Friday Morning, May 16, 1958

8:30 A.M. Business Meeting - Imperial Ballroom

Scientific Session: REGULAR PROGRAM

Eulogy - Evarts A. Graham

by Tom Burford

1. Further Studies in the Surgical Management of Carcinoma of the Lung.

Edward D. Churchill, Richard H. Sweet, J. Gordon Scannell

and Earle Wilkins (by invitation), Boston, Mass.

Eight years ago the authors presented before this society the results of surgical treatment of carcinoma of the lung at the Massachusetts General Hospital in the years 1930 to 1950. The years since that report have been characterized by a greater awareness of the disease on the part of the medical profession. The authors, therefore, propose to review the surgical experience with primary cancer of the lung at this hospital in the years 1950-1956 with this in mind. During this period approximately 600 proven cases were seen, of which about 300 came to thoracotomy, comparable in number to the earlier series. In addition, it is possible to present a long-term follow-up of the survivors of the 1930-1950 group.

2. Should we Insist on "Radical Pneumonectomy" as a Routine Operation for Carcinoma of the Lung?

Julian Johnson, Charles K. Kirby and William S. Blakemore

(by invitation), Philadelphia, Pa.

In an effort to improve the results of resection for carcinoma, of the lung, many surgeons have turned to the so-called "radical pneumonectomy," attempting to apply the principle of "en bloc" resection for this lesion. A widely circulated motion picture on the subject implies that the surgeon who does not practice "radical pneumonectomy" does an incomplete operation. In discussing this subject around the country, we have been impressed with a general reluctance of thoracic surgeons to admit that radical pneumonectomy is not their routine for carcinoma of the lung, and those who do admit it, tend to do so sheepishly.

We have maintained a conservative approach to the problem of cancer of the lung in a series of about 700 patients admitted to the Hospital of the University of Pennsylvania. Pulmonary resection was carried out in 38 per cent of these patients with a 7 per cent hospital mortality. The five year survival rate was 25 per cent for those undergoing resection, or 9 per cent for all patients seen more than five years ago.

We have been unable to find results significantly superior to these as far as five year survival is concerned in any unselected series, including those of the strongest proponents of the radical approach. We shall discuss this problem in some detail. We believe that the presence or absence of blood vessel invasion in the surgical specimen is more important in the prognosis than the extensiveness of the mediastinal resection. This leads us to believe that the advocation of radical pneumonectomy as the routine operation for cancer of the lung by all thoracic surgeons throughout the country is unjustified at the present time.

3. Results in the Treatment of Bronchogenic Carcinoma-An Analysis of 1008 Cases.

Sol Center (by invitation), Miami, Fla., and

Thomas H. Burford, St. Louis, Mo.

One thousand eight patients with bronchogenic carcinoma were seen and treated at the Barnes Hospital Chest Service between January 1, 1948 and January 1, 1956. The diagnosis of cancer of the lung was verified in one hundred percent of cases by microscopic section. The date of follow-up was July 1, 1957. All patients were followed for a minimum of one and one-half years to a maximum of nine and one-half years. Operability and resectability rates are presented. Factors influencing prognosis are analyzed and discussed. Survival figures are given.

4. Coronary Artery Disease After 25 Years.

Claude S. Beck, Cleveland, Ohio

This work is based upon approximately 6,000 experimental operations on the coronary arteries over the past 25 years. The motivation of this work was to improve the crippled coronary circulation. To improve the abnormal circulation requires understanding of the normal circulation. This work had this common denominator and resulted in the establishment of a new physiology for the disease.

Some of the concepts are new but others are given a practical application and are different but not new. They are as follows: Reduction of coronary artery inflow - a, under normal conditions, b, under conditions in which a red cell can go anywhere within the heart's substance. The theory of oxygen differentials and the production of electric currents in the heart. Effect of measured quantities of blood on the electric stability of the heart. Amount of blood that can pass by openings of 1.5 and 1.0 mm. in the coronary artery system. Total coronary inflow versus even distribution. Even distribution produced by inter-coronaries. Predominance of even distribution over total inflow.

Operative methods to produce intercoronaries. What operation can do and its limitations. Selection of patients. Clinical results. Mortality - in the last 178 consecutive patients operated upon September 1, 1955 to July 1, 1957 there were 2 operative deaths, 1.2%. The mortality was 3 for 25 minutes but the death factor was reversed and it fell back to 2 again.

5. The Clinical Significance of Cor Pulmonale in the Reduction of Cardiopulmonary Reserve Following Extensive Pulmonary Resection.

William E. Adams, Robert W. Harrison (by invitation), Edwin T. Long

(by invitation) and Benjamin Burrows (by invitation), Chicago, Ill.

Extensive pulmonary resection occasionally results in an immediate marked reduction of cardiorespiratory reserve leading to cor pulmonale, right heart failure and death. Many individuals are able to compensate to reduction of lung volume in the early postoperative period only later to develop symptoms and disability attributable to reduced cardiopulmonary reserve. Thirty patients who had survived extensive pulmonary resection (pneumonectomy or bilateral lobectomy) two to fourteen years were studied in an effort to define the resulting physiologic alterations. The functional capacities of these individuals ranged from near normal to complete disability. Observations included pulmonary function studies, electrocardiograms and cardiac catheterization with measurement of pulmonary artery and right ventricular pressures, cardiac output and peripheral arterial oxygen saturations at rest and during exercise. Ventilatory studies failed to reveal marked abnormalities other than reduction in vital capacity and maximum breathing capacity commensurate with the amount of lung tissue resected. Generally, there was little relation between changes in peripherial arterial oxygen saturation during exercise and functional capacity. Right ventricular or pulmonary artery pressures at rest were found to be increased 25 to 200 per cent above normal levels. During exercise the right heart pressures rose markedly attaining levels 50 to 140 per cent higher than the resting levels. There appeared to be a close correlation between the amount of elevation in right heart pressures during exercise and the individual's functional capacity; i.e., dyspnea and fatiguability on exertion.

Conclusions drawn from such observations are that pulmonary hypertension, especially occuring during exertion, is a major factor in the production of the disability occuring at long periods of time after extensive pulmonary resection.

6. Effect of Severe Unilateral Hypoxia on the Partition of Pulmonary Blood Flow in Man.

Aaron Himmelstein, P. Harris (by invitation), H. W. Fritts, Jr.

(by invitation) and Andre Cournand, New York, N. Y.

Using a method previously reported from this laboratory, the effect of severe unilateral hypoxia on the partition of the pulmonary blood flow has been studied in five subjects with minimal lung disease. The method combined bronchospirometry, cardiac catheterization, and arterial cannulation. During a control period, one lung breathed a 25% and the other a 21 % oxygen in nitrogen mixture. During hypoxia, a 5% mixture was substituted for the one containing 21%. The total pulmonary flow was measured by dividing the combined oxygen uptakes of both lungs by the arterio-venous oxygen difference. The flow through the lung breathing 25% oxygen was calculated by assuming full saturation of the blood in its pulmonary veins. The flow through the hypoxic lung was then obtained by difference. In three subjects the level of the arterial saturation during hypoxia first fell, then rose as hypoxia was continued. This rise was associated with a reduction in the fraction of blood flowing through the hypoxic lung. In the fourth patient the result was equivocal. In the fifth, the saturation fell to and remained at 80%, no change in flow was evident, but pulmonary arterial hypertension developed. The implications of these observations will be discussed.