Benign lesions mimicking malignant tumors of the esophagus.

Three cases of benign lesions which mimicked malignant tumors of the esophagus are described. In all three cases, two inflammatory pseudotumors and one case of diffuse leiomyomatosis, the clinical presentations, radiologic features, and gross pathologic findings led to the mistaken diagnosis of carcinoma at thoracotomy. The benign nature of the processes was recognizable only on microscopic examination. Although most benign tumors of the esophagus are localized solitary lesions that are easily distinguished from carcinoma, occasionally benign conditions may present as infiltrative, ulcerated mass lesions. Inflammatory pseudotumor and diffuse leiomyomatosis should be included in the differential diagnosis of esophageal malignancies.

Cardiac tamponade complicating closure of a median sternotomy.

A case of intraoperative cardiac tamponade manifested during closure of a median sternotomy is presented. We postulate that cardiac tamponade was caused by acute dilatation of the cardiac chambers as a result of intraoartic balloon pumping in a patient with aortic and mitral regurgitation. It has been shown experimentally that acute rises in ventricular end-diastolic pressure result in increased intrapericardial pressure and that if a certain point on the pericardial pressure-volume curve is reached, cardiac tamponade will occur. Sternotomy closure was accomplished easily as soon as the need for intra-aortic balloon pumping diminished.

Tracheobronchial mucoepidermoid carcinoma. Clinicopathological features and results of treatment.

Mucoepidermoid carcinomas of the tracheobronchial tree are extremely uncommon and, as a result, opinions regarding their natural history are conflicting. In an effort to determine whether the tumors are aggressive or relatively benign, we have collected seven well-documented, previously unreported cases from among 4,250 primary pulmonary carcinomas and 116 bronchial adenomas. The two tracheal and five endobronchial lesions presented here include one high-grade and six low-grade tumors. Curative resections were performed, including segmental tracheal resections in two patients, lobectomy in three patients, and pneumonectomy in two patients, and the follow-up is complete to the time of this report. Long-term survivals ranging from 5 to 23 years, averaging 12.8 years, have been achieved in the six patients with a low-grade carcinoma. The one high-grade variant proved fatal within 28 months of diagnosis despite two surgical attempts at control and radiotherapy. It is concluded that these tumors exhibit a spectrum of virulence with low-grade lesions amenable to long-term surgical cure. The optimum treatment of high-grade lesions remains problematical.

Primary lung cancer surgery in stage II and stage III.

We reviewed 100 operations performed on 95 consecutive patients with stage II (n = 7) and stage III (n = 88) primary lung cancer. The five-year survival of patients with N1 involvement was 58% and with N2 disease was 21%. Of 13 patients with Pancoast or chest wall involvement, 58% survived five years. The entire group had a 34% five-year survival and a median survival of 32 months. Preoperative and/or postoperative radiotherapy, in the presence of nodal disease, appears to improve local control, but an effective chemotherapy program is needed for unrecognized visceral metastases. In the absence of contraindications, surgical excision offers the best likelihood of survival and quality of life.

Primary cancer of the lung. A 42-year experience.

Between April, 1932, and July, 1974, 3,808 patients with primary lung cancer were studied and 1,848 underwent resection. Among untreated patients, 95% were dead with a year. Unresected cancer of the lung is so lethal that efforts to streamline surgical management should not be neglected. In good-risk patients with isolated lesions the approach can be direct. If surgical excision is indicated, regardless of a positive or negative sputum cytology, bronchoscopic biopsy, or brush biopsy, such investigations become superfluous. Needle biopsy is also inconclusive and in addition is hazardous. Preoperative investigation should focus on cardiopulmonary reserve more than on ways to obtain tissue for verification. With the passage of time, the extent of resection has become more conservative. The value of palliative resection is now better appreciated in terms of quality of life, its prolongation, and, for some, a possibility for cure.

Transthoracic versus extrathoracic esophagectomy: mortality, morbidity, and long-term survival.

Extrathoracic esophagectomy for carcinoma is an acceptable substitute for transthoracic resection if it can be shown to have comparable or superior safety and no adverse effect on long-term survival. To test this hypothesis, we employed extrathoracic esophagectomy in 30 consecutive patients with carcinoma of the esophagus from January, 1978, to July, 1984. During this period, 65 comparable patients underwent transthoracic resection through a left thoracotomy for lower esophageal lesions or a right thoracotomy and laparotomy for upper thoracic lesions. Only patients with carcinoma limited to the gastric cardia were excluded from the study. Overall morbidity was higher in the extrathoracic than in the transthoracic group (13 of 30 or 43.3% versus 15 of 65 or 23.1%; p = 0.05), but the differences in hospital mortality (4 of 65 or 6.2% for the transthoracic group versus 4 of 30 or 13.3% for the extrathoracic group) and duration of hospital stay (17.4 +/- 11.7 days for the transthoracic group versus 20.5 +/- 13.4 days for the extrathoracic group) were not statistically significant. Considering all patients who either died or sustained a postoperative complication, we found significant differences favoring transthoracic resection in those subgroups of patients who were able to undergo primary reconstruction at the time of resection (12 of 57 or 21.1% versus 15 of 28 or 53.6%; p = 0.004), those with advanced Stage III lesions (11 of 47 or 23.4% versus 12 of 20 or 60%; p = 0.006), those with tumor of the lower esophagus (8 of 35 or 22.9% versus 6 of 10 or 60%; p = 0.04), and those with tumor that could be resected through a left thoracotomy (2 of 18 or 11.1% versus 17 of 30 or 56.7%; p = 0.002). Actuarial survival curves for all transthoracic and extrathoracic resections and separate analysis for Stage I and Stage III tumors revealed no statistically significant differences between these two techniques.

Pancoast tumors: improved survival with preoperative and postoperative radiotherapy.

Long-term survival after treatment of Pancoast tumors has been limited in most series to those patients without positive lymph nodes or residual tumor. In our series of 18 consecutive patients treated with preoperative irradiation and resection, 14 underwent supplemental postoperative radiotherapy because of positive lymph nodes, tumor at the resection margin, or both. No hospital deaths occurred. Eight patients subsequently died, 6 because of metastatic disease; only 2 deaths were secondary to local recurrence. Ten patients are alive at 6 months to 13 years after resection, and 9 of the 10 have no evidence of tumor recurrence. The overall five-year observed survival (Kaplan-Meier) for the entire series was 56.1 +/- 12.7% (+/- standard error). Although the number of patients is small, the addition of postoperative radiotherapy for those with unfavorable operative findings resulted in long-term survival comparable to that of patients with negative nodes and margins.

Intraaortic balloon pump morbidity: a comparative analysis of risk factors between percutaneous and surgical techniques.

We reviewed our concurrent experience with percutaneous insertion versus surgical placement of the intraaortic balloon pump over a two-year period both to compare morbidity and to provide guidelines for the choice of method in particular patient groups and clinical settings. The effects on morbidity of sex, age, emergency placement, coexisting peripheral vascular disease, and duration of counterpulsation were determined. Sex was a highly significant factor, with low complication rates (3/29 or 10.3%) for percutaneous insertion in men and an inordinately high morbidity (12/17 or 70.6%) in women (Fisher exact test: p = 4.611 X 10(-5)). This difference may be due to the smaller size of the femoral artery in women. We conclude that percutaneous insertion is the preferred technique for most men but that direct exposure of the femoral artery should be employed in women. Given the serious morbidity encountered with each technique, there is no justification to broaden the indications for intraaortic balloon counterpulsation.

Thoracic surgery and the war against smoking: Richard H. Overholt, MD.

Richard H. Overholt was born at the beginning of the twentieth century when thoracic surgery hardly existed. During the first 20 years of his life progress in the field was slow. The next 20 years, which coincided with Overholt's surgical training and his early years as a thoracic surgeon, saw a rapid and almost explosive growth. Overholt's contributions were legion. They included the world's first successful right pneumonectomy, advancements in surgical treatment of tuberculosis, development of segmental resection, and introduction of the prone operative position. He was a bold and creative pioneer thoracic surgeon with consumate technical skills. Sixty years ago, when Overholt started his career as a thoracic surgeon, the hazards of smoking were not appreciated, the habit was fashionable, and consumption of tobacco was rapidly rising. In the early 1930s Overholt was among the very few physicians who recognized the perils of smoking and initiated a long but initially unrewarding antismoking crusade. By the early 1950s evidence about the ill effects of tobacco use began to accumulate. Organized medicine, voluntary health groups, and governmental agencies joined in a concerted effort to educate and to contain smoking. During the ensuing 30 years the antismoking movement achieved ever-increasing success. Today, it is widely recognized that smoking is a major health hazard and tobacco consumption is on the decline. Richard Overholt issued the first warning signals about the perils of tobacco and served as an indefatigable leader of the antismoking crusade throughout his professional career.

Surgical management of chest wall tumors.

A new technique for reconstruction of the chest wall providing immediate chest wall stability was employed in six patients who required extensive chest wall resection for a variety of neoplasms. Despite preoperative impairment of pulmonary function, early extubation was possible in all patients. Pulmonary function was well preserved on follow-up examination.

Esophagectomy without thoracotomy for carcinoma of the esophagus.

During the past 2.5 years, 13 patients underwent esophagectomy for carcinoma of the esophagus without the use of a thoracotomy. During the same period, 81 operations on the esophagus or cardia were performed, 73 of which were esophagogastrectomies. Two patients died, for a hospital mortality rate of 2.7 percent. Of the 13 patients, there were 7 women and 6 men with an average age of 59.7 years. The lesion was located in the cervical esophagus in two, the upper thoracic esophagus in eight and the lower esophagus in three. One patient died on the 12th postoperative day, for a hospital mortality rate of 7.7 percent. Satisfactory relief of dysphagia was accomplished in all surviving patients, five of whom have died from the disease, for an average survival of 13.1 months. Seven are currently alive, with the longest period of survival 20.5 months. Esophagectomy without thoracotomy can be carried out with low mortality and morbidity rates. It is most applicable to patients with early lesions, particularly those in the cervical esophagus and the upper thoracic esophagus.