A population-based evaluation of the seventh edition of the TNM system for lung cancer.

Our study describes the new seventh edition of the TNM system for lung cancer in a national population and its clinical implications. We classified 1,885 operated patients with lung cancer, reported to the Cancer Registry of Norway (Oslo, Norway) from 2001 to 2005, according to the sixth and the seventh edition of the TNM system. We compared survival differences adjusting for known prognostic factors. Furthermore, we evaluated the overall predictive ability of both editions using Harrell's concordance index. Survival curves by stage for each of the editions were similar; however, a better description of stage IIIB was observed in the seventh edition. Survival rates of T1b and T2a tumours were similar (log rank p = 0.94). The concordance index was 0.68 for both editions, indicating no overall difference in their predictive accuracy. In the seventh edition, 211 (29%) stage IB patients migrated to stage II and 161 (48%) patients migrated from stage IIB to IIA. Stage migrations could change the treatment for up to 326 (17.3%) of the study patients. The seventh edition did not improve the overall predictive ability of the TNM system; however, the new classification implies changes in treatment for nearly one-fifth of the cases. The implications of the seventh TNM edition for the outcomes of patients should be studied further.

Survival after resection for primary lung cancer: a population based study of 3211 resected patients.

BACKGROUND: Very few population based results have been presented for survival after resection for lung cancer. The purpose of this study was to present long term survival after resection and to quantify prognostic factors for survival. METHODS: All lung cancer patients diagnosed in Norway in 1993-2002 were reported to the Cancer Registry of Norway (n = 19 582). A total of 3211 patients underwent surgical resection and were included for analysis. Supplementary information from hospitals (including co-morbidity data) was collected for patients diagnosed in 1993-8. Five year observed and relative survival was analysed for patients diagnosed and operated in 1993-9. Factors believed to influence survival were analysed by a Cox proportional hazard regression model. RESULTS: Five year relative survival in the period 1993-9 was 46.4% (n = 2144): 58.4% for stage I disease (n = 1375), 28.4% for stage II (n = 532), 15.1% for IIIa (n = 133), 24.1% for IIIb (n = 63), and 21.1% for stage IV disease (n = 41). The high survival in stage IIIb and IV was due to the contribution of multiple tumours. Cox regression analysis identified male sex, higher age, procedures other than upper and middle lobectomy, histologies such as adenocarcinoma and large cell carcinoma, surgery on the right side, infiltration of resection margins, and larger tumour size as non-favourable prognostic factors. CONCLUSIONS: Survival was favourable for resected patients in a population based group including subgroups such as elderly patients, those with advanced stage, small cell lung cancer, tumours with nodal invasion, and patients with multiple tumours. These results question the validity of the current TNM system for lung cancer with regard to tumour size and categorization of multiple tumours.

Functional imaging of the thoracic outlet syndrome in an open MR scanner.

Symptoms due to thoracic outlet syndrome may present only in abduction, a position that cannot be investigated in conventional MR scanners. Therefore, this study was initiated to test MRI in an open magnet as a method for diagnosis of thoracic outlet syndrome. Ten volunteers and 7 patients with a clinical suspicion of thoracic outlet syndrome were investigated at 0.5 T in an open MR scanner. Sagittal 3D SPGR acquisitions were made in 0 and 90 degrees abduction. In the patients, a similar data set was also obtained in maximal abduction. To assess compression, the minimum distance between the first rib and the clavicle, measured in a sagittal plane, was determined. In the neutral position, no significant difference was found between patients and controls. In 90 degrees abduction, the patients had significantly smaller distance between rib and clavicle than the controls (14 vs 29 mm; p < 0.01). On coronal reformatted images, the compression of the brachial plexus could often be visualised in abduction. Functional MR examination seems to be a useful diagnostic tool in thoracic outlet syndrome. Examination in abduction, which is feasible in an open scanner, is essential for the diagnosis.

[Bronchial resections]. / Bronkialreseksjoner.

In the period 1982-96, 18 bronchial resections were performed. Simple resection was carried out in eight patients, and in ten lung tissue was also removed; six upper lobes and three middle lobes were involved, and in one patient bilobectomy was necessary. The histologic diagnosis was carcinoid in 15 cases (83%), mucoepidermoid carcinoma in two, and in one case neurofibroma. Two patients had postoperative complications, but both recovered completely. All patients were followed up regularly by bronchoscopy. One patient had carcinoid with liver and bone metastases at the time of operation in 1989, but is still alive. Another died from metastases, the rest were in good condition at the most recent follow up. Bronchial resection is a safe procedure which should be preferred to standard pneumonectomy, in order to save as much lung tissue as possible. The frequency of bronchial resections for carcinoids (compared with standard pneumonectomy) was 60%.

[Mortality in operable lung cancer]. / Overlevelse ved operabel lungecancer.

We have retrospectively examined the medical records and prospectively studied the survival of the 50 men and 26 women who underwent surgery for primary non-small cell lung cancer at our hospital during the period 1982 to 1986. Adenocarcinoma was the predominant histologic type of tumour (55%). Pneumonectomy was performed in only 17% of the cases. Surgery was considered to be radical in 54 patients. This was not dependent on sex, histology or type of resection. 60% of the patients were alive after three years. Almost all of them had undergone radical resection. The surviving patients (at follow-up 1 July, 1990) had been younger at the time of surgery and had a lower erythrocyte sedimentation rate than those who had died. As a group, however, they had not lived longer than those who died.

[Combined lung and heart surgery]. / Kombinert lunge- og hjertekirurgi.

Patients with concomitant pulmonary carcinoma and serious heart disease represent a therapeutic challenge. With the introduction of combined lung-heart surgery, both conditions may be treated adequately and safely. At Rikshospitalet, combined surgery was performed in four cases during the period 1984-88. In three patients heart surgery and lung resection were performed in one anesthetic session. In the fourth case the heart disease was corrected first and the tumor removed a few weeks later. After 1-4 years follow-up none of the patients has clinical manifestations of either condition. Combined surgery is only applicable if tumor removal is confined to wedge resection or lobectomy.

[Hairy cell leukemia and Mycobacterium malmoense infection]. / Hårcelleleukemi og infeksjon med Mycobacterium malmoense.

We describe a patient with hairy cell leukemia and protracted fever. The patient's condition deteriorated during treatment with alfa Interferon 2b, and his fever persisted. A slight widening of the upper mediastinum appeared after 2.5 months. Mediastinoscopy with lymph node biopsy revealed granulomatous infiltrates with acid-fast bacilli. Cultures of the lymph node material later showed growth of Mycobacterium malmoense. The patient was treated with rifampicin, doxycycline, etambutol and cycloserin for sixteen months and remains afebrile and is gaining weight. His general condition is still improving. An aggressive diagnostic approach is necessary in febrile patients with hairy cell leukemia.

Coarctation of the aorta, early and late results of various surgical techniques.

In the 10-year period 1973-1983, 158 patients aged one day to 16.4 years were operated upon for coarctation of the aorta; 25% of them were less than one month of age. The main surgical procedure was aortoplasty with a prosthetic patch (114 patients), and resection and end-to-end anastomosis (36 patients). Associated cardiovascular anomalies were found in 42%. There were 11 early and 6 late deaths and the majority of these were due to severe coexistent cardiac lesions. The frequency of moderate and severe recoarctation was much higher in patients operated on with resection and end-to-end anastomosis than in those with aortoplasty and prosthetic patch, 25% and 6.7%, respectively. In 18 patients, surgery for recoarctation was necessary using aortoplasty and a prosthetic patch technique. There were no postoperative complications or deaths in these patients. So far, in 2 cases with a prosthetic patch, aneurysmal dilatation of the aorta adjacent to the patch has developed.

[Aneurysm after patch graft aortoplasty in aortic coarctation]. / Aneurisme etter patchplastikk for coarctatio aortae.

In the period 1973-83, 114 patients with coarctation of the aorta were operated on with patch plasty. Early results were encouraging. Two of these patients had to be reoperated, however, because of aneurysmatic dilatation of the aorta adjacent to the prosthetic patch. In one case acute rupture of the aneurysm occurred eight years after the patch plasty, and surgery was performed under dramatic conditions as a life-saving procedure. In the other patient increasing dilatation of the distal part of the aortic arch was observed at chest X-ray 4-5 years after the operation. DSA revealed a large aneurysm proximal and distal to the site of coarctation, and he was operated with excision of the aneurysm and closure of the aorta with a patch of PTFE. Careful follow-up of patients operated for coarctation of the aorta is important. In addition to clinical investigation, patients with patch plasty must be referred to chest X-ray examination every 2nd to 3rd year for a relatively long time.

Morbidity in valvular heart replacement: risk factors of systemic emboli and thrombotic obstruction.

A study on a cohort of 839 patients with valvular heart replacement between June 1977 and May 1985 showed that the linearized rates of systemic emboli and thrombotic obstruction were 1.4/100 pts/year for Aortic Valve Replacement (AVR), 2.2/100 pts./year for Mitral Valve Replacement, and 3.00/100 pts./year for Double Valve Replacement (DVR). The 5-year free-from-thromboembolism (TE) survival was 95% for AVR and 92% for MVR. The hazard function (the instantaneous risk) for TE peaked in the first six months after operation for AVR and MVR. Another analysis using the Cox regression model to estimate risk factors of systemic emboli and thrombotic obstruction pinpointed two factors in the AVR group: presence of aortic regurgitation (AR) and age at operation. In the MVR group the sole predictor covariate was sex of the patients, with a higher hazard for females. Our results underline the importance of patient-related factors besides the type of prosthesis as predictors of morbidity from TE.

Four years' results of a prospective, randomized clinical trial comparing polytetrafluoroethylene and modified human umbilical vein for below-knee femoropopliteal bypass.

Polytetrafluoroethylene (PTFE) (Gore-Tex) and human umbilical vein (Biograft) arterial grafts were compared for below-knee femoropopliteal bypass grafting in a prospective randomized clinical trial. One hundred five patients (105 limbs) entered the trial. Seventy-six percent suffered from rest pain, ulceration, or gangrene. The median postoperative ankle-arm blood pressure index was 0.36. Twenty-three limbs had three patent tibial arteries, 46 limbs had two tibial arteries, 31 limbs had one patent artery, and five limbs had isolated popliteal segments. Thirty-four percent were repeat operations. Fifty-five patients were allocated to receive PTFE grafts and 50 to receive human umbilical vein grafts. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. During the first 4 years (maximum 1609 days) 40 PTFE grafts and 24 umbilical veins occluded. At 1 year the PTFE patency rate was 53% and at 4 years was 22%. For umbilical vein the corresponding figures were 74% and 42% (p = 0.005, Gehan test). During follow-up the incidence of PTFE failure was on the average 2.1 times higher than that of umbilical vein failure (95% confidence limits 1.2 to 3.4).

Blood flow measurement in PTFE grafts.

In vascular surgery peroperative control of the result of reconstruction is essential. PTFE-grafts have been known to be "resistant" to flow registration with electromagnetic flowmetry because of the electrical isolation. Similarly, intraoperative Doppler registration has been impossible because of the attenuation of the ultrasound in the graft wall. The leading disturbances are obviously caused by air in the graft material and are not caused by the material itself. By squeezing the graft carefully between the thumb and forefinger, blood slowly penetrates the wall colouring it red. The squeezing is performed intermittently to avoid occlusion of the graft. Excellent flow registration is obtained after less than 2 min squeezing of the thin walled graft, while at least 5 min squeezing is necessary to obtain signals from thick walled grafts. To obtain satisfactory ultrasound signals more squeezing is necessary.

Some observations on cerebral perfusion during cardiopulmonary bypass.

Blood flow was recorded with an electromagnetic flow probe on one internal carotid artery (ICA) during cardiopulmonary bypass (CPB) in 5 patients. The ICA flow was monitored continuously along with arterial blood pressure, epidural intracranial pressure, and cerebral electrical activity using a cerebral function monitor (3 patients). The ICA flow increased by 50 to 100% at the inception of extracorporeal circulation. This rapid enhancement of flow occurred within a thirty-second period and was due to rapid arterial hemodilution caused by introduction of the priming solution. A transitory fall in ICA flow was observed during subsequent minutes when the well-recognized drop in blood pressure took place and the cerebral perfusion pressure (CPP = blood pressure - epidural intracranial pressure) was reduced to less than 30 mm Hg. In only one instance, however, when CPP fell to 15 mm Hg, was the fall in flow lower than the prebypass level. Throughout the rest of CPB, with steady-state hemodilution and CPP levels in the range of 30 to 50 mm Hg, ICA flow was markedly enhanced (50 to 100% above the prebypass level). The flow pattern, however, disclosed a pressure-passive system, indicating that cerebral autoregulation was impaired or that the CPP levels were lower than the individual lower limit of cerebral autoregulation during the period of steady-state hemodilution on CPB. A transient depression of cerebral electrical activity was seen in 2 patients shortly after the introduction of CPB. This phenomenon is suggestive of qualitatively insufficient perfusion and was observed even when ICA bulk flow was increased (hematocrit values, 13 to 17%).

Morphological changes in the saphenous vein after dilatation with silastic tubes. An experimental study.

In an attempt to make veins more suitable for bypass grafting, an experimental model in dogs was developed. The saphenous vein on the hind limbs was cannulated with a silastic tube, a ligature was placed proximally and distally, and the tube was left in situ for 1 to 9 weeks. Morphological studies including electron microscopy revealed "arterialization" of the veins with fibromuscular hyperplasia, increased deposition of collagen and preserved vasa vasorum. The endothelium was replaced by irregular cells, probably altered fibroblasts coated by an amorphous material. It is suggested that the "arterialized" veins may become more suitable for bypass grafting. But the luminal surface may be thombogenic and thus the usefulness of the graft may be diminished by thrombosis.

A randomized clinical trial of PTFE versus human umbilical vein for femoropopliteal bypass surgery. Preliminary results.

PTFE (Goretex) and modified human umbilical vein (Biograft) vascular grafts were compared in femorodistal popliteal artery bypass surgery in a randomized clinical multicentre trial. During 18 months 104 patients (104 limbs) entered the trial. Twenty-five patients suffered from claudication, 54 suffered rest pain and 25 patients had ulceration or gangrene. The median preoperative ankle-arm blood pressure index was 0 . 34. Twenty-three limbs had 3 patent tibial arteries, 45 limbs had 2 tibial arteries, 31 limbs had 1 tibial artery while 5 limbs had an isolated popliteal segment. Thirty-six of the operations were redo-operations. Fifty-four patients were allocated to PTFE and 50 to umbilical vein. During follow-up (maximum 650 days) 24 PTFE grafts occluded against 12 umbilical veins. The 1-year patency rate was 40 per cent in the PTFE group against 75 per cent in the umbilical vein group (P = 0 . 014, Gehans test). During the first year the PTFE failure rate was on average 3 . 1 times higher than that of the umbilical vein.

Pulmonary arteriovenous fistula.

Two cases of congenital pulmonary arteriovenous fistula are reported. Both patients had cyanosis and clubbing of their fingers and toes and also dyspnoea at exercise. Diagnostic procedures included cardiac catheterization and pulmonary angiography, and in both patients a solitary pulmonary arteriovenous fistula could be demonstrated. Lobectomy was performed in both cases, and at follow-up the patients were quite well with normal laboratory tests.

Coarctation of the aorta in infancy.

In 57 infants with coarctation of the aorta severe congestive heart failure was the indication for surgical correction. More than half of them were less than 1 month of age. Associated cardiovascular anomalies were found in 48 patients. The surgical techniques utilized were resection and end-to-end anastomosis of the aorta and patch plasty using a Dacron patch or the left subclavian artery. The total mortality was 47%, and most of the deaths were due to severe associated cardiovascular anomalies. Of the 30 surviving patients 5 have been reoperated for coarctation 10 months to 8 years after the initial correction. However, recoarctation should be regarded not as an unsuccessful result but rather as a measure of the survival of these desperately ill infants.