Combined modality therapy for stage IIIA non-small cell carcinoma of the lung.

53 patients with stage IIIA non-small cell carcinoma of the lung (NSCCL) were treated with multimodality therapy consisting of induction radiotherapy (55.8 Gy) and two cycles of concurrent chemotherapy with cisplatin, 25 mg/m2 for 4 days by continuous infusion and bolus etoposide, 100 mg/m2 on days 2 and 4 of each cycle followed by surgery and adjuvant chemotherapy. Of 53 evaluable patients, 47 achieved clinical responses (9 complete response, 38 partial response) after induction therapy for a response rate of 89%. 47 patients were resectable after induction therapy, but 8 patients refused surgery and 6 patients were not eligible for surgery based on poor pulmonary function (medical contraindications). 33 patients underwent thoracotomy and in 6 patients, resection was technically unfeasible. Thus complete surgical resection was accomplished in 27 patients. After all therapy, 28 patients achieved a complete response (53%) and 19 patients a partial response (36%). Toxicities were mild. At a maximum of 75 months (median, 28 months) of follow-up, the median survival of the entire group is 24 months. The median survival of resected patients has not been reached; their 6-year survival rate is 55%. Unresected patients survived for a median of 11 months. This multimodality regimen is well-tolerated, induces a high response and resectability rate and prolongs survival in resected patients.

Failure of Dacron prostheses caused by structural defect.

Intrinsic prosthetic failure is quite uncommon since the advent of Dacron prostheses. Only 24 cases of arterial prosthetic failure have been described in the literature. Our experience consists of two additional failures of knitted Dacron prostheses. The first patient developed aortojejunal fistula due to a defect of the aortic prosthesis 6 years after resection and replacement of an abdominal aortic aneurysm. The analysis of the graft revealed a defect in the form of a dropped stitch, which caused a weak spot where the prosthesis was able to be torn apart longitudinally. The second patient had femoropopliteal bypass and 6 years later developed degeneration with aneurysmal formation of the entire length of the prosthesis. Optical microscopy of this prosthesis exhibited mostly transverse failures which were coincident with valleys of the corrugated prosthesis. This was indicative of a defect that rendered the corrugation root too weak to withstand normal arterial pressures. This presentation emphasizes the seldom and serious complication of prosthetic failure due to defect of the prosthetic material. Details of scanning electron microscopy of the prosthesis, clinical presentation, angiography, and pathological findings with treatment also are discussed.

Dacron vs vein for femoropopliteal arterial bypass. Should the saphenous vein be spared?

The increasing need for the saphenous vein to bypass lesions of the coronary and other small arteries prompts a reconsideration of its routine use for femoropopliteal bypass. Evaluation after five years in 124 consecutive patients (135 procedures) demonstrated no significant difference in overall definitive patency between venous grafts (63%) and Dacron prostheses (65%). Dacron prostheses were avoided when below-knee anastomoses were required, but when the distal anastomoses were made above the knee, the five-year patency for veins and Dacron was equal (67%). Although the quality of the distal runoff influenced the long-term patency, effects were similar for veins and for Dacron. The data support the use of Dacron prostheses for femoropopliteal bypass proximal to the knee joint, allowing preservation of the saphenous vein for possible use elsewhere.

Primary osteogenic sarcoma of the heart.

The clinical course of a 17-year-old boy with primary osteogenic sarcoma of the left atrium with partial obstruction of the mitral valve and the right pulmonary veins is described. After operative removal of the tumor, echocardiography documented its rapid recurrence. Despite two subsequent open-heart operations and adjuvant chemotherapy and radiotherapy, the patient died twenty-one months after the initial symptoms. Previous reports of such tumors are reviewed, and technical difficulties of removal are discussed.

Atrioventricular sequential pacemakers: indications, complications, and long-term follow-up.

Our experience with 32 patients with atrioventricular (AV) sequential pacemakers and an average follow-up of 22 months is presented. The pertinent literature and physiology are reviewed. The indications, advantages, and complications of AV sequential pacemakers are analyzed. Half of the patients required bifocal pacing for control of arrhythmia alone, while half required control of arrhythmia associated with congestive heart failure due primarily to a noncompliant left ventricle. It is anticipated that the hemodynamic improvement occurring as a results of AV sequential pacing will increase the use of this mode of cardiac pacing in selected patients.

Preoperative chemotherapy and radiation therapy for stage IIIa carcinoma of the lung.

Thirty-six patients with stage IIIa histologically proven non-small cell carcinoma (T3 N2 or T2 N2) underwent concomitant radiation therapy and chemotherapy before pulmonary resection. The therapy consisted of two cycles of continuous infusion of cis-platinum, 25 mg.m-2.day-1 (days 1 through 4) every 4 weeks and concomitant irradiation, 55 Gy, of the tumor and mediastinum. Two to 3 weeks after treatment, the patients were reevaluated for thoracotomy and pulmonary resection. Five patients were found to have unresectable lesions. Thirty-one patients had complete resection, 27 by radical pneumonectomy and 4 by radical lobectomy, giving a resectability rate of 86%. Complete sterilization of lung tumor and mediastinal nodes proven histologically was achieved in 10 patients (28%) and 17 patients (47%). The 3-year survival rate is 61.7% for patients who had resection. Median follow-up is 27 months (range, 6 to 61 months). The preliminary study indicates that preoperative cis-platinum and concomitant radiation therapy is tolerated, appears to increase resectability, and may improve survival in patients with stage IIIa lung cancer.

Factors affecting long-term survival of patients with bronchogenic carcinoma.

From January 1963 to December 1968, 148 patients underwent thoracotomy for bronchogenic carcinoma. In 123 patients either lobectomy or pneumonectomy was performed (resectability rate of 84 per cent). The over-all operative mortality was 3.4 per cent. Forty of the patients undergoing resection (34 per cent) are alive and free of cancer five years after surgery. Tumor size, nodal involvement, cell type, location, symptoms, and extent of surgery were studied in relation to the long-term results. Five year survival was directly related to the size of the tumor and the extent of nodal involvement. No patients with mediastinal nodal involvement or with lesions larger than 7 cm in diameter were among the long-term survivors.

Survival and limb salvage in patients with infected arterial prostheses.

A series of 590 cases with a 2.5% rate of infection of arterial prostheses is presented. When one of the anastomoses was in the inguinal area, the incidence of prosthetic infection was higher. Two infections not involving the anastomotic site healed with conservative management. The three patients with aortoduodenal fistulas died. The long-term survival was 62%, and the amputation rate was 31%. During the last two years, a more aggressive surgical approach of total removal of the infected prosthesis and its replacement with an extraanatomic bypass has been instituted. With this approach, only one death and one amputation has occurred in six patients.

The treatment of patients with recurrent ventricular fibrillation.

During the four year period from 1972 to 1975, eleven patients, eight with recurrent and three with first attacks of ventricular fibrillation, underwent aortocoronary bypass graft and/or resection of ventricular aneurysm. All patients had old myocardial infarction from seven weeks to six years. Left ventricular angiography demonstrated discrete aneurysm of the anterior wall of the left ventricle in nine of the patients and akinesis or hypokinesis of the anterior and posterior wall of the left ventricle in the remaining two. Coronary angiography was carried out in ten patients and revealed significant disease of the left anterior descending and right coronary arteries in ten and nine patients, respectively. There was no operative mortality, and there were two late deaths. Eight patients have improved significantly and have had no further sign of ventricular irritability. The present study indicates that aortocoronary bypass graft and/or resection of ventricular aneurysm is an effective method of therapy for patients with repeacted ventricular fibrillation who have ventricular aneurysm and ischemic heart disease.

Twelve-year follow-up of trimodality therapy for stage IIIA non-small cell lung cancer.

Non-small cell carcinoma of the lung (NSCLC) remains a formidable problem with a poor 5 year survival for stage III patients. Between 1985-1991, 53 patients with biopsy proven Stage IIIA NSCLC were treated with a trimodality treatment program. Chemotherapy, consisting of two cycles of continuous infusion cisplatinum and bolus etoposide, was started on days 1 and 28 of radiation therapy (54 Gy + 5.4 Gy boost in 6 1/2 weeks) directed to the lung primary and mediastinum. Four to six weeks after radiation therapy, patients underwent thoracotomy for radical pulmonary resection. Three weeks post surgery, the same chemotherapy was repeated for two cycles every 28 days. Forty-seven out of 53 patients (89%) achieved a clinical response after induction chemoradiation. Of these 47 patients, 33 underwent thoracotomy and 27 of them completed surgical resection. Treatment was well-tolerated. All surviving patients have no or minimal respiratory toxicities. With a median follow up of 9 1/2 years, surgically treated patients have a disease specific survival of 42% at 12 years. One patient survived beyond 9 years without surgery. Concurrent chemoradiation plus surgery is well tolerated and offers patients with Stage IIIA NSCLC significant long term survival benefit and warrants further assessment in a randomized trial.