Metachronous cancers or late recurrences after resection of stage I lung cancer.

In 2 patients with stage I lung cancer, tumors recurred at their resection lines 10 years after the original surgical resections. These cases suggest that the prognosis of late cancer occurrences after resected primary lung malignancies might be related to the interval of time between primary and subsequent cancers rather than to their categorization as recurrent or metachronous cancers.

Incidence of arrhythmias after thoracic surgery: thoracotomy versus video-assisted thoracoscopy.

PURPOSE: Atrial arrhythmias, especially supraventricular tachycardia (SVT) and atrial fibrillation, are common after thoracotomy and lung surgery. There are few existing data on the incidence of postoperative arrhythmias after video-assisted thoracoscopy (VAT). The purpose of the present investigation was to retrospectively determine the incidence of postoperative arrhythmias in patients who underwent VAT compared with those who underwent thoracotomy, and which factors are associated with an increased risk for arrhythmias in both groups. DESIGN: A retrospective investigation. SETTING: A metropolitan university hospital. PARTICIPANTS: The medical records of 124 patients who underwent thoracotomy and 81 patients who underwent VAT over a 2-year period were reviewed. MEASUREMENTS AND MAIN RESULTS: There was a 17% incidence of atrial arrhythmias after thoracotomy and 10% after VAT, but the difference was not statistically significant. In both groups, atrial fibrillation was the most common atrial arrhythmia. CONCLUSION: Patients receiving digoxin were at higher risk for postoperative arrhythmias. Patients older than 65 years were at risk for arrhythmias after thoracotomy and patients older than 80 years were at risk for arrhythmias after VAT. Patients who had postoperative arrhythmias had prolonged hospital stays compared with patients who did not have arrhythmias.

Adoptive transfer of ex vivo activated memory T-cells with or without cyclophosphamide for advanced metastatic melanoma: results in 36 patients.

Autolymphocyte therapy (ALT) is the infusion of autologous peripheral blood mononuclear cells (PBMC) activated ex vivo by a cytokine-rich supernatant (T3CS) generated from a previous autologous lymphocyte culture using low doses of the anti-CD3 mitogenic monoclonal antibody. The mechanism of action is enhancement of a recall response by CD45RO+ (memory) T-cells (ALT cells) to host tumour without dependence on exogenous interleukin (IL)-2. The existence of anti-tumour-specific T-cells in melanoma patients has been well described, and efforts to utilise them therapeutically have achieved modest tumour response rates. However, few long-term survival data have been reported. From 1986 to 1992, we treated 36 patients with disseminated melanoma using ALT alone (26 patients) or adoptive chemoimmunotherapy using ALT and cyclophosphamide (CY) (10 patients). Over this time period, the cell activation method evolved from using cytokine supernatants derived from a one-way allogeneic mixed lymphocyte culture (MLCS), to the current practice of utilising anti-CD3 and autologous cytokines (T3CS). There were 21 men and 15 women, average age 57 years, range 30-82. 27 had failed prior therapies and 9 had no prior therapy. A total of 161 infusion of ALT cells were given: 65 with cells activated in MLCS and 96 with T3CS. There were no grade 3 adverse events, and an approximate 20% incidence of grades 1 and 2 reactions to ALT-cell infusions. Transient cytopenias were seen in patients receiving CY. Sixty-one per cent (22/36) of patients received the planned six ALT-cell infusions, while 39% did not due to progressive disease. In 33 evaluable patients, there were four complete responses, four partial responses and 6 patients with stable disease (SD). Responding patients and those with SD had prolonged survival compared to historical controls when matched for number of organ systems involved. Ex vivo depletion of CD45RO+ T-cells revealed preferential lysis of autologous and HLA-A-matched melanoma targets that was dependent on these memory T-cells. These data suggest that adoptive cellular therapy using ex vivo activated memory T-cells with and without CY is active, has low toxicity, is tumour-specific and can result in clinical benefit in patients with disseminated melanoma.

Early aggressive surgical management of parapneumonic empyemas.

We have analyzed our experience with 90 consecutive patients who were operated on for parapneumonic empyema between 1981 and 1992. Patients whose empyema did not resolve with chest tube drainage were taken to the operating room. Nineteen patients had limited thoracotomy and drainage. Seventy-one patients had formal thoracotomy, debridement, pleurectomy, and decortication. We found that an age greater than 60 years, cardiac disease, end-stage renal disease, end-stage bronchitis, prolonged tube drainage, and immunosuppression are associated with increased morbidity and mortality. In those patients who do not respond well to a short course of chest tube drainage, we recommend early aggressive surgical approach, including formal thoracotomy and definitive treatment. This allowed for early discharge from the hospital without chest tubes or open draining wounds. In extremely ill patients, limited thoracotomy may be all that is safe or possible and usually suffices.

Pleural effusion in non-Hodgkin's lymphoma.

Intrathoracic non-Hodgkin's lymphoma (NHL) usually presents with roentgenographic evidence of mediastinal lymph node enlargement, pulmonary masses, pleural effusion, and a clinical picture of a systemic disease with lymphadenopathy. The presentation of NHL with pleural effusion as the major roentgenographic abnormality and no clinical peripheral lymphadenopathy or organomegaly is unusual. During a seven-year period, we encountered 19 patients with NHL in whom pleural effusion was the major roentgenographic and clinical finding. Pleural fluid cytologic results were diagnostic in only two patients. Closed pleural biopsy was positive in three. Eight of 11 patients had diagnostic immunophenotypic lymphocyte cell marker studies. Seven of nine patients had diagnostic thoracoscopy and one thoracotomy. The CT scan identified biopsy sites when pleural fluid and tissue studies were nondiagnostic. Lymphomatous tissue was obtained from the pleura in 17 of the 19 patients supporting the contention that pleural effusion in patients with NHL is usually due to pleural lymphoma rather than obstruction to mediastinal lymphatics.

Primary endobronchial actinomycosis in association with foreign body aspiration.

A 66-year-old diabetic man presented with a bilobar pneumonia two months after aspiration of a chicken bone. Flexible fiberoptic bronchoscopy demonstrated a mass in the bronchus intermedius. Histologic examination of endobronchial biopsy specimens revealed bone fragments, vegetable matter, and sulfur granules containing Actinomyces organisms. The patient responded to bronchoscopic removal of the foreign body and penicillin therapy. To our knowledge, the association of actinomycotic infection with an aspirated endobronchial foreign body has not previously been reported.

Pulmonary infection with Mycobacterium avium-intracellulare: diagnosis, clinical patterns, treatment.

Most physicians fail to recognize Mycobacterium avium-intracellulare (MAI) as a major pathogen for pulmonary disease among patients admitted to hospitals throughout the United States. In a review of all records of positive MAI cultures during the 10 years beginning July 1, 1979, at The Mount Sinai Hospital, New York City, we have identified 244 patients who had pulmonary disease primarily or secondarily complicated by MAI. We also identified another 243 patients as false positive for MAI infection. We classed as false positives patients who had no subsequent positive culture and whose clinical picture was and remained incompatible with MAI infection. We identified four distinct clinical patterns in the 244 patients with true positive MAI infections: (a) pulmonary nodules ("tuberculomas") indistinguishable from pulmonary neoplasms (78 patients); (b) chronic bronchitis or bronchiectasis with sputum repeatedly positive for MAI or granulomas on biopsy (58 patients, virtually all older white women); (c) cavitary lung disease and scattered pulmonary nodules mimicking M. tuberculosis infection (12 patients); (d) diffuse pulmonary infiltrations in immunocompromised hosts, primarily patients with AIDS (96 patients). The diagnosis should be established either by surgical resection and culture of resected nodules, or by three repeated positive acid-fast bacillus cultures of sputum or fluid and tissue obtained by bronchoscopy, or by biopsy of other tissue which shows granulomas and one or more positive MAI cultures. Surgical resection is the best treatment for "solitary" MAI nodules. Multiple antituberculous drug therapy is indicated for patients with chronic infection that impairs function or causes hemoptysis. The presence of MAI in the sputum or lung aspirates of patients with AIDS usually heralds the presence of a preterminal disseminated infection.

Computed tomography of mediastinal collaterals in SVC syndrome.

A patient undergoing treatment for abdominal lymphoma presented with a superior vena cava (SVC) syndrome. The presence of a wide mediastinum and "nodular" mediastinal densities on CT presented a diagnostic problem, necessitating thoracotomy. The thoracotomy was negative for tumor or infection. We believe that the presence of an indwelling catheter and mediastinal lipomatosis resulted in the SVC syndrome. The "nodular" densities represented an unusual set of mediastinal collaterals that must be distinguished from adenopathy.

Granulomatous Pneumocystis carinii pneumonia in three patients with the acquired immune deficiency syndrome.

Pneumocystis carinii pneumonia is a frequent manifestation of the acquired immune deficiency syndrome (AIDS). It usually presents radiologically as diffuse bilateral infiltrates and histologically as a foamy, eosinophilic intra-alveolar exudate containing the organisms' cysts. We recently studied two rare cases of P carinii pneumonia presenting as pulmonary nodules on chest x-ray films in two patients with AIDS. The corresponding histologies were a combination of the usual intra-alveolar pattern, with an alveolar and interstitial granulomatous appearance. Pneumocystis carinii was present in both areas and was the only organism found in the tissues examined. A third case presented with the more common radiographic appearance but also had a granulomatous histology. We conclude that P carinii pneumonia should be considered in the differential diagnosis of pulmonary nodules in immunocompromised patients and that pathologists should be aware of the possibility of a granulomatous reaction to this organism.

Bronchoscopy in diffuse lung disease: evaluation by open lung biopsy in nondiagnostic transbronchial lung biopsy.

Transbronchial lung biopsy through the flexible bronchoscope is used widely for the diagnosis of diffuse lung disease; however, a significant number of specimens obtained by the bronchoscopic 2-mm biopsy forceps will reveal nonspecific findings, eg, interstitial fibrosis or nonspecific pneumonitis. Such a report may be an accurate reflection of the presence of idiopathic pulmonary fibrosis or nonspecific pneumonitis, but may merely indicate that the true diagnosis has been missed. We retrospectively studied 38 patients with diffuse lung disease whose transbronchial lung biopsies yielded nonspecific abnormalities. Subsequently, these patients were subjected to open lung biopsies. Nineteen of the 38 patients (50%) had a specific diagnosis made by open lung biopsy. The diagnoses included bronchiolitis obliterans, alveolar proteinosis, metastatic carcinoma, lymphoma, tuberculosis, and bronchioloalveolar cell carcinoma. Although transbronchial lung biopsy is useful in the diagnosis of many diffuse lung diseases, it is not a replacement for open lung biopsy. When nonspecific findings by transbronchial lung biopsy do not correlate with the clinical picture, open lung biopsy should be performed.

Computed tomography findings in tuberculous mediastinitis.

Tuberculous mediastinitis can be an elusive diagnosis. Computed tomography may be performed in patients before establishing this diagnosis, and one should consider this disease when mediastinal mass with infiltration of adjacent fat planes is noted. Five such cases are described.

Inflammatory pseudotumor of the thymus.

A 44-year-old man with inflammatory pseudotumor of the thymus is reported. The patient was seen with fever, myalgia, and dyspnea and was found to have an anterior mediastinal mass and bilateral pleural effusions. The resected lesion consisted of a well-circumscribed mass of chronic inflammatory and fibrous tissue that virtually replaced the thymus. There was no morphological evidence of neoplasia. The patient's symptoms and roentgenographic abnormalities resolved with excision of most of the mass. To our knowledge, this report is the first instance of inflammatory pseudotumor of the thymus.

Factors affecting overdrive suppression of idioventricular pacemakers and associated potassium shifts.

A characterization of the factors controlling overdrive suppression of idioventricular pacemakers was investigated in canine hearts with complete atrioventricular block perfused in vitro. The following results were obtained: 1) overdrive suppression increases as a function of driving rate in a sigmoidal fashion; 2) overdrive suppression is maximal after 3 min; 3) the pause is a function of spontaneous rate prior to overdrive; 4) overdrive causes an initial net K loss; 5) overdrive is followed by a transient net K grain; 6) increasing [K]o does not affect K loss; 7) net K loss with drive is less in pre-driven hearts; 8) net K uptake after overdrive is little affected by ventricular activity; 9) acetylcholine does not alter ventricular K balance; and 10) paired stimulation increases overdrive suppression and K loss whether or not each stimulus is followed by a contraction. The following conclusions are drawn. The factors controlling overdrive suppression include the spontaneous rate prior to drive, the rate, duration and pattern of drive, an increase in [K]o during the drive and a decrease in [K]o after drive, but not on acetylcholine-mediated inhibition.

Extracorporeal membrane oxygenation for massive pulmonary thromboembolism.

This study was undertaken to determine whether extracorporeal membrane oxygenation (ECMO) could modify the effects of massive lethal thromboembolism and prevent death. Twenty anesthetized dogs were prepared for venoarterial perfusion with a demand pump and membrane lung and were perfused slowly for 1 1/2 hours to lessen homologous blood shock; 1 ml per kilogram of 24-hour-old tantalum-impregnated thrombus was injected intravenously. The dogs had profound systemic hypotension with an elevated mean pulmonary artery pressure (62.9 +/-4.5 mm Hg) immediately after embolization. Control animals generally died within 15 minutes. Four of the 10 ECMO-supported animals lived for six days, at which time they were restudied and killed. Not only can ECMO maintain an animal that would otherwise die quickly of massive pulmonary thromboembolism, but such support, even though temporary, can greatly improve the chances of survival.

Norepinephrine, potassium and overdrive suppression.

The influence of norepinephrine on ventricular overdrive suppression and attendant potassium shifts has been studied in isolated perfused canine hearts with complete atrioventricular block. It was found that: 1) there is a potassium loss during the drive and a potassium uptake after the drive); 2) reducing the driving rate from 240 to 120/min decreases potassium loss; 3) norepinephrine increases potassium uptake and spontaneously beating ventricles and during the recovery from 120/min drive; 4) norepinephrine enhances K loss during and after a 240/min drive; 5) norepinephrine shortens the overdrive pause under all the conditions tested; 6) in ventricles driven at a constant rate, norepinephrine causes a small loss of ptoassium; 7) reserpinized hearts show a small potassium loss during drive and a larger potassium uptake after drive; yet, the suppression is longer; 8) norepinephrine increases K loss with drive and decreases overdrive suppression in reserpinized hearts; 9) norepinephrine enhances the increase in oxygen consumption caused by overdrive; and 10) norepinephrine antagonizes the depressant effect of high [K]0 on automaticity. It is concluded that norepinephrine shortens the pause independently of potassium levels and antagonizes the inhibittory influence of high K. The effect or norepinephrine on K movements depends on the ventricular rate and such rate-dependence is related to oxygen availability with respect to the increased metabolic demand.