Imperial Ballroom

7. Long-term Survival Following Surgical Resection for Bronchogenic Carcinoma

GILBERT L. ASHOR*, WILLIAM H. KERN*, BERT W. MEYER,

GEORGE G. LINDESMITH, QUENTIN R. STILES

and BERNARD L. TUCKER*, Los Angeles, California

The overall prognosis of patients with lung cancer remains poor, however, a significant number survive for a prolonged period of time after surgical resection. Lobectomy or pneumonectomy was performed for 358 patients with carcinoma from January 1937 to June 1961. Ninety-four (26%) survived five years or longer after resection. Our surgical and pathological experience with these 94 patients was reported previously. Sixty-four of these patients survived for 10 years or longer. This study is an analysis of the clinical and pathological features of the 64 patients surviving 10 years or more in an effort to determine those features that may be associated with long term survival.

All cases were reviewed and reclassified histologically. The average age of the 54 men and 10 females at the time of resection was 57. There were 22 central, 20 intermediate and 22 peripherally located lesions. Bronchiolar and adenocar-cinomas were relatively frequent among the ten year survivors. No survivor occurred in those patients with oat cell carcinoma.

Pneumonectomy was performed for 31 patients and lobectomy for 33. Although lobectomy carried a better 10-year survival rate than pneumonectomy (28% vs. 12.8%), there were substantial differences in the composition of each group.

Many of those surviving 10 years or more had pathologic conditions which ordinarily would be considered unfavorable for survival: large size of tumor (average 4.2 cm.), regional lymph node metastases (27%), tumor at the bronchial margin and pleural invasion (19%), and centrally located lesions (34%). Despite these findings in many of the patients, 64 of 358 (18%) who underwent surgical resection for bronchogenic carcinoma survived greater than 10 years.

Therefore we believe reasonable attempts at curative resection for bronchogenic carcinoma seem indicated in spite of unfavorable pathologic findings since some of these patients will survive for 5 and even 10 years.

*By invitation

8. Long Term Intermittent Adjuvant Chemotherapy for Primary Resected Lung Cancer

HIDEO KATSUKI*, YUTAKA YAMAGUCHI*,

TATSUYA OKAMOTO*, KOICHIRO SHIMADA* and

MASHAHIKO OKITA*, Chiba, Japan

Sponsored by John R. Benfield, Torrance, California

Adjuvant chemotherapy for lung cancer is an appealing previously unsuccessful approach towards improving the results of pulmonary resections. We have tested long term intermittent adjuvant chemotherapy in 126 patients, and the results as compared to 101 controls shall be reported. Commencing with a preoperative course which was repeated immediately after operation, at 2-month intervals, during the first postoperative year, and at 6-month intervals during the next 2 postoperative years, Mitamycin M (MMC) and Toyomycin (TM) were given. Four weeks were necessary for each course which consisted of MMC 0.1 - 0.12 mg/kg twice weekly for a total of 40 mg, and TM 0.02 mg/kg 5 times per week to a total dosage of 10 mg.

The overall 5 year survival of the 126 adjuvant chemotherapy patients (Group I) was 42% as compared to 24% in the controls (Group II). Group I patients with negative nodes and "curative" resections had a 57% five-year survival. More striking was the difference between patients in Groups I and II who had lymphatic metastases at the time of resection. For example, the 5-year survival among 20 patients in Group I whose lymph node metastases were not apparent until postoperative study of the specimens was 53%, as compared to only 30% among the controls who met the same criteria. Similarly, among 68 in whom resection was done, although lymphatic spread was recognized at the time of resection, the 5-year survival rate was 24% in patients who received adjuvant chemotherapy as compared to 11% in controls. Although there were side effects from the chemotherapy which occasionally required temporary interruption, there were no apparent adverse effects upon operative mortality and morbidity. We conclude that long-term intermittent chemotherapy adjunctive to pulmonary resection is both safe and worthwhile. The concept of adjuvant chemotherapy should continue to be tested.

*By invitation

9. Multiple Primary Lung Cancer

NAEL MARTINI and MYRON R. MELAMED*, New York, New York

The first Memorial Hospital patient with two separate primary carcinomas of lung was seen and treated in 1954 and 1955. In the 20 years since then, there have been a total of 42 such patients, representing slightly over 1% of the 3,300 patients treated for primary lung cancer. Thirteen had synchronous tumors; two had two evident lesions pre-operatively by chest x-ray; nine were first diagnosed as having two separate carcinomas at thoracotomy and the two remaining cases at autopsy.

In 29 patients the tumors were metachronous, varying from 6 months to 16 years between diagnoses, with a median time of 3½ years. Of interest, in 7 of these patients, one of the carcinomas was radiologically occult and was detected by cytology.

Histologic patterns in the two carcinomas were the same in 27 patients, most commonly epidermoid, and they were different in 15 patients. The two tumors were located in different lungs in 29 patients, in different lobes of the same lung in 7 patients, and in the same lobe in 6 patients.

Survival of patients with synchronous tumors was essentially the same as for solitary, resectable lung carcinomas. Surgical mortality was zero. In patients with metachronous tumors, surgical mortality was high at the second operation (26%). There were five survivors living longer than 3 years, and two for more than 5 years. In the remaining patients death was due to compromised pulmonary function as well as carcinoma.

The problems involved in establishing the diagnosis of multiple lung cancers, the choice of treatment and the expectation for survival will be discussed.

*By invitation

10. Immune Responses to Human Lung Carcinoma-Associated Antigens

JACK A. ROTH*, E. CARMACK HOLMES*, ARTHUR W. BODDIE*,

and DONALD L. MORTON, Los Angeles, California

Tumor antigen preparations would be clinically useful in the immunodiagnosis and immunotherapy of lung cancer. However, the existence of such unique antigens associated with lung carcinomas remains controversial. We have detected in vitro and in vivo cell-mediated immune responses to soluble tumor antigens extracted from 8 lung carcinomas. Ten of 13 lung cancer patients (77%) showed significant in vitro lymphocyte stimulation to one or more tumor antigens. Tumor antigen and antigen from autologous uninvolved lung were solubilized by 3M KCL extraction and lymphocyte stimulated protein synthesis was assessed by measuring H^-leucine incorporation following incubation with antigen. One of two patients stimulated to an autologous lung cancer antigen. Furthermore, cross-reactivity of extracts among lung cancer patients demonstrated a common antigen. Nine of these patients also reacted to the normal lung extract, indicating response to a lung tissue-associated antigen. Only 7 of 28 control patients (25%) with benign disease or other neoplasms reacted to these antigens in vitro. Delayed cutaneous hypersensitivity reactions to lung tumor or normal antigens correlated significantly with the in vitro responses.

These results indicate that both tumor-associated and tissue-associated antigens of human lung carcinomas do, in fact, exist.

INTERMISSION - VISIT EXHIBITS (Albert Hall)

*By invitation

11. Operative Stabilisation of Non-Penetrating Chest Injuries

BRYAN P. MOORE*, London, England

Sponsored by Hermes Grille, Boston, Massachusetts

Since 1958, 112 severe or moderately severe non-penetrating chest injuries have been treated. An aggressive policy has been adopted towards correcting or preventing major paradoxical chest wall movement by infra-medullary pinning of ribs, costal cartilages and sternum. Where possible, positive pressure mechanical ventilation and tracheostomy have been avoided. Fifty patients underwent stabilising operations. The surgical approach was antero-lateral in 12 ( average 3.3 pins), postero-lateral in 35 (average 6.8 pins) and mid-sternal in three.

Tracheostomy was performed in eight of these 50 patients. Three died, on the 1st, 3rd and 25th days after injury. The tracheostomy was used for aspiration of secretions only in three others and for postoperative I.P.P.V. in two others. The duration of I.P.P.V. was 14 days and one day. Oro-tracheal intubation with mechanical ventilation after operation extending to more than a few hours was required for three patients of whom one died. The two survivors were ventilated for one and for five days. There was a total of eleven hospital deaths in these 50 cases, but in two, the severity of the initial injuries was thought to make death inevitable. Three of the patients who died were over 70.

Operative stabilisation permits avoidance or reduction in time of tracheostomy and mechanical ventilation. Permanent chest wall deformity is reduced or avoided.

*By invitation

12. Cannulation of the Proximal Aorta During Chronic Membrane Lung Perfusion

M. TERRY McENANY*, WARREN ZAPOL*, JURGEN SEEBACHER*,

MAREK SKOSKIEWICZ*, ROBERT SCHNEIDER*, JOHN ERDMANN*,

MICHAEL SNIDER*, DAVID KANAREK* and ANTHONY PECK*,

Boston, Massachusetts

Sponsored by J. Gordon Scannell, Boston, Massachusetts

Prolonged extracorporeal support for acute respiratory failure is a reality. Recent experience with four patients treated with veno-arterial bypass for from five to eleven days has demonstrated definite advantages in delivering oxygenated blood to the aortic root rather than the descending aorta. Oxygenated blood is delivered from a 3.5 M^ spiral coil membrane lung to the tip of the infusion catheter and, with normal cardiac output, there is little retrograde perfusion. In order to deliver membrane-oxygenated blood to the proximal aorta, thereby perfusing coronary and cerebral circulations with pump output, a thin-walled, steel, spring-enforced polyurethane cannula (0.250" - .300" O.D., 0.215" - 0.265" I.D.) is inserted through the common femoral artery up to the aortic root (2 cases) or transverse arch (2 cases). Distribution of oxygenated (membrane) blood was well demonstrated directly by cine-angiography and ¹³³Xenon perfusion scan. Membrane oxygenated blood perfused the coronary arteries only when the catheter tip was near the sinuses of Valsalva (with a pump output of 2.5 L/min and left ventricular output of 5 L/min). With this positioning, complete aortic mixing of membrane-oxygenated and heart blood was demonstrated. With cannulation of the transverse arch (tip between the innominate and left subclavian arteries) the pump delivers oxygenated blood preferentially to the left common carotid and subclavian arteries while right common carotid flow is uniformly de-oxygenated if left ventricular output is more than 3 L/min.

Chronic bypass resulted in long term survival or marked respiratory improvement in two patients with post-traumatic gram-negative pneumonitis, while two patients with post-transfusion respiratory failure and viral pneumonitis died, after eleven and nine days, with inexorable pulmonary failure. Autopsies demonstrated no emboli or intimal lesions from this proximal cannulation, and we feel that its use will lead to improved cardiac and cerebral function on extracorporeal oxygenation.

*By invitation