A population-based evaluation of the seventh edition of the TNM system for lung cancer.

Our study describes the new seventh edition of the TNM system for lung cancer in a national population and its clinical implications. We classified 1,885 operated patients with lung cancer, reported to the Cancer Registry of Norway (Oslo, Norway) from 2001 to 2005, according to the sixth and the seventh edition of the TNM system. We compared survival differences adjusting for known prognostic factors. Furthermore, we evaluated the overall predictive ability of both editions using Harrell's concordance index. Survival curves by stage for each of the editions were similar; however, a better description of stage IIIB was observed in the seventh edition. Survival rates of T1b and T2a tumours were similar (log rank p = 0.94). The concordance index was 0.68 for both editions, indicating no overall difference in their predictive accuracy. In the seventh edition, 211 (29%) stage IB patients migrated to stage II and 161 (48%) patients migrated from stage IIB to IIA. Stage migrations could change the treatment for up to 326 (17.3%) of the study patients. The seventh edition did not improve the overall predictive ability of the TNM system; however, the new classification implies changes in treatment for nearly one-fifth of the cases. The implications of the seventh TNM edition for the outcomes of patients should be studied further.

Some observations on cerebral perfusion during cardiopulmonary bypass.

Blood flow was recorded with an electromagnetic flow probe on one internal carotid artery (ICA) during cardiopulmonary bypass (CPB) in 5 patients. The ICA flow was monitored continuously along with arterial blood pressure, epidural intracranial pressure, and cerebral electrical activity using a cerebral function monitor (3 patients). The ICA flow increased by 50 to 100% at the inception of extracorporeal circulation. This rapid enhancement of flow occurred within a thirty-second period and was due to rapid arterial hemodilution caused by introduction of the priming solution. A transitory fall in ICA flow was observed during subsequent minutes when the well-recognized drop in blood pressure took place and the cerebral perfusion pressure (CPP = blood pressure - epidural intracranial pressure) was reduced to less than 30 mm Hg. In only one instance, however, when CPP fell to 15 mm Hg, was the fall in flow lower than the prebypass level. Throughout the rest of CPB, with steady-state hemodilution and CPP levels in the range of 30 to 50 mm Hg, ICA flow was markedly enhanced (50 to 100% above the prebypass level). The flow pattern, however, disclosed a pressure-passive system, indicating that cerebral autoregulation was impaired or that the CPP levels were lower than the individual lower limit of cerebral autoregulation during the period of steady-state hemodilution on CPB. A transient depression of cerebral electrical activity was seen in 2 patients shortly after the introduction of CPB. This phenomenon is suggestive of qualitatively insufficient perfusion and was observed even when ICA bulk flow was increased (hematocrit values, 13 to 17%).

David M. Hume memorial lecture. In situ vein bypass in the treatment of femoropopliteal atherosclerotic disease: a ten year study.

The in situ vein bypass technic for femoropopliteal atherosclerotic disease is described. Several factors influence the long-term results, the most important being a history of myocardial disease, the size of the vein graft, and sufficient runoff.

Blood flow measurement in PTFE grafts.

In vascular surgery peroperative control of the result of reconstruction is essential. PTFE-grafts have been known to be "resistant" to flow registration with electromagnetic flowmetry because of the electrical isolation. Similarly, intraoperative Doppler registration has been impossible because of the attenuation of the ultrasound in the graft wall. The leading disturbances are obviously caused by air in the graft material and are not caused by the material itself. By squeezing the graft carefully between the thumb and forefinger, blood slowly penetrates the wall colouring it red. The squeezing is performed intermittently to avoid occlusion of the graft. Excellent flow registration is obtained after less than 2 min squeezing of the thin walled graft, while at least 5 min squeezing is necessary to obtain signals from thick walled grafts. To obtain satisfactory ultrasound signals more squeezing is necessary.

Correction of Fallot's tetralogy after palliative operations.

During the period 1960 to 1978, 98 patients underwent intracardiac repair of Fallot's tetralogy after palliative operations. Preoperative symptoms were cyanosis, dyspnea, increased fatigue with squatting and hypoxic spells. The hemoglobin concentration varied from 19 to 22 g/100 ml. At correction only 65 of 95 shunts were patent and needed surgical closure. Seventeen early deaths occurred (19%), the main causes being cardiac failure and arrhythmia. One patient died 3 years after correction from pneumonia. The subjective clinical result was excellent or good in all surviving patients. At repeat heart catheterization in 26 patients a high percentage of residual ventricular septal defects and pulmonary stenosis/insufficiency was found. However, the majority of defects were of minimal haemodynamic significance, and so far did not seem to do harm to the patients' subjective function.

Coarctation of the aorta, early and late results of various surgical techniques.

In the 10-year period 1973-1983, 158 patients aged one day to 16.4 years were operated upon for coarctation of the aorta; 25% of them were less than one month of age. The main surgical procedure was aortoplasty with a prosthetic patch (114 patients), and resection and end-to-end anastomosis (36 patients). Associated cardiovascular anomalies were found in 42%. There were 11 early and 6 late deaths and the majority of these were due to severe coexistent cardiac lesions. The frequency of moderate and severe recoarctation was much higher in patients operated on with resection and end-to-end anastomosis than in those with aortoplasty and prosthetic patch, 25% and 6.7%, respectively. In 18 patients, surgery for recoarctation was necessary using aortoplasty and a prosthetic patch technique. There were no postoperative complications or deaths in these patients. So far, in 2 cases with a prosthetic patch, aneurysmal dilatation of the aorta adjacent to the patch has developed.

The great saphenous vein used in situ after vein valve extirpation. Long term results.

In 227 patients 252 extremities were operated on with femoropopliteal bypass using the in situ vein technique. The valves were extirpated through incisions in the vein. At discharge 14 grafts were thrombosed, mainly because of inadequate size of the vein graft. Ten years after surgery more than 50% of the patients had died, and only 25% of the implanted grafts were patent. The dominating cause of death was coronary infarction. Thirty one limbs were amputated. At the end of follow-up 51 grafts were patent 10 to 17 years after surgery, mean 10.84 ears. With regard to mortality and long term patency the most important factors were: Preoperative history of myocardial disease, smoking, size of the vein graft and peripheral "run-off".

Morphological changes in the saphenous vein after dilatation with silastic tubes. An experimental study.

In an attempt to make veins more suitable for bypass grafting, an experimental model in dogs was developed. The saphenous vein on the hind limbs was cannulated with a silastic tube, a ligature was placed proximally and distally, and the tube was left in situ for 1 to 9 weeks. Morphological studies including electron microscopy revealed "arterialization" of the veins with fibromuscular hyperplasia, increased deposition of collagen and preserved vasa vasorum. The endothelium was replaced by irregular cells, probably altered fibroblasts coated by an amorphous material. It is suggested that the "arterialized" veins may become more suitable for bypass grafting. But the luminal surface may be thombogenic and thus the usefulness of the graft may be diminished by thrombosis.

Traumatic arteriovenous fistulas. A follow-up study.

Over the period 1958 to 1972 14 patients with traumatic arteriovenous fistulas were treated. The mean period from trauma to surgical closure of the fistula was 13.3 years. No form of reconstructive vascular surgery had been performed initially. The dominating symptom of arteriovenous fistula was a pulsating tumor with a marked thrill. Excision of the fistula and reconstruction of the artery and vein was performed in 11 patients. In 3 patients the fistula was first ligated resulting in early recurrence of the shunt. At follow-up 3-15 years postoperatively all fistulas were closed, but 5 patients had moderate symptoms.

Morbidity in valvular heart replacement: risk factors of systemic emboli and thrombotic obstruction.

A study on a cohort of 839 patients with valvular heart replacement between June 1977 and May 1985 showed that the linearized rates of systemic emboli and thrombotic obstruction were 1.4/100 pts/year for Aortic Valve Replacement (AVR), 2.2/100 pts./year for Mitral Valve Replacement, and 3.00/100 pts./year for Double Valve Replacement (DVR). The 5-year free-from-thromboembolism (TE) survival was 95% for AVR and 92% for MVR. The hazard function (the instantaneous risk) for TE peaked in the first six months after operation for AVR and MVR. Another analysis using the Cox regression model to estimate risk factors of systemic emboli and thrombotic obstruction pinpointed two factors in the AVR group: presence of aortic regurgitation (AR) and age at operation. In the MVR group the sole predictor covariate was sex of the patients, with a higher hazard for females. Our results underline the importance of patient-related factors besides the type of prosthesis as predictors of morbidity from TE.

Survival after resection for primary lung cancer: a population based study of 3211 resected patients.

BACKGROUND: Very few population based results have been presented for survival after resection for lung cancer. The purpose of this study was to present long term survival after resection and to quantify prognostic factors for survival. METHODS: All lung cancer patients diagnosed in Norway in 1993-2002 were reported to the Cancer Registry of Norway (n = 19 582). A total of 3211 patients underwent surgical resection and were included for analysis. Supplementary information from hospitals (including co-morbidity data) was collected for patients diagnosed in 1993-8. Five year observed and relative survival was analysed for patients diagnosed and operated in 1993-9. Factors believed to influence survival were analysed by a Cox proportional hazard regression model. RESULTS: Five year relative survival in the period 1993-9 was 46.4% (n = 2144): 58.4% for stage I disease (n = 1375), 28.4% for stage II (n = 532), 15.1% for IIIa (n = 133), 24.1% for IIIb (n = 63), and 21.1% for stage IV disease (n = 41). The high survival in stage IIIb and IV was due to the contribution of multiple tumours. Cox regression analysis identified male sex, higher age, procedures other than upper and middle lobectomy, histologies such as adenocarcinoma and large cell carcinoma, surgery on the right side, infiltration of resection margins, and larger tumour size as non-favourable prognostic factors. CONCLUSIONS: Survival was favourable for resected patients in a population based group including subgroups such as elderly patients, those with advanced stage, small cell lung cancer, tumours with nodal invasion, and patients with multiple tumours. These results question the validity of the current TNM system for lung cancer with regard to tumour size and categorization of multiple tumours.

Infected arterial prosthetic graft with loss of limbs. A case report.

A case of serious infection after arterial graft implantation is reported. Sixteen months after the operation, a large abscess developed in the iliac fossa around the graft. On admission he was in a poor condition with septicaemia. Following arteriography, which showed occlusion of the lumbar aorta as well as the iliac arteries, both legs became completely ischaemic. Various surgical procedures were performed, including thrombectomy, axillofemoral bypass and femoropopliteal bypass. However, permanently sufficient circulation of the limbs could not be maintained and a femoral and crural amputation was necessary.

Atrial septal defect of secundum type in patients under 40 years of age. A review of 481 operated cases. Symptoms, signs, treatment and early results.

In the period 1957--1976 481 patients under 40 years of age were operated on. Dyspnoea and increased fatigue were dominating symptoms in more than half of the series. In 202 cases the anomaly was discovered at routine examination in the absence of relevant symptoms. Almost half of the patients were operated under hypothermia, in the others extracorporeal perfusion was used. Four hospital deaths occurred, two of which were related to cardiopulmonary bypass.

Long-term shunt palliation for Fallot's tetralogy.

One hundred and sixty-two systemic-pulmonary shunts of various types were performed in 136 patients with Fallot's tetralogy. There were 72 Blalock-Taussig shunts, 31 Potts and 24 of Waterston shunts. Furthermore, systemic-pulmonary anastomoses with interposed grafts were made in 34 cases. The patients were followed up for 1 to 23 years, average 12 1/2 years. The total mortality varied from 25% in the Waterston group to 42% in the Potts group. The immediate palliative effect of the shunt operation in the surviving patients seemed to be independent of the type of shunt used. At follow-up, 9 of 69 patients originally operated upon with a Blalock-Taussig shunt were alive with their original shunt, while the corresponding figure in the Potts group was 12 of 30. More than 20 years after palliation, one of 15 patients were alive with an original Blalock-Taussig shunt and 9 of 22 with a Potts anastomosis. Surgical problems in construction of the shunts and the long-term results are briefly discussed.

Pulmonary arteriovenous fistula.

Two cases of congenital pulmonary arteriovenous fistula are reported. Both patients had cyanosis and clubbing of their fingers and toes and also dyspnoea at exercise. Diagnostic procedures included cardiac catheterization and pulmonary angiography, and in both patients a solitary pulmonary arteriovenous fistula could be demonstrated. Lobectomy was performed in both cases, and at follow-up the patients were quite well with normal laboratory tests.

Coarctation of the aorta. Follow-up of 218 patients operated on after 13 years of age.

Twohundred and eighteen patients aged 13 years or more at operation for coarctation of the aorta were selected for a long-term postoperative follow-up study. The mean age of operation was 25,3 years, range 13 to 62 years, and the mean follow-up period was 13 years, range 2 to 28 years. The surgical mortality rate was 1.4%, all 3 patients being in their fourth decade. There were 35 late deaths (16,3%), 26 having cardiovascular disease as the causation; 3 patients developed a dissecting aneurysm of the ascending aorta, and 11 died suddenly of unknown cause. Persisting hypertension was found in approximately one third of the patients. A highly significant correlation was demonstrated between the systolic blood pressures before and after surgery. Aortic valve disease occurred in 31 patients (14,2%). Coarctation of the aorta should be operated on in childhood, and a close postoperative long-term follow-up in all patients is recommended.

Atrial septal defects of secundum type in patients less than 40 years of age. A follow-up study.

The series comprised 479 consecutive patients from all parts of Norway operated on in the period 1955-1976. Only 8% were less than 7 years at surgery. Dominating preoperative symptoms were dyspnea and increased fatigue. The follow-up period ranged from 2 to 21 years, mean 10,28 years. There were 4 early deaths (within 30 days after surgery), and at follow-up further 5 patients had died. Excluding a man who died in a traffic accident the total mortality is 1,7%. Of the 470 surviving patients 81,7% were improved, 17% were unchanged and 1,3% had deteriorated. In patients with symptoms dyspnea and palpitations were common complaints. Different types of arrhythmia were found in 31 patients. One third were paroxysmal tachy-arrhythmias, and 9 patients had atrial fibrillation. Only 3 of the 31 patients had some type of preoperative arrhythmia, and 26 were more than 20 years of age of surgery. Seven patients were reoperated because of a residual left to right shunt, 5 of them were initially operated in hypothermia dn inflow occlusion. During the follow-up period 10 patients had late cardiovascular disorders.

Arterial occlusive disease of the upper extremity.

Twenty-five upper extremities were operated upon in 24 patients because of arterial occlusive disease. Transthoracic endarterectomy was performed in 4 patients with short central occlusions of the subclavian artery. In the remaining patients, various bypass procedures were performed using reversed autogenous veins or prosthetic grafts. There were 2 early and 6 late deaths. One prosthetic graft had to be removed 2 months after the operation because of infection. At follow-up, 9 months to 17 years after surgery, 11 bypass grafts were patent. One vein graft and one prosthetic graft had occluded. The surgical technique, types of graft to be used, and the relation to long-term patency are briefly discussed.

Lung cancer. Treatment and early results.

Of 1053 patients with primary cancer of the lung, 549 (52%) underwent thoracotomy and 40% a presumably radical resection. Lobectomies were performed in 227 patients (41% of those operated), pneumonectomy in 160 (29%). Early mortality (death within 30 days) was 5.5% with the highest figure (11%) after pneumonectomy, 5% after explorative thoracotomy and 3% after lobectomy. Cardiorespiratory failure and myocardial infarction occurred in 19 (3.5%) of the operated cases and were responsible for 14 early deaths. Bronchopleural fistula developed in 11 patients. Of 874 morphologically classified tumours, squamous cell composed 45%, undifferentiated large cell 17%, small cell anaplastic 14%, adenocarcinoma 19%, carcinoid 2% and others 3%. Of 21 tumours typed as small cell anasplastic prior to therapy, six were differently classified at the later (postoperative/postmortal) stage.