MONDAY AFTERNOON, April 28,1980
2:00 P.M. Scientific Session - Continental
Ballroom
8. A
Prospective Study of 461 Lung Carcinomas With Positive Mediastinal Lymph Nodes
NAEL MARTINI,
MUHAMMAD B. ZAMAN*and
EDWARD J. BEATTIE,
JR., New York, N. Y.
From 1974 to 1978, 989
patients with carcinoma of the lung were treated at our institution. All were
staged according to the A.J.C. staging system. Of these, 461 patients had
clinically evident mediastinal lymph node metastases. 208 were considered
inoperable at diagnosis, based on histology of oat cell carcinoma, known
distant metastases, or malignant effusion. The remaining 253 patients were
surgically explored and treated by resection and/or implantation. 176 (70%) of
this latter group had either palliative resection or implantation of their
disease. The median survival in this group of patients was 9 months.
There were 77 patients who had complete,
potentially curative resection of their primary tumor and all accessible
mediastinal lymph nodes. The vast majority of these were also treated by
postoperative external radiation therapy to the mediastinum. In this group,
there were 28 epidermoid carcinomas, 29 adenocarcinomas, 13 bronchiolar
carcinomas, and 7 large cell carcinomas. At one year of follow-up 53 of 77 patients
(69%) were alive and well. 56 patients were at risk for 2 years, and 32 of
these (57%) are alive, and 41 patients were at risk for 3 years and 18 (44%)
are alive. Survival at 3 years was slightly better in glandular carcinoma
(adenocarci-noma or bronchiolar) than in epidermoid carcinoma (56% versus 40%).
We conclude that there is a select group of patients with mediastinal lymph
node metastases who can be effectively treated by combined resection and
radiation therapy with prolonged survival.
*By invitation
9. Pathologic Stage Grouping of the Patients
with Resected Carcinoma of the Lung
THOMAS W. SHIELDS,
EDWARD W. HUMPHREY,
CHARLES E.
EASTERIDGE, MARY MATTHEWS*,
ROBERT J. KEEHN*,
Chicago, Illinois; Minneapolis, Minnesota;
Memphis, Tennessee
and Washington, D. C.
The data from a new series of 569 patients
with "curative" resection of non-oat cell tumors were analyzed by the life
table method to evaluate the validity of the postresection pathologic staging
classification suggested by the American Joint Committee. The cell types were:
squamous: 305, adenocarcinoma: 172, large cell: 73 and mixed: 19. Each patient
was assigned a pathologic TN classification on examination of the resected
specimen (all patients were judged clinically to have no distant metastases-M0).
There were 173 lesions classified at T1N0; 37 as T1N1;
212 as T2N0; 115 as T2N1 and 32
with either T3 with any N, or N2 with any T. In analyzing
the data, a subset of lesions (25) initially staged as T2N0
was identified which should be pathologically staged as T1N0.
These are small central lesions, 3 cm or less in size, located distal to a
lobar take-off. Regardless of the presence of atelectasis or pneumonitis to the
hilar area, these behave as do the more peripherally located lesions of similar
size. Three year survival of 66.5 and 68.5 percent respectively were noted in
these patients as compared to 53.6 percent for the patients with lesions
greater than 3 cm in size which could be classified as T2N0
regardless of their location. When lymph nodes were positive (N1)
such small central lesions (20) had a better survival than either of the other
T1N1 or T2N1 lesions. It is
therefore suggested that all small central lesion, 3 cm or less in size, distal
to a lobar take-off be considered a T, lesion. In addition it was noted that
patients with T1N1 lesions had a three year survival of
only 36.7 percent, which is similar to that of those with T2N1
lesions (39.8%). Therefore, it would appear more appropriate to classify these
patients as having Stage II rather than Stage I disease. The other patients in
Stage I have a much better survival experience: T1N0
lesions have three and five year survivals of 68.5 and 54.4 percent, and those
with T2N0 lesions 53.6 and 40.0 percent respectively.
*By invitation
10. Diagnosis, Stage and Prognosis of Lung
Carcinoma by Preoperative Assay of Lung Tumor Antigen-Sensitive T-Lymphocytes
WILLIAM G.
RAMEY*, GEORGE A. HASHIM*,
ANTOINE S.
MUNTHER*, ALEXANDER J. SWISTEL*,
WARREN B.
BURROWS*, and HUGH F. FITZPATRICK,
New York, New York
Levels of circulating
T-lymphocytes sensitized to human lung tumor-associated antigens (LTA) were
correlated with lung carcinoma detection, pathological tumor stage, and patient
survival in preoperative studies of 62 patients by the antigen-stimulated
active rosette-forming T-cell (AgARFC) assay. Incubation with LTA of peripheral
blood lymphocytes (PEL) from patients found to have lung cancer produced
increased AgARFC compared to incubation without LTA or with breast tumor
extracts. Significant levels of LTA-sensitive T-cells were found in
preoperative PEL of 80% of Stage I (8/10; p<0.005), 67% of Stage II (4/6;
p<0.05), and 50% of Stage III (8/16) primary lung cancer patients, compared
with 15.4% of patients with either benign lung lesions (2/9) or lung metastases
(0/4) of nonpulmonary malignancies (by chi-square analysis). Postoperative
survival correlated significantly with preoperative levels of LTA-sensitive
T-cells by AgARFC assay within Stage I (r = 0.865; p<0.005), Stage I-II (r =
0.676; p<0.005), and Stage III (r = 0.550; p<0.05) groups of lung cancer
patients. Preoperative PEL from patients with Stage I-II lung cancer were more
frequently sensitized to LTA in the AgARFC assay than PBL of patients with
nonpulmonary carcinomas (0/11; p< 0.005) or of smokers without pulmonary
lesions (1/6; p<0.025). These findings demonstrate a high rate of detection
of early, resectable lung carcinomas by preoperative AgARFC assay of PBL
sensitization to LTA, and a significant correlation of LTA-sensitive T-cell
level with tumor stage and patient survival. The AgARFC assay may be of
prognostic as well as diagnostic value in the evaluation of patients with lung
carcinoma.
*By invitation
11. Follow-up Report on Regional BCG Treatment of
Lung Cancer
MARTIN F. McKNEALLY,
JOSEPHB. McILDUFF*,
HARVEY W. KAUSEL, RALPH D. ALLEY, CAROLE MAVER*
and LLOYD LININGER*,
Albany, New York
Four years ago, our group
reported the preliminary results of a trial of adjuvant intrapleural BCG
following surgical resection of lung cancer. A total of 161 resected patients
have entered this randomized trial. We now report the long term follow-up of
this trial, including our early experience with the use of cutaneous BCG
restimulation after intrapleural treatment in Stage I patients.
These studies lead us to
conclude that: 1) Intrapleural BCG prolonged the time to recurrence for
patients with Stage I lung cancer in the study interval 1973-1977. The fact
that cancer has recurred in 9 of the 30 BCG treated Stage I patients suggests that
the benefit described in our initial report probably was not an artifact
related to maldistribution of surgically curable cases in this group. 2) No
benefit was demonstrable in Stage II, III patients. 3) The addition of
cutaneous restimulation may increase the efficacy of intrapleural BCG.
*By invitation
12. The Clinical Value of Quantitative Ventilation
Perfusion Lung Scans in the Surgical Management of Bronchogenic Carcinoma
JORGE A. WERNLY*, P.
DAVID MYEROWITZ*,
PETER T. KIRCHNER*,
DAVID E. OXFORD*,
CORINNE A. SOVIK*,
HARVEY M. GOLOMB*,
TOM R. DEMEESTER,
Madison, Wisconsin and Chicago, Illinois
Quantitative ventilation (Xe 133) and
Perfusion (Tc99) lung scans were done in 22 patients requiring Pneumonectomy in
order to predict post-operatives FEV,, The contribution of the lung to be
resected and therefore the expected reduction in postoperative pulmonary
function, was calculated from both the ventilation and perfusion scans using
two different multiple regression equations. The predicted post-operative FEV,
were derived by subtracting the calculated values from the pre-operative FEV,,
and compared to the actual post-operative FEV, measured four weeks after
pneumonectomy. Post-operative FEV, could be better predicted using the
perfusion scan (coefficient of correlation = 0.85, standard error = 0.19) than
using the ventilation scan (coefficient of correlation = 0.82, standard error =
0.22). There was a mean percent error of 9 ± 8% for the FEV, values predicted
on the basis of the perfusion and 11.6 ± 9% for the FEV, values calculated on
the basis of the ventilation.
Based on these findings, all patients
requiring pneumonectomy had pre-operative pulmonary function test and
quantitative perfusion lung scans in an effort to predict post-operative
pulmonary function. Patients with a predicted FEV, value of less than one
liter/sec, were considered medically inoperable. Thirty-four patients with a
predicted post-operative FEV, greater than one liter/sec underwent
pneumonectomy. Three operative deaths occurred in this group, one of which was
related to pulmonary insufficiency. Seventeen of these patients had a
pre-operative FEV, of less than two liter/sec and would not have been
considered candidates for pneumonectomy if an equal split of pulmonary function
was assumed for each lung. There were no deaths or post-operative respiratory
insufficiency in these patients.
Similar calculations were used in 36 patients
requiring lobectomy. The contribution of the to be resected lobe to the total
pulmonary function was estimated in a semiquantitative fashion using the
quantitative perfusion scans in order to identify which patients with marginal
pulmonary function could tolerate surgical reduction in lung volume.
It is concluded that perfusion scan is a reliable means of predicting
postoperative function after pneumonectomy. It allows the surgeon to safely
determine which patients with marginal pulmonary function can receive the
benefits of resectional therapy with minimal risk of developing chronic
respiratory failure.
INTERMISSION - 45 MINUTES
VISIT EXHIBITS
*By invitation
13. Total Anomalous Pulmonary Venous Connection;
Ten Years Experience Including Postoperative Ventricular Function Studies
JOHN W. HAMMON*,
HARVEY W. BENDER,
THOMAS P. GRAHAM*and
HAROLD G. ERATH*,
Nashville, Tennessee
The surgical experience with
total anomalous pulmonary venous connection (TAPVC) since 1969 was reviewed.
Twenty-five patients with TAPVC were studied. The average age at operation was
4 months with 17 children less than 3 months of age. All patients had marked
pulmonary hypertension and had been treated for congestive heart failure.
Operative mortality was 5/25 (20%). 4 of 5
deaths were in critically ill neonates requiring preoperative ventilatory
support. All operative survivors have been followed for a mean 4.5 years (6
mos.-10 years). There have been no late deaths or reoperations. All children
have had normal growth patterns. Ten patients have been recatheterized.
Pulmonary artery systolic pressure fell from 79 mm Hg ± 6.9 before operation,
32 mm Hg ± 2.6* post surgery. Pulmonary capillary wedge pressure was slightly
elevated at 12 mm Hg at the postoperative evaluation. Ventricular function has
been evaluated in eight patients before and after surgery using quantitative
angiocardiography. Left ventricular end diastolic volume index (LVEDVI) was
markedly depressed at 27.3 ± ml/m2 preoperatively, an average 75% of
normal values. Postoperatively LVEDVI rose to 58.4 ± 4 ml*/m2 which
averaged 110% of normal values. Left ventricular ejection fraction was
depressed at 51 ± .04% before operation was within normal limits at 65 ± .02%*
postoperatively. Left atrial maximal volume index measured postoperatively was
found to be 27.9 ± 4.4 ml/m2 which averages 93% of normal values.
Thus, in postoperative survivors left ventricular function is normal and left
atrial size is adequate.
*P < .05 from
preoperative
*By invitation
14. Current Results with Mustard's Operation in
Isolated Transposition of the Great Arteries
GEORGE A. TRUSLER,
WILLIAM G. WILLIAMS*,
TERUO IZUKAWA* and
PETER M. OLLEY*, Toronto, Ontario
The current wave of enthusiasm for the Senning
operation prompted a review of our results with the Mustard procedure. Two
hundred and five infants and children with isolated transposition of the great
arteries (TGA) were operated on from 1963 to October 1979. To identify trends,
the results in the last 100 patients, were compared with the earlier group of
105 children.
Early mortality was less with only 2 deaths in
the recent group compared to 11 deaths in the first group. There were five late
deaths in the recent group due to: cardiac failure (2), dysrrhythmias,
pulmonary venous obstruction and congenital respiratory tract anomaly. Complete
pulmonary venous obstruction only occurred once in the last 100 cases but left
pulmonary venous obstruction, also a technical problem, occurred twice.
Inferior vena caval obstruction was rarely seen at any time but technical
changes designed to reduce the incidence of dysrrhythmias have increased the
incidence of partial superior vena caval obstruction which was identified 9
times in the last 100 patients. The incidence of dysrrhythmia is lower and a
current prospective study indicates that all of the last 15 infants were in
sinus rhythm when discharged from hospital. The most serious late problems are
right ventricular failure and tricuspid incompetence.
This review suggests that current results with
the Mustard repair are similar to those reported for the Senning repair. The
choice of operation would appear to depend on the preference of the surgeon and
possibly the age of the infant.
*By invitation
15. Management of Pulmonary Atresia with
Hypoplastic Pulmonary Arteries by Right Ventricular to Pulmonary Arterial
Reconstruction
J. M. PIEHLER*,
G. K. DANIELSON, R. B. WALLACE,
D. C. McGOON,
R. E. FULTON*and D. D. MAIR*,
Rochester, Minnesota
The presence of hypoplastic pulmonary arteries
in the symptomatic patient with pulmonary atresia and ventricular septal defect
(VSD) precludes one-stage complete correction and mandates some type of
preliminary palliative procedure. Since 1976, we have palliated 38 patients
(pts) by establishment of right ventricular to pulmonary arterial (RV-PA)
continuity without closure of the VSD. The ages ranged from 2-54 years (mean 13.3);
12 pts had 15 prior systemic-pulmonary arterial shunts. The mean hemoglobin was
18.1 gm/dl and the mean arterial oxygen saturation was 72%. There were
three hospital deaths (8"%), all in pts with prior shunts; no deaths occurred
in the 26 pts without shunts (p = 0.05). All survivors manifested clinical
improvement; there was a mean decrease in hemoglobin of 3.6 gm/dl (p <0.001)
and a mean increase in arterial oxygen saturation of 15.2% (p<0.001).
Cardiac catheterization, performed in 12 pts
10-26 months (mean 17.2) after operation, revealed a 2.20 fold increase in mean
pulmonary artery size (p = 0.0001), defined as the ratio of the sum of the
diameters of the right and left pulmonary arteries to the diameter of the
descending aorta. There was no significant difference between right and left
pulmonary arterial enlargement (2.35 and 2.04 fold increase, respectively,
p>0.1). Three pts have now undergone completion of correction by placement
of a valved RV-PA conduit with patch closure of VSD.
These results were compared with those
obtained in a comparable group of 13 pts with pulmonary atresia, VSD, and
similarly hypoplastic pulmonary arteries treated initially with
systemic-to-pulmonary arterial shunting. The mean pulmonary arterial
enlargement of only 1.55 times initial size detected on late restudy (mean 33.4
months postoperatively), p = 0.005, was statistically less than that of the
reconstruction group (p<0.05), was less predictable, and was associated with
more pulmonary arterial and anastomotic distortion (46% vs. 8%). The results of
RV-PA reconstruction suggest that this is a more satisfactory initial procedure
for the management of the symptomatic patient over 2 years of age who has
pulmonary atresia, VSD, and hypoplastic pulmonary arteries.
*By invitation
16. Hypertensive Mechanisms in Coarctation of the
Thoracic Aorta
FREDERICK S.
PARKER, JR., BRUCE FARRELL*,
DAVID H. P.
STREETEN*, HENRY M. SONDHEIMER*,
GUNNAR H.
ANDERSON* and MARIE S. BLACKMAN*,
Syracuse, New York
The renin angiotensin system continues to be
implicated in the hypertension associated with coarctation of the thoracic
aorta and in the paradoxical hypertension following its definitive repair.
Available data, however, remain contradictory and unclear. Depletion of
extracellular volume by sodium restriction, loop diuretics and use of specific
antagonists of the renin-angiotensin system such as saralasin, an angiotensin
II antagonist, have helped unmask abnormal plasma renin activity in other
hypertensive states. In an attempt to more clearly define the role of this
system in coarctation these methods were applied to a group of preopera-tive
and postoperative patients.
Eight children, ages 5 to 16, with coarctation
of the thoracic aorta were given a two day 200 mg sodium diet. Following furosemide
administration 2 hour upright plasma renins were obtained, measured by
radioimmuno-assay and compared to five normal controls. A standard saralasin
(angiotensin II antagonist) test was then performed. Following surgical
correction all patients developed paradoxical hypertension. Plasma renins were
measured and a repeat saralasin infusion performed within 24 hours of surgery.
Results: All preoperative patients developed elevated plasma renin levels (22.6
± 10 ng/ml/hr.) compared to controls (4.5 ± 2.0 ng/ml/hr.) p<.01. Six of
eight patients were saralasin responders preoperatively. (Systolic ↓14 +
3.5 mm Hg, diastolic ↓11.8 ± 6.7 mm Hg.). The same six of eight patients
were saralasin responders postoperatively. (Systolic ↓16.7 ± 5.6mm Hg,
diastolic ↓18 ± 4.6 mm Hg.). Postoperative plasma'renins were also
elevated in the same saralasin responders (13.9 ± 6.8 ng/ml/hr.).
This study strongly suggests that the renin
angiotensin system plays an important role in the hypertension associated with
coarctation and in the mechanism of paradoxical hypertension following
coarctation repair. The combination of a low sodium diet and diuresis appears
to unmask increased plasma renin activity in coarctation patients and the
saralasin infusion test offers confirmatory evidence.
*By invitation
