Immunohistochemical demonstration of chromogranins A and B in neuroendocrine tumors of the lung.

Fifty neuroendocrine tumors of the lung (16 carcinoids, two atypical carcinoids/well-differentiated neuroendocrine carcinomas [WDNCs], 13 neuroendocrine carcinomas of intermediate cell type [SCNCs], and 19 neuroendocrine carcinomas of small cell type [SCNs]) were immunohistochemically investigated with antibodies against chromogranins A and B. All carcinoids and WDNCs were positive for both chromogranins A and B, whereas in cases of ICNC and SCNC both markers were only expressed in six and five cases, respectively. One ICNC was only positive for chromogranin A. In cases of SCNC five tumors were exclusively positive for chromogranin A and six were positive only for chromogranin B. Chromogranins are therefore excellent markers for the immunohistochemical demonstration of carcinoids and WDNCs. It may be speculated that expression of chromogranins in cases of ICNC and SCNC represents a higher degree of differentiation in these tumors.

Intraoperative cryoanalgesia for postthoracotomy pain relief.

In a randomized study, 63 patients were investigated for the benefits of cryoanalgesia after thoracotomy. Analgesia and its dependent effects such as enhancement of mobility, respiratory function, and reduced need of narcotics were evaluated. No significant differences in these variables were observed between the cryoanalgesia group and the control group. However, moderate to severe neuralgia was found in a number of patients in the cryoanalgesia group in the late postoperative period. Cryoanalgesia for pain relief after thoracotomy is not recommended.

Operation for N2 small cell lung carcinoma.

Of 48 patients with limited small cell lung carcinoma treated by different modes, but always including radical operation, a series of 25 patients with N2 lymph node metastases is reported. In a first period (1970 to 1977) treatment consisted solely of radical resection in 3 patients; chemotherapy was added to operation in 6, and local radiotherapy was added in 2. Since 1977, 14 patients were treated according to a comprehensive therapy protocol including radical resection (six pneumonectomies, one bilobectomy, seven lobectomies), chemotherapy, local radiotherapy, and prophylactic cranial irradiation. Eleven patients, in whom N2 disease was confirmed preoperatively, received chemotherapy as the first step, followed by "adjuvant" resection. Projected 5-year survival rate is 25% for the entire N2 group and 47% for the comprehensively treated group. Seven patients of this latter group are alive 12, 19, 30, 48, 66, 73, and 74 months after comprehensive therapy, equivalent to an observed 2-year survival rate of 38%. This is the largest reported series of patients with resected small cell lung carcinoma in the N2 stage treated at a single institution; the results are so encouraging that we can no longer advocate general refusal of radical lung resection for small cell lung carcinoma in the N2 stage if it is part of a multimodal therapeutic protocol.

Isolated right ventricular assist for postcardiotomy myocardial infarction.

Due to myocardial infarction, profound postcardiotomy right heart failure developed in a 57-year-old man after implantation of an aortic homograft for infective aortic valve endocarditis. Despite maximum medical therapy and intraaortic balloon counterpulsation, signs of endorgan injury developed, and therefore a Thoratec (Pleasanton, CA) right ventricular assist device was implanted. After 17 days of support, myocardial and endorgan function had recovered and the fully mobilized patient was successfully weaned from support and discharged from the hospital.

Multimodal therapy of small cell lung cancer in TNM stages I through IIIa.

Since 1977, Innsbruck University Hospital has been employing a multimodal therapy concept for small cell bronchial carcinomas in stages I to IIIa. This concept includes all three treatment forms effective in this tumor, namely, chemotherapy, surgery, and radiotherapy. The therapy scheme is stage-dependent and begins in stages T1-3 N0-1 with lung resection and in stage N2 with chemotherapy. To date, 45 patients have been included in a prospective, nonrandomized (phase II) trial: 7 in TNM stage I, 11 in stage II, and 27 in stage IIIa (6 T3 and 21 N2). The actuarial 5-year survival rate of the entire group (including therapy-related lethality, early recurrences, and protocol violations) is 36%; it is 57% for those in stage I, 28% for those in stage II, and 34% for those in stage IIIa. Median survival time is 18 months. Patients with completed multimodal treatment have a 5-year survival rate of 56% regardless of disease stage. Three patients died of tumor-unrelated causes after 47, 52, and 54 months.

Stenosis of left mainstem bronchus in a case of cicatricial pemphigoid.

A case of a 22-year-old male with cicatricial pemphigoid and involvement of the bronchial system is reported. Manifestations of cicatricial pemphigoid in the mucous membranes of the airway distal to the larynx have not been hitherto described. The patient developed severe stenosis of the left mainstem bronchus 2 years after onset of the disease. Successful treatment by sleeve resection and end-to-end anastomosis was achieved. Diagnostic bronchoscopy in patients with severe dyspnoea suffering from cicatricial pemphigoid is recommended. Operative treatment of airway stenoses distal to the larynx caused by cicatritial pemphigoid is feasible.

Resection of the tracheal bifurcation through a left thoracotomy.

The surgical management of tumors of the left main bronchus with involvement of the lower trachea is one of the most difficult problems of tracheobronchial surgery. Two cases of adenocystic carcinoma in this location are presented, where resection of the tumor and reconstruction of the airway were performed through a left thoracotomy. In one case reconstruction of the tracheobronchial tree could be accomplished without loss of lung parenchyma; in the second case the left lung had to be removed since the lobar bronchi were infiltrated by the tumor. Such extensive left tracheobronchial resections have so far not been reported in the literature.

Transesophageal sonography in central bronchial carcinoma.

A new application of transesophageal sonography was tested in eight patients suffering from central bronchial carcinoma. Due to ultrasound technology, a real time investigation is feasible which enhances the diagnostic method of computed tomography (CT) by discriminating between tumour and mediastinal organs which cannot be delineated by CT only. Different sonographic densities and the movement between organ and tumour contribute to the diagnostic accuracy of sonography if operability is questionable due to possible organ infiltration by tumour. The method is limited by the air filled organs (trachea, bronchi), as ultrasound does not penetrate adequately.

Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting.

OBJECTIVES: Cannulation and clamping of a severely atherosclerotic ascending aorta during coronary artery bypass grafting (CABG) can lead to cerebral embolization of atheromatous debris and should therefore be avoided whenever possible. A variety of surgical techniques including performance of extraanatomical coronary bypass conduits has been described to solve this problem. We report on a preliminary series of four patients in whom the axillary artery was used as an inflow vessel for venous coronary artery bypass grafts which were performed on the beating heart in order to achieve an aortic no touch concept. METHODS: The axillary artery was exposed between the pectoralis major muscle and the deltoid muscle via an infraclavicular incision. A saphenous vein graft of at least 40 cm in length was sutured to the axillary artery and then brought into the pericardial cavity following an intercostal and transpleural route. The graft was anastomosed to the target vessel using local coronary occlusion. The procedure was carried out via sternotomy in three patients who also received additional internal mammary artery in situ grafts for adequate coronary revascularization. In one high risk patient an isolated axillocoronary bypass was performed in a minimally invasive fashion via anterolateral minithoracotomy. RESULTS: The procedure was completed without major technical difficulties in all four patients. The mean graft length required was 33.2 +/- 1.6 cm, postoperative ultrasonic duplex scans of the axillocoronary grafts revealed a mean flow of 62.5 +/- 23.6 ml/min. No stroke or brachial plexus injury occurred. Three patients are in angina class I (Canadian Cardiovascular Society Classification), one patient is in class II postoperatively. After a mean follow-up of 11.5 +/- 6.6 months postoperatively all grafts remain patent. CONCLUSION: Axillocoronary bypass grafting can be easily performed for management of the untouchable ascending aorta. Straightforward surgical technique and the accessibility to noninvasive diagnostics seem to offer advantages over other extraanatomical bypass grafts.

Quality of life after cardiac surgery in the elderly.

BACKGROUND: Cardiac surgery in the elderly is performed with increasing frequency. Beside low mortality an evident gain in quality of life is the most important aim of therapy. To investigate the medium term outcome of cardiac surgery, we evaluated patients over 75 years of age who were operated on within a 1.5-year period. METHODS: Between 01/98 and 06/99, 124 patients (76 male, 48 female), mean age of 76.6 (range 75-86) years were operated on. Eighty-four per cent had isolated coronary or valve procedures and 16% had combined procedures. Pre- and postoperative NYHA classification, follow-up period, perioperative mortality and the subjective satisfaction were recorded. RESULTS: Total perioperative mortality was 6.4%. After a mean follow-up time of 15.2 (range 6-24) months, patient satisfaction with the operative results was excellent in 73%, good in 26% and low (unsatisfied) in 1%. CONCLUSIONS: Cardiac surgery in the elderly can be performed with an acceptable morbidity and mortality. The fact that 99.1% of the patients are satisfied with their operation and the dramatic improvement in functional status (96.5% NYHA I and II) justify cardiac surgery in this age.

Therapeutic effect of cryosurgery of murine osteosarcoma--influence on disease outcome and immune function.

Experiments comparing conventional operative treatment and cryosurgery of a murine osteosarcoma showed that local tumor destruction by freezing in situ was similar or superior to amputation concerning survival and formation of metastasis, depending on tumor stage. Limited local resection was less effective. Immune functions affected by cryosurgical tumor destruction included depression of natural killer cell activity and decrease of tumor-specific autologous IgG antibodies in the serum.

Use of the greater omentum for treatment and prophylaxis of anastomotic and stump dehiscence in major airway surgery.

In 6 patients suffering from anastomotic dehiscence following bronchoplastic procedures of the central airways or from acute bronchial stump fistula following pneumonectomy, the therapeutic efficiency of omentopexy in the management of the fistula was investigated. In 5 other patients with an increased risk of anastomotic leakage after sleeve pneumonectomy or pneumonectomy with carinal resection the omentum was effectfully used to prevent such complication. 4 out of 5 evaluable patients had successful treatment of the anastomosis and stump fistula. Complications arising from the additional laparotomy were not observed.

[Value of surgery in the treatment of small-cell bronchial cancer]. / Der Stellenwert der Chirurgie in der Behandlung des kleinzelligen Bronchialcarcinoms.

As a result of strict cooperation between oncologists, surgeons and radiotherapists we developed a comprehensive combination therapy for small cell lung cancer (limited disease): Stage I, II: radical tumour resection; chemotherapy (Cohen); cerebral radiation prophylaxis; locoregional radiotherapy; Stage III: Chemotherapy; cerebral radiation prophylaxis; lung resection in an extension required by the initial tumour; radiotherapy (local). The preliminary results in 15 patients are encouraging.

Critical checking of the radiological diagnosis of "complete remission" and "partial remission" following induction chemotherapy of small-cell lung cancer in the light of postoperative histological examination.

A multimodal therapy concept for small-cell lung cancer, which for patients with established pretherapeutic homolateral lymph-node metastases (N2) prescribes induction chemotherapy with subsequent resection as well as supplemental chemo- and radiotherapy, provided the opportunity to evaluate histologically the radiological diagnoses "complete remission" and "partial remission" using resection specimens. In 17 patients a 75% to 100% reduction in tumor size was achieved according to radiological diagnosis. Predictions of "no evidence of disease" or "evidence of disease" were only correct in ten cases. In the remaining seven cases, histology showed the radiological findings to be incorrect. This gives a 77% sensitivity for radiological diagnosis with no specificity. Moreover, differentiation between therapy effect on the primary tumor and on the N2 metastases gives similar results: sensitivity 64% and 67% respectively, specificity 33% and 25% respectively. It is concluded that, particularly after the tumor responds well to therapy, radiological techniques are unsuitable for establishing a diagnosis of "no evidence of disease" or "evidence of disease" in small-cell lung cancer. This is because on the one hand the radiological methods available do not permit clear differentiation between vital tumor tissue and necrosis or fibrosis, while on the other hand groups of vital tumor cells beyond the resolution power of X-ray technology will escape detection.

The role of surgery in the combined management of small cell bronchial carcinoma.

Even after the introduction of modern chemotherapeutic regimens and radiotherapeutic approaches in the treatment of small cell bronchial carcinoma (SCLC), the results are still disillusioning. Long-term remissions are rare even in patients with limited disease. We review 66 patients with SCLC (limited disease) which we treated either by single therapies (chemotherapy, radiotherapy, surgery n = 16), or by different combinations of the possible therapeutic measures. Favorable results were achieved by a comprehensive treatment including operation, chemotherapy and prophylactic cranial and local irradiation: 11 of 15 patients survived 3 to 97 months after the onset of therapy, 4 of those more than 24 months. Based on our own experience and the results of other authors we feel that surgical resection should be again included as an essential part of treatment: tumor resection is the rational primary therapeutic approach for cases without lymph node metastases in the mediastinum and for tumors of uncertain histological type. If there is evidence of lymph node involvement in the mediastinum (N2), surgery should be performed after a remission has been successfully induced by chemotherapy (so-called adjuvant surgery).

[Successful resuscitation in severe hypothermia following near-drowning]. / Erfolgreiche Reanimation bei ausgeprägter Hypothermie nach Beinahe-Ertrinken.

A six-year-old boy fell into an ice-cold mountain stream and was immediately washed away. He was rescued 65 min later, 6 1/2 km downstream, seemingly lifeless with a rectal temperature of 16.4 degrees C. He was flown by helicopter to the surgical clinic of Innsbruck University, while resuscitation measures were undertaken by an accompanying doctor. After cannulation of the femoral artery and vein, extracorporeal circulation (ECC) with a child-size oxygenator was started and the blood rewarmed over 96 min in steps of 3 degrees C. Once circulatory stability and adequate cardiac output had been achieved ECC was gradually discontinued while the patient was still slightly hypothermic. Ten months after the accident the boy is restored to health, except for minimal residual neurological signs. There is a high chance for full neurological recovery.

Endoscopic removal of a pedunculated bronchial lipoma by means of the hot snare.

The complete endoscopic removal by means of the hot snare of a pedunculated bronchial lipoma with a carcinoma in situ in its covering bronchial epithelium is reported. To our knowledge, the endoscopic removal of peripheral polypoid bronchial lesions has not been reported to date. The advantage of this technique lies in its ability to permit an exact histologic examination of the lesion, in contrast to laser vaporisation.