American Association for

Thoracic Surgery

58TH ANNUAL MEETING

Scientific Program

MONDAY MORNING, MAY 8, 1978

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

Regency Ballroom

8:45 A.M. Scientific Session

Regency Ballroom

1. Resective Tracheobronchoplasties for Carcinoid Tumor

NSIDINANYA OKIKE*, W. SPENCER PAYNE, PHILIP E. BERNATZ

and PAUL F. LEONARD*, Rochester, Minnesota

Fifteen patients-eight male and seven female, aged 10 to 70 years- with lower respiratory carcinoid tumors treated by a variety of resective tracheobronchoplastic procedures represent 8.3% of 180 carcinoids treated in a recent 20-year period.

All 15 had respiratory symptoms, and 2 also had the carcinoid syndrome. X-ray changes ranged from a mass or atelectasis (or both) through unilateral lung hyperinflation to clear lungs with subtle filling defects in major airways. All tumors were visualized endoscopically and 13 patients had biopsies. All tumors were "typical" carcinoids histo-pathologically. Before operation, the patients had minimal or no respiratory insufficiency, although flow-volume and ventilation-perfusion abnormalities were noted when major airways were affected.

Anesthetic management was generally by orotracheal tube alone, although this was occasionally supplemented by sterile tubing brought into the operative field. Use of the Carlens tube was reserved for more distal bronchial lesions.

Surgical management at thoracotomy was as follows: (1) simple wedge tracheobronchotomy without lung resection (four patients); (2) bronchial sleeve resection without lung resection (three patients); or (3) bronchial sleeve with upper lobe resection (eight patients). These 15 operations were performed with eight technical anatomic variations.

No early or late deaths occurred. There was one case of early transient atelectasis. Three patients required late endoscopic removal of suture granulation tissue. All patients are living without recurrence of tumor or carcinoid syndrome or other respiratory complications 1 to 19 years postoperatively.

*By invitation

2. Tracheobronchial Mucoepidermoid Carcinoma: Clinico-pathological Features and Results of Treatment

HOWARD K. LEONARDI*, MERLE A. LEGG* and

WILFORD B. NEPTUNE, Boston, Massachusetts

Mucoepidermoid carcinomas of the tracheobronchial tree are extremely uncommon lesions and, as a result, opinions regarding their natural history are conflicting. Some investigators have concluded that these tumors are uniformly aggressive in their clinical behavior, while others have tended to group them within the broad category of bronchial adenomas with few specific comments about their malignant potential.

In an effort to clarify existing uncertainties concerning the virulence of these tumors, seven well-documented, previously unreported cases have been collected from a clinical experience with over 4,200 primary pulmonary malignancies and 114 bronchial adenomas. Two tracheal and five endobronchial lesions are included. Clinical, roentgenographic, bronchoscopic and histologic features are presented with particular emphasis on the pathological criteria for establishing grades of malignancy. One high-grade and six low-grade variants were identified.

Curative resections, including segmental tracheal resection in two patients, lobectomy in three patients and pneumonectomy in two patients, were performed and follow-up is complete to the time of this report. Long term survivals ranging from five years to 22 years, averaging 11.6 years, have been achieved in the six cases of low-grade malignancy. The one high-grade variant proved fatal within 24 months of diagnosis despite two surgical attempts at control and adjuvant radiotherapy.

It is concluded that these tumors exhibit a spectrum of virulence with the low-grade lesions amenable to long-term surgical cure. The optimum treatment of high-grade lesions remains problematical.

*By invitation

3. Combined Therapy for Small Cell Undifferentiated Carcinoma of the Lung

ISIDORE MANDELBAUM, NED B. HORNBACK*

BEN-TEK JOE*and LAWRENCE EINHORN,

Indianapolis, Indiana

Fifty-eight patients with small cell lung cancer were treated from September, 1974 to March, 1976 with combined chemotherapy and radiotherapy. Surgical resection of the lung lesion was performed in two patients and a number of surgical diagnostic methods carried out in the remaining patients with disseminated or unresectable lesions. Nineteen patients were from the V.A. Hospital and 39 from University Hospital. Of the latter, 24 were males and 15 females.

The median Karnofsky performance status was 60. Thirty-nine patients had extensive disease and 19 had disease limited to the chest and supraclavicular area.

All patients received chest radiotherapy and prophylactic whole brain radiotherapy. Adriamycin, Cytoxan, and Vincristine were given on day one and continued every three weeks. There were 26 (45%) partial remissions of a median duration of 26 weeks. There were 23 patients (41%) with complete remission.

Nine of 58 patients (16%) are alive and disease free from 16 plus to 30 plus months. Seven of 19 patients with limited disease (37%) are presently alive and disease free. This includes the two patients in whom Surgical resection was performed.

Combined therapy influences favorably the prognosis of small cell cancer of the lungs especially in those patients with limited disease and favorable performance status.

*By invitation

4. Long Term Survivors After Resection of Lung Carcinoma

THOMAS W. SHIELDS, EDWARD W. HUMPHREY,

GEORGE A. HIGGINS, JR.* and ROBERT J. KEEHN*, Chicago,

Illinois, Minneapolis, Minnesota and Washington, D.C.

As of June 1976, 257 of 2238 patients with lung cancer who were entered into one of four surgical adjuvant chemotherapy lung trials prior to June 1966 have survived ten years. One hundred twenty-five of these 257 patients were eligible for 15 year survival; 67 patients did so. One hundred thirty-three lobectomies, 120 pneumonectomies and four lesser resections were the procedures performed. The cell type was squamous cell in 185 patients, adenocarcinoma in 24, other cell types in 47 and unknown in one. Lymph node metastases at the time of resection were absent in 185 of the patients, present in either the lobar or hilar nodes in 59, in the mediastinal nodes in 11 and the status was unknown in two.

Ninety-seven patients have died since the tenth year anniversary. The major causes of death were cardiovascular and pulmonary diseases and second primary carcinomas. The latter were the cause of death in 25 patients. In the entire group of 257 patients, 61 (23%) developed a second primary tumor; 25 were in the lung and 36 in another organ system. The more common sites were the head and neck region, the bladder, and the colon. One-half of the patients with a new primary other than in the lung underwent some form of definitive treatment, whereas only about a third with a second lung primary underwent definitive treatment. There were four lobectomies, 2 completion pneumonectomies, one wedge resection and two patients received irradiation. Only three of these patients survived to the fifteenth year. Frequent observation is indicated for earlier detection and possible treatment of this usually fatal occurrence.

INTERMISSION - VISIT EXHIBITS

*By invitation

5. Endobronchial Lymphoscintography (EBLS): A New Diagnostic Modality

DREW C. G. BETHUNE*, DAVID S. MULDER*, and

RAY C. J. CHIU, Montreal, Quebec, Canada

A safe, simple method of visualizing the lymphatic drainage of the lungs has been developed using colloidal radionucleotides. The tracer is injected submucosally via a bronchoscope, and scanning of the thoracic lymph nodes is performed several hours later using a gamma camera.

Development and testing of the method was done in 7 canine experiments. Injection needles for both rigid and flexible bronchoscopes were designed. The procedure has been used in a preliminary group of 11 patients. In addition, direct injections of esophageal tumors were carried out in 2 patients.

The canine thoracic and cervical lymph nodes were well visualized following EBLS. In the human studies ₉₉Tc sulfur colloid, ₉₉Tc phytate and ₁₉₈Au colloid were used, the latter appearing to be the most promising. New cases are being added to the series rapidly at present Two esophageal carcinoma patients subsequently found to be unresectible had no spread of isotope from the injections into the tumors, suggesting lymphatic obstruction by the tumor. In others peribronchial,subcarinal, paratracheal, cervical and even para-aortic nodes were visualized. Reversal of the normal RUL lymphatic drainage pattern was seen in a patient with SVC syndrome caused by an infiltrating bronchogenic carcinoma. From LLL injection sites, both contralateral and ipsilateral spreads were seen.

This technique allows delineation of the lymphatic drainage patterns of particular lung regions in the individual patient. This information should facilitate the selective choice of further diagnostic procedures and aid in management and follow up.

*By invitation

6. Tracheal Growth in Puppies

JOHN D. BURRINGTON, Chicago, Illinois

Subglottic stenosis both congenital and acquired remains an important cause of long term tracheostomy in infants and children. Operative procedures designed to relieve stenosis involve division of tracheal rings and have not been widely applied in children for fear of interfering with normal tracheal growth.

To study normal tracheal growth, ten anesthetized beagle puppies 10 to 14 days old had their trachea and cricoid cartilage exposed under sterile conditions. After measuring the external diameter of the cricoid, third and fifth tracheal rings, dots were then placed circumferencially two millimeters apart in the perichondrium and cartilage using a 25 gauge needle dipped in India ink. The neck was re-explored after 2, 4 and 6 months for direct measurement of external diameter and distance between ink dots. Unoperated liter mates were sacrificed at 2,4 and 6 months for microscopic examination of tracheal cartilage.

RESULTS: The ten fold increase in body weight from 500 grams to 5 kilograms was accompanied by a ten fold increase in tracheal cross section from 19.53 mm² to 198 mm². The relationship of tracheal cross section appeared to be linearly related to body weight. The distance between ink dots increased evenly from 2 mm to 9 mm over the entire circumference of the tracheal cartilage. Microscopic examination indicates that tracheal cartilage grows continuously from the entire outer surface and ends without specific growth centers.

It is concluded from these studies that division of tracheal rings to relieve subglottic stenosis should not interfere with cross sectional growth of the trachea in infants and children.

11:15 A.M. Presidential Address

AS I REMEMBER THEM

J. Gordon Scannell