33. A Case for Anatomic Correction in Atrioventricular Discordance? Effects of Surgery on Tricuspid Valve Function

Marjan Jahangiri*, Andrew N. Redington*, Martin J. Elliott*, Jaroslav Stark, Victor T. Tsang*, Marc R. de Leval†, London, United Kingdom.

Discussant: Tom R. Karl, M.D.

OBJECTIVE: To assess tricuspid valve function in atrioventricular discordance (AVD) following palliative procedures (pulmonary artery banding and Blalock-Taussig shunt) and corrective procedures (anatomic correction, AC; physiologic correction, PC).

METHODS: Tricuspid valve dysfunction was assessed by transthoracic echocardiography and graded into no regurgitation (0), mild (1), moderate (2)and severe (TR) before and after 150 operations performed in 99 patients with AVD who underwent surgery between 1988 and 1999. The ventricular arterial connection was discordant in 92% and double outlet right ventricle in 8%. 66% had a VSD and 28% had pulmonary stenosis. Twenty six patients underwent pulmonary artery banding and 25 had a modified Blalock-Taussig shunt performed. Eighty patients underwent PC and nineteen underwent AC (atrial-arterial switch, n=15; atrial-Rastelli, n=4).

RESULTS: Table I summarises patients with TR and the effect of surgery on this (3 in the PC group had tricuspid repair and 4 had replacement). The operative mortality in patients who underwent PC was 7% as compared to no death in the AC group (p=0.59).The median follow-up was 3.2 years (range; 3 months-10.2 years).

CONCLUSIONS: Volume loading (shunt) or right to left septal shift (PC) worsens TR whereas volume reduction (banding) or left to right septal shift (AC) has beneficial effects on tricuspid valve function. Anatomic correction can be performed with a low morbidity and mortality in selected patients with AVD and provides superior functional result.

Operation, N	Preop TR Score mean±SD	Postop TR Score mean±SD	p-value
Pulmonary Artery Banding, 20	1.83±0.72	0.86±0.55	<0.001
Blalock-Taussig Shunt, 16	1.59±0.80	2.42±0.61	<0.001
PC, 27	1.50±0.69	1.05±0.94	NS
AC, 15	1.59±0.87	0	<0.001

†Graham Fellow, 1973-1974

*By Invitation

TUESDAY MORNING, MAY 2, 2000

7:00 a.m. C. WALTON LILLEHEI RESIDENT FORUM SESSION

Supported by an unrestricted educational grant from St. Jude Medical, Inc.

Constitution Hall, Metro Toronto Convention Centre

(8 minute presentation, 7 minutes discussion)

Moderators: Eric A. Rose, M.D.

Edward D. Verrier, M.D.

L1. Gene Transfer of Bcl-2 Does Not Affect Myocardial Stunning But Ameliorates the Deletorious Effects of Chronic Remodeling

Allan S. Stewart*, Henry L. Zhu*, Derek R. Brinster*, Hugh L. Sweeney*, and Timothy J. Gardner, Philadelphia, Pennsylvania

OBJECTIVE: Numerous studies implicate apoptosis as an important consequence of ischemia/reperfusion injury. However, no study reproducibly associates the reduction of apoptosis with an improvement in post-ischemic myocardial function. Data is lacking to determine if apoptosis is advantageous to organ survival or deleterious to myocardial function. This experiment employs gene transfer of bcl-2 to significantly reduce apoptosis and correlate that reduction with acute and chronic measurements of contractility.

METHODS: An adenovirus encoding for bcl-2 was constructed and injected into the lateral wall of 20 New Zealand white rabbits. 20 rabbits recieved adenolac-Z as a control. Five days post-injection, the rabbits were subjected to 30 min or proximal circumflex occlusion followed by reperfusion. 10 rabbits in each group underwent four hours reperfusion, while the remaining underwent 6 weeks of reperfusion. Functional measurements were obtained with echocardiography, aortic flow probe measurements, and sonomicroscopy. Infarct percentage was assessed with TTC staining. Histological analysis was performed with HandE, trichrome staining, and TUNEL assay. Gene expression was assessed with Western blot and RT-PCR.

RESULTS: Bcl-2 reduced the percentage of apoptotic cells from 19.2±3.5% to 4.1±1.7% (p<.05). However, this decrease did not result in a significant improvement in contractility, ventricular stroke work, or ejection fraction in the acute group. In contrast, bcl-2 was found to significantly improve regional wall motion, ejection fraction, stroke work, and enhanced diastolic relaxation in the chronic group. A decrease in fibrosis, cell-cell slippage, and ventricular wall thickness was seen in the bcl-2 chronic group, but not seen in the acute group.

CONCLUSIONS: Apoptosis was demonstrated after reperfusion injury but had no influence on post-ischemic myocardial stunning. However, apoptosis was found to adversely influence chronic remodeling and ventricular function. Gene transfer of bcl-2 may be a useful strategy to protect the heart from the deletorious consequences of apoptosis induced remodeling.

*By Invitaiton

L2. Epidermal Growth Factor Augments Post-Pneumonectomy Lung Growth

Aditya K. Kaza*, John A. Kern*, Stewart M. Long*, Victor E. Laubach*, Joshua A. Tepper*, Kimberly S. Shockey*, Curtis G. Tribble, and Irving L. Kron, Charlottesville, Virginia

OBJECTIVE: We hypothesized that post-pneumonectomy compensatory lung growth can be augmented by the administration of exogenous epidermal growth factor (EGF).

METHODS: Adult Sprague-Dawley rats were divided into three groups. Sham left thoracotomy was performed in the first group (C), left pneu-monectomy in the second group (P), and left pneumonectomy with administration of EGF (0.2ug/g, at 72 hour intervals) in the third group (P¢). The right lung growth was studied in each group at 1, 3, 5, 10 and 21 days after surgery. Wet lung weights were measured. Volumetric analysis was performed using saline displacement technique after intra-tracheal instillation of 2% glutaraldehyde to a pressure of 25cm. Lung weights (g) and volumes (cc) were expressed as a ratio to the total body weight (kg) (lung weight and volume indices).

RESULTS: Using ANOVA, we noted a significant increase in lung weight index between the P and P' group at 21 days (3.61 vs 4.62, p=0.006). Contrast analysis also revealed a significant increase in lung weight index between P and P' at 3 days (2.75 vs 3.08, p=0.034). Lung volume index was evaluated using ANOVA, which showed significant increase in right lung volume between the P and P' groups at 5 (15.09 vs 16.98), 10 (18.81 vs 24.48) and 21 (21.01 vs 28.54) day intervals (p<0.001).

CONCLUSIONS: This study demonstrates that administration of exogenous epidermal growth factor has a significant impact on post-pneumonectomy lung growth. This process may be mediated by an up-regulation of growth factor receptor expression in the contra-lateral lung after pneumonectomy. We believe that this is the first demonstration that adult lung growth can be exogenously enhanced.

*By Invitation

L3. Early Sustained Reduction of Pulmonary Angiotensin-Converting Enzyme Activity Following Superior Cavopulmonary Anastomosis in the Lamb

Sunil P. Malhotra*, V. Mohan Reddy*, Frank L. Hartley and Kirk Riemet, San Francisco, California

OBJECTIVE: The Glenn shunt is a superior cavopulmonary anastomosis (SCPA) widely used for palliation of various forms of congenital heart defects. However, pulmonary arteriovenous malformations (PAVMs) of varying clinical significance develop in 15-60% of patients following surgery. Histological analysis of these PAVMs reveals the proliferation of numerous dilated, thin-walled vessels. To assess alterations in regulators of vascular tone following SCPA, changes in angiotensin-converting enzyme (ACE) activity and plasma angiotensin II (AT-II) levels were examined.

METHODS: Lambs, aged 30-40 days, underwent an end-to-end anastomosis of the superior vena cava to the right pulmonary artery. In age matched controls, a sham operation was performed. PAVMs developed in all SCPA lambs by 6 weeks after surgery, as demonstrated by contrast echocardiography. Animals (n=16) were then studied at various time points following surgery. ACE activity was measured in lung homogenates. Levels of AT-II in the right pulmonary vein were measured by ELISA.

RESULTS: Compared to controls, ACE activity in the right lung of Glenn animals was reduced 86% at 4 and 14 days, 52% at 50 days, and 13% at 133 days following surgery. This correlated with a 70% reduction in AT-II levels in SCPA animals studied at 4-14 days following surgery, while levels at 50 and 133 days approached control levels.

CONCLUSIONS: ACE activity is an indicator of endothelial integrity. Diminished activity following SCPA suggests pulmonary endothelial damage. Moreover, the resulting decrease in AT-II production, a pulmonary vasoconstrictor, may promote chronic dilatation of the right pulmonary vascular bed. The role of these perturbations of the affected vasculature in PAVM formation remains to be determined.

*By Invitation

L4. Should Mediastinal Drainage Be Autotransfused Postoperatively in the Cardiac Surgery Patient?

John S. Thurber*, Edward R. Zech*, Loretta Aiken*, and Gary H. Meyers*, Bethesda, Maryland

OBJECTIVE: Autotransfusion (AT) of mediastinal drainage in the post-operative cardiac surgery patient has been a method of perioperative blood conservation for over 20 years. The risks and benefits of this practice have been reviewed in a number of reports, with conflicting results. This study prospectively evaluates the risks/benefits of the use of AT.

METHODS: A prospective, randomized study of 128 patients undergoing elective cardiac surgery was performed. Patients were randomized into one of two groups: the experimental group received autotransfused mediastinal drainage (AT) for 6 hours after surgery (n=62), and the control group was treated with standard chest drainage with no AT (n=66). Both groups received homologous blood transfusion when the hemoglobin fell to less than 8.0 g/dl. Pre- and post-operative variables recorded included: hematocrit, platelets, PT/PTT, fibrinogen and d-dimer levels, and homologous blood products infused.

RESULTS: Packed red blood cells were required in 9 of 62 (15%) patients in the AT group, and in 14 of 66 (22%) patients in the non-AT group (p=ns). Total homologous blood product exposure was slightly higher in the non-AT group (25% vs. 19% AT, p=ns). Pre- and post-operative hematologic parameters were similar between the two groups. D-dimers were elevated in the serum of 11% of AT patients, compared with 3% of non-AT patients (p=0.03). There was an increased cost for nursing effort and equipment involved with the AT patients.

CONCLUSIONS: The use of AT in the postoperative cardiac surgery patient did not result in significant reduction in the use of homologous blood products, and did result in increased cost. Therefore, in the setting of routine blood conservation practices, the postoperative use of AT in the cardiac surgery patient is not recommended.

*By Invitation

L5. Subdiaphragmatic Venous Hemodynamics in the Fontan Circulation

Tain-Yen Hsia*, Sachin Khambadkone*, Francesco Migliavacca*, and †Marc R. de Leval, London, United Kingdom

OBJECTIVE: To investigate Subdiaphragmatic venous physiology in Fontan patients (FP) in order to understand some of the early and late problems and to improve their management.

METHODS: Doppler flow were evaluated in subhepatic inferior vena cava (IVC), hepatic vein (HV) and portal vein (PV) with respiratory monitoring and a tilt table to assess effects of respiration and gravity. 19 controls (group A) and 44 FP, 29 in functional class 1 (group B)and 15 in class 3 (group C), were studied. IVC, HV and wedged-HV (WHV) pressures were measured during catheterization in 11 controls and 8 class 3 FP. Difference between HV and WHV is the transhepatic venous pressure gradient(TVPG).

RESULTS: Shown below, ratio of inspiratory/expiratory antegrade flows (R)represented effect of respiration. Gravity effect was evaluated by a ratio of flow rates in supine/upright positions (G). * denotes p-values <0.05, † <0.0001, # =0.07.

CONCLUSIONS: This is the first time hydrostatic force have been evaluated in FP. Gravity reduced class 1 FP's IVC and HV flow; progression to class 3 did not exacerbate this. In the PV, while FP have lost normal expiratory augmentation to flow, gravity more adversely influenced class 3 than class 1 FP. This poorer flow dynamics is coupled to higher splanchnic pressures and a lower gradient. Reduced TVPG in class 3 FP further suggests the hepatic sinusoidal reserve is impaired, creating an open tube phenomenon. These observations may account for some late gastrointestinal problems in FP.

FlowRatio	R (IVC)	R(HV)	R(PV)	G (IVC)	G(HV)	G(PV)
Avs.B	1.2 v 1.6	1.7v 2.9*	0.8 v 1.0*	1.2 v 1.8*	1.7 v 2.3#	1.9 v 2.1
Bvs.C	1.6 v 1.5	2.9 v 3.1	1.0 v 1.1	1.8 v 1.7	2.3 v 2.4	2.1 v 3.1*
Pressures mm Hg	IVC	HV	WHV	TVPG
Control vs Fontan	6.2±2.0 v	5.9±1.9v	8.4±2.9 v	2.5±2.4 v
	13.7±3.7†	15.7±5.0†	15.0±4.0†	0.5±0.7 *

†1973-74 AATS Graham Fellow

*By Invitation

L6. Laparoscopic Gastric Ischemic Preconditioning Prior to Transhiatal Esophagectomy

Sandra M. Jones*, Daniel Gagne*, Mary Beth Malay*, Dennis L. Fowler*, Robin S. Macherey* and Rodney J. Landreneau, Pittsburgh, Pennsylvania

OBJECTIVE: Cervical esophagogastric anastomotic disruption following THE is a significant problem. Ischemia of the "proximal gastric tip" is a primary cause of anastomotic failure. We sought to determine if gastric blood flow could be improved with the preoperative performance of LAP ischemic preconditioning, by selectively ligating the short gastric (SG) or the left and short gastric (LG/SG) blood supply to the stomach 3 weeks prior to THE.

METHODS: Fifteen 25 kg mongrel dogs underwent a 2 stage experiment of LAP followed 3 weeks later by THE. Prior to each stage, hemodynam-ics were stabilized. Blood flow was assessed using the fluorescent microspheres method. Three groups were separated into 5 dogs each. Group 1 LAP alone, group 2 LAP/ligation of SG only, group 3 LAP/ligation of LG/SG. Microsphere injection occurred prior to pneumoperitoneum and at completion of LAP. All 15 dogs underwent THE 3 weeks later. Microsphere blood flow injection was made after anesthesia and after esophago-gastic anastomosis. All animals were euthanized and gastric perfusion (near anastomosis) was analyzed. Differences in blood flow were evaluated using Student's T test.

RESULTS: The mean baseline blood flow was 0.58ml/mg tissue. After THE, proximal gastric blood flow fell to 19% of baseline(0.11ml/mg) in the control (group 2), to 31%(0.18ml/mg) in SG (group 3), and to 59% (0.34ml/ mg)in LG/SG (growp 3). This relative preservation of blood flow among the LG/SG group was significant compared to the control group 1(0.11ml/ mg vs 0.34ml/mg, p=0.02)Preoperative ligation of SG vessels alone (group2) did not provide significant "ischemic conditioning" improvement in proximal gastric blood flow following THE.

CONCLUSIONS: Ischemic preconditioning of the proximal stomach during preoperative LAP can significantly improve blood flow to the "gastric tip" prior to THE. Future consideration of this procedure during LAP staging of esophageal carcinoma may be considered to reduce anastomotic complications following THE.

*By Invitation

^§L7. Assisted Venous Drainage Presents Risk of Undetected Air Microembolism

Angelo LaPietra*, Eugene A. Grossi, Bradley A. Pua*, Rick A. Esposito*, Aubrey C. Galloway, Christopher C. Derivaux*, Lawrence Classman* and Stephen B. Colvin, New York, New York

OBJECTIVE: Methods for minimally invasive cardiac surgery rely on augmented venous return (AGVR) techniques (kinetic or vacuum) for cardiopulmonary bypass. Such techniques can introduce venous air emboli (AE) which can pass to patients. We examined this potential with different AGVR techniques.

METHODS: An in vitro bypass system was created using kinetic (Biomedicus Pump) (K-AGVR) or vacuum (hardshell reservoir) (V-AGVR) systems. Roller or centrifugal pumps were used on the arterial side with a fiber oxygenator and a 37m arterial filter. Air was introduced into the venous line via an open 25g needle. Test conditions included varying the amount of venous negative pressure (-15 to 75mmHg), AGVR type, and arterial pump (AP).

RESULTS: Changes in negative venous pressure did not affect the number of microbubbles introduced into the system. K-AGVR filled quickly with micro and macro bubbles requiring manual clearing. Microbubbles/ min (mean±SD) are shown below for the venous inlet, pre-oxygenator, and patient side of the arterial filter.

CONCLUSIONS: Some AGVR configurations permit a significant quantity of microbubbles to reach the patient despite filters. Centrifugal pump has air handling disadvantages when used for K-AGVR, but aids in clearing AE when used as the arterial pump. The surgeon using these techniques should be aware of the potential risks and how to minimize them.

	Venous Inlet	Pre-Oxygenator	Patient Side
AP: Roller
V-AGVR	9754±2898	16±21	010
K-AGVR	10004±1258	14218±905	817
AP: Centrifugal
V-AGVR	8639±2987	249±690*	010
K-AGVR	9806±2758	1317±3311*	0+0

^§Authors have a relationship with Heartport, Baxter Healthcare, St. Jude Medical & Medtronic

*By Invitation

L8. Hemodynamic Changes During Beating-Heart CABG Surgery

Quoc-Bao Do*, Olivier Chavanon*, Pierre Couture*, Andre Denault*, Raymond Carrier*, Montreal, PQ, Canada.

OBJECTIVE: To study the effect of different manipulations during beating-heart CABG, we monitored the systemic arterial pressure (SAP), the pulmonary arterial pressure (PAP), the mixed venous oxygen saturation (SvO₂) and the cardiac output (COI)on 54 patients who underwent complete revascularization. Five patients also had a transoesophageal echocardiography (TEO) to assess mitral valve dynamics and ventricular function. Mean patient's age was 66.4±9.2 years, and 3.3±0.8 distal anastomosis were performed per patient.

METHODS: Stabilization of the heart were done using a "fork-type" stabilizator, and the target coronaries were clamped proximally and distally to the anastomosis site without preconditioning.

RESULTS: Changes in SAP, PAP, SvO₂ and COI, as shown in this table, occurred during the stabilization period preceding coronary anastomosis.

CONCLUSIONS: The mobilization and stabilization of the heart rather than clamping the coronaries, were responsible for some minor hemody-namic changes during beating-heart CABG surgery. The marked elevation of PAP during LAD and DG revascularization suggests that compression of left ventricle outflow tract may be the cause.

	LAD	DG	MG	RC(PDA)
Clamp (min)	9.5±0.4	7.4±0.3	8.3±0.4	8.6±0.6
ΔSAP (%)	-8.6±2.9	-14.0±4.9	-16.3±2.0	-15.1±2.5
ΔPAP (%)	23.9±4.6	37.7±14.4	12.5±5.3	12.7±3.8
ΔSv02(%)	-8.5±1.2	-8.1±0.7	-6.5±1.4	-9.6±0.6
ΔCOI (%)	-4.2±2.9	4.5±2.8	-6.3±1.9	-2.6±1.7

No correlation between Sv0₂, COI, SAP, PAP and clamping time were found. They were no significant mitral regurgilation on TEO, although some diastolic and systolic regional dysfunction were found during left anterior (LAD) and the diagonal (DG) coronary clamping.

*By Invitation

9:00 a.m. SCIENTIFIC SESSION

Constitution Hall, Metro Toronto Convention Centre

Moderators: Delos M. Cosgrove, M.D.

Tirone E. David, M.D.

34. Late Results of Aortic Valve Sparing Operations

Tirone E. David, Susan Armstrong*, Joan Ivanov*, Christopher M. Feindel, and Gary Webb*, Toronto, ON, Canada

Discussant: Magdi H.Yacoub, M.D.

OBJECTIVE: To determine the late results of aortic valve sparing operations in patients with aortic root and/or ascending aortic aneurysms.

METHODS: All patients with aortic root and/or ascending aortic aneurysms who had aortic valve repair have been followed prospectively at annual intervals. The mean age of 161 consecutive patients operated on from July 1987 to June 1999 was 54+17 years, range 16 to 84 years. Forty-two patients had the Marfan syndrome according to Gent criteria. Thirty-one patients had type A aortic dissection, 15 had mega-aorta syndrome, 34 had coronary artery disease and 9 had mitral regurgitation. The technique of reimplantation of the aortic valve was performed in 48 patients and remodeling of the aortic root in 113. The follow-up was complete and ranged from 0 to 134 months, mean of 34±28.

RESULTS: There were 3(2%) operative and 16(10%) late deaths. Cardiovascular events were the cause of death in 15 of 19 patients. Actuarial survival at 10 years was 80%±5% for all patients and 100% for those with the Marfan syndrome. Aortic dissection and mega-aorta syndrome were independent predictors of death. The most recent Doppler echocardiogram showed trace or no aortic insuffiency (AI) in 77 patients, mild in 70, moderate in 8, and severe in 3. The 3 patients with severe AI were reoperated on uneventfully. The freedom from moderate or severe AI was 85%±5% at 10 years. Aortic root remodeling and the need for repair of cusp prolapse were associated with a higher risk of AI (p=0.03). The freedom from reoperation was 98%±1% at 10 years.

CONCLUSIONS: Aortic valve sparing operations to treat aortic and/or ascending aortic aneurysms provide excellent and lasting functional results in patients with normal aortic cusps including those with the Marfan syndrome.

*By Invitation

35. Repair Is Preferable to Replacement for Ischemic Mitral Regurgitation

Per Nils Wierup*, A. Marc Gillinov*, Eugene H. Blackstone, Delos M. Cosgrove, Ehab S. Bishay* and Patrick M. McCarthy, Cleveland, Ohio

Discussant: D. Craig Miller, M.D.

OBJECTIVE: To determine whether mitral valve (MV) repair is preferable to MV replacement for ischemic mitral regurgitation (MR).

METHODS: From 1985 to 1997, 402 patients (pts) with ischemic MR underwent either MV repair (n=339) or MV replacement (n=63), Myocardial infarction (MI) was acute in 24% and remote in 76%. By multivariable logistic regression, pts were more likely to receive a repair if they were male (P=.04), had chronic ischemic MR (P=.001), underwent non-emergency operation (P=.002), had restricted leaflet motion (P<.0001), or underwent ITA grafting (P=.002). These factors were used for propensity matching. Factors associated with early and late mortality were identified by multivariable, multi-phase hazard function analysis.

RESULTS: Hospital mortality was 11%. The timing of MI and operative strategy influenced hospital mortality (table). In propensity-matched pts, survival after MV replacement was 76%, 60%, and 43% after 30 days, 1 year (yr), and 5 yrs. In contrast, survival after MV repair was 91%, 80%, and 60% at these same time intervals (P=.003). Risk factors for death within the first yr of operation included older age (P=.002), greater wall motion abnormality (P=.006), and replacement rather than repair (P=.0005). All pts were predicted to benefit from repair; however, the benefit became more pronounced with advancing pt age and less apparent in pts with more severe heart failure (P=.001). Freedom from repair failure was 93% at 5 yrs.

CONCLUSIONS: For surgical management of ischemic MV regurgitation, MV repair is the treatment of choice.

Hospital Mortality (%)
Time of Infraction	Repaired (%)	Total	Repair	Replace	P value (repair vs. replace)
Acute	71	22	17	35	.1
Remote	87	8	5	30	<.001
P value	<001	.002	.009	.7

*By Invitation

36. Induction Chemoradiation Plus Surgical Resection Is Feasible and Highly Effective Treatment for Pancoast Tumors: Initial Results of SWOG 9416 (Intergroup 0160) Trial

Valerie W. Rusch, John J. Crowley*, Michael J. Kraut* and David R. Gandara*, New York, New York; Seattle, Washington; Detroit, Michigan; Sacramento, California

Discussant: Douglas J. Mathisen, M.D.

OBJECTIVE: Rates of complete resection (50%) and 5 year survival (30%) for Pancoast tumors have not changed for 30 years. However, combined modality therapy has improved outcome in other Stage HI non-small cell lung cancers. This prospective intergroup trial tested the feasibility of concurrent inducton chemoradiation and surgical resection in mediastinoscopy negative Pancoast tumors with the ultimate objective of improving resectability and overall survival.

METHODS: Patients with pathologically proven T3-4 N0-1 Pancoast tumors received 2 cycles of cisplatin and etoposide chemotherapy concurrent with 45 Gy radiation. In patients with no evidence of disease progression thoracotomy was performed 3-5 weeks later. Two cycles of chemotherapy were given postoperatively.

RESULTS: From 4/95-9/99, 116 patients were entered on study. This analysis includes 101 eligible patients, 71 men and 30 women with a median age of 56 yrs. Induction therapy was completed as planned in 93% patients with 2 Grade 5 and 17 Grade 4 toxicities (predominantly cytopenia). To date, 81 patients have undergone thoracotomy with the most common procedure being lobectomy + chest wall resection. 1 patient died postoperatively. A pathologic complete response (pCR) occurred in 57.5% patients and 63% rumors were downstaged. At 1 year overall survival was 77% for T3, 80% for T4 tumors; at 3 years 50% for both T3 and T4 tumors. Most common site of relapse was the brain.

CONCLUSIONS: 1) This combined modality approach was highly feasible in a multi-institutional setting; 2) pCR rates were unexpectedly high; 3) resectability and overall survival are improved compared to historical controls; 4) improved outcome was especially notable for T4 tumors which usually have a grim prognosis.

*By Invitation