Hyperthermia with implanted electrodes: in vitro and in vivo correlations.

Hyperthermia as a treatment for cancer has elicited much recent interest. However, major difficulties persist both in the technology for heating deep-seated tumors, and in thermal dosimetry. We have investigated a heating technique for deep-seated neoplasms that employs an internal implanted electrode and an external electrode to apply radiofrequency current to a tumor mass. The internal electrode consists of an array of stainless steel needles or wires which define a Faraday cage within the tumor, while the external electrode consists of a variety of electrical conductors at the skin surface. Phantom measurements have closely reproduced calculated temperature distributions. The temperature profiles within the volume enclosed by the internal electrode show relatively homogenous heating. Temperature measurements in a rat tumor model have demonstrated that significant heating within such an internal electrode array is easily obtained. The heating may extend some centimeters outside the electrode. Using a dog model we have shown that with such a treatment technique the temperature profiles obtained are reproducible both spatially and temporally. A case report of a clinical application is presented. A 5 cm bronchogenic carcinoma was easily heated without significant heating of the surrounding normal lung, and without apparent toxicity. Such a technique may be applicable to a variety of operable but unresectable neoplasms. The reproducibility and relative homogeneity of heating suggest possible usefulness in combined modality trials.

Infarcted extralobar pulmonary sequestration.

A 32-year-old man who presented with symptoms suggesting empyema was found at thoracotomy to have infarction of an extralobar pulmonary sequestration. He was completely relieved by excision of the sequestration after securing the systemic vascular pedicle which had undergone torsion. Recognition of the anomalous bloody supply and other congenital anomalies in such cases is emphasized.

Treatment of malignant disease in trachea and main-stem bronchi by carbon dioxide laser.

The use of the carbon dioxide laser to remove intraluminal malignant lesions of the trachea and main-stem bronchi is described. Forty-three patients, 30 men and 13 women from 23 to 79 years of age, have received from one to three laser treatments to provide an improved airway with relief of major respiratory tract obstruction. There has been one intraoperative death and there have been three immediate postoperative deaths. Improvement in respiratory status has been accomplished in all surviving patients and has persisted for from 1 to 36 months. The carbon dioxide laser treatment does not cure cancer but does provide an improved airway with low risk so that other treatment can be used. A major advantage of this form of treatment is decreased bleeding and the ability to provide an improved airway. The disadvantages are the necessity for general anesthesia and expense of the equipment.

Potential value of digital radiography. Preliminary observations on the use of dual-energy subtraction in the evaluation of pulmonary nodules.

The radiographic demonstration of calcification in a solitary pulmonary nodule renders the possibility of malignancy extremely unlikely, although rare exceptions have been reported. Conventional roentgenograms and tomograms sometimes provide inconclusive evidence although CT can be highly accurate in both identifying and quantifying calcium content. An alternative method is dual-energy subtraction utilizing scanned projection digital radiography. Forty-one patients with solitary (occasionally multiple) pulmonary nodules were examined with the technique, employing second-generation fan-beam equipment: 28 nodules or masses were noncalcified and 13 calcified. Of the former, 20 were pathologically proved, 16 being malignant and 4 benign (2 granulomas, 2 bronchiectasis); in 3 of the remaining 8, a presumptive diagnosis was reasonably certain (1 granuloma, 2 metastases), while in 5 the diagnosis was not made. In 8 of the 13 calcified lesions, the diagnosis can reasonably be regarded as confirmed as granulomas; 5 are being followed up with that presumptive diagnosis.

Concatenations.

Concatenations, linkings of events and ideas, are demonstrated to show the progress of thoracic surgery. The development of our knowledge of pulmonary anatomy, pleural drainage, and thoracic anesthesia, independently and collectively, has proven invaluable in the current successful surgical treatment of many pulmonary diseases.

Laser endoscopy.

A carbon dioxide laser operating in the invisible infrared range (10.6 mu) generates a beam of energy that is almost completely absorbed by biological tissue with release of intense heat and rapid destruction. A laser attached to a rigid bronchoscope has been used in 18 patients ranging in age from 21 to 62 years to treat a variety of causes of airway obstruction. These include tracheal stenosis and granulation tissue (6 patients), adenoma (1), web (2), and carcinoma (9). The results were good in 15 and poor in 3 patients. However, all patients had an improved airway after laser treatment with the best results occurring in patients with benign, inflammatory disease. The advantages of the laser are a lack of bleeding, minimal edema after treatment, and minimal scar formation. The disadvantages are the expense of the machine, and the need for general anesthesia and direct visualization of the lesion.

A method of early irrigation of the contaminated postpneumonectomy space.

A modified balanced drainage system was used with other measures in a patient with an obstructing pulmonary carcinoma, infection, and necrosis. Management included right pneumonectomy, perioperative systemic antibiotics, protection of the remaining lung, and a modified balanced drainage system that allowed early irrigation of the postpneumonectomy space. On the tenth postoperative day, irrigations were discontinued, the right chest was filled with an antibiotic solution, and the thoracostomy tubes were removed. The mediastinum remained in a satisfactory position, and the patient recovered without evidence of empyema. He died of a cerebral metastasis five and a half months postoperatively. This method combines principles that have been used for many years. A balanced drainage-irrigation system permits early irrigation of the contaminated postpneumonectomy space while the mediastinum is still mobile. Prolonged hospitalization and formal closure of the thoracostomy sites can be avoided.

Acute empyema in children treated by open thoracotomy and decortication.

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years. The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay. Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function. We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.

Middle lobe syndrome: diagnosis and management.

Ninety-eight patients with middle lobe syndrome were reviewed. There were 31 male and 67 female patients ranging in age from 4 to 80 years. The most common presenting symptoms were cough, dyspnea, fever, hemoptysis, and chest pain. Diagnostic studies included chest roentgenogram, bronchoscopy, and bronchography. Sixty-five patients had full recovery following intensive medical therapy. Thirty-one patients underwent surgical resection for persistent disease. There were five post-operative complications and 1 death in this series.

Transthoracic exposure for anterior spinal surgery.

The anterior approach to the vertebral column is used to treat fractures, spinal deformities, and destructive lesions secondary to tumor or infection. The thoracic surgeon, working with orthopedic surgeons and neurosurgeons, is uniquely qualified to provide surgical exposure expediently and assist in postoperative care. Forty-five patients with spinal deformities secondary to trauma (18 patients), congenital anomalies (16 patients), neoplastic disease (7 patients), and inflammation (4 patients) were treated by a transthoracic (37 patients) or thoracoabdominal (10 patients) anterior approach to the vertebral column. Two patients had subsequent operations. Free and vascularized rib grafts were used for stabilization and fusion with good results and few complications (8 patients). These results indicate that interspecialty cooperation results in expedient surgical exposure and good postoperative care.

Procedures in the evaluation of chest disease.

The evaluation of chest disease may require one or more procedures. Bronchoscopy, both rigid and flexible, mediastinoscopy, mediastinotomy, chest tube drainage, lung biopsy, thoracoscopy, and pleural biopsy are described, with indications, contraindications, and results detailed.

The surgical approach to interstitial lung disease.

The thoracic surgeon can provide a valuable service to his referring physicians and patients in establishing a definitive pathologic and etiologic diagnosis of diffuse interstitial lung disease (see Fig. 1). The myriad of etiologic agents results in a diagnostic conundrum that cannot be solved in many cases on the basis of history, physical examination, chest roentgenograms, gallium scans, bronchial lavage, and transbronchial biopsy. For a patient who has respiratory symptoms with diffuse interstitial lung disease on chest radiogram or one who has significant respiratory insufficiency on the basis of pulmonary function studies but has a normal chest radiogram, open lung biopsy should be carried out with anticipation of a very high yield from a low-risk procedure. Establishing a correct diagnosis is now important in terms of the administration of, withdrawal of, or change in therapy; the use of corticosteroids; and the use of immunosuppressive agents or of cytotoxic agents. It is not enough to give a patient who is breathless an aminophylline derivative and place him on corticosteroids if he becomes sicker. There are many diseases with a specific etiology and with a specific, appropriate treatment, and the thoracic surgeon can provide this information.

Carbon dioxide laser therapy.

A carbon dioxide laser coupled with a ventilating bronchoscope has been used to treat 135 patients with symptomatic obstruction of the trachea and main stem bronchi. This laser has the advantages of being controllable and hemostatic, and can be used repetitively. It does not interfere with other modes of treatment such as radiation therapy or chemotherapy.

Esophageal hiatus hernia after fundoplication.

The cases of three patients who underwent fundoplication to correct gastroesophageal reflux and who subsequently had herniation above the diaphragm of abdominal contents through the esophageal hiatus are described. In two patients, the fundoplication was performed through a transabdominal approach, and in one patient through a transthoracic approach. The main symptoms were vague but persistent (48 hours) abdominal pain in three, associated with nausea and vomiting in one. The diagnosis was confirmed with an upper GI series in all three; the proximal stomach was displaced in all, the transverse colon in one. Elective reoperation to reduce the displaced abdominal contents and to narrow the esophageal hiatus was done in the three cases. All recovered uneventfully and were relieved of their preoperative symptoms. Eight years later, one patient developed a gastric carcinoma requiring esophagogastrectomy; another patient remained asymptomatic 1 year after operation; the third was lost to follow-up 1 month after his operation. The presence of herniation of abdominal contents through the esophageal hiatus is a rare complication that should be suspected in patients who previously underwent fundoplication, either through the abdominal or thoracic approaches, and who complain of mild but persistent abdominal pain. Narrowing of the esophageal hiatus by approximating with sutures the diaphragmatic crura at the time when the fundoplication is done would appear to be an important technical point to avoid this complication. When it occurs, elective repair is advisable.

Substernal and intrathoracic goiter. Reconsideration of surgical approach.

Thirty-one patients were operated on for benign thyromegaly extending to the thorax in an 11-year period at the University of Alabama in Birmingham. Neck mass (65%), dysphagia (36%), and dyspnea (32%) were the most common symptoms. All patients were euthyroid. Five patients had previous thyroid surgery. A thyroid scan was performed on 24-patients. Fourteen (58%) suggested a thoracic extension while ten (42%) failed to identify a thoracic extension. The indications for resection were increasing symptoms, increasing size despite the use of dessicated thyroid therapy, and to establish a diagnosis. The left thyroid lobe extended into the thorax more frequently (70%) than the right. Most patients had multinodular goiter (94%). Three patients had occult carcinoma (10%) and two patients had Hashimoto's disease. Median sternotomy combined with a collar incision to provide exposure for excision of intrathoracic thyroid extension was used in six patients. There was no operative mortality. There was no increase in operative morbidity and a slight increase in average stay from 5.3 days with a collar incision alone to 6.8 days with the combined incisions. Median sternotomy does not increase morbidity or mortality. Specific indications for more liberal use of sternotomy extension of a collar incision are proposed for the management of substernal and intrathoracic goiters.

Intrapulmonary teratoma: a case report and review of the literature.

Intrapulmonary teratomas are rare; only 30 cases have been reported in the world literature. These tumors are thought to originate from the third pharyngeal pouch. They occur equally in men and women and usually are diagnosed in the second to fourth decade of life. They are more often benign than malignant, although malignant lesions may have a favorable postoperative prognosis and benign lesions may exhibit high morbidity and mortality because of their size and location. These tumors present radiographically as lobulated masses that may contain calcification or peripheral collections of air. They most often occur in the upper lobes. The computed tomographic findings of intrapulmonary teratoma are less well known but have been described in two cases. An additional case is presented with a review of the literature and a tabular summary of the characteristics of this unusual entity.

Radiographic evidence of calcification in pulmonary hamartomas.

Eight cases of solitary intrapulmonary hamartomas are presented to show the unusually high frequency of calcification (75%, six of eight cases) in this series. Possible contributory factors were high percentage of chondromatous variant (seven of eight cases), large size of the tumors, and use of computed tomography.

CT manifestation of non-Hodgkin's lymphoma as a solitary pulmonary nodule in a patient with acquired immunodeficiency syndrome.

We present a case of acquired immunodeficiency syndrome with primary pulmonary non-Hodgkin's lymphoma that manifested as a solitary pleura-based mass lesion. Its differentiation from an infectious process imposed a diagnostic dilemma. The importance of awareness of such an entity for earlier diagnosis is stressed.