MONDAY AFTERNOON, APRIL 18, 1977

2:00 P.M. Scientific Session Grand Ballroom

7. Radiation Carcinoma of the Lung - The St. Lawrence Tragedy

EARLE S. WRIGHT* and CECIL M. COUVES,

St. John's, Newfoundland, Canada

St. Lawrence is a small community in Southern Newfoundland with an economy based on fishing and mining of Flurospar. This mineral, calcium fluoride is widely employed in the manufacture of aluminum and to a lesser degree in the spray propellant industry.

The mines commenced commercial operation in 1933 and have now become linked with the names Schneeberg and Joachemistal as historical landmarks in the tragic history of radiation induced lung carcinoma.

To the present date the death toll from this disease in the St. Lawrence miners has reached 78. This is approximately 29 times the provincial death rate from lung carcinoma in males of a comparable age group. Further examination of the statistics show that the incidence of the lesion in those miners at risk has been 36%.

An increasing awareness of the magnitude of the problem led to intensive investigations culminating in the discovery in 1959 of radon gas and its daughter nucleotides as the primary carcinogenic agent. Further research indicated that the most likely source of the radioactive contamination was in the water seeping into the mines through the fluorspar granite. Heavy smoking in the mining population is probably a secondary co-carcinogen.

The histopathology of these tumours is surprising since squamous cell carcinoma predominates. This is in marked contrast to the findings among uranium miners in Colorado where oat-cell carcinoma is the major cell type. Radiotherapy has been the chief mode of treatment due to widespread reluctance on the part of the miners to undergo surgery.

The development of measures designed to protect the miners from further radiation risks were first instituted in 1960. These techniques have been singularly effective and control of "the St. Lawrence problem" has been achieved.

*By invitation

8. Results of Surgical Treatment in Stage I Lung Cancer

NAEL MARTINI and EDWARD J. BEATTIE, JR.,

New York City, New York

From 1973 to 1975, 70 patients underwent pulmonary resection for Stage I non-oat cell carcinoma of the lung. Each of these patients was carefully evaluated for disease extent and classified as having a Stage I cancer only after the resected specimen was histologically reviewed and all regional nodes in the mediastinum assessed.

There were no postoperative deaths. At one year of followup 66 of 70 patients (94%) were alive and free of disease. 34 patients were at risk for 2 years and 28 of these (82%) are alive and well. At present, 9 are dead of distant metastases and one of unrelated causes. No patient has had local recurrence and none was lost to followup.

Correctly staged early lung cancers have an excellent survival at 1 to 2years with surgery alone. Merits of various adjuvant programs in this group of patients can only be correctly assessed if followups are prolonged and the number evaluated large.

*By invitation

9. Immunoprofile Studies in Patients with Bronchogenic Carcinoma, Significance and Prognosis

GEORGE A. LIEBLER*, JOSEPH P. CONCANNON*,

GEORGE J. MAGOVERN and MILTON H. DALBOW*,

Pittsburgh, Pennsylvania

Immunoprofile studies consisting of the measurement of lymphocyte mitogen stimulation (LMS) with phytohemagglutinin (PHA), concanavalin A (Con A), and pokeweed mitogen (PWM), T and B cell distributions, peripheral lymphocyte counts, skin tests with 5 microbial antigens and de novo sensitization with dini-trochtorobenzene (DNCB) was performed. These studies were performed prior to irradiation therapy and chemotherapy for 145 patients with a primary bronchogenic carcinoma, 55 patients with mammary cancer, and 35 patients with genitourinary malignancies. Many of the patients had a surgical procedure prior to their initial immune studies. Similar studies were made for 63 healthy volunteers.

The results of these studies indicate that the immune system of patients with cancer is frequently depressed when compared with healthy volunteers. It was anticipated that if immune competence was to show a correlation with survival, these measurements of general immunity should show a stage of disease related correlation. Since the prognosis for patients with lung cancer is generally poor, these patients should demonstrate a more uniformally abnormal immune system than patients with mammary cancer or GU malignancies. Although the degree to which the immune system is disturbed appears to be related to the stage of disease, patients in early disease stages may also demonstrate abnormal immune measurements. Further, there appears to be little difference between the immune status of patients with bronchogenic carcinoma and patients with mammary or GU cancers within comparable disease staging groups.

Analysis of the data for each of the immune parameters measured, by life table technique, indicates a good correlation between a disturbed immune system and a poor prognosis for patients with carcinoma of the bronchus. Disturbed immunity does not appear to be as critically related to survival in the other types of cancer.

*By invitation

10. Extensive Pulmonary Laceration Caused by Blunt Trauma

JOHN R. HANKINS, T. CRAWFORD McASLAN*,

BAEKYO SHIN*, ROBERT AYELLA*, R. ADAMS COWLEY

and JOSEPH S. McLAUGHLIN, Baltimore, Maryland

During the past 4'/2 years, of 210 patients treated for lung injury resulting from blunt trauma (contusion or laceration with pneumothorax), 13 required emergency thoracotomy because of failure to respond to conservative measures. In each, an extensive pulmonary laceration was found.

The indications for thoracotomy were: Massive hemothorax, in 10 patients; profuse air leak not responding to chest tube suction, in 2 patients; and massive intratracheal bleeding, in 1 patient. Rib fractures were present in every patient. However, in only 10 patients was the pulmonary laceration directly produced by the sharp end of a fractured rib. In 3 patients the laceration was far removed from the rib fractures and evidently was caused by a shearing force.

The laceration was treated by pulmonary resection in 8 cases and by suture of the laceration in 4. One patient who developed irreversible cardiac arrest underwent exploratory thoracotomy only.

Four patients survived, 2 of whom had received lobectomy and 2, suture only. Among the 9 who expired, death was caused primarily by extrathoracic injuries in 6.

We conclude that extensive pulmonary laceration is an important cause of morbidity and mortality among patients with blunt chest injury. The importance of early diagnosis and prompt thoracotomy is emphasized. In many of these patients the initial chest tube drainage was not profuse. Later, while they were being treated for other injuries, blood loss increased precipitously. At least two of those who died might have been saved by earlier thoracotomy.

INTERMISSION - VISIT EXHIBITS

*By invitation

11. Prophylactic Antibiotics in the Treatment of Penetrating Chest Wounds - A Double Blind Study

FREDERICK L. GROVER, J. DAVID RICHARDSON*, JOHN G. FEWEL*,

KIT V. AROM*, GEORGE E. WEBB* and J. KENT TRINKLE,

San Antonio, Texas

Considerable controversy exists as to whether antibiotics should be administered "prophylactically" to patients with penetrating chest trauma. No prospective study of this problem has been reported. Seventy-five patients with isolated penetrating chest injury were therefore prospectively randomized in a double blind study to determine the efficacy of "prophylactic" antibiotic treatment. Group A (38 pts.) were given 300 mg. of clindamycin phosphate (CP) every 6 hours, beginning with admission until 1 day following chest tube removal, or for 5 days, whichever was shorter. Group B (37 pts.) were given a placebo on the same schedule. The patients' hospital course, fever, WBC, culture data, and x-rays were serially recorded.

RESULTS: Both groups were of comparable age, sex, and magnitude of injury.

	Pts. With WBC Elev.	Highest Ave. WBC	No. with Temp.>101	Pleural Cult. Pos.	Wound Cult. Pos.	Chest Tube Cult. Pos.
Group A	25 (66%)	11,850	11 (29%)	4/21 (19%)	5/11(45%)	2/9 (22%)
(CP)
Group B	30 (81%)	13,260	17 (46%)	7/19(37%)	7/9 (78%)	3/7 (43%)
	Clinical Empyema	Pneumonia	Atelectasis	Hosp. Days	No. with 9 Hosp. Days	Operation Required
Group A	1 (3%)	4 (11%)	14 (37%)	6.7	3	1 (3%)
(CP)		(p<05)
Group B	6 (16%)	13 (35%)	15 (41%)	7.7	9	6 (16%)
(Control)

CONCLUSIONS: Group A patients (CP) consistently demonstrated less evidence of sepsis and required fewer operations for infectious complications than Group B. Antibiotics are advantageous as adjunctive therapy in the management of penetrating chest trauma.

*By invitation

12. Early Pleural Decortication for Empyema Thoracis in Immuno-suppressed Patients

NOEL H. FISHMAN and DAVID G. ELLERTSON*,

San Francisco, California

Treatment of pleural empyema by tube thoracostomy followed by rib resection and open drainage commits a patient to months of chronic drainage and packing. It is also predicated on the ability of the normal pleural space to localize and isolate purulent infections. Patients with impaired immune response often remain toxic during thoracostomy drainage of empyema because they fail to develop a satisfactory' inflammatory tissue barrier to the spread of infection. Incompletely drained areas provide a focus for the infection to disintegrate adjacent pulmonary tissue. The mortality of pleural empyema is extremely high, therefore, in immuno-suppressed patients.

Since 1970 we have electively decorticated acute pleural empyema in 7 patients who were immuno-deficient for the following reasons: (1) immuno-sup-pressive drugs for cadaver renal transplant, (2) high dose steroids for saggital sinus thrombosis, (3) high dose steroids for systemic lupus erythematosus, (4) multiple myeloma, (5) disseminated Hodgkin's disease, (6) hemolytic anemia and pulmonary infiltrates of unknown etiology, and (7) myelofibrosis.

The patient with multiple myeloma died postoperatively from uncontrolled bleeding from pleural tumor. Five patients (71%) left the hospital completely healed within 3 to 4 weeks after surgery, and all are alive 2 to 5 years later. The empyema in the patient with myelofibrosis was successfully treated, but the patient ultimately succumbed in the hospital to her underlying disease.

Acute pleural decortication for empyema consists of a formal thoracotomy incision through which the pleural space is completely mobilized, debrided, and irrigated. Necrotic lung tissue is also carefully debrided without lobectomy or incision into viable parenchyma. Multiple chest tubes are inserted. The muscles are closed anatomically with non-absorbable sutures, but the skin and subcutaneous tissues are closed loosely. This procedure in immuno-suppressed patients has the advantage of early, thorough drainage of infection, maximal preservation of lung tissue, and substantial reduction of morbidity.

*By invitation