Random versus predictable risks of mortality after thoracotomy for lung cancer.

Over a period of 12 1/2 years, 476 patients underwent thoracotomy for lung cancer at two affiliated hospitals. Hospital mortality for all patients was 5.25% and for those undergoing pulmonary resection, 5.67%. Hospital mortality is more indicative of true risk than is the 30 day mortality figure, which we regard as arbitrary and misleadingly low. Thirty-seven preoperative risk factors were analyzed for their effects on both morbidity and mortality, and 12 classes of postoperative complications were analyzed for their effect on mortality. All preoperative risk factors together accounted only for 12% of the risk of mortality (R2 by multiple regression analysis). Only three of these factors bore a significant association with mortality: patient age 60 years or over (p less than 0.05), need for pneumonectomy (p less than 0.005), and premature ventricular contractions on the admission electrocardiogram (p less than 0.05). All the listed postoperative complications together accounted for only 28% of the risk of mortality. Of these complications, four showed a significant association with postoperative death: infectious complications (pneumonia and empyema) and cardiovascular accidents (pulmonary embolism and myocardial infarction). In both analyses, the remainder of the risk of death must be attributed either to factors not considered or to purely random factors. It follows that much the greater part of the risk of death from surgical treatment of lung cancer could not be predicted from the preoperative status of the patients.

Adverse prognostic effect of N2 disease in treated small cell carcinoma of the lung.

We reviewed survival of patients with clinically localized small cell carcinoma of the lung treated by surgical resection, combination chemotherapy, and prophylactic cranial irradiation. Long-term survival was defined as continuing complete remission 30 months after the start of treatment. Initial TNM staging determined the course of treatment. Ten patients with disease in Stages I and II were treated over 30 months ago by initial resection followed by the full course of chemotherapy. Only one has had a relapse, whereas 80% remained disease-free at 30 months. Five of these patients have passed 5 years. Four patients with T3 N1 disease were treated by two cycles of chemotherapy, surgical resection, and cranial irradiation plus resumption of chemotherapy thereafter; two remained in remission at 30 months. Sixteen patients initially with N2 disease were treated according to the same schedule; 10 of the 16 underwent successful resection. All 16 patients have had a relapse, but the relapse occurred very late in three--at 27, 30, and 37 months. The reasons for the apparently poor prognosis of N2 disease are not clear. Considerations of tumor response kinetics and somatic mutation suggest that these biologic factors are fundamentally responsible. Other studies may find disease control achieved in a very few patients with N2 disease.

Histologic alterations in small cell carcinoma of the lung after two cycles of intensive chemotherapy.

In patients treated nonsurgically for "limited" small cell carcinoma of the lung, the most frequent site of relapse is within the chest. We have treated patients with clinical Stage III M0 disease (T3 and/or N2, M0) by two cycles of chemotherapy, surgical resection of the primary site and mediastinal nodes, and continued chemotherapy thereafter. Since May, 1979, the regimen has consisted of cyclophosphamide, doxorubicin, vincristine, and etoposide on a 3 week cycle. The first 12 patients so treated had partial or complete remission after two cycles. Resection was technically not possible in two. Residual small cell carcinoma was not identifiable in the specimens from two of the 10 patients undergoing resection. Microscopic tumor extended to a resection line in two of the eight with residual tumor. Malignant tissue appearing to have the structure of papillary adenocarcinoma was found in hilar and paratracheal nodes in one patient, but nowhere in the resected lung; some residual small cell carcinoma remained in the lung. Nuclear ballooning and eosinophilic inclusions were noted in cells still identifiable as small cell carcinoma in one case. Marked fibrotic scarring was noted in eight cases, acute and organizing bronchopneumonia in three, and multiple small parenchymal abscesses in one case. Long disease-free survival occurred in one patient, in whom residual tumor could not be found in the specimen; in at least one more in whom residual tumor was present; and even in one patient in whom tumor was present at the bronchial resection line.

The prospect of disease control by surgery combined with chemotherapy in stage I and stage II small cell carcinoma of the lung.

Ten patients with localized small cell carcinoma of the lung (clinical stages I and II) were treated by surgical resection more than 2 years ago; operation was followed by a course of intensive combination chemotherapy. Relapse of the disease has occurred in the central nervous system in 1 patient. One patient died of a surgical complication, and another died more than 4 years later of an unrelated malignancy. All others remain well, and 3 patients have survived longer than 5 years following resection.

Phase II trial of extended indications for resection is small cell carcinoma of the lung.

Surgical resection offers distinct theoretical advantages as the "local" modality in treatment of Stage I and II small cell carcinoma of the lung. We have treated 10 such patients by initial resection since 1975; all survivors but one received adjuvant chemotherapy for the full course thereafter. One patient died of a pulmonary embolus; the other nine remain without evidence of disease from 7 to 69 months after resection. A trial was undertaken of extended indications for resection in selected patients with Stage III-M0 disease. Criteria for patient selection have been developed gradually; these exclude patients for reasons of refusal, physiological inadequacy, disease unsuited to gross total eradication, or lack of adequate initial response to chemotherapy. Of six patients who survived the exclusion criteria and underwent resection, one has had a relapse at 26 months. All others remain without evidence of disease, 5 to 25 months after the start of treatment. We believe that systematic patient selection on the basis of defined criteria will identify a subset of patients having markedly improved chances for disease control. This group may represent as many as half of the patients first presenting with localized or MO disease. Patients excluded as candidates for resection have continued to receive standard nonsurgical combined-modality therapy.

Selective surgical resection in small cell carcinoma of the lung.

Surgical resection has failed notably as definitive treatment for small cell carcinoma of the lung. Newer treatment programs combining intensive chemotherapy with radiation therapy achieve a significant response in about 85 percent of cases, with about 50 percent of patients showing clinically complete remission. Long-term survival without recurrence has been the outcome in a small minority of cases. A frequent mode of failure after treatment of limited disease is recurrence within the chest. The course of one patient treated early in this series suggests that exclusion of initial surgical resection from programs of combined treatment may be a serious omission. Since that time, four patients have undergone initial resection, apparently with uniformly favorable courses to date. Selection criteria based on staging factors are proposed. Admittedly, only a minority of patients will be suitable for this treatment at the time of first diagnosis. Much opportunity exists for improvement in survival rates of patients, even those with limited disease.

Pulmonary complications in primary acquired hypogammaglobulinemia: surgical considerations.

With the discovery and routine use of antibiotics, a virtually new disease--primary acquired hypogammaglobulinemia--was recognized. More precise clinical, genetic, and laboratory endeavor has proved, in fact, that it is really one of a whole host of individual disease entities, all with the common feature of inadequate production and marshalling of gamma globulin to combat infection. Although the condition has been recognized in children's medicine for two decades, the survival of these early victims into adolescence and adulthood is now bringing them to the attention of surgeons as candidates for drainage or resection of suppurative disease of the lung, air tubes, and pleura. In fact a triad has emerged, with some of these patients having infectious disease in the lungs and sinuses associated with enlargement of the spleen when first seen. Often it is the radiologist who first suspects the diagnosis when he recognizes one or more features of this diagnostic triad. Three personal cases are presented together with a technique of management that appears successful. As with the recognition of any new disease, occult and subclinical presentations become more common as suspicion progresses, and ease of confirmation is afforded.

The role of pericardiotomy in treatment of pericarditis with effusion.

Experience with 23 patients with pericarditis and pericardial effusion is discussed. The methods of drainage with their relative merits are mentioned, as are the etiology of pericarditis, signs and symptoms of the disease as well as various techniques for establishing the diagnosis.

"Aspiration disease".

Aspiration disease, a term used to define both an acute and chronic form of a disease entity, is described. Etiological factors, pathophysiology and therapy are discussed with emphasis on aspiration of gastric juice. A brief mention of a small clinical experience is included.

Ischemic colitis in esophageal substitution: an unusual and lethal complication of colon interposition.

This is a report of one patient with the unusual complication of ischemic colitis in a segment of interposed right colon which was used for esophageal substitution. The presentation was unusual in that the patient had three episodes of massive lower gastrointestinal bleeding. The diagnosis was established by selective angiography and a barium contrast study.