Monday Morning, April 8, 1963

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

Emerald Room

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

Emerald Room

1. A Continuing Clinical Survey of Adenomas of the Trachea and Bronchus in a General Hospital

Earle W. Wilkins, Jr., R. Clement Darling (by invitation),

Lamar Soutter, and Ronald C. Sniffen (by invitation), Boston, Mass.

Since our initial report nine years ago, the total experience of the Massachusetts General Hospital in the management of adenomas of the trachea and bronchus has been reviewed. Over the period of years, 1909 through 1961, there have been 70 carcinoid adenomas and 6 cylindromas diagnosed by histological examination at this hospital. This series has been analyzed according to the duration and type of symptoms as well as roentgenologic and bronchoscopic findings. Transthoracic resection was carried out in 59 patients; 17 patients received either no treatment or palliative therapy in the form of repeated bronchoscopic resections or small doses of irradiation. Follow-up data are presented for all patients. Emphasis is placed on type and extent of disease encountered and mode of therapy used. Optimal and alternative methods of management are discussed.

2. Primary Carcinoma of the Lung: Experience with 1340 Patients

Raymond J. Barrett, J. C. Day, P. V. O'Rourke,

Hossein Sadeghi (by invitation), Richard W. Perry

(by invitation), and William M. Tuttle, Detroit, Mich.

Between January 1, 1947, and April 1, 1962, the authors have seen 1340 patients with primary carcinoma of the lung. Male-female ratio was 8:1, over 80% were of the white race, and more than 65% were in the age range' of 50-70 years. Approximately 50% o£ the tumors were of squamous cell type; "oat cell", and adenocarcinoma accounted for slightly less than 20% each. "Alveolar cell" incidence was approximately 3%. Explorability and resecta-bility varied with the type of patient population in the respective hospital. Thus explorability ranged from a low of 21% to a high of 70%. Correspondingly, the resectability rate varied from below 5% to a high of 40% in the institution where the bulk of the resections were performed. Slightly over half the resections were pneumonectomies with a mortality rate of 7%. The remainder, consisting of lobectomies, bilobectomies, and an occasional segmental resection, had a mortality rate below 3%. An extensive follow-up of the series is underway and prognosis will be related to site of the tumor, it's size and cell type, extent of the resection, incidence of positive nodes and effect of adjuvant radiotherapy.

3. A Follow-up On Patients With Bronchogenic Carcinoma Locally "Cured" By Pre-operative Irradiation

Norman H. Baker (by invitation), Columbus, Ohio,

R Adams Cowley, and Fernando G. Bloedorn

(by invitation), Baltimore, Md.

A myriad of adjunctive procedures have been added to surgery for bronchogenic carcinoma in the past thirty years in the hope of improving long term results. Recently pre-operative irradiation followed by resection has shown some promise in the treatment of this disease. The resected lung and mediastinal nodes are reported to be sterilized (containing no viable tumor cells histologically) in fifty percent of the cases. This group should theoretically give the highest cure rate. All cases that had been receiving pre-operative irradiation followed by resection since 1956 were reviewed. There were 19 patients in whom the specimen was reported to contain no tumor. Careful re-examination of the specimens disclosed undetected tumor in two. The remaining 17 patients were followed up to the present time. The long term results in this group were disappointing. These cases will be reviewed and the operability, pathology and survival will be discussed.

4. Hypertrophic Pulmonary Osteoarthropathy

H. Edward Rolling, Gordon K. Danielson,

Ralph W. Hamilton (all by invitation), and

William S. Blakemore Philadelphia, Pa.

Pulmonary neoplasms in man occasionally are associated with pulmonary osteoarthropathy. In two of our patients with pulmonary neoplasms the first manifestations were pain in the extremities and characteristic changes in the limbs. These findings have been recognized in many patients with various pulmonary diseases. In the affected limbs there is an overgrowth of vascular connective tissue which is invaded by periosteal new bone formation. Overgrowth of tissue in the digits gives rise to clubbing of them in man but not in other species. We have used the measurement of the increased blood flow in the limbs to follow the course of the disease. In patients where the blood flow was measured before, during and/or after operation, the blood flow was found to return to normal as the hilium was dissected, and the changes in the extremities regressed during the postoperative period. The regression has been noted following removal of the intrapulmonary lesion, vagotomy, or even exploratory thoracotomy. These observations and others made upon dogs indicate that the increased limb flow is maintained by a reflex, probably with afferent impulses arising in the pleura and traveling in the vagus nerves. Illustrative laboratory and patient observations will be presented.

5. Pleurectomy in the Treatment of Pleural Effusion Due to Metastatic Malignancy

R. Jensik, J. E. Cagle (by invitation), C. Perlia

(by invitation), S. Taylor (by invitation), S. Kofman

(by invitation), and E. J. Beattie, Jr Chicago, Ill.

An analysis of our patients dying from breast carcinoma with pleural metastases revealed that about 40% of them died from pulmonary insufficiency. Hence, a vigorous attack on malignant pleural effusion was begun. Fifty-one pleurectomies were done on 49 patients in the five-year period from January 1957 to January 1962. All of these procedures were done to halt the rapid accumulation of pleural effusion caused by carcinomatous invasion of the pleura. The commonest sites for the primary disease were the breast (17 cases) and the lung (12 cases). In eight patients the primary was undetermined. The ages ranged from 32 to 80 in 32 females and 17 males. The operative mortality was 5.8%. Six additional patients died of their disease within a month of their pleurectomy, and five patients have been lost to follow-up. The remaining 35 patients have had an average survival time of 9.3 months; one patient was doing well 26 months after surgery. The interval between the treatment of the primary disease and the onset of pleural effusion was not directly related to survival time after pleurectomy. Plural fluid cytology was positive in only 14 of 32 patients who had this examination.

6. Spontaneous Pneumothorax

W. G. Gobbel, Jr., W. G. Rhea, Jr., I. A. Nelson (all by invitation),

and R. A. Daniel, jr. Nashville, Tenn.

Since the incidence of recurrence of spontaneous pneumothorax after conservative non-operative treatment has been poorly documented and the place of surgical treatment inadequately defined, 119 consecutive cases on whom follow-up data were available have been studied. General consensus seems to dictate that a patient must have several episodes of spontaneous pneumothorax before being considered for surgical treatment, suggesting that the incidence of recurrence is low and/or results of surgical treatment are poor. In this study the recurrence rate after conservative non-operative management was 52% after the first pneumothorax, 62% after the second, and 83% after the third during the follow-up period that averaged six years. Thirty-one cases were treated by parietal pleurectomy and excision or oversewing of bullae and blebs. There were no operative deaths. There have been no recurrences over an average follow-up period of five and one-half years. Bullae and/or blebs were present in all operative cases. There was no evidence that the operation impaired pulmonary function. Since the incidence of recurrence is great after conservative non-operative management as contrasted to the very satisfactory results without mortality after parietal pleurectomy with bullae and bleb excision, early surgical intervention is recommended.

7. Colon Replacement of the Esophagus in Children

William A. Hopkins, Atlanta, Ga.

Studies have already shown that the colon is an adequate transplant for the esophagus in children. We have had the opportunity of utilizing colon transplant to replace the esophagus in seven cases of congenital atresia of the esophagus. The colon was used in one case of stricture following repair of tracheoesophageal fistula. The first one of these children was done at the age of six, and the child is now eleven years of age and doing well. Motility studies on the transplanted colon have been carried out by cinefluorography. Surgery was performed after the children had an upper esophagostomy and gastrostomy for a period of four to six years and, in one case, after eleven years. The operation was performed with two teams; transplantation of the right colon to the anterior mediastinum was accomplished in all cases. There was no mortality or morbidity in this group of cases. The technique of surgery utilized, as well as the long-term studies on the nutrition of these children, has been completed and presented in the paper. They all, without exception, are progressing well. A movie demonstrating the cinefluorographic motility of the esophagus and its emptying function will be shown.