Thoracic malignancies associated with AIDS.

The immunocompromised state is a major risk factor for the development of malignant tumors. Individuals with human immunodeficiency virus (HIV), and acquired immunodeficiency syndrome (AIDS) represent a large segment of the immunocompromised group of patients. Kaposi's sarcoma, B-cell non-Hodgkin's lymphoma, primary central nervous system lymphoma, and invasive cervical carcinoma are malignant tumors that are all AIDS-defining illnesses. Lung cancer is also seen with a higher frequency in AIDS patients. Malignant tumors are more aggressive in this group of patients as compared with the general population. Prognosis is poor, although with the improved survivals seen with new treatment in these patients, aggressive therapy is still warranted.

Malignancies associated with the immunocompromised state.

Neoplastic disease occurs more frequently in immunocompromised patients than in the general population. These tumors occur at an earlier age and behave more aggressively. Their origin is linked to viral infection and other causes of immunodeficiency, such as antirejection drugs. Despite aggressive therapy, these patients have a poor prognosis when compared with immunocompetent individuals with similar tumors.

Surgical management of empyema.

The cause and presentation of empyema thoraces has changed little since it was first described. The natural history of the disease can be divided into different stages. Different therapeutic measures, medical and surgical, are available for the treatment at various stages. The management of empyema is discussed, emphasizing the surgical aspects.

Decortication in thoracic empyema. Indications and surgical technique.

Decortication for empyema is a well-established procedure and is based on sound surgical principles. When applied in properly selected patients, rapid recovery with a good functional result is to be expected. Best results are obtained when the optimal time for surgical intervention is chosen, usually relatively early in the course of the process for which it is employed. Although modern supportive care and antibiotic therapy are important, a properly performed operation, employed at the proper time, is a major determinant of a successful outcome.

Open approaches to posterior mediastinal tumors and the spine.

Open operations continue to be the appropriate approach in the diagnosis and treatment of many posterior mediastinal lesions. Transthoracic approach to the spine is required for appropriate access to allow complex reconstructive procedures to be done. The surgeon must be aware of the anatomic details of the region to avoid disabling neurologic injuries and allow precise and appropriate surgical management. Thoracoscopic approaches are now being used in some situations. The role of open and thoracoscopic techniques in the treatment of mediastinal and spinal problems will certainly continue to evolve as experience with newer techniques increases.

Surgical treatment of lung cancer in patients with human immunodeficiency virus.

BACKGROUND: Since January 1986, more than 20 patients have been seen at the University of Miami/Jackson Memorial Medical Center and the Miami Veterans Administration Medical Center with concurrent human immunodeficiency virus infection and bronchogenic carcinoma. Four of these patients were treated surgically with curative intent. METHODS: The histories, records, operative reports, and pathology reports of the 4 patients were reviewed. RESULTS: The 4 surgically treated patients had stage I T1 N0 M0 lung cancer. Three patients had T4 cell counts of less than 200/microL and were managed by lobectomy. These patients died 5, 3 1/2, and 5 months postoperatively. More recently, a fourth patient had a T4 cell count of 963/microL and was treated with wedge resection. He is currently alive 12 months postoperatively. CONCLUSIONS: It is concluded that surgically treated patients with lung cancer, human immunodeficiency virus infection, and T4 cell counts lower than 200/microL have high mortality and morbidity. Although it may be best to base surgical intervention on the stage of the patient's human immunodeficiency virus infection, further analysis is essential to determine which subgroup of human immunodeficiency virus-positive patients, if any, would benefit from surgical treatment of lung cancer.

Lung cancer in patients with human immunodeficiency virus infection.

This retrospective study determined the clinical course of lung cancer in patients with human immunodeficiency virus (HIV) infection. A total of 23 patients with HIV infection archived as lung cancer were studied: 16 were identified from about 1,000 lung cancer patients entered in the tumor registry and medical records of Jackson Memorial Hospital, 7 were identified from about 1,000 HIV-positive patients entered in the Special Immunology registry of Veterans Administration Medical Center, 4 patients did not have pathologic confirmation of lung cancer, and 19 patients, all men, met the criteria for analysis (histopathologic diagnosis of lung cancer and HIV+ by serology). The median age was 47 (range: 36-66). Risk factors for HIV were homosexuality (6 patients), blood transfusion (3), promiscuity (5), intravenous drug abuse (4), and none (3). Six patients had a history of coexistent pulmonary tuberculosis and 5 had Pneumocystis carinii pneumonia. Median survival from diagnosis of lung cancer was 3 months. Advanced stages of both HIV infection and lung cancer may account for the poor survival. All patients were men and noted to be younger than other patients with lung cancer.

Multidisciplinary approach to the treatment of locally and regionally advanced non-small cell lung cancer: University of Miami experience.

An intensive multimodality therapy protocol incorporating neoadjuvant chemotherapy was initiated in July 1985 for patients with either borderline resectable or unresectable non-small cell carcinoma of the lung. Thirty-five patients, 21 men and 14 women were entered till March 1991. The median age was 58 years (27-74). Histology was squamous in 15, adenocarcinoma in 11, large cell in 6, and adenosquamous carcinoma in 3. Initial stages were IIIA in 19 patients, IIIB in 14 and II in 2. All patients tolerated preoperative chemotherapy with 5-FU, etoposide and cisplatin (FED). The response to chemotherapy was complete response in 2 (6%), and partial response in 22 (63%). Thirty-two patients underwent surgery. 26 patients were rendered disease free including two found disease free at surgery. Fifteen underwent pneumonectomy, 14 lobectomy and 3 biopsy only. Interstitial radiation therapy was used in 7 patients. The median survival of all patients was 19 months, those who underwent incomplete surgical resection was 12 months and patients rendered disease free at operation 21 months. Thirteen patients are alive and free of disease, including 6 patients alive longer than 5 years. Only patients who responded to chemotherapy and also had complete resection survived more than 2 years. Aggressive neoadjuvant therapy with FED, followed by resection, brachytherapy, postoperative radiation therapy, and adjuvant chemotherapy can be safely accomplished with encouraging survival in stage III patients.

MDR-1 gene expression, anthracycline retention and cytotoxicity in human lung-tumor cells from refractory patients.

Lung-tumor cells from pleural effusion of four refractory patients and in cell lines established from them were analyzed for anthracycline retention, cytotoxicity, and MDR-1 gene and P-glycoprotein expression. Murine leukemic P388 and doxorubicin-resistant P388/R84 lines were used as controls. The 50% growth-inhibitory concentration (IC50) for doxorubicin among lung-tumor lines varied from 0.16 to 0.31 microM in soft agar. Heterogeneity in doxorubicin or daunorubicin retention and response to the efflux-blocking action of 25 microM prochlorperazine was noted in pleural effusion of FCCL-1, -4, and -8. Among the cell lines established, an efflux-blocking effect in a subpopulation was noticed only in FCCL-1 and -4. Although the MDR-1 gene was present in all cell lines, including P388, its expression was pronounced only in P388/R84 and FCCL-1. In situ hybridization of antisense RNA probe to tumor cells showed high heterogeneity for MDR-1 message in the human lung-tumor cells as compared with the murine cells. Northern and slot blot hybridization confirmed in situ hybridization in lines with high levels of MDR-1 expression. The synthesis of MDR-1 mRNA and P-glycoprotein in tumor lines was correlated. The results suggest that because of extensive tumor-cell heterogeneity in human tumors, monitoring of MDR expression by in situ hybridization, quantitation of P-glycoprotein content by laser flow cytometry (and/or immunohistochemical methods), and drug efflux (by laser flow cytometry) may be the best ways to monitor multidrug resistance in human tumors.

New strategies are needed in diffuse malignant mesothelioma.

BACKGROUND: Medical records of 50 patients with malignant mesothelioma were reviewed to determine the clinical features and factors influencing survival. METHODS: Charts of all patients whose conditions were diagnosed as malignant mesothelioma were abstracted and analyzed by statistical software. RESULTS: The male-to-female ratio was 4:1. The age distribution was younger than 45 years of age, 10%; 45-54 years of age, 12%; 55-64 years of age, 37%; 65-74 years of age, 33%; and 75 years of age or older, 8%. Both mean and median ages were 58 years. Among the 32 patients in whom asbestos exposure was recorded, 24 had documented exposure. The sites were pleura, 73%; peritoneum, 20%; and both, 6%. The histologic types were epithelial, 51%; sarcomatous, 10%; mixed, 15%; and not specified, 24%. The stage at presentation was Stage I, 37%; II, 39%; III, 12%; IV, 6%; and unknown, 6%. The common symptoms in pleural disease were dyspnea and pain; in peritoneal disease, abdominal distension and pain were common. The median time from first symptom to diagnosis was 3 months (range, 0-23 months). The median survival after the appearance of symptoms, the diagnosis, and the treatment were 13, 10, and 8 months, respectively. CONCLUSIONS: The survival was independent of age, sex, and smoking behavior. It was longer in patients with earlier-stage disease, a good performance status, a longer duration of symptoms, an absence of pain, and who were treated with combined surgery and chemotherapy. Chemotherapy using anthracyclines yielded more remissions (9 of 21) than that using nonanthracyclines (0 of 13). The remission rate after primary chemotherapy with anthracyclines (7 of 16) may be higher than in recurrent tumor (2 of 14). In future trials, stratification into primary chemotherapy and chemotherapy of recurrent cancer is suggested. There is a need for multitechnique trials incorporating primary chemotherapy.

Long-term surgical results in sudden death syndrome associated with cardiac dysfunction after myocardial infarction.

To evaluate the surgical results in patients with inducible ventricular tachyarrhythmias due to coronary disease and left ventricular dysfunction, the authors reviewed their experience in 170 patients who had survived one or more cardiac arrests after myocardial infarction and were unresponsive to drug therapy based on electrophysiologic studies (EPS). There were nine operative deaths (5%). Based on intraoperative EPS, surgical remodeling of left ventricular dysfunction (aneurysm resection, infarct debulking, and septal reinforcement) with map-guided cryoablation and coronary artery bypass graft was performed in 34 patients (group A), and left ventricular remodeling and coronary artery bypass graft without guided endocardial resection was performed in 25 patients (group B). Forty-three patients (group C) had coronary artery bypass graft with implantation of an automatic implantable cardioverter defibrillator (AICD). Group D (68 patients) received AICD only. After operation, based on EPS results, four patients in group A (12%) and three patients in Group B (15%) required AICD implantation. Overall survival at 6 years was 65%, 48%, 85%, and 58% in patient groups A, B, C, and D, respectively (p = not significant). During follow-up in group A patients, none died suddenly and none needed AICD. In group B, two patients required AICD 3 and 5 years later, and five patients died suddenly. The incidence of sudden death was 2.3%/patient/year and 3.5%/patient/year after AICD implantation (groups C and D). At 6 years, cardiac-event-free survival was 80% and 70% for groups A and B and 38% and 24% for groups C and D, respectively (p less than 0.001). Patients receiving map-guided ablative procedures had significantly improved cardiac-event-free survival rates.

Late complications of plombage.

Plombage was used commonly in the management of tuberculosis before the early 1950s. From 1977 through 1990, 4 patients were seen with complications of plombage performed decades previously. Lucite spheres were used in 3 patients and paraffin in 1. One patient had bilateral apical plombage. In all cases, complications were related to infection or migration of the foreign material. Two patients had extrusion of foreign material or fluid into the chest wall. One patient had hemoptysis and infection due to erosion of a Lucite sphere into the lung. Another had intestinal obstruction subsequent to erosion into the esophagus. The patient with bilateral plombage had development of asynchronous complications on both sides. Treatment consisted of removal of the foreign material and individualized management of the remaining space. There were no operative deaths and the outcome was good in all cases.

Clinical experience with subxiphoid drainage of pericardial effusions.

To assess the effectiveness of subxiphoid pericardial tube drainage for treatment of pericardial effusion, we reviewed 41 consecutive patients who underwent this procedure during a 14-year period. The patients ranged in age from 7 months to 75 years. All were symptomatic preoperatively. The diagnosis of pericardial effusion was confirmed by echocardiogram in all but 2 patients. Eight patients had acute pericardial tamponade. Subxiphoid pericardial drainage was performed under general (n = 35) or local anesthesia (n = 6). A portion of the anterior pericardium was excised in each patient. There were no perioperative deaths. Thirty-day mortality was 19.5%; there were five late deaths. All deaths were unrelated to pericardial effusion or to the operation. One patient had recurrent effusion requiring pericardiocentesis on the 21st postoperative day. He died five days later of extensive lymphoma. Twenty-eight patients were followed from 1 month to 10 years; mean follow-up was 31.5 months. None developed recurrent effusion or pericardial constriction. We conclude that subxiphoid pericardial drainage is effective for treatment of pericardial effusion.

Brain metastases in malignant pleural mesothelioma. Case report and review of the literature.

Recent advances in pleural malignant mesothelioma include the sequential use of palliative surgery, perioperative radiation therapy, and systemic chemotherapy. Radical treatments may not only palliate but also improve survival in some patients. The latter may be associated with the appearance of metastases in unusual sites including the central nervous system. In malignant mesothelioma, brain metastases were previously reported in 19 patients at autopsy and in only 1 patient antemortem. We detail the clinical presentation in the second patient with pleural malignant mesothelioma thus far reported to develop brain metastases. The difficulties in diagnosis, the role of immunoperoxidase stains in malignant mesothelioma, excellent tolerance of different modalities of treatment, and a review of the literature of brain metastases in mesothelioma are discussed. Based on our report, the possibility of brain metastases should be investigated by careful clinical examination prior to a radical treatment in patients with progressive refractory mesothelioma.

Primary choriocarcinoma of the lung: report of a case treated with intensive multimodality therapy and review of the literature.

Primary choriocarcinomas of the lung are extremely rare. Like choriocarcinomas elsewhere, they possess rapid growth ability and a high propensity to metastasize. There is minimal information available on the treatment of lung choriocarcinoma. In the case reported herein, neoadjuvant chemotherapy with 5-fluorouracil (5-FU) infusion, etoposide, and cisplatin induced a partial response permitting complete excision of a massive tumor of the right upper lobe involving the chest wall and superior vena cava. The patient relapsed with a metastasis to the brain that was surgically excised. Contralateral lung metastases were soon noted and responded well to systemic chemotherapy; yet the patient died of a new brain metastasis. To our knowledge, this is the first example of a primary choriocarcinoma of the lung treated with intensive multimodality therapy. The latter seems to offer a potential benefit if certain guidelines are followed.

Evolving role of surgical treatment in limited-disease small cell lung carcinoma.

The diagnostic role of surgical procedures in small cell lung carcinoma (SCLC) is well established. The therapeutic role of surgery has changed over the years. At present, curative resection is the treatment of choice in peripheral T1-2 N0M0 SCLC, and adjuvant chemotherapy may be beneficial. Surgery is also indicated in SCLC patients diagnosed by a limited pathologic sample in whom the clinical course suggests nonsmall cell lung carcinoma (NSCLC). The resection may reveal either a mixed tumor or an alternate diagnosis and may be potentially curative. Surgery, at the time of maximal response to chemotherapy in T3N0M0 SCLC, may be curative and reveal the presence of NSCLC elements. The best survival is in patients found to be tumor-free at surgery, and the worst survival is in N2 patients.

Mechanism of death in patients with the automatic implantable cardioverter defibrillator.

Fifty patients underwent primary implantation of an automatic implantable cardioverter defibrillator between August 1983 and April 1988 and were entered into a long-term surveillance program. There were a total of 14 deaths (28%) in the entire group occurring at a mean of 8.7 months postimplantation. Eleven deaths were cardiac and three were noncardiac (two pneumonia, one leukemia). The group of deceased patients were similar to the survivors in all respects except for a statistically lower ejection fraction (23% vs 32%) at the time of implantation. In addition, 13/14 (93%) of the deceased patients experienced at least one appropriate AICD discharge at a mean of 4.5 months post implantation. Recorded ECGs at the time of death revealed that most of the sudden deaths were due to electromechanical dissociation and not to AICD-treatable arrhythmias. These data suggest therefore that death in AICD patients is usually cardiac, due primarily to low ejection fraction and occurs in patients who have previously received AICD discharges.