Results of irradiation or chemoirradiation following resection of gastric adenocarcinoma.

PURPOSE: To evaluate the results of postoperative irradiation +/- chemotherapy for carcinoma of the stomach and gastroesophageal junction. METHODS AND MATERIALS: The records of 63 patients who underwent resection for stomach cancer were retrospectively reviewed. Twenty-five patients had complete resection with no residual disease but with high-risk factors for relapse. Twenty-eight had microscopic residual and 10 had gross residual disease. Doses of irradiation ranged from 39.6 to 59.4 Gy with a median dose of 50.4 Gy in 1.8 Gy fractions. Fifty-three of the 63 (84%) patients received 5-fluorouracil (5-FU)-based chemotherapy. RESULTS: The median duration of survival was 19.3 months for patients with no residual disease, 16.7 months for those with microscopic residual disease, and 9.2 months for those with gross residual disease (p = 0.01). The amount of residual disease also significantly impacted locoregional control (p = 0.04). Patients with linitis plastica did significantly worse in terms of survival, locoregional control, and distant control than those without linitis plastica. The use of 4 or more irradiation fields was associated with a significant decrease in the rate of Grade 4 or 5 toxicity when compared to the patients treated with 2 fields (p = 0.05). CONCLUSIONS: There was a significant association between survival and extent of residual disease after resection as well as the presence of linitis plastica. Distant failures are common and effective systemic therapy will be necessary to improve outcome. The toxicity of combined modality treatment appears to be reduced by using greater than 2 irradiation fields.

Leiomyosarcoma of the pulmonary veins.

Primary sarcomas of the great vessels are rare, but the most common site is the inferior vena cava. Herein are reported five new cases arising from the pulmonary veins with clinicopathologic correlation and comparison to previously reported cases. All new cases occurred in women ranging in age from 23 to 64 years at diagnosis (mean, 56 years). They had symptoms suggestive of left heart failure, including three patients with dyspnea, one with hemoptysis, and one with cough. Three cases showed tumor extension along the pulmonary veins into the left atrium. Tumors ranged in size from 2.8 to 7 cm in greatest dimension. Histologically, all were leiomyosarcomas. They were highly cellular tumors. Three cases had predominantly spindle cell morphology and two were predominantly epithelioid; one had foci of calcification. Most showed extensive necrosis. All tumors were reactive with antibodies to actin and desmin. Two cases were reactive with antibodies to MIC-2 (dotlike); two cases showed reactivity to keratin antibodies; and two showed reactivity for estrogen, progesterone receptor protein, or both. None were positive for antibodies to S-100 protein. All cases were treated with surgical excision. Follow-up ranged from 2 months to 21 years (mean, 4.8 years). Two patients were alive and well; two were alive with metastases; and one died of disease. Pulmonary vein sarcomas represent intermediate- to high-grade leiomyosarcoma. Although often lethal, complete surgical excision can lead to long-term survival. They occur predominantly in women and may express hormone receptors. Therefore, hormonal manipulation may offer promise as adjuvant therapy.

Staging systems of lung cancer.

The staging of lung cancer involves assessment of the anatomic extent of disease based on the best available data. Such a definition of neoplastic burden facilitates the systematic analysis and meaningful communication of diagnostic, therapeutic, and prognostic information. Clinical staging involves the best estimate of extent of disease before performance of surgical resection or biopsy procedures (or both). Surgical-pathologic staging is based on the histopathologic analysis of resected specimens, including determining the extent of local and regional disease. During the past 50 years, two major classification schemes for staging of lung cancer have evolved--one for non-small-cell lung cancers (the TNM system, indicating the status of primary tumor [T], regional lymph node [N], and metastatic [M] involvement) and the other for small-cell carcinoma of the lung (based on limited versus extensive disease). In this report, we review the evolution of the current staging systems used for primary lung cancer and their prognostic implications.

Video-assisted thoracic surgical procedure: management of a solitary pulmonary nodule.

Solitary pulmonary nodules continue to challenge all diagnostic skills. Herein we describe video-assisted thoracic surgical intervention, a new, minimally invasive technique that aids physicians in obtaining a definitive histologic diagnosis in a select group of patients with an indeterminate solitary pulmonary nodule.

Dirofilaria immitis: a rare, increasing cause of pulmonary nodules.

Dirofilariasis is an unusual but increasing cause of solitary pulmonary nodules. In this study, we reviewed the entire experience with dirofilariasis at our institution. Five such patients were identified. In all patients, the Dirofilaria immitis infection manifested as a solitary pulmonary nodule, and all patients underwent thoracotomy for diagnosis. None required systemic treatment. D. immitis is found in dog, cat, wolf, coyote, and fox populations throughout the United States, but the highest concentrations have been noted in the eastern, southeastern, and southern coastal states. The distribution of human cases of D. immitis infection has a similar pattern. Pulmonary dirofilariasis should be included in the differential diagnosis of peripheral noncalcified pulmonary nodules, especially in endemic areas.

Video-assisted thoracic surgical procedures: the Mayo experience.

OBJECTIVE: To describe an initial 3-year experience with video-assisted thoracic surgical procedures (VATS) at Mayo Clinic Rochester. DESIGN: We review the cumulative data on 771 VATS performed between June 1, 1991, and May 31, 1994, and assess the applications for this technique. MATERIAL AND METHODS: The indications for VATS, our techniques used, and the associated mortality and morbidity are summarized. In addition, the frequency of conversion of VATS to open procedures and the reasons for choosing this strategy are discussed. RESULTS: The 771 study patients (401 male and 370 female patients) had a median age of 62 years (range, 7 to 96). For all VATS. we used one-lung general anesthesia, without carbon dioxide insufflation. Indications for performing VATS were a pulmonary nodule in 333 patients, pleural effusion in 208, pulmonary infiltrate in 117, pneumothorax in 51, mediastinal mass in 22, pleural mass in 17, air leak in 13, and other in 10. The procedure was a wedge excision in 352 patients, examination of the pleural cavity in 128, pleural biopsy in 86, talc pleurodesis in 85, wedge excision and mechanical pleurodesis in 46, decortication in 27, excision of a mediastinal mass in 12, sympathectomy in 4, and other in 16. The rate of conversion of VATS to thoracotomy was 33.1% and did not change throughout the period of the study. The most common reasons for conversion were to complete a resection of a malignant lesion or to remove a deep nodule. The overall operative mortality was 1.9%. Complications occurred in 43 patients (8.3%) who underwent VATS without conversion to an open procedure and included prolonged air leak in 14, respiratory failure in 8, pneumothorax in 6, and atrial fibrillation in 5. The median hospitalization was 5 days (range, 1 to 104). CONCLUSION: VATS is safe and useful for selected thoracic conditions. We favor conversion to thoracotomy when curative resection of a malignant lesion is intended.

Oxygen-exacerbated bleomycin pulmonary toxicity.

Bleomycin is an antineoplastic agent with potential for producing pulmonary toxicity, attributed in part to its free radical-promoting ability. Clinical and research experiences have suggested that the risk of bleomycin-induced pulmonary injury is increased with the administration of oxygen. We report a case in which the intraoperative administration of oxygen in the setting of previous bleomycin therapy contributed to postoperative ventilatory failure. Our patient recovered with corticosteroid therapy. Physician awareness of a potential interaction between oxygen and bleomycin may help reduce the morbidity and mortality related to bleomycin therapy.

Rationale for surgical therapy of Barrett esophagus.

Barrett esophagus has malignant potential and seems to be an acquired abnormality. It is associated with chronic gastroesophageal reflux disease and represents its severest form. The literature comparing medical treatment with antireflux surgery was reviewed. Questions regarding the advantages of surgery, who should undergo surgery, whether surgery can change the course of Barrett esophagus, the change in cancer risk, who needs surveillance, and cost-effectiveness were addressed. The incidence of developing Barrett cancer was 1 in 145 patient-years in reviewing 2032 patient-years of medical therapy compared with 1 in 294 patient-years in reviewing 4122 patient-years after surgery. Median follow-up time in the 2 groups was 2.7 years in the medically treated patients and 4.0 years in the surgically treated patients. Surveillance of Barrett esophagus is required irrespective of treatment. Laparoscopic antireflux surgery was found to be cost-effective after 7 years. Although these data do not prove that surgery is superior to medical treatment in the prevention of cancer related to Barrett esophagus, we found a tendency for surgery to be better than medical therapy to prevent the development and progression of Barrett carcinoma.

Current techniques for the surgical management of malignant lesions of the thoracic esophagus and cardia.

Cancers of the esophagus and cardia remain serious conditions that cause many thousands of deaths every year throughout the world. In North America, cancer of the esophagus and gastric cardia is an endemic disease of low order and stable incidence. Nevertheless, it is responsible for many deaths and considerable suffering. With current methods of treatment, substantial palliation and amelioration of patient disability are possible, and some patients gain long-term survival with comfort and even cure. A combination of surgical resection and reconstruction is the chief modern method of management of such cancers. Herein we discuss a variety of standard surgical procedures that are currently available and present detailed illustrations of these procedures. The selection of a specific operation depends largely on the site of the neoplasm. With all these procedures, function is restored and the local and regional neoplastic tissue is removed without compromising the potential for cure. Associated operative mortality is approximately 7%. The late results of the operations illustrated depend primarily on the cell type, grade, and stage of the neoplasm encountered at the time of surgical treatment. For patients who have undergone resection, 5-year survival rates have ranged from 15 to 54%, the results depending on the stage of the cancer. Of equal importance is the fact that oral diet can be maintained in 93% of patients despite recurrence of the neoplasm.

Radiology in the intensive-care unit.

Portable chest radiography is an essential component of clinical patient management in the intensive-care unit. With routine use of this procedure, unexpected cardiopulmonary abnormalities are frequently detected, and malposition or complications of intravascular devices and endotracheal, thoracostomy, or nasogastric tubes are also commonly found. The pulmonary parenchyma may be assessed for changes of acute lung injury, cardiogenic edema, areas of pneumonitis, atelectasis, or other abnormal collections of fluid or air. In mechanically ventilated patients, barotrauma occurs frequently and may be manifested by subtle intrathoracic collections of air. Technical factors may limit the resolution of the anteroposterior chest radiograph obtained at the bedside, but crucial clinical information is often gained. Portable chest radiographic findings, the role of computed tomography and ultrasonography, and interventional radiologic procedures pertinent to patients in the intensive-care unit are reviewed.

Locally recurrent non-small-cell lung cancer after complete surgical resection.

Between Jan. 1, 1976, and Dec. 31, 1985, at our institution, 37 patients who had undergone prior complete surgical resection of non-small-cell lung cancer received definitive thoracic radiation therapy (TRT) for locally recurrent disease. Of the 37 recurrences, 33 were in the pulmonary parenchyma or the hilar, mediastinal, or supraclavicular lymph nodes; the other 4 were in the chest wall. The initial stage of disease was I in 43%, II in 35%, and IIIA in 19%, whereas at the time of local recurrence, the stage was I in 8%, II in 11%, IIIA in 57%, IIIB in 22%, and IV in 3% (this patient had multiple pulmonary nodules encompassible within a single TRT field). The locally recurrent lesions were squamous cell carcinoma in 30%, adenocarcinoma or large-cell carcinoma in 46%, mixed types in 5%, and unknown type in 19%. All patients received megavoltage TRT, most often 4,000 cGy in 10 fractions administered in a split-course schedule. In addition, 15 patients received multiagent chemotherapy, usually a combination of cyclophosphamide, doxorubicin hydrochloride, and cisplatin or a regimen that included these drugs. The 2-year and 5-year survivals were 30% and 4%, respectively, and the median duration of survival was 13.7 months. Survival was not improved by the addition of chemotherapy. Approximately half of the patients had radiographic and symptomatic responses after TRT. Of 33 patients assessable for post-TRT patterns of failure, 46% had local failure only, 18% had local plus systemic failure, and 32% had systemic failure only. Two-thirds of the patients died as a direct consequence of progressive chest disease, despite receiving TRT.(ABSTRACT TRUNCATED AT 250 WORDS)

Solitary pulmonary nodules: clinical prediction model versus physicians.

OBJECTIVE: To determine whether a clinical prediction model developed to identify malignant lung nodules based on clinical data and radiologic lung nodule characteristics could predict a malignant lung nodule diagnosis with higher accuracy than physicians. MATERIAL AND METHODS: One hundred cases were obtained by using a stratified random sample from a retrospective cohort of 629 patients with newly discovered 4- to 30-mm radiologically indeterminate solitary pulmonary nodules (SPNs) on chest radiography. A chest radiologist, pulmonologist, thoracic surgeon, and general internist made predictions of a malignant lesion and recommendations for management (thoracotomy, transthoracic needle aspiration biopsy, or observation) on the basis of radiologic and clinical data used to develop the clinical prediction rule. The predictions of a malignant lung nodule were compared with the probability of malignant involvement from a previously validated clinical prediction model to identify malignant nodules on the basis of three clinical characteristics (age, smoking status, and history of cancer greater than or equal to 5 years previously) and three radiologic characteristics (nodule diameter, spiculation, and upper lobe location). RESULTS: Receiver operating characteristic analysis showed no significant difference between the logistic model and the physicians' predictions. Calibration curves revealed that physicians overestimated the probability of a malignant lesion in patients with low risk of malignant disease by the prediction rule; this finding suggests a potential for the decision rule to improve the management of patients with SPNs that are likely to be benign. CONCLUSION: The prediction model was not better than physicians' predictions of malignant SPNs. The prediction rule may have potential to improve the management of patients with SPNs that are likely to be benign.

An integrated approach to evaluation of the solitary pulmonary nodule.

In this article, we describe an integrated approach for detection and evaluation of solitary pulmonary nodules. Initial evaluation of the solitary pulmonary nodule includes tomography, fluoroscopy, and comparison with previously obtained roentgenograms. Subsequently, thin-section computed tomography and phantom densitometry can be used for analysis, if indicated. The rationale for the use of computed tomography in the radiologic staging of bronchogenic carcinoma is to expedite and assist in the identification of the subset of patients with resectable tumors. For nonsurgical tissue diagnosis, fiberoptic bronchoscopy is generally the initial procedure for lesions 2.0 cm or larger in diameter, and transthoracic needle biopsy is used for those smaller than 2.0 cm.

Diagnosis of corticotropin-producing bronchial carcinoid tumors causing Cushing's syndrome.

Cushing's syndrome due to ectopic production of adrenocorticotropic hormone (corticotropin) has been recognized for many years. Traditionally, clinicians have thought that most cases were due to lung carcinomas and that the clinical manifestations differed from those for pituitary-dependent Cushing's syndrome. We report two cases of corticotropin-producing bronchial carcinoid tumors that were clinically and biochemically indistinguishable from pituitary-dependent Cushing's syndrome. Review of the literature revealed that bronchial carcinoid tumors are the most common cause of Cushing's syndrome due to ectopic secretion of corticotropin. On biochemical and anatomic studies, they are frequently indistinguishable from pituitary-dependent Cushing's syndrome and thus may be difficult to diagnose. Inferior petrosal sinus sampling for corticotropin and computerized imaging of the chest may be the best aids in making the diagnosis.

Extramedullary hematopoiesis manifesting as a symptomatic pleural effusion.

The occurrence of extramedullary hematopoiesis in the pleura is rare and is usually asymptomatic. It is generally diagnosed on postmortem examination. Herein we describe a 61-year-old woman with agnogenic myeloid metaplasia who sought medical assessment because of progressive dyspnea. Thoracentesis yielded sanguineous fluid with 10% myeloblasts. A 99mTc bone marrow scan demonstrated increased tracer activity throughout both lungs, an outcome consistent with extramedullary hematopoiesis. Fine-needle aspiration and video-assisted thoracoscopy were considered but deferred because of the potential risk of profuse bleeding. Treatment with low-dose external beam irradiation to the left posterior pleura was successful. To date, no hemothorax has recurred.

Achalasia: prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal transit, and esophageal diameter and symptoms in response to pneumatic dilation.

The aims of this study were to investigate a group of patients with achalasia prospectively to determine (1) the relationship between changes in symptoms and esophageal motor function in response to pneumatic dilation and (2) the effects of the balloon size as well as the frequency and duration of inflation on the outcome of treatment. Fourteen patients with achalasia who were symptomatic for a median duration of 27 months participated in the study. The patients were randomized to one combination of the following pneumatic dilation conditions: a 30- or 35-mm balloon dilator, one or two balloon inflations, and 20, 40, or 60 seconds per balloon inflation. A comprehensive assessment of their symptoms and esophageal motility, transit, and diameter were performed before and 3 months after pneumatic dilation. Pneumatic dilation provided significant relief of dysphagia (P < 0.01), but other symptoms (heartburn, regurgitation, and chest pain) remained unchanged. Pneumatic dilation also caused a significant decrease in lower esophageal sphincter pressure and esophageal diameter and improved esophageal emptying of a solid bolus. Nevertheless, no significant association was detected between changes in the symptom score for dysphagia and changes in objective response measures as a result of pneumatic dilation. Changes in the symptom score for dysphagia or objective responses were similar regardless of the size of the dilator used or the frequency and duration of the balloon inflations.(ABSTRACT TRUNCATED AT 250 WORDS)

Gossypibomas mimicking echinococcal cyst disease of the lung.

Gossypibomas, masses of retained cotton materials, may produce a variety of postoperative complications. This case report of hemoptysis of 18 months' duration and cavitating chest masses in a 62-year-old man with previous cardiac operations illustrates several salient features about the presentation, differential diagnosis, and management of gossypibomas.

Intrathoracic stomach. Presentation and results of operation.

Between January 1, 1980, and December 31, 1990, 147 patients (93 female and 54 male) were found to have an intrathoracic stomach. Median age was 69 years (range 34 to 89). Signs and symptoms occurred in 140 patients (95.2%) and were primarily obstructive. They included postprandial pain in 87 (59.2%), vomiting in 46 (31.3%), and dysphagia in 44 (29.9%); only 23 patients (15.7%) had symptoms of gastroesophageal reflux. Anemia was present in 31 patients (21.1%) and melena in 3. Elective repair was done in 119 patients and included an uncut Collis-Nissen repair in 81 patients (68.1%), a Belsey Mark IV repair in 19 (16.0%), a Nissen repair in 17 (14.3%), and a Harrington (anatomic) repair in 2 (1.7%). Thirty-two patients had complications (26.9%). There were no operative deaths. Median follow-up was 42 months. Results were excellent in 69 patients (60.0%), good in 38 (33.0%), fair in 6 (5.2%), and poor in 2 (1.7%). Five patients had emergency operations for suspected strangulation; three had gastric necrosis, and one died. Two of the four operative survivors had excellent results. Twenty-three other patients were followed up with medical management for a median of 78 months (range 12 to 268 months). In four patients progressive symptoms developed, and one patient died from aspiration. We conclude that patients with an intrathoracic upside-down stomach who have obstructive symptoms at initial presentation should undergo repair and that elective operation is safe and effective. Gastric strangulation, however, is rare.

Multiple primary lung cancers. Results of surgical treatment.

During a 13-year period, multiple primary lung cancers were diagnosed in 80 consecutive patients. Forty-four patients had metachronous cancers. The initial pulmonary resection was lobectomy in 36 patients, bilobectomy in 3, pneumonectomy in 1, and wedge excision or segmentectomy in 4. The second pulmonary resection was lobectomy in 16 patients, bilobectomy in 2, completion pneumonectomy in 7, and wedge excision or segmentectomy in 19. There were two 30-day operative deaths (mortality rate, 4.5%). Actuarial 5- and 10-year survival rates after the first pulmonary resection for stage I disease were 55.2% and 27.0%, respectively. Five-year and 10-year survival rates for stage I disease after the second pulmonary resection were 41.0% and 31.5%, respectively. The remaining 36 patients had synchronous cancers. The pulmonary resection was lobectomy in 18 patients, bilobectomy in 3, pneumonectomy in 10, and wedge excision or segmentectomy in 8. There were two 30-day operative deaths (mortality rate, 5.6%). Actuarial overall 5- and 10-year survival rates after pulmonary resection were 15.7% and 13.8%, respectively. We conclude that an aggressive surgical approach is safe and warranted in most patients with multiple primary lung cancers and that the presence of synchronous primary cancers is ominous.

Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance.

Cardiac tachydysrhythmias occurred in 53 (22 percent) of 236 consecutive patients undergoing pneumonectomy. All patients had preoperative electrocardiograms which showed normal sinus rhythm. Patients did not receive digitalis before surgery. Atrial fibrillation was the most common dysrhythmia (64 percent; 34/53), followed by supraventricular tachycardia (23 percent; 12/53) and atrial flutter (13 percent; 7/53). No episodes of ventricular tachycardia were documented. Elevated concentrations of cardiac enzymes were associated with 12 (28 percent) of 43 tachydysrhythmias. Recurrent or persistent dysrhythmias were documented in 29 (55 percent) of 53 patients despite medical management or electrocardioversion (or both). Thirty-one percent (9/29) of these patients subsequently died during their hospitalization. There was no correlation between standard preoperative pulmonary function tests and the incidence of postoperative dysrhythmia. In addition, there was no correlation of dysrhythmia with postoperative diagnoses, surgical staging for lung cancer, postoperative arterial blood gas levels, or the fact that a completion pneumonectomy or chest wall resection was undertaken. An increased incidence of tachydysrhythmia was noted in patients undergoing intrapericardial dissections and those who developed postoperative interstitial or perihilar pulmonary edema. Twenty-five percent (13) of the patients experiencing tachydysrhythmias died within 30 days following their pneumonectomy. We conclude that tachydysrhythmias after pneumonectomy are associated with significant mortality, have poor correlation to preoperative pulmonary function, and occur more frequently following intrapericardial dissection and in patients who develop postoperative interstitial pulmonary edema or perihilar pulmonary edema.