The role of resection in the treatment of pulmonary metastases from Ewing's sarcoma.

We have investigated the role of resection in the treatment of patients with isolated pulmonary metastases from Ewing's sarcoma. In a retrospective review, 19 patients with the diagnosis of Ewing's sarcoma treated at the National Cancer Institute from 1965 to 1985 who underwent chest exploration for resection of pulmonary nodules were evaluated. Ten patients (53%) were made disease free by resection of pulmonary metastases, six patients (32%) were found to have unresectable disease, and three patients (16%) were found to have benign pulmonary disease. The actuarial 5 year survival rate of the 10 patients successfully made disease free by resection was 15%, and the median survival of this group was 28 months. In contrast, the median survival of the six patients not made disease free was 12 months, and no patient with residual disease was alive 22 months after thoracotomy (p2 = 0.0047). There were no postoperative deaths and only three minor postoperative complications for 25 operative procedures. Various prognostic variables were analyzed to determine their influence on postmetastasectomy survival. There was no difference in postmetastasectomy survival between patients who underwent resection of synchronous versus metachronous pulmonary metastases (p2 = 0.90). Patients who underwent resection of fewer than four malignant nodules had a significantly longer postmetastasectomy disease-free survival (p2 = 0.0019) and overall survival (p2 = 0.06) than those undergoing resection of four or more nodules. Patients who underwent resection of metastases that developed during chemotherapy had a significantly shorter postmetastasectomy survival that those who underwent resection of metastases that developed after chemotherapy (p2 = 0.0295). Our data show that selected patients with Ewing's sarcoma metastatic to the lungs may benefit from an aggressive surgical approach. Also, a significant proportion of these patients will have benign pulmonary disease and can thus avoid additional intensive systemic therapy.

Predicting postoperative pulmonary function in patients undergoing lung resection.

OBJECTIVE: Our aim was to determine the effect of lung resection on spirometric lung function and to evaluate the accuracy of simple calculation in predicting postoperative pulmonary function in patients undergoing lung resection. DESIGN: We reviewed preoperative and postoperative pulmonary function test results on patients who were followed in the multidisciplinary lung cancer clinic between July 1991 and March 1994 and who underwent lung resection. The predicted postoperative FEV1 and FVC were calculated based on the number of segments resected and were compared with the actual postoperative FEV1 and FVC. SETTING: This study was conducted at a university, tertiary referral hospital. PATIENTS: All patients were evaluated at a multidisciplinary lung cancer clinic and underwent lung resection by one surgeon (L.A.L.). MEASUREMENTS AND MAIN RESULTS: Sixty patients undergoing 62 pulmonary resections were reviewed. The predicted postoperative FEV1 and FVC were calculated using the following formula: predicted postoperative FEV1 (or FVC) = preoperative FEV1 (or FVC) x (1-(S x 0.0526)); where S = number of segments resected. The actual postoperative FEV1 and FVC correlated well with the predicted postoperative FEV1 and FVC for patients undergoing lobectomy (r = 0.867 and r = 0.832, respectively); however, the predicted postoperative FEV1 consistently underestimated the actual postoperative FEV1 by approximately 250 mL. For patients undergoing pneumonectomy, the actual postoperative FEV1 and FVC did not correlate as well with the predicted postoperative FEV1 and FVC (r = 0.677 and r = 0.741, respectively). Although there was considerable variability, the predicted postoperative FEV1 consistently underestimated the actual postoperative FEV1 by nearly 500 mL. Of the patients undergoing lobectomy, eight also received postoperative radiation therapy. When analyzed separately, patients receiving combined therapy lost an average of 5.47% of FEV1 per segment resected. This contrasts with a 2.84% per segment reduction in FEV1 for patients who did not receive radiation therapy. CONCLUSIONS: This simple calculation of predicted postoperative FEV1 and FVC correlates well with the actual postoperative FEV1 and FVC in patients undergoing lobectomy. The predicted postoperative FEV1 consistently underestimated the actual postoperative FEV1 by approximately 250 mL. The postoperative FEV1 and FVC for patients undergoing pneumonectomy is not accurately predicted using this equation. The predicted postoperative FEV1 for patients undergoing pneumonectomy was underestimated by an average of 500 mL and by greater than 250 mL in 12 of our 13 patients. Thus, by adding 250 mL to the above calculation of predicted postoperative FEV1, we improve our ability to we identify a minimal postoperative FEV1 for patients undergoing pneumonectomy. Finally, combined modality treatment with surgery followed by radiation therapy may result in additive lung function loss.

Long-term survival after resection of pulmonary metastases from carcinoma of the breast.

Resection of isolated pulmonary metastases may yield improved survival in select patients. Between 1981 and 1991, 44 women (median age, 55 years) with a history of breast cancer underwent 47 thoracotomies with no operative deaths and only three minor postoperative complications (3/47, 6.4%). Confirmation of the metastatic origin of the lung lesion was made by direct histological comparison with the primary. Three patients had benign nodules and were excluded, and 4 patients had less than complete resection at thoracotomy. The median survival after thoracotomy of the remaining 37 patients with completely resected metastases was 47 +/- 5.5 months, and their actuarial 5-year survival was 49.5%. Patients with a disease-free interval of longer than 12 months had a longer survival (median survival, 82 +/- 6 months; 5-year survival, 57%) than patients with a disease-free interval of 12 months or less (median survival, 15 +/- 3.6 months; 5-year survival, 0%) (p = 0.004). Patients with estrogen receptor-positive status (n = 14) tended to have longer survival after resection than patients with estrogen receptor-negative status (n = 15) (median survival, 81 +/- 9 months versus 23 +/- 6 months, respectively; p = 0.098). Other clinical variables analyzed did not predict survival after thoracotomy. We conclude that resection of pulmonary metastases in patients with breast cancer can be done safely and may result in long-term survival for a substantial number of patients. Patients with a disease-free interval of longer than 12 months have an excellent prognosis after complete resection.

VATS increases costs in patients undergoing lung biopsy for interstitial lung disease.

Proliferation in the use of video-assisted thoracic surgery (VATS) has occurred without data demonstrating benefit. Few studies have critically compared VATS with limited thoracotomy (LT) in homogeneous patient populations undergoing standardized procedures. We retrospectively reviewed the hospital records of 37 consecutive patients referred for elective lung biopsy as part of an ongoing interstitial lung disease protocol to determine whether VATS improved outcome or reduced costs. Sixteen patients underwent VATS, and 21 patients underwent LT lung biopsy over a 31 month period. The two groups were homogeneous in regard to clinical symptoms, radiologic findings, age, sex, and preoperative pulmonary function. The operative mortality was not different between the two groups (VATS, 0/16, and LT, 1/21). The postoperative stay was 4.8 +/- 1.0 days for VATS and 5.0 +/- 0.5 days for LT (p = not significant). Operating time, number of specimens obtained, chest tube output, and day of chest tube removal did not differ. There was no difference in the amount of analgesics required during the postoperative period. Operating room cost for VATS was significantly greater than that for LT ($2,663 +/- $384 versus $1,801 +/- $94; p = 0.04) despite the use of nondisposable equipment. Anesthesia-related costs were also greater for VATS ($309 +/- $11 versus $244 +/- $15; p = 0.002). In conclusion, lung biopsy in patients with interstitial lung disease can be performed safely and efficiently with either VATS or LT, but VATS results in higher procedure-related costs.

Primary leiomyosarcoma of the thoracic aorta presenting as a contained rupture.

Primary neoplasms of the aorta are rare and usually present with signs and symptoms due to intraluminal obstruction. A case of a 48-year-old man who presented with a contained rupture of the thoracic aorta secondary to a leiomyosarcoma is reported.

Response to chemotherapy does not predict survival after resection of sarcomatous pulmonary metastases.

Between 1979 and 1988, 26 patients with pulmonary metastases from adult soft-tissue sarcomas were treated with Adriamycin (doxorubicin hydrochloride), Cytoxan (cyclophosphamide), and DTIC before metastasectomy. Thirty-eight thoracotomies were performed with postoperative complications in 5 patients (5/38, 13.2%) and one postoperative death (1/38, 2.6%). Two patients had benign lesions at thoracotomy and were excluded from further survival analysis. The median survival of the remaining 24 patients after thoracotomy was 18.5 +/- 5.9 months, and the actuarial 5-year survival was 22%. Five patients (5/24, 21%) achieved a clinically complete response with preoperative chemotherapy, but all had recurrence in the lung and underwent resection of pulmonary metastases. Seven patients (7/24, 29%) achieved a partial response and had residual disease resected at thoracotomy. Twelve patients (12/24, 50%) showed either no change or disease progression while receiving chemotherapy and were referred for resection. Postthoracotomy disease-free survival and postthoracotomy overall survival did not differ significantly between the three groups. One patient in the group showing no change or progression of disease while receiving chemotherapy is alive without recurrence 57 months after initial pulmonary metastasectomy. Chemotherapy can be used for the initial treatment of pulmonary metastases from adult soft-tissue sarcomas. However, survival after resection of pulmonary metastases cannot be accurately predicted based on the clinical response to preoperative chemotherapy.

c-erbB-2/p185-directed therapy in human lung adenocarcinoma.

BACKGROUND: These experiments were conducted to determine whether p185 can be therapeutically targeted in adenocarcinoma of the lung using an anti-p185-gelonin conjugate. c-erbB-2/p185 is overexpressed in up to one third of non-small cell lung cancers. CALU-3 is a human lung adenocarcinoma cell line that overexpresses p185. muMoAb-4D5 is a murine anti-p185 monoclonal immunoglobulin G1. Gelonin is a potent type 1 ribosomal inhibitory protein. METHODS: 4D5 and gelonin were covalently modified and linked. Purification was confirmed by SDS-polyacrylamide gel electrophoresis. Dose-dependent cytotoxicity was quantified using 3H-thymidine uptake by CALU-3 cells after incubation with 4D5-gelonin conjugate or with control substances (4D5, gelonin, unconjugated 4D5 + gelonin, or control antibody MOPC-21). RESULTS: The 4D5-gelonin conjugate showed a 50% inhibitory concentration of 3.5 x 10(-10) mol/L, but 4D5 alone demonstrated no cytotoxic effect. Gelonin and the unconjugated 4D5-gelonin mixture had one tenth the cytotoxicity of the 4D5-gelonin conjugate (inhibitory concentration = 6.5 x 10(-9) mol/L and 8.5 x 10(-9) mol/L, respectively). The conjugate exhibited minimal toxicity against a p185-negative cell line (NIH3T3). CONCLUSIONS: Selective and efficient killing of human lung adenocarcinoma cells can be achieved in vitro using c-erbB-2/p185-directed therapy.

Primary cardiac sarcomas.

In marked contrast to benign cardiac tumors, primary cardiac sarcomas occur infrequently. Moreover, there is no uniform approach to treating such patients, and the benefits of postoperative chemotherapy are unclear. Between 1964 and 1989, 21 patients with primary cardiac sarcomas underwent surgical resection alone (n = 7), chemotherapy alone (n = 1), or combined operation and postoperative chemotherapy based on adriamycin (n = 13). Twenty-four operations were performed on 20 patients with relief of symptoms in all. Eleven patients had complete resection. Operative mortality was 8.3% (2/24). Histology and originating chamber(s) included angiosarcoma (n = 7; 6/7 in right atrium, 1 in left atrium), malignant fibrous histocytoma (7; all in left atrium), fibrosarcoma (2; 2/2 in left atrium), rhabdomyosarcoma (2; 1 in left atrium, 1 in right ventricle), leiomyosarcoma (2; 1 in left atrium, 1 in left ventricle); and one undifferentiated sarcoma (right atrium). Overall actuarial survival was 14% at 24 months after resection. Patients with complete resection had a median survival of 24 months compared with only 10 months in all other patients (p = 0.035). Postoperative chemotherapy did not enhance survival in patients with incomplete resection. At this time, aggressive and complete surgical resection seems to offer the best hope for palliation and survival in an otherwise fatal disease.

Prognostic significance of computed tomography in resected N2 lung cancer.

We reviewed 124 patients from 1982 to 1988 who had a resected primary non-small cell lung cancer metastatic to mediastinal (N2) lymph nodes and a preoperative assessment of the mediastinum with computed tomography of the chest. Sixty-three patients studied had computed tomographic evidence of mediastinal lymph node enlargement. In these patients the survival at 5 years was only 6.6%, compared with the 5-year survival of 13.5% in 61 patients in whom the mediastinum was normal. Plain chest roentgenography with evidence of mediastinal adenopathy did not predict a poorer outcome. In addition, patients with tumors located in the left upper lobe were found to have an improved survival. These patients had a 5-year survival of 20.8%. Tumor histology, central location of the tumor, extranodal extension, and type of resection did not result in a significant survival difference.

Vascular pedicle rib graft in anterior transthoracic fusion procedures. Technical note.

A method is described in which anterior fusion of the thoracic vertebral column is performed using a rib strut graft maintained on its vascular pedicle. This straightforward technique is useful in selected patients undergoing anterior thoracic fusion procedures and can be used in conjunction with other anterior spinal implants. By maintaining bone graft blood supply, this technique promotes an optimum fusion environment, which may enhance the speed of graft incorporation and the ultimate strength of the construct.

Human oncogene-transfected tumor cells display differential susceptibility to lysis by lymphokine-activated killer cells (LAK) and natural killer cells.

NIH 3T3 tertiary transfectants containing the N-ras or c-Ha-ras oncogenes derived from human tumors were tested for susceptibility to lymphokine-activated killer (LAK) cell and natural killer (NK) cell lysis. N-ras tertiary transfectants contained a human acute lymphocytic leukemia-derived N-ras oncogene. C-Ha-ras transfectants contained either the position 61-activated form of the oncogene (45.342, 45.322, and 45.3B2) or the position 12-activated form (144-162). In 4 hr 51Cr release assays, seven of seven in vivo grown human oncogene transfected NIH 3T3 fibroblasts were lysed by murine LAK effectors, whereas six of seven were lysed by human LAK effectors. There was no difference in susceptibility to lysis between cells transfected with the N-ras oncogene, the position 61 activated c-Ha-ras oncogene, or the position 12 activated c-Ha-ras oncogene. Cultured NIH 3T3 fibroblasts, as well as in vitro and in vivo grown NIH 3T3 tertiary transfectants were resistant to lysis by murine NK effectors and were relatively resistant (4/6 were not lysed) to lysis by human NK effectors. We conclude that human oncogene-transfected tumors are susceptible to lysis by both murine and human LAK cells while being relatively resistant to lysis by murine and human NK cells. Different oncogenes or the same oncogene activated by different point mutations do not specifically determine susceptibility to lysis by LAK or NK. Also the presence of an activated oncogene does not appear to be sufficient for inducing susceptibility to these cytotoxic lymphocyte populations.

Mycobacterium tuberculosis in lung transplant recipients.

The diagnosis and treatment of Mycobacterium tuberculosis, although difficult in normal hosts, are even more complex in transplant recipients. As a result of the use of immunosuppressive agents, transplant recipients are not only predisposed to primary tuberculous infections, but they are also uniquely at risk for reactivation of latent infection acquired prior to transplantation or transmitted via the donor organ. The diagnosis of pulmonary tuberculosis can be even more elusive in the setting of lung transplantation where other pulmonary complications can make diagnosis difficult. Here we report a case of a patient who died of disseminated M. tuberculosis 12 wk after lung transplantation, and we review tuberculous infections in lung transplant recipients.

Interleukin 2-activated cytotoxic lymphocytes in cancer therapy.

LAK are cytolytic lymphocytes with the unique capacity for killing NK-resistant fresh human tumor cells in short-term assays. LAK kill autologous as well as allogeneic tumors with complete cross-reactivity. Initial studies on the classification of LAK conclude that LAK are distinct from the classical NK and T lymphocyte systems, based on a number of criteria including surface phenotype, activation conditions, and a spectrum of susceptible target cells. LAK kill ras oncogene-transfected fibroblasts like they kill fresh tumors. As yet, the target cell determinant responsible for susceptibility to LAK lysis is unknown. Activation of LAK requires only IL 2 and is blocked by monoclonal antibodies to the IL 2 receptor. Because only IL 2 alone is sufficient for LAK activation, we have done in vitro testing to determine whether fresh PBL could be activated in the presence of tumor, as might be desirable in vivo. LAK were activated sufficiently to mediate significant destruction of fresh tumor. We also tested whether LAK could be maintained in the presence of large tumors, providing IL 2 was added. Again, results were positive, suggesting that LAK either recycle or are a self-renewing population that depend on IL 2 for continued functions. Because of these and other findings, we have initiated a clinical protocol to test whether LAK made from the PBL of patients with brain tumor could eliminate residual glioma tumor cells. Autologous LAK plus rIL 2 to maintain lytic ability are injected during surgery. Preclinical studies in a rat glioma model have shown this approach to be safe, and previous in vivo murine studies have concluded that LAK kill tumors in Winn-type lung colony formation tests (Kedar et al. 1982). Much work is needed before we can understand the LAK phenomenon and determine its usefulness in cancer therapy, as well as its inherent biologic role. We hope that this chapter will stimulate both interest and the basic research needed to realize LAK potential.