tissue diagnosis in the majority of the cases but interestingly in one, biopsy of the mucosa revealed the identical histoiogic report as was obtained by paraffin section studies of the centrifugal pleural fluid. Histo-logically the diagnoses were small cell lymphosarcoma, reticulum cell lymphosar-coma, Hodgkin's disease and Hodgkin's sarcoma. The exact tabulation is incorporated in the report although the majority were small cell lymphosarcoma.

The treatment consisted of surgical resection, X-ray therapy and nitrogen mustard. Complete resection consisted of lobectomy in three patients and pneumonectomy in two. In two cases incomplete resection was done. All five patients survived resection: One is now five years since pneumonectomy without evidence of recurrence (lymphoblastoma); one died three years postoperatively of an acute illness; two have been lost to follow-up after three years; one is alive one year after surgery. Of the two partially resected cases, one survived eight years and the other is still alive six years later, having had in the interim, one year ago, an abdominal perineal resection for colon carcinoma.

30. Chest Wall Prosthesis.

Bert H. Cotton, George A. Paulsen (by invitation) and

Jack Dykes (by invitation), Los Angeles, Calif.

Twenty cases of chest wall tumors are reported, divided into primary and secondary neoplasms. The treatment of these tumors was surgical excision with replacement of the chest wall by a prosthesis. Following large block resections of the thoracic wall an attempt has been made to maintain rigidity by replacement with a suitable material to aid in the mechanics of respiratory physiology. The developmental phases of providing functioning chest wall prosthesis are discussed in this paper. Various prosthetic materials and methods with their adaptation to various sized defects are presented. Advantages, disadvantages and complications met in this series are summarized.

A short movie showing the use of stainless steel mesh as chest wall replacement accompanies the paper.

31. Thymic Neoplasms.

Donald B. Effler and Lawrence J. McCormack

(by invitation), Cleveland, Ohio

Thymic tumors are frequently observed in myasthenia gravis; otherwise they are considered to be rare neoplasms and of little clinical interest. Malignant tumors of the thymus are also reported, but the intimate relationship between thymic tumor and malignancy deserves added emphasis.

This report concerns 17 patients with thymic tumor; all have been studied at the Cleveland Clinic within the past five years. Diagnosis by direct biopsy or excision was established in each case. Nomenclature based on histopathologic features is discussed and a simplified classification of thymic tumors has been used.

The nebulous relationship between myasthenia gravis and thymic tumor has been discussed in the literature; the authors believe that this emphasis has been out of proportion to more important features of the tumor. Thymic neoplasms occur more frequently than generally recognized; misdiagnosis as lymphoblastoma, lymphoma or mediastinal carcinoma is common, as the thymus contains mixed tissue elements. It becomes increasingly apparent that thymic tumors occur in all age groups and carry a high incidence of malignancy. Unless there is obvious tumor extension or gross metastases are apparent, both gross and histopathologic distinctions between benign and malignant tumor of the thymus are impossible.

The authors believe that all thymic tumors should be considered malignant. A program of combined surgical and radiologic therapy is suggested. This combined therapy even in those cases with obvious malignancy demonstrated by intrapleural and intrapericardial metastases may greatly improve an otherwise hopeless prognosis. Excision alone in the apparently benign thymic tumor is inadequate; late metastases or recurrence occur too frequently. The concept of high malignant potential in thymic neoplasm deserves particular emphasis.

6:30-8:30 P.M. COCKTAIL PARTY, Informal.

Chalfonte-Haddon Hall.