Los Angeles Ballroom

13. Pulmonary Neoplasm with Solitary Cerebral Metastasis: Results of Combined Excision

DONALD J. MAGILLIGAN, JR.*, J. SPEED ROGERS*,

ROBERT S. KNIGHTON* and JULIO C. DAVILA, Detroit, Michigan

At Henry Ford Hospital, since 1960, twenty patients have undergone lung resection for pulmonary malignancy and attempt at gross total removal of a solitary cerebral metastasis. Neurologic symptoms led to the discovery of lung cancer in 5 patients. In the other 15, neurologic symptoms appeared from 2-10 months (Avg. 5.3 mos) following pulmonary resection. The predominant presenting neurologic symptoms were: headache 6, hemiparesis 9, hemiplegia 2, seizures 1, visual disturbance 1, and ataxia 1. Brain scanning, pneumoencephalography and particularly arteriography were used for localization and to determine singularity. Of the twenty patients, 7 had good results. Six of these seven are alive more than one year after removal of the metastasis with minimal or no neurologic symptoms. One patient died three years after craniotomy due to bronchoesophageal fistula from recurrence of his pulmonary cancer. He had no neurologic symptoms. Four of twenty patients had a fair result with survival from 9 to 20 months but with significant relief of their neurological symptoms. The result in nine patients was classified as poor - with either no significant neurologic improvement or survival less than six months. Included in this group is the one operative death. Of the group with good results all were operated on after 1968 whereas in the fair and poor groups only 3 or 13 were operated during this period. The improved results with the more recent experience is due to earlier and more accurate diagnosis and encourages us to pursue an aggressive surgical approach to the pulmonary neoplasm with solitary cerebral metastasis.

*By invitation

14. Gallium 67 Scanning for Carcinoma of the Lung

T. R. DeMEESTER*, C. BEKERMAN*, J. G. JOSEPH*,

M. S. TOSCANO*, N. J. GROSS* and D. B. SKINNER, Chicago, Illinois

Gallium 67 citrate is the best radiopharmaceutical currently available for localizing tumors. We have prospectively evaluated its use in 47 patients with pulmonic lesions suspected to be primary carcinoma and in whom subsequent histological diagnosis was obtained. 34/37 patients with histologically proven carcinoma of the lung had a positive gallium scan giving a tumor sensitivity of 92%. 8/9 patients with benign lesion had a negative gallium scan giving a tumor specificity of 89%. These results give a statistical validity of usefulness for the gallium scan in diagnosing carcinoma of p < .001. Squamous cell lesions had the highest sensitivity (94%). Adenocarcinoma was the least sensitive. The gallium scan was equally useful in the evaluation of peripheral and central lesions. There was no difference among T1, T2 and T3 lesions in their ability to take up gallium.

Twenty-eight patients with proven carcinoma of the lung had their mediastinum evaluated by gallium scanning and compared to lymph node biopsies obtained on mediastinoscopy. Of 14 patients with proven lymph node metastasis, 8 showed evidence of lymph node involvement on gallium scan. Of 12 patients with normal mediastinal nodes, 10 were normal on gallium scan. This gave a sensitivity for determining positive mediastinal lymph nodes of 57% and specificity of 83%.

It is concluded that gallium 67 citrate has a high sensitivity and specificity for uptake in malignant lung lesions of various sizes and is therefore helpful in the diagnosis of malignancy. It appears particularly valuable in assessing peripheral solitary nodules. Gallium scan is less useful than mediastinoscopy in assessing mediastinal lymph node metastasis, however, a positive scan can be used to identify metastatic lymph nodes for biopsy during mediastinoscopy.

*By invitation

15. Immune Reactivity in Primary Carcinoma of Lung and Its Relation to Prognosis

HAROLD J. WANEBO*, NYOTO MIYAZAWA*, BHASKAR RAO*,

NAEL MARTINI, and EDWARD J. BEATTIE, JR., New York, New York

Studies of immune reactivity were performed in 151 patients who underwent thoracotomy from 1971 to 1974. 131 patients had primary lung cancer and 20 patients had benign lesions. Skin tests with DNCB and intradermal antigens were performed in all patients and in vitro immune parameters (lymphocyte stimulation with mitogens and common antigens and enumeration of T and B cell levels) were performed in one-half of these patients. The DNCB skin test was positive in 73% of the patients with lung cancer and all (100%) of the patients with benign disease (P <* .05). DNCB reactivity was related to the clinical stage of disease. The incidence of positive DNCB reactions was 78% for Stage I & II cancers (37 patients), 73% for resectable Stage III cancer (22 patients), and 66% in patients with unresectable or inoperable Stage III cancer (72 patients). There were also differences according to the histology of primary cancer. The incidence of DNCB+ responses was 80% in patients with epidermoid cancer (46), 57% in patients with adenocarcinoma (46), 64% in patients with oat cell carcinoma, and 80% in patients with terminal bronchiolar carcinoma (10) and 84% in 17 patients with miscellaneous histologic diagnoses. In vitro immune studies showed better correlation with clinical stage, than observed with skin tests. Of these studies measurement of lymphocyte stimulation with mitogens and common antigens showed a better correlation with clinical stage than T or B cell counts per se.

There was a correlation of disease free survival with DNCB reactivity in patients with Stage III cancer who had a minimum of one year followup. Of 37 patients who were DNCB+, 10 (37%) were free of disease at one year compared to 2 of 19 patients (11%) who were DNCB- (P < .01). The details and clinical significance of these studies will be discussed.

*By invitation

16. Regional Immunotherapy with Intrapleural BCG for Lung Cancer: Surgical Considerations

MARTIN F. McKNEALLY*, HARVEY W. KAUSEL and

RALPH D. ALLEY, Albany, New York

Stimulation of the regional lymph nodes with intrapleural BCG reduces the growth of experimental lung tumors in mice (Civerchia, Dhar, Maver and McKneally, Fed. Proc. 34:1036, 1975). Used in combination with isoniazid in the immediate post-resection interval, it appears to prolong disease-free survival in patients with lung cancer when contrasted with a simultaneous randomized control group. In 17 patients with Stage I lung cancer treated with post-operative BCG, there were no recurrences and no deaths. In 22 patients with Stage I disease in the control group, there were 9 recurrences and 5 deaths (Median duration of follow-up for both groups = 12 months. P = 0.016). In Stage II and Stage III disease, the effect is less clear. There were 6 recurrences in 12 such patients treated with BCG and 7 recurrences in 9 control patients (Median duration of follow-up for both groups = 6 months. P = n.s.).

The vaccine is administered by injection through the chest tube in patients undergoing subtotal pulmonary resection. After pneumonectomy, it is administered by thoracentesis. Use of this route raises certain technical and judgmental problems for the operating surgeon,

1. An immediate influenza-like syndrome of fever, chills and malaise follows intrapleural injection of BCG. Patients should not be treated until they are hemodynamically stable.

2. Delivery of the vaccine to the regional lymph nodes requires its administration into the free pleural space. Sinus tract formation by prolonged catheter drainage for air leak frustrates this purpose. Care should -be taken to seal off parenchymal air leaks at the time of surgery by the use of pleural flaps and tents, and suture ligation of minor air leaks.

3. Suppurating lymphadenitis and severe ulceration of injection sites has been reported in anergic patients given intrapleural BCG for cutaneous melanoma. The preoperative immunologic status of the patients should be evaluated by a routine panel of skin tests to recall antigens, and completely anergic lung cancer patients should be excluded. Following these guidelines, we have experienced no major complications of intrapleural BCG immunostimulation in 40 patients undergoing pulmonary resection for malignant disease.

INTERMISSION - VISIT EXHIBITS

*By invitation

17. Surgical Treatment of Clamping Injury of the Ascending Aorta

BRITT LITCHFORD*, J. EDWARD OKIES*, SHUICHIRO SUGIMURA*

and ALBERT STARR, Portland, Oregon

Clamp injury of the ascending aorta with intimal tear and dissection is a rare and dangerous complication of aortic cross-clamping infrequently mentioned in the literature. Since the clamp is generally applied near the distal aortic cannulation site, recannulation in the femoral (or iliac) artery or in the transverse arch of the aorta must be accomplished to allow reapplication of the cross-clamp at the base of the innominate artery. The ascending aorta should then be opened transversely over the tear and repaired directly with Teflon felt bolsters.

Successful treatment of this complication in two recent patients and review of three earlier cases underscores the importance of the direct approach to aortic dissection resulting from clamp injury. Three patients in whom the dissection was dealt with directly survived the operation, but one patient died 24 days post-operatively secondary to complications of the paraplegia that occurred at the time of the dissection (pulmonary infection and sepsis). Two patients who had indirect management of their dissection died of extension of the dissection with massive hemmorhage, one on the operating table and the other three weeks post-operatively.

Immediate recognition of this complication in combination with an aggressive direct approach can result in survival in an otherwise lethal condition.

*By invitation

18. Infectious Complications Following Median Sternotomy and Cardiopulmonary Bypass

ALFRED T. OULLIFORD*, ROBERT H. ZEFF*, O. WAYNE ISOM*,

JOSEPH N. CUNNINGHAM*, PHYLLIS TEIKO*, and

FRANK C. SPENCER, New York, New York

Between Jan. 1, 1971 and Dec. 31, 1974, 2,465 patients underwent median Sternotomy and Cardiopulmonary bypass to correct a variety of congenital and acquired cardiac lesions. Thirty-nine patients (1.5%) developed wound infections which required operative intervention for control.

Twenty-nine patients had their infections recognized and treated within 30 days of cardiac surgery. Perfusion time in excess of three hours, excessive postoperative bleeding, re-exploration for bleeding, prolonged pharmacologic support for low-output states, external cardiac massage, tracheostomy, presence of diabetes, resternotomy and emergency operation were factors associated with a high rate of wound infection.

Following debridement, closed antibiotic irrigation was instituted in 27 patients and open drainage in two. Of those treated with the closed antibiotic irrigating technique, 88% were discharged from hospital with healed wounds within three weeks of diagnosis. Mortality in this group of patients was 14% (4 patients).

A second group of 10 patients had their infections recognized and treated after 30 days of original cardiac surgery. Infections in this group were more indolent than in the first. Eight had sternal dehiscence and two had chondritis.

Four patients required open drainage; in four, sternal closure and closed antibiotic irrigation could be achieved. The mortality in this group was 20% with an average hospital stay of 75 days. Six patients required more than one procedure for the control of persistant chondritis.

In patients undergoing coronary artery bypass grafting with only saphenous veins, an infection rate of 1.3% was noted. When a single internal mammary artery was used, the infection rate rose to 1.8%, when both were used it was 8.8%. Factors believed to be responsible for this increase are discussed.

The data emphasize the importance of early diagnosis, which permits effective treatment with closed antibiotic irrigation in the majority of cases.

11:15 Address of Honored Speaker

THE DOCTOR'S DILEMMA

Eoin O'Malley, M.Ch., F.R.C.S.I.

Professor of Surgery

University College

Dublin, Ireland

*By invitation