The importance of surgical and multimodality treatment for small cell bronchial carcinoma.

In a cooperative international lung cancer multimodality treatment trial, 112 patients with small cell lung cancer underwent initial surgical resection and were then randomized to receive one of two intensive postoperative chemotherapeutic regimens, followed by prophylactic cranial irradiation in the disease-free patients. Regimen A consisted of eight courses of cyclophosphamide, doxorubicin, and vincristine and regimen B of two courses of three sequential drug combinations: (1) cyclophosphamide, lomustine, and methotrexate; (2) cyclophosphamide, doxorubicin, and vincristine; and (3) ifosfamid and etoposide. In 47 patients the diagnosis was known preoperatively and in 65 it was not confirmed until the resected specimen was examined (all diagnoses were reviewed by a referee pathologist). Each patient was classified by the pathologic TNM characteristics. There were 38 patients with stage I disease, 39 patients with stage II, and 35 patients with stage IIIa disease. In stage IIIa there were nine patients with T3 N0-1 disease and 26 with T1-3 N2 disease (most N2 disease was clinically undetected until thoracotomy or was discovered only by routine histologic examination of the resected mediastinal nodes). Early survival rates at 24 months calculated by the life table method are as follows: stage I, 76%; stage II, 56%; and stage IIIa, 49% (T3 N0-1, 89%; T1-3 N2, 35%). Survival rates at 36 months are 62%, 50%, and 41% (74% and 29%), respectively. The projected 36-month survival rate for 43 patients with N0 disease is 65%; for 43 with N1 disease, 52%; and for 26 with N2 disease, 29%. No difference in survival has been noted in either chemotherapy treatment group. It is concluded that initial surgical resection for limited small cell cancer (stage I, II, and T3 N0-1) followed by intensive chemotherapy is an appropriate therapeutic approach. For T1-3 N2 disease the results are inconclusive.

Pain treatment after thoracotomy: is it a special problem?

BACKGROUND: Although it is frequently stated in the literature that thoracotomy is one of the most painful operative incisions, few data supporting this view are available. METHODS: Patients' postoperative pain experience can be assessed on the basis of their usage of patient-controlled analgesia. In a prospective trial the daily self-administered doses of analgesics in 55 patients within the first 4 days after posterolateral thoractomy were compared with those in 30 patients for the same number of days after median laparotomy. The visual analog scale was used as a second measure to evaluate postoperative pain. RESULTS: On the basis of patient-controlled analgesia usage on the first postoperative day and the visual analog scale score for the first 2 days, a small but significant difference between the two patient groups was found which showed that thoracotomy is less painful than median laparotomy. CONCLUSIONS: The common belief that posterolateral thoracotomy is a very painful operative access is not true. Therefore it is not necessary to use special techniques for postthoracotomy pain relief in these patients. Patient-controlled analgesia is sufficient for pain relief after major thoracic or abdominal incisions.

Intraoperative cryoanalgesia for postthoracotomy pain relief.

In a randomized study, 63 patients were investigated for the benefits of cryoanalgesia after thoracotomy. Analgesia and its dependent effects such as enhancement of mobility, respiratory function, and reduced need of narcotics were evaluated. No significant differences in these variables were observed between the cryoanalgesia group and the control group. However, moderate to severe neuralgia was found in a number of patients in the cryoanalgesia group in the late postoperative period. Cryoanalgesia for pain relief after thoracotomy is not recommended.

Neopterin: a prognostic variable in operations for lung cancer.

BACKGROUND: We studied the prognostic value of preoperatively measured neopterin to predict survival of lung cancer patients. Neopterin is produced and secreted by interferon-gamma-stimulated monocytic cells. High urinary neopterin concentrations are found in patients with viral infections, allograft rejection episodes, and some malignant diseases. In various tumor types high urinary neopterin concentrations are associated with a worse prognosis. METHODS: Preoperative neopterin levels of 110 patients (29 women, 81 men) with lung cancer including 7 patients with small cell lung cancer were measured and related to the time of survival after operation. Patients with clinically suspected stage IIIB lung cancer were not operated and therefore not enrolled in this study. Infectious diseases were not apparent at the time of preoperative urine sampling. Median postoperative follow-up period was 17.4 months. RESULTS: In a univariate analysis, patients with a preoperative neopterin concentration of more than 212 micromol/mol creatinine (4th quartile) were determined to have a significantly lower survival probability. In a multivariate analysis, a neopterin concentration of more than 212 micromol/mol creatinine (p < 0.01) and T-stage status (p < 0.005) were determined to be significantly predictive variables for worse survival prognosis. CONCLUSIONS: Preoperative neopterin proved to be a reliable prognostic factor for survival. Immunology may provide an accurate assessment of tumor aggression and its clinical behavior. In this sense, neopterin can serve as an immunologically based estimation of malignant outgrowth. In patients who are operable by clinical tumor stage but have a high risk for operation, elevated preoperative neopterin may help in the decision for a nonoperative treatment.

Operation for N2 small cell lung carcinoma.

Of 48 patients with limited small cell lung carcinoma treated by different modes, but always including radical operation, a series of 25 patients with N2 lymph node metastases is reported. In a first period (1970 to 1977) treatment consisted solely of radical resection in 3 patients; chemotherapy was added to operation in 6, and local radiotherapy was added in 2. Since 1977, 14 patients were treated according to a comprehensive therapy protocol including radical resection (six pneumonectomies, one bilobectomy, seven lobectomies), chemotherapy, local radiotherapy, and prophylactic cranial irradiation. Eleven patients, in whom N2 disease was confirmed preoperatively, received chemotherapy as the first step, followed by "adjuvant" resection. Projected 5-year survival rate is 25% for the entire N2 group and 47% for the comprehensively treated group. Seven patients of this latter group are alive 12, 19, 30, 48, 66, 73, and 74 months after comprehensive therapy, equivalent to an observed 2-year survival rate of 38%. This is the largest reported series of patients with resected small cell lung carcinoma in the N2 stage treated at a single institution; the results are so encouraging that we can no longer advocate general refusal of radical lung resection for small cell lung carcinoma in the N2 stage if it is part of a multimodal therapeutic protocol.

Multimodal therapy of small cell lung cancer in TNM stages I through IIIa.

Since 1977, Innsbruck University Hospital has been employing a multimodal therapy concept for small cell bronchial carcinomas in stages I to IIIa. This concept includes all three treatment forms effective in this tumor, namely, chemotherapy, surgery, and radiotherapy. The therapy scheme is stage-dependent and begins in stages T1-3 N0-1 with lung resection and in stage N2 with chemotherapy. To date, 45 patients have been included in a prospective, nonrandomized (phase II) trial: 7 in TNM stage I, 11 in stage II, and 27 in stage IIIa (6 T3 and 21 N2). The actuarial 5-year survival rate of the entire group (including therapy-related lethality, early recurrences, and protocol violations) is 36%; it is 57% for those in stage I, 28% for those in stage II, and 34% for those in stage IIIa. Median survival time is 18 months. Patients with completed multimodal treatment have a 5-year survival rate of 56% regardless of disease stage. Three patients died of tumor-unrelated causes after 47, 52, and 54 months.

Long-term results of surgery for adenoid cystic carcinoma of the trachea and bronchi.

AIMS: Over a period of 26 years, 16 patients (9 women, 7 men) underwent surgery for primary adenoid cystic carcinoma (ACC) of the trachea and bronchi. The median age at diagnosis was 41.4 years (range 25-67). Nine tumours were located in the bifurcational area, five in the trachea, one in the middle-lobe bronchus and one in the parenchyma of the left lower lobe. METHODS: Surgical procedures were as follows: three tracheal transversal resections; five resections of the distal trachea including the bifurcational region, followed by bifurcational reconstruction; two right-sleeve pneumonectomies; three left-sleeve pneumonectomies; two lobectomies; and one explorative sternotomy. RESULTS: Eleven patients were available for follow-up at least 5 years after surgery. Three of these patients (27%) had local recurrence 155+/-30 (range 120-175) months after surgery. Distant metastases occurred in six patients (55%) after a median time interval of 96+/-68 (range 24-180) months after surgery. CONCLUSIONS: Five-year and 10-year survivals were excellent, 79 and 57% respectively, but the long-term outcome was poor due to late local recurrences and late metastatic spread. It is not yet certain whether a cure can really be achieved in ACC.

Stenosis of left mainstem bronchus in a case of cicatricial pemphigoid.

A case of a 22-year-old male with cicatricial pemphigoid and involvement of the bronchial system is reported. Manifestations of cicatricial pemphigoid in the mucous membranes of the airway distal to the larynx have not been hitherto described. The patient developed severe stenosis of the left mainstem bronchus 2 years after onset of the disease. Successful treatment by sleeve resection and end-to-end anastomosis was achieved. Diagnostic bronchoscopy in patients with severe dyspnoea suffering from cicatricial pemphigoid is recommended. Operative treatment of airway stenoses distal to the larynx caused by cicatritial pemphigoid is feasible.

Resection of the tracheal bifurcation through a left thoracotomy.

The surgical management of tumors of the left main bronchus with involvement of the lower trachea is one of the most difficult problems of tracheobronchial surgery. Two cases of adenocystic carcinoma in this location are presented, where resection of the tumor and reconstruction of the airway were performed through a left thoracotomy. In one case reconstruction of the tracheobronchial tree could be accomplished without loss of lung parenchyma; in the second case the left lung had to be removed since the lobar bronchi were infiltrated by the tumor. Such extensive left tracheobronchial resections have so far not been reported in the literature.

Transesophageal sonography in central bronchial carcinoma.

A new application of transesophageal sonography was tested in eight patients suffering from central bronchial carcinoma. Due to ultrasound technology, a real time investigation is feasible which enhances the diagnostic method of computed tomography (CT) by discriminating between tumour and mediastinal organs which cannot be delineated by CT only. Different sonographic densities and the movement between organ and tumour contribute to the diagnostic accuracy of sonography if operability is questionable due to possible organ infiltration by tumour. The method is limited by the air filled organs (trachea, bronchi), as ultrasound does not penetrate adequately.

[The radiological diagnosis of bronchial atresia (author's transl)]. / Die Röntgendiagnostik der Bronchusatresie.

Congenital atresia of the apico-dorsal segmental bronchus of the left upper lobe in a 10-year-old boy is described. The radiological features of bronchial atresia are described in detail and the view is expressed that the diagnosis can be made on plain films of the chest with tomography. According to present day concepts, treatment is not indicated in the absence of symptoms.

The importance of surgery as the first step in multimodality treatment of small cell bronchial carcinoma. The ISC Lung Cancer Study Group.

For patients with small cell lung cancer (SCLC) in their early stages (TNM I, II), surgery for cure was used to eliminate the primary tumour and its regional lymph-nodes followed by intermittent chemotherapy and radiotherapy within the first six postoperative months. After the pathohistological examination of the operation-specimen a two-arm-randomization was performed: standard chemotherapy (1000 mg/m2 cyclophosphamide, 50 mg/m2 doxorubicin, 1.4 mg/m2 vincristine) compared with sequential chemotherapy using three different drug-combinations (A: 1500 mg/m2 cyclophosphamide, 100 mg/m2 lomustine, 15 mg/m2 methotrexate; B: 1000 mg/m2 cyclophosphamide, 40 mg/m2 doxorubicin, 1 mg/m2 vincristine; C: 5 x 1.6 g/m2 ifosfamide plus mesna, 5 x 120 mg/m2 etopside). Thereafter disease-free patients only received prophylactic cranial irradiation (PCI: administering 3600 TD Gy/18 fractions) according to the protocols of the International Society of Chemotherapy Studies I and II. Preliminary evaluations in March 1990 of 170 patients from 24 cooperating departments for thoracic surgery showed that the projected life-table four-year-survival rate of 63 patients with SCLC at pTNM-stage I was 61%, of 54 patients at pTNM-stage II was 35%, of 13 patients at stage pT3, 4 NO, 1 MO was 59% and of 40 patients at stage pT N2 MO was 35%. The indication for surgery is emphasized for pTNM-stages I + II. For N2-lesions surgery would not be recommended in general, but the survival rate seems to indicate that this treatment was not detrimental, being rather more favourable compared with chemotherapy or radiotherapy alone. The continuation and enlargement of these studies seem not only justified, but emphatically indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery for cure followed by combined modality treatment for small cell bronchial carcinoma. ISC Lung Cancer Study Group.

For patients with small cell lung cancer (SCLC) at early stages (TNM I, II) surgery for cure is used to eliminate the primary tumour and its regional lymph-nodes followed by intermittent chemotherapy and radiotherapy within the first six postoperative months. After the pathohistological examination of the operation-specimen a two-arm-randomization is performed: standard chemotherapy compared with sequential chemotherapy using three different drug-combinations. Thereafter tumour-free patients only receive prophylactic cranial irradiation. In preliminary evaluations of March 1988, of 121 patients from 20 cooperating departments it was found that the projected life-table survival rate, three years postoperatively, of 47 patients with SCLC at stages pT1-3 N0 M0 was 65%, of 46 patients at stages pT1-3 N1 M0, 56% and of 28 patients at stages pT1-3 N2 M0, 34%. The indication for surgery were emphasized for pTNM-stages I+II. For N2-lesions surgery would not be recommended in general, but the survival rate seemed to indicate that this treatment was not detrimental, but rather more favourable compared with chemotherapy or radiotherapy only. The continuation and enlargement of these studies seem not only justified but emphatically indicated. Multicentre cooperation has to be organized to collect within a reasonable period of time a sufficient number of patients to enable subdivisions to be made according to various prognostic factors.

[Rationalisation of surgical diagnosis by means of real-time sonography]. / Rationalisierung der chirurgischen Diagnostik durch die Real-Time-Sonographie.

A report is given of the results obtained on implementing sonography routinely in the diagnosis of general surgical conditions. Fields in which this procedure has proved of particular value are acute surgical emergencies, polytrauma, biliary surgery, post-operative complications, septic processes, palpable abdominal masses and the investigation and follow up of patients with tumours. Ultrasound-directed fine-needle puncture plays an important role within this last-mentioned group of indications. In order to make optimum use of sonography in interpreting specifically surgical problems, this readily-available bedside examination is performed by the experienced surgeon himself. Further diagnostic tactics and their consequences are discussed.

[Lung cancer: present concepts of treatment]. / Das bronchuskarzinom: der heutige stand der behandlung.

The role of the various treatment modalities of bronchial carcinoma in respect to clinical stage and histology is described. Criteria to select patients for surgical treatment and for radiotherapy with curative or palliative intent are discussed. The present state of cytotoxic therapy in respect to adjuvant treatment as well as its use in metastatic disease is summarized. In small cell carcinoma combination chemotherapy may result not only in palliation, but in an improved survival in a high percentage of patients. Recommended protocols, remission rates and the long-term prognosis of treated patients are summarized.

[Economic aspects of ultrasound diagnosis. A retrospective study exemplified by cholecystolithiasis]. / Okonomische Aspekte der Ultraschalldiagnostik. Eine retrospektive Studie am Beispiel der Cholecystolithiasis.

Cholecystolithiasis is a good example to show the economic effects of using ultrasonography consequently as one of the first diagnostic procedures. In this way it is possible to reduce the examination costs about 50% for the out-patient as well as for the diagnosis during the hospital stay.

Closure of complex defects in the chest wall with muscle flaps.

Aggressive treatment of thoracic malignancy may be complicated by complex defects in the chest wall. These may be associated with serious complications such as chronic infection, respiratory or cardiac failure, or major haemorrhage. Closure of the defect and restoration of the integrity of the chest wall is important for both functional and cosmetic reasons. Local flaps are often used, but may be inadequate or unavailable. Reconstruction with free flaps is better in these cases, as this provides as much abundant well-vascularised tissue as is required. We present 12 patients treated successfully for complex chest wall defects using various forms of local and free flap reconstruction. There were five complications, three healed spontaneously and two required secondary procedures before they healed.