American Association for

Thoracic Surgery

61ST ANNUAL MEETING

Scientific Program

MONDAY MORNING, MAY 11, 1981

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

International Ballroom

8:45 A.M. Scientific Session - International Ballroom

1. The Significance of Positive Superior Mediastinal Nodes Identified at Mediastinoscopy in Patients with Resectable Cancer of the Lung

F. GRIFFITH PEARSON, NORMAN C. DELARUE,

RIIVO ILVES*, THOMAS R. J. TODD*, and

JOEL D. COOPER, Toronto, Ontario

A literature review reveals seven papers reporting survival data in patients with resectable lung cancer, in whom metastases to mediastinal nodes were identified at thoracotomy and completely resected. Five year survival in these series ranges from 0% to 30%. In only two reports is the precise location of involved nodes defined, and in none of these reports does the survival data consider the incidence of non-resectability, incomplete resection, or operative mortality. Adjuvant radiotherapy, and/or chemotherapy was used in three of the seven series.

There are four papers describing the results of resection in patients with involved superior mediastinal nodes identified by mediastinoscopy, - prior to deliberate exploration and resection. In three of the four reports, there were no five year survivors. These data suggest that superior mediastinal nodes identified at mediastinoscopy may have a different implication on prognosis than mediastinal nodes identified at the time of thoracotomy and resection.

This paper describes our experience between 1964 and 1978 in 55 patients with positive nodes identified at mediastinoscopy, who were managed by preoperative irradiation followed by thoracotomy. This is a highly selected subset of 55 cases with relatively localized, ipsilateral mediastinal involvement, and comprises no more than 20% of the positive nodes identified by mediastinoscopy in presumably operable cases.

Of the 55 patients, nine were non-resectable and there were 10 postoperative deaths (8 early and 2 late). The high operative mortality is attributed to the complications of relatively high dose preoperative irradiation employed. In the 36 patients surviving resection, the absolute five year survival rate is 13.9% (5 of 36). In the 23 patients surviving resection for squamous cell tumors, the absolute five year survival rate 17.4% (4 of 23). Absolute survival figures are reported since follow-up is complete in all patients, and all patients who are currently alive were operated on prior to 1973. These data suggest that ipsilateral, localized, superior mediastinal node involvement which is identified at mediastinoscopy, and managed by preoperative irradiation and resection is associated with a disappointingly low long-term survival.

*By invitation

2. Trial of Extended Indications for Resection in Small Cell Carcinoma of the Lung.

JOHN A. MEYER*, ROBERT L. COMIS*.

SANDRA J. GINSBERG*, PHILLIP M. IKINS*,

WILLIAM A. BURKE* and FREDERICK B. PARKER, JR.,

Syracuse, New York

Treatment of "limited" small cell carcinoma of the lung by intensive chemotherapy and irradiation results in clinically complete remission (CR) in 60-80% of cases. The commonest single site of relapse after CR is within the chest, 60-77% of relapses in some reviews, suggesting that resection with adjuvant chemotherapy might be superior in clinical Stage I and II cases. We have treated ten such patients by initial resection since 1975; one died of a pulmonary embolus on the 7th day. All others remain in CR with 6 off treatment at 19-63 months after resection, unmaintained for 5-48 months. Survival data are as of October 1980.

Since February 1979, carefully studied Stage III-MO cases (T3 and/or N2) have been treated with chemotherapy and evaluated for resection at 6 weeks. Patients were excluded for carinal involvement, malignant pleurisy, severe SVC syndrome, contralateral mediastinal node involvement, inadequate physiologic status, or response inadequate to allow clean resection. Of 8 patients entered to date, one was excluded for inadequate response; one because of profound thrombocytopenia necessitating discontinuation of treatment. Two patients showing little or no response at 6 weeks received radiotherapy followed by resection, and died at 8 and 10 months. Since then, such patients have been excluded from resection. In 4 patients responding to chemotherapy, grossly complete removal of the primary tumor and dissection of mediastinal nodes were possible. None of these have shown relapse; 2 are off treatment at 20 and 17 months, unmaintained for 7 and 6 months; the other 2 are still maintained. Prophylactic cranial irradiation is given to all patients.

We conclude that: 1) TNM staging is useful in subclassification of "limited disease" patients; 2) Best treatment for Stage I and II cases appears to be surgical resection and adjuvant chemotherapy; 3) In a defined subset of Stage III-MO cases, clean surgical resection is feasible after initial response to chemotherapy. No relapses have yet been encountered under these limiting conditions.

*By invitation

3. Surgical Adjuvant Treatment for Lung Cancer - Preliminary Report of the National Cancer Institute Lung Cancer Study Group (LCSG)

CLIFTON F. MOUNTAIN, Houston, Texas

The LCSG is conducting clinical trials of surgical adjuvant treatment designed to test the efficacy of a number of therapeutic approaches reported to favorably influence survival and disease free interval in patients with non-small cell lung cancer. A trial was designed to reproduce the experiment of McKneally who reported significant benefit for completely resected stage I patients treated with a single postoperative intrapleural injection of BCG followed by isoniazid (INH), compared with a group receiving Placebo + INH. As of 8/11/80, 405 eligible patients have been randomized to a double-blinded clinical trial duplicating the McKneally experiment except that control patients were given INH Placebo and lymph node biopsies were required for staging. There have been 73 recurrences (including 5 second primaries) and 56 deaths (15 non-cancer). With a median follow-up of 13 months no significant evidence in favor of either treatment arm can be demonstrated, and the trial has not confirmed the efficacy of intrapleural BCG as a surgical adjuvant.

For patients with completely resected stage II and III adeno or large cell carcinoma, a trial is in progress to test the efficacy of polychemotherapy versus immunotherapy. The chemotherapy consists of Cytoxan + Adriamycin + Cis-platinum and the immunotherapeutic regimen of intrapleural BCG + INH + Levamisole. Based on 55 eligible patients, with a median follow-up of 8 months, one arm of this trial shows promising, but not statistically significant results.

A third trial evaluates the efficacy of adjuvant radiotherapy to influence the outcome in patients with stage II and III completely resected squamous cell carcinoma. Seventy-nine eligible patients have been randomized and with a median follow-up duration of 10 months the deaths and recurrences have occurred equally in the treatment arms with no significant differences.

*By invitation

4. Survival Following Resection for Second Primary Bronchogenic Carcinoma

ROBERT J. JENSIK, L. PENFIELD FABER,

C. FREDERICK KITTLE, and RONALD L. MENG*,

Chicago, Illinois

The increasing incidence of bronchogenic carcinoma forecasts the possible development of a second primary in those patients successfully treated for their initial lesion. Guidelines for appropriate surgical therapy of the second primary are needed and evaluation of results in this group of patients will provide necessary information for future management.

A second pulmonary resection has been done in 60 patients for a simultaneous or successive primary bronchogenic carcinoma, with an interval between the two surgical procedures varying from 2 months to 17 years. The cumulative probability of second tumor occurrence was shown to be 27% by the end of the first year, rising to 58% by the end of the third year. Three patients developed a second tumor 11 to 17 years after their first operation.

The surgical procedures performed for the second lesion were completion pneumonectomy-12, lobectomy-8, and segmentectomy-40.

Twenty-one patients are alive with 3 surviving between 12 to 15 years, free of cancer. Life table analysis of survival following the second resection is 33% at 5 years, 20% at 10 years, and 12% at 15 years. The 6 operative deaths represent a 10% postoperative mortality.

The possibility of the development of a second tumor emphasizes the importance of continued long term surveillance of patients undergoing an initial successful resection. A second primary lung cancer can be succussfully treated by a second resection.

INTERMISSION - VISIT EXHIBITS

*By invitation

5. Automatic Defibrillation in Man: The Initial Surgical Experience

LEVI WATKINS, JR.*, M. MIROWSKI*, PHILIP R. REID*,

MORTON M. MOWER*, MYRON L. WEISFELDT*, and

VINCENT L. GOTT, Baltimore, Maryland

The automatic implantable defibrillator (AD) is an electronic device that continuously monitors cardiac electrical activity, recognizes malignant ventricular tachyarrhythmias (MVT) and delivers corrective 25 joules de-fibrillatory shocks. Ten patients age 16-72 underwent implantation of the AD for documented MVT refractor to medical therapy. All had survived at least 2 episodes of sudden death and preoperative programmed electrical stimulation demonstrated inducible MVT in 7.

Implantation of the device requires positioning of a superior vena cava (SVC) catheter electrode within the right atrium, attachment of an apical electrode extrapericardially over the left ventricular apex and placement of the pulse generator subcutaneously in the abdomen. 3 of the first 4 patients had undergone previous cardiac surgery so implantation was performed via a left thoracotomy. In this approach the SVC electrode is introduced into the left internal jugular vein, localization within the right atrium is confirmed by x-ray or fluoroscopy. In patients without previous surgery or in patients in whom implantation is done concomitantly with open-heart procedures a median sternotomy approach is employed. With this technique, the SVC catheter is introduced into the innominate vein and localization within the atrium confirmed by palpation. There were no operative deaths or major surgical complications.

After implantation seven documented episodes of spontaneous MVT occurred and each was successfully terminated. Preliminary results are encouraging and demonstrate that the AD is capable of correcting lethal ventricular arrhythmias in man. This new therapeutic modality continues to expand the role of surgery in the treatment of cardiac arrhythmias.

*By invitation

6. Cardiac Transplantation in Perspective for the Future: Attainable Results, Long-Term Complications, Rehabilitation, and Cost

JOHN L. PENNOCK*, PHILIP E. OVER*, BRUCE A. REITZ*,

STUART W. JAMIESON*, CHARLES P. BIEBER*,

EDWARD B. STINSON* and NORMAN E. SHUMWA Y,

Stanford, California

Two hundred and twelve cardiac transplants have been performed in 194 patients from Jan. 1968 to Sept. 1980. Postoperative survival rates (PSR), calculated by the actuarial method for program yrs 1968-73 (66 pts) are 44, 35, 27, 21, and 18% at 1, 2, 3, 4, and 5 yrs postop. PSR for program yrs 1974-80 (128 pts) are 63±4, 54±5, 52±5, 44±5, and 40±6% at 1-5 yrs postop. This increase results primarily from improvement in survival achieved during the first three months postop. (59±7%, 1968-73 vs. 80±4%, 1974-80), reflecting changes in early postop. management. Such changes include the introduction of antithymocyte globulin of rabbit origin, T-cell monitoring for the early diagnosis of rejection, transvenous graft biopsy, and retransplantation.

Infection remains the primary cause of death following transplantation -63/114 pts (55%), followed by acute rejection - 22/114 pts (19%), graft arteriosclerosis (GAS) - 13/114 pts (11%), and malignancy - 6/114 pts (5%). The development of GAS has been examined in 85 one-year survivors defined by annual coronary arteriograms. Twenty-one pts developed coronary lesions and in 11 pts the disease resulted in graft failure. HLA-A2 incompatibility was associated with a higher incidence of GAS than was apparent for all other A locus incompatibilities (p <.0003). Likewise, post-op, serum triglyceride levels greater than 280 mg% were associated with the development of GAS (p <.0002). Lymphoma/leukemia (L) has been shown to be associated with recipient age (<20 yrs - 3/7 pts, 21% L/yr - 14.3 risk yrs vs. 41-50 yrs - 3/61 pts, 1.9% L/yr - 154.3 risk yrs), diagnosis (idiopathic cardiomyopathy - 9/53 pts, 6.9% L/yr - 129.6 risk yrs vs. atherosclerosis - 2/71 pts, 0.9% L/yr - 217.3 risk yrs), and transplant order (1st transplant - 7/124 pts, 2.1% L/yr - 336.3 risk yrs vs. 2nd transplant -4/10 pts, 32.1% L/yr - 12.5 risk yrs).

Ninety-six patients have survived at least one year after transplantation; 83% of these achieved rehabilitation at that time interval and returned to employment or activity of choice. The longest survival time is now 10 years and 8 months.

Cost-benefit considerations have recently been the focus of increasing societal attention. Therefore, discussion of the historical costs of cardiac transplantation at our institution will be presented, together with the outlook for reduction of such costs in the future.

*By invitation