Monday Morning, April 16, 1962

8:30 A.M. Business Session (Limited to Members)

Khorassan Room

8:45 A.M. Scientific Session: REGULAR PROGRAM

Khorassan Room

1. Combined Preoperative Irradiation and Resection for Bronchogenic Carcinoma

Donald L. Paulson, Robert R. Shaw, John L. Kee,

Richard E. Collier (by invitation), and John T. Mallams

(by invitation), Dallas, Tex.

The natural history of bronchogenic carcinoma is such that surgery alone, however radical, is limited in its application to about one-third of the cases when first seen. Biologic factors of location, cell type and the response of the host predetermine operability. In spite of its limitations, surgery has been the only curative treatment heretofore adyocated for bronchogenic carcinoma in a localized phase. Results following resection may be improved mainly through a better selection of patients for surgery without a corresponding improvement in the cure rate for all patients with this disease. Irradiation therapy, although used mainly for inoperable lesions and postoperatively, has been proven to be of value in producing palliative results as well as prolonging life in individual cases. Preoperative irradiation in combination with resection has been utilized by the authors since 1956 for bronchogenic carcinomas located in the superior sulcus involving the chest wall and more recently for both operable and inoperable hilar lesions. A preliminary report of the results in over 40 cases of bronchogenic carcinoma treated by means of combined pre-operative irradiation and resection will be made.

2. Veterans Administration Surgical Adjuvant Lung Cancer Chemotherapy Study: Present Status.

Felix A. Hughes, and George Higgins (by invitation),

Memphis, Tenn.

(Spokesmen for the VA Adjuvant Cooperative Group)

Since 1957 the cooperative group in 22 VA Hospitals has placed in the lung study 1,007 patients following pulmonary resection for bronchogenic carcinoma. Four hundred and fifty four of these patients are being followed at the present time. Information will be presented regarding the effect of nitrogen mustard administered as an adjunct to pulmonary resection on postoperative mortality and on subsequent survival of patients. The 30 day postoperative mortality in pre-study cases, in a group of cases given only saline, in the control groups of the concurrently randomized cases for the 0.4 mg/kg nitrogen mustard treated, and for the present 0.3 mg/kg series of cases has approximated 10%. The 30 day mortality of the cases treated with 0 4 mg/kg nitrogen mustard was 21.5% (20/92); for the present series treated with 0.3 mg/kg it is 15.5% (47/303). The complications and causes of death will be analyzed. Fifty percent three year survival has followed "curative" resection, while "palliative" resection has resulted in about 20% three year survival. New drugs available for adjuvant group trial will be discussed, as will the optimum time for adjuvant drug administration following pulmonary resection. Protocols for a treatment program using resection, radiotherapy, and chemotherapy are being formulated.

3. Larynx and Lung Cancer in the Same Patient: A Report of 40 Cases

William G. Cahan, and Pompeyo Montemayor

(by invitation), New York, N. Y.

In a patient with cancer of the larynx, the possibility of a cancer of the lung existing either synchronously or metachronously should be considered. At Memorial Center there have been at least 40 instances in which primary carcinomas of larynx and lung have occurred in the same patient, 9 synchronously and 31 at a later date. When the cancers occur synchronously, the question of priority of management arises, and it has been our experience that the more malignant of the two, namely, the cancer of the lung, should be removed first. In the post-laryngectomy patient there is a particular problem in that the tracheotomy is often associated with tracheobronchial inflammation. These inflammatory processes, such as tracheitis sicca, often result in cough and sputum which may be bloody. Not infrequently symptoms are attributed entirely to the chronic irritation, but can be, manifestations of a separate lung cancer. In the follow-up of laryngectomized patients, it is suggested that chest x-rays be taken at 6-month intervals in order to be alert to the possibility of early lung cancer formation. In addition, any longstanding cough, with or without production of sputum through the tracheotomy, should be suspected of indicating lung cancer. In this series there have been 4 patients who have lived five years after their last surgical procedure Most of those who died of disease did so from lung rancer and its extension There is little question that increased numbers of survivors can be expected if the lung cancers were brought earlier to surgical management.

4. Intrathoracic Tumors Associated with Hypoglycemia

Herbert C. Maier, and David Barr

(by invitation), New York, N. Y

Various metabolic abnormalities are being recognized more frequently with a variety of intrathoracic tumors. When hypoglycemia is present, the patient is frequently considered to have mental difficulty and the correct diagnosis may be long delayed This paper gives a summary and analysis of the various types of tumors found within the thorax which may be associated with severe hypoglycemic states. The recognition of this clinical entity is not difficult if the possibility of various nonpan-creatic tumors causing a low blood sugar is borne in mind The intrathoracic tumors causing hypoglycemia are chiefly large extrapulmonary growths of certain mesodermal types The tumor may be present for some years before the metabolic disturbances become manifest. If treatment is unduly delayed, chronic hypoglycemia may result in brain damage. With surgical excision of these tumors a return of the blood sugar to normal levels can usually be anticipated. Knowledge concerning the malignant potential of such tumors is still meager but in some instances a recurrence of hypoglycemia signals the appearance of metastases.

5. Clinical Evaluation of a New, Effective Mucolytic Agent

Watts R. Webb, Jackson, Miss.

Approximately one-fourth of all postoperative deaths are due to pulmonary complications and most of these are secondary to airway obstruction from retained secretions. This study has evaluated the effectiveness of N-acetyl cysteine in liquefying secretions during the operative and postoperative periods, and during the care of suppurative lung disease. The volume and character of the sputum and clinical results have been followed in over 200 patients. This agent has proved extremely effective in reducing the viscosity of mucoid and purulent secretions to aid their removal. In vitro, it produces liquefaction within one minute of contact. It has been safely administered by nebulization, direct instillation into a tracheotomy or through an indwelling percutaneous intratracheal catheter. The incidence of postoperative endotracheal suctioning, bronchoscopies, atelectasis and pneumonia has been markedly reduced. In particular, the postoperative respiratory care of small children has been greatly simplified. During operation, it is effective as a spray down the endotracheal tube for clearing tenacious secretions. Tracheostomy care is improved as crusting with secretions is prevented. Use prior to bronchograms has improved the filling in cases with heavy secretions. Mucosal biopsies and resected specimens have shown no mucosal changes The only adverse effect noted has been a rare incidence of bronchospasm in susceptible individuals.

6. The Premature or Critically-Ill Infant with Esophageal Atresia: Increased Success with a Staged Approach

Thomas M. Holder, Victor G. McDonald, Jr.,

Kansas City, and Morton M. Woolley, Los Angeles, Calif.

(all by invitation)

Sponsored by Robert E. Gross, Boston, Mass

Today the fullterm infant with esophageal atresia has a good chance for survival with primary repair (80-90%). Most deaths occur in the premature infants or in patients who have already developed serious pneumonia (25 to 50% survival). The usual cause of death in these small patients is pulmonary complications. The present approach is one which (A) directs therapy toward clearing of pulmonary complications, and (B) allows for growth and maturation of the baby prior to the definitive procedure. This is accomplished by (A) a Stamm gastrostomy under local anesthesia as soon as the diagnosis of tracheo-esophageal fistula is made, (B) a retropleural division of the tracheo-esophageal fistula under local anesthesia 24 to 48 hours later, and (C) the definitive repair of the esophagus when the patient's condition and size (5 to 6 pounds) permits. Using this approach, 13 patients ranging in size from 2 pounds 13 ounces to 5 pounds 8 ounces, have been treated with 9 successes - a mortality of 31% in a group in which one would anticipate a 65 to 75% mortality with primary repair. Two of the 4 deaths occurred in infants with other major anomalies.