Monday Morning, May 16, 1966

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

Ballroom

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

Ballroom

1. Tumors of the Thoracic Skeleton: Diagnosis and Management

A. Ochsner, Jr., George L. Lucas*, and G. McFarland*,

New Orleans, La.

In a 12 year period, 127 cases of bony and cartilaginous tumors involving the thoracic skeleton were studied in the Bone Pathology Laboratory. These cases have been reviewed. Sixty-nine were tumors of the ribs, 6 of the sternum, 15 of the thoracic vertabrae, 26 of the scapula and 14 of the clavicle (3 tumors involved more than one area). Forty-five were metastatic tumors, 36 were primary malignant tumors and 46 were primary benign tumors (includes 7 cases of fibrous dysplasia) The relative frequency of the different types of tumors is presented. The metastatic tumors were most commonly from the lung and breast. The primary malignant tumor most commonly encountered was the chondrosarcoma and the primary benign tumor seen most frequently was the osteochondroma. The presenting symptom varied with location and type but was usually pain, and in some instances a mass. The diagnostic problems are discussed, particularly the limits of X-ray and other laboratory studies and the questions relative to biopsy. Management, which is influenced by the type and location of the tumor, is discussed. Prognosis is evaluated.

2. Thymoma at the Massachusetts General Hospital

Earle W. Wilkins, Jr., L. Henry Edmunds, Jr.*, and

Benjamin Castleman*, Boston, Mass.

A quarter century of experience with thymoma is presented in this review of cases treated at the Massachusetts General Hospital between 1939 and 1964. The series of 63 patients includes only those in whom tissue confirmation was obtained during life. Follow-up is complete; 52 patients were initially diagnosed at least 5 years previously Thirty-seven patients had associated myasthenia gravis; 26 presented no evidence of myasthenia. Factors discussed in detail include pathological classification, prognostic significance of invasive tumor and presence of myasthenia, the role of radiation, and the accuracy of the 10-year survival rate as opposed to the conventional 5-year period in determination of potential cure. Modern methods of post-operative management are emphasized, particularly in the myasthenic. Discrepancies of conclusions with previous series are discussed The paper includes appropriate charts illustrating survival in relation to myasthenia gravis, encapsulated or invasive tumor, completeness of tumor excision, and use of irradiation.

3. Hyponatremia from Inappropriate Antidiuretic Hormone Elaboration in Carcinoma of the Lung

C. Porter Claxton, Jr.*, Harry T. McPherson*, Will C. Sealy, and

W. Glenn Young, Jr., Durham, N.C.

A variety of endocrine disturbances are known to be associated with carcinoma of the lung, but only rarely has the secretion of an inappropriate antidiuretic hormone been linked with this malignancy. Over an 18 month period three patients with carcinoma of the lung were discovered to have this latter endocrinopathy. The serum sodium in the patients was reduced to 108, 119, and 126 mEq/L respectively. All exhibited normal extracellular fluid volume, relatively hypertonic urine, and absence of renal and adrenal dysfunction. In two patients, symptoms of water intoxication were present; and in one a suspicion of cerebral metastasis was entertained Management with fluid restriction to 800 to 1,000 cc. per day increased the serum sodium to 130 to 140 mEq/L In one patient improvement followed radiation to the lesion, while in another excision of all the known intrathpracic tumor failed to revert the electrolytes to normal levels in the immediate postoperative period. Though this occurs in a small percentage of patients with carcinoma of the lung, the striking symptoms as well as the ease with which symptoms can be controlled demands that this endocrinopathy be kept in mind in all patients with cancer of the lung.

4. Reoperation for Bronchogenic Carcinoma

Wilford B. Neptune, Francis M. Woods, and Richard H. Overholt,

Boston, Mass.

Thirteen patients have had a second pulmonary resection for broncho-genie carcinoma (from 2400 verified cases, with 1176 primary resections). All originally had had a favorable operation and good cardiopulmonary reserve. The new or recurrent tumor was discovered early, and the second operation was done for what appeared to be localized disease. One patient initially had bilateral primary tumors treated with a staged resection of the lower lobes. Four patients had their second operation on the contra-lateral side: one had a wedge resection one year following a pneumonectomy; one had a bilateral, bisegmental resection; two had bilateral lobectomies. Eight patients were reoperated on the ipsilateral side: one had resection of the middle lobe following an initial resection of the upper lobe; the other seven had completion of the pneumonectomy. There was one postoperative death. Five patients have subsequently died. There are seven patients still - alive and well - from 15 to 136 months after the initial operation, and these are now from 5 to 93 months following the second operation.

5. Thoracic Outlet Syndrome

David B. Roos*, Denver, Colo.

Sponsored by William R. Waddell

Neurovascular compression in the shoulder region has long been recognized as a common and distressing problem, but the exact mechanism and site of compression are often not clearly understood. The numerous labels that have added more to the confusion than the understanding of the shoulder compression problems have been replaced by the single entity called thoracic outlet syndrome which leads to clearer understanding, more accurate diagnosis and more effective treatment. Compression of the brachial plexus and subclavian vessels against the first thoracic rib is the common denominator of all the syndromes, whether vascular or neurological. The various symptoms with which the syndrome may present are listed. Onset may be spontaneous or follow trauma. The physical signs and tests that lead to a clear diagnosis are described. The author's adaptation of plethysmography as a helpful diagnostic aid is illustrated. A new surgical approach to first rib resection through the axilla is described, and results of this operation in 60 cases are tabulated. Of the 50 patients in the neurological group, all were relieved by the operation, but three of the ten in the vascular group failed to benefit.

6. Considerations in the Management of Acute Traumatic Hemothorax

Arthur C. Beall, Jr., H. Wayne Crawford*, and

Michael E. DeBakey, Houston, Texas

At the 1965 Meeting of the Association moderate controversy arose in regard to management of acute traumatic hemothorax, both associated and unassociated with heart wounds. Some of these comments led to re-evaluation of methods employed for care of such patients in our own institutions. Review of experience with more than 650 patients with acute traumatic hemothorax admitted over the past 10 years now forces us to disagree with some of the statements made at last year's meeting. Heart wounds still are treated primarily by pericardiocentesis, reserving cardiorrhaphy for patients who do not respond to pericardial aspiration or who again develop tamponade following aspiration. Although thoracentesis may be used for minor degrees of hemothorax, most patients with acute traumatic hemothorax are managed primarily by intercostal thoracostomy tube drainage, depending upon rapid pulmonary re-expansion to prevent empyema rather than fearing contamination by the tube. Occasionally, when satisfactory evacuation of hemothorax cannot be accomplished in this way, early thoracotomy with removal of clotted blood has prevented formal decortication in almost all instances. Emergency thoracotomy, as in patients with heart wounds, is reserved for specific indications. Results supporting these concepts will be presented and indications for both emergency and delayed thoracotomy will be discussed.

7. Thoracic Repercussions of Amoebiasis

Rodolfo Herrera, Guatemala City, Guatemala

Intestinal infestation with Entamoeba histolytica is frequently complicated by hepatic involvement. Hepatic amoebiasis, in its turn, is sometimes complicated by neighboring extension. This extension below and above either diaphragm creates what we have grouped as the thoracic repercussions of amoebiasis. Behavior of Entamoeba histolytica probably varies with the endemic zone in which it is present. In Guatemala, amoebiasis is not only very frequent (20% to 30% incidence in some hospitals), but it is also especially prone to be associated with thoracic complications. These can be divided in five groups: 1) non specific inflamatory changes of the pleura, 2) empyema (perforation of hepatic abscess into the pleural cavity), 3) pulmonary inflamatory changes ("amoebic pneumonitis"), 4) amoebic lung abscess (perforation of hepatic abscess into lung parenchyma), 5) pericardial, splenic, and other less frequent complications. Examples of these complications, the symptomatic evidence for the diagnosis, the therapeutic management, and the results obtained, will be presented.

*By Invitation