Does HIPE data capture the complexity of stroke patients in an acute hospital setting?

The Hospital Inpatient Enquiry (HIPE) system is currently used as a principle source of national data on discharges from acute hospitals. The Casemix Programme is used to calculate funding for patient care (HIPE activity and Specialty Costs Returns). Th coding is usually undertaken by clerical personnel. We were concerned that the medical complexity of our stroke patients was not captured by the process. The aims of this study were to compare activity coded by HIPE coding staff and medical staff in consecutive stroke patients discharged from the hospital. One hundred consecutive discharged patients with stroke as primary diagnosis were coded by clerical staff [usual practice] and by medical staff. We compared the coding and any differences. We calculated the financial comparison of subsequent differences in Diagnostic Related Groups (DRGs) and Relative Values (RVs). Clinician coded DRGs resulted in a higher assigned RV in 45 cases. The total RV value for HIPE using clerical coding was 595,268.94 euros and using medical coding was 725,252.16 euros. We conclude that medical input is useful in detailing the complications arising in stroke patients. We suggest that physicians should assist in the HIPE coding process in order to capture clinical complexity, so that funding can be appropriately assigned to manage these complex patients.

Surgical treatment of pleural mesothelioma.

From 1939 through 1981, 170 patients were seen and treated for pleural mesothelioma. Twenty-one tumors were benign, 47 were fibrosarcomatous, and 102 were epithelioma. Resection was the main mode of treatment in benign and fibrosarcomatous mesothelioma. Treatment of diffuse epithelial mesothelioma presented the greatest challenge. Surgical therapy, radiation therapy, and chemotherapy were used in combination in these patients. The review of our patients treated prior to 1972 had shown no benefit from including pulmonary resection in the surgical treatment of these tumors. Since then, all patients with diffuse mesothelioma were treated by pleurectomy without pulmonary resection. Both internal and external radiation therapy were also used to enhance local control. Forty-nine percent of patients with epithelial mesothelioma lived 1 year. The median survival in patients whose disease was controlled by these methods was 21 months. Despite the poor prognosis in malignant mesothelioma, better controlled by these methods was 21 months. Despite the poor prognosis in malignant mesothelioma, better survival was achieved when the treatment included operation combined with radiation and chemotherapy.

Pulmonary resection in metastatic carcinoma.

Resection of pulmonary metastases in osteogenic sarcoma has been reported by us to result in a five-year survival rate of 27 percent. A later report of surgical management of pulmonary metastases from all types of sarcomas showed a five-year survival rate of 26%. This report reviews the experience with 188 patients treated surgically for pulmonary metastasis from a variety of carcinomas, demonstrating that a similar rate of survival is obtainable by surgical excision of these metastases. A total of 188 patients underwent 242 thoractomies for metastatic pulmonary carcinomas. The most frequent sites of origin were the colon, melanoma, breast, and testicular carcinoma. Surgical treatment of these metastases is justified when the following criteria are adhered to: (1) primary site controlled or controllable; (2) no extrapulmonary metastatic sites demonstrable; (3) good surgical risk; and (4) no effective treatment available by nonsurgical means.

Chest wall invasion in carcinoma of the lung. Therapeutic and prognostic implications.

From 1974 through 1983, 125 patients underwent operation at Memorial Sloan-Kettering Cancer Center for non-small cell carcinoma of the lung invading the chest wall. (Excluded are those with superior sulcus tumors or distant metastases at presentation.) Eighty patients were male and 45 were female. Ages ranged from 33 to 88 years (median 60 years). Histologically, the tumors were epidermoid carcinoma in 46%, adenocarcinoma in 46%, and large cell carcinoma in 8%. All patients underwent thoracotomy (pneumonectomy 19, bilobectomy seven, lobectomy 75, wedge resection 10, and no pulmonary resection 14), with an operative mortality of 4%. At thoracotomy, mediastinal lymph node dissection was routinely performed, and the postsurgical stage was T3 N0 M0 in 53%, T3 N1 M0 in 13%, and T3 N2 M0 in 34%. Extrapleural resection was performed in 66 patients. En bloc resection of chest wall and lung was performed in 45 patients with an operative mortality of 2%. Complete resection of tumor was possible in 77 patients (62%). Extension of tumor beyond the parietal pleura significantly decreased resectability. The median survival of 48 patients having incomplete resection was 9 months, despite perioperative interstitial and external radiation. The actuarial 5 year survival rate (Kaplan-Meier) of 77 patients having complete resection was 40%. This percentage was not significantly influenced by the patient's age or sex or by tumor size or histologic type. Lymphatic metastases significantly reduced survival, with a 5 year actuarial survival rate of 56% for patients with T3 N0 M0 disease and 21% for those with T3 N1 M0 or T3 N2 M0 disease (p = 0.005). The extent of tumor invasion of the chest wall appeared to influence survival, but in the absence of lymphatic metastases the difference at 5 years was not significant. Complete resection offers a significant chance for long-term survival in lung cancer directly extending into parietal pleura and chest wall. Extrapleural resection or en bloc chest wall resection can be performed with a low operative mortality and an expected 5 year survival in excess of 50% in the absence of lymphatic metastases.

Medical tumors of the chest wall. Solitary plasmacytoma and Ewing's sarcoma.

UNLABELLED: Primary solitary plasmacytoma and Ewing's sarcoma of the chest wall are relatively uncommon tumors, and data concerning treatment and results are sparse. To assess the results of therapy we reviewed our 40-year experience. METHODS: Records of 24 patients with solitary plasmacytoma and 62 with Ewing's sarcoma arising in the chest wall who were admitted to our institution from 1949 to 1989 were reviewed. RESULTS: In the group with plasmacytoma (n = 24), ages ranged from 35 to 75 years (median 59 years); male/female ratio was 2.4:1. The presenting complaint was pain or mass or both in 92% (22/24). Primary therapy was local only in 5 (resection in 3, radiotherapy in 2), chemotherapy in 16 (resection in 5, radiotherapy in 10, and chemotherapy alone in 1); 3 patients did not receive therapy. Multiple myeloma developed subsequently in 75% (18/24). Overall 5-year survival was 38% (median 56 months). Age, sex, site of primary tumor, and local therapy did not significantly impact on survival. Ages in the patients who had Ewing's sarcoma (n = 62) ranged from 2 to 39 years (median 16 years); male/female ratio was 1.6:1. Presenting complaint was pain or mass or both in 98% (61/62). Primary therapy was local in 17 (resection in 7, radiotherapy in 7, resection plus radiotherapy in 3) and chemotherapy in 45 (plus resection in 29, resection and radiotherapy in 10, and radiation therapy alone in 3). Overall 5-year survival was 48% (median 57 months). Age, sex, and site of primary tumor did not significantly impact on survival. Patients in whom distant metastases developed (n = 48) had a significantly decreased survival (5 year, 28%) compared with those who did not have metastases (n = 14; 5 year, 100%). CONCLUSION: Plasmacytoma of the chest wall, even if solitary at presentation, should be considered a systemic disease, and therapy should be directed as such. For Ewing's sarcoma, although resection or radiotherapy may offer local control, because of the prevalence of distant metastases (77%), systemic therapy should be considered an integral part of treatment.

Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer. Impact of magnetic resonance imaging.

UNLABELLED: We designed a prospective study to evaluate the accuracy of magnetic resonance imaging in distinguishing a benign from a malignant adrenal mass in patients with otherwise operable non-small-cell lung cancer. METHODS: Potentially operable non-small-cell lung cancer was prospectively staged. If a unilateral adrenal mass was found by computed tomographic scanning, respiratory compensated and cardiac gated thin section magnetic resonance imaging of the adrenal glands was done. One radiologist interpreted the magnetic resonance imaging scan blinded and, on the basis of the relative signal strengths of the T1- and T2-weighted images, judged whether the adrenal mass was benign or malignant. The patients then underwent a percutaneous needle biopsy of the adrenal mass, if technically feasible. If the result of the needle biopsy was nondiagnostic or if the biopsy was not feasible, an adrenalectomy through a posterior approach was performed. RESULTS: Twenty-seven patients with a unilateral adrenal mass entered the study-11 men and 16 women whose ages ranged from 42 to 75 years (median 58 years). Four patients had epidermoid and 23 adenocarcinoma of the lung. The clinical locoregional stage was I in 9, II in 1, IIIA in 16, and IIIB in 1. Twenty-five completed the magnetic resonance imaging procedure. Five adrenal masses (19%) were metastatic non-small-cell lung cancer (adenocarcinoma = 4, epidermoid = 1); 22 masses (81%) were benign (adenoma = 20, hyperplasia = 2). There were no significant differences in age, sex, histologic type, or locoregional stage between those with a benign versus a malignant mass. However, the malignant masses were significantly larger (3.8 +/- 1.9 cm; range 2.5 to 7.1; median 3.1) than the benign masses (2.0 +/- 0.4 cm, range 1.2 to 2.8; median 2.0) (p < 0.001). Among those having magnetic resonance imaging (n = 25), the technique correctly predicted a malignant mass in the four patients with a histologically confirmed metastasis from non-small-cell lung cancer. However, among the 21 histologically benign masses, the magnetic resonance imaging was interpreted as benign in 5, malignant in 14, and indeterminate in 2. Therefore, although the false-negative rate was 0%, the false-positive rate was 67%. CONCLUSION: Most adrenal masses in patients with otherwise operable non-small-cell lung cancer are benign. Currently available magnetic resonance imaging methods cannot replace biopsy.

Treatment and prognosis in bronchial carcinoids involving regional lymph nodes.

From 1953 to 1992, 25 patients were surgically treated for bronchial carcinoids with metastases to regional lymph nodes (N1 or N2). The tumors were located centrally, involving main or lobar bronchi in 12 patients and were peripheral in 13. Histologically, 12 of the carcinoids were classified as typical and 13 as atypical (neuroendocrine carcinoma). Pneumonectomy was performed in 11 patients, sleeve lobectomy in one, lobectomy in seven and bilobectomy in six. A formal mediastinal lymph node dissection was done in 20 patients. At final staging, 10 had N1 disease and 15 had N2. No adjuvant treatment was given to the 10 patients with N1 disease. External radiation therapy was given after the operation to 9 of 15 patients with N2 disease. The overall 5-year survival (Kaplan-Meier) was 75% (median 62 months). No difference in survival was found between patients with N1 or N2 disease. However, survival and recurrence rate differed between typical and atypical carcinoids. In typical carcinoids, the 5-year survival was 92% and, in atypical carcinoids, it was 60% (p = 0.02). We conclude that complete resection for bronchial carcinoids results in long-term survival despite the presence of regional lymph node metastases. Recurrence appears to depend more on cell type than nodal status. Postoperative radiation therapy does not appear to be beneficial.

Vocal cord medialization for unilateral paralysis associated with intrathoracic malignancies.

Patients with unilateral vocal cord paralysis from intrathoracic malignancies may have significant dysfunctions of speech, swallowing, ventilation, and effective coughing as a result of inadequate compensation of the nonparalyzed cord. In patients with already compromised pulmonary function, aspiration can be a life-threatening event. Sixty-three patients with intrathoracic malignancies required surgical correction of vocal cord paralysis. Primary pathology included lung cancer (49), esophageal cancer (nine), and miscellaneous tumors (five). Symptoms included hoarseness (62), dyspnea (21), aspiration (26), weight loss (19), dysphagia (14), and pneumonia (14). The surgical procedures included medial displacement of the vocal cord with silicone elastomer (48), temporary Gelfoam injection (seven), and Teflon (polytetrafluoroethylene) injection (eight) to move the affected cord to a medial position. In 11 patients, the operation was performed in the acute postoperative setting to improve pulmonary toilet. Symptomatic improvement was noted in the following proportions of affected patients: hoarseness, 92%; dyspnea, 90%; dysphagia, 93%; aspiration, 92%; pneumonia, 93%; and weight loss, 47%. Overall success rate of the intervention was 57 of 63 patients (90%). All 11 patients treated in the acute setting had immediate improvement. A variety of complications occurred in 17% of patients. Surgical management of vocal cord paralysis in patients with intrathoracic malignancies prevents life-threatening pulmonary complications in the acute postoperative setting. In chronic situations, it provides patients with improved speech, swallowing, and pulmonary function, resulting in improved quality of life, even for patients not cured of their disease.

Predictors of survival in malignant tumors of the sternum.

From 1930 to 1994, 54 patients with primary malignant tumors of the sternum were seen. Fifty patients were first seen with a mass, and one half of them also had pain in the sternal region. Two patients had no symptoms at presentation. Among 39 solid tumors were 26 chondrosarcomas, 10 osteosarcomas, 1 fibrosarcoma, 1 angiosarcoma, and 1 malignant fibrous histiocytoma. Of these, 25 were low-grade and 14 were high-grade tumors. Among 15 small cell tumors were 8 plasmacytomas, 6 malignant lymphomas, and 1 Ewing's sarcoma. Partial or subtotal sternectomy was done in 37 patients and total sternectomy in 3. Of the remaining 14 patients, 3 had local excision; 10 had external radiation or chemotherapy without operation, or both; and 1 had no treatment. All but one patient treated by wide resection (N = 40) had some form of skeletal reconstruction of the chest wall defect. Thirty-one (78%) underwent repair with Marlex mesh, and in 25 this was combined with methyl methacrylate. The skin edges were closed per primum in 32 patients; 8 required muscle, omentum, or skin flaps. Resection in chondrosarcomas yielded a 5-year survival (Kaplan-Meier) of 80% (median follow-up, 17 years). The 5-year survival in osteosarcomas was 14%. Resection was curative in 64% of low-grade sarcomas but in only 7% of high-grade sarcomas. In small cell tumors, resection and radiation were helpful for local control; all failures were a result of distant metastases. We conclude that primary sarcomas of the sternum though uncommon are potentially curable by wide surgical excision. With rigid prostheses to repair the skeletal defects, the surgical complication rates are low. Overall survival after complete surgical resection is related to tumor histologic type and grade.

Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement: a randomized clinical trial.

UNLABELLED: Delayed gastric emptying after esophagogastrectomy can pose a significant early postoperative problem. Because erythromycin, which stimulates the gastric antral and duodenal motilin receptor, has been shown to significantly increase gastric emptying in patients with diabetic gastroparesis, we decided to evaluate its effect on gastric emptying after esophagogastrectomy. METHODS: Twenty-four patients (18 men and six women, age range 41 to 79 years, median 66 years) were randomized to receive either erythromycin lactobionate (200 mg in 50 ml normal saline solution intravenously) (n = 13) or placebo (50 ml normal saline solution intravenously (n = 11) 11 days after esophagogastrectomy (with pyloric drainage procedure). After erythromycin or placebo had been infused over a 15-minute period, patients ingested a solid meal (scrambled egg with bread) labeled with technetium 99m sulfur colloid (500 microCi) over approximately 15 minutes. Dynamic images of the stomach were then acquired over 90 minutes in the supine position by gamma imaging. Results were expressed as percentage of counts retained in the stomach (percent gastric retention) over time. RESULTS: There were no side effects of erythromycin. In the placebo group, the mean percent of radiolabeled meal retained in the stomach after 90 minutes was 88%, which was significantly greater than in the erythromycin group, 37% (p < 0.001). In addition, analysis of covariance demonstrated that the rate of gastric emptying (slope of the line) was significantly greater in the erythromycin-treated group than in the placebo group (p < 0.0001). CONCLUSION: Early satiety after esophagogastrectomy may be due to delayed gastric emptying and not due to a decrease in the gastric reservoir. Intravenous erythromycin significantly improves gastric emptying in patients after esophagogastrectomy by stimulating gastric motility.

Local recurrent mammary carcinoma failing multimodality therapy. A solution.

Chest wall recurrence following radiation and hormonal therapy is an uncommon but serious and disabling condition. A chest wall ulcer secondary to treatment for recurrence also presents the same dilemma. Over the past 35 years, the Thoracic Service at our institution has treated 35 patients for these problems by surgical resection and reconstruction. Eight patients were seen after the first recurrence, six after the second, ten after the third, and ten after the fourth. One patient had chest wall resection with mastectomy when recurrence followed radiation therapy. Following resection of the tumor, 21 patients had reconstruction using mesh or a mesh "sandwich." There were no operative deaths and no respirator need. Twenty patients are alive from five to 120 months, with a median of 50 months. One of 35 patients had chest wall recurrence. Surgical resection of recurrent mammary carcinoma resistant to all other therapy is a viable alternative for both palliation and cure.

Lung resection for colorectal metastases. 10-year results.

BACKGROUND: Metastasectomy for colorectal carcinoma to the lung is controversial. We analyzed results of this approach to justify its credibility. METHODS: We studied 144 patients by retrospective review after complete resection of lung metastases from colorectal cancer from 1965 through 1988. Patient selection and prognostic factors influencing survival were analyzed. Survival was analyzed by the Kaplan-Meier method, and comparisons were made by log-rank analysis. RESULTS: A total of 170 thoracotomies were performed in 144 patients. The overall 5- and 10-year survival was 40% and 30%, respectively. Those patients undergoing complete resection of their metastases survived significantly longer than those undergoing incomplete resections. CONCLUSION: It appears that resection of pulmonary metastases from colorectal carcinoma translates into long-term survival benefit.

The changing role of surgery for pulmonary metastases.

From 1960 to 1977, 663 resections for pulmonary metastases were performed in 448 patients, 202 with a sarcoma and 246 with a carcinoma. The majority of the patients (70%) had wedge resection or segmentectomy. Operative mortality was 1.0% (7 patients in 663 thoracotomies). With the increased effectiveness of chemotherapy in some specific areas--osteogenic sarcoma and carcinoma of the testis, breast, and colon--the role of surgery is changing. Surgery is now indicated to establish the histology of a solitary lesion, resect metastases unresponsive to chemotherapy, and to reclassify lesions that stabilize but do not disappear totally with chemotherapy.

The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor.

Median sternotomy has been the accepted approach for dealing with mediastinal tumors or bilateral pulmonary disease, but exposure to the lower lobes and to mediastinal tumors extensively involving a hemithorax is often limited. Based on the reported experience from double-lung transplantation, we explored the use of clamshell incisions for these difficult problems. From March 1991 to December 1993, we prospectively studied the utility of clamshell incisions in 90 patients for the following indications: bilateral pulmonary metastases (62 patients), primary lung carcinoma with mediastinal involvement (13 patients), primary tumors of the mediastinum (14 patients), and mesothelioma (1 patient). Bilateral anterior thoracotomies with a transverse sternotomy (clamshell incision) were employed in 71 patients and a unilateral anterior thoracotomy with partial or complete median sternotomy (hemiclamshell incision) was used in 19 patients. For closure, we used pericostal sutures and sternal wires, usually augmented by sternal K-wire stents or Steinmann pins to prevent sternal override. Exposure to all areas of the mediastinum, pericardium, pleura, and lung was excellent. Specifically, the clamshell incision afforded markedly better access to lower lobe disease and hemithoracic extension of mediastinal disease than that possible with median sternotomy. There were no deaths or significant morbidity, and all patients tolerated the incisions well without mechanical respiratory difficulties. There was one wound infection. There was no late sternal override and the cosmetic results were found to be excellent during a follow-up of 2 to 33 months. We conclude that clamshell incisions constitute an improved surgical approach for the management of bilateral pulmonary or combined pulmonary and mediastinal disease.

Influence of surgical resection and brachytherapy in the management of superior sulcus tumor.

We analyzed the results of surgical treatment of all patients presenting with untreated superior sulcus tumors between 1974 to 1991 inclusive at our institution. Most patients received preoperative radiotherapy. We attempted to analyze the influence of surgical resection and intraoperative brachytherapy in obtaining locoregional control and disease-free survival. One hundred twenty-four patients underwent thoracotomy and 100 patients underwent resection. The overall 5-year survival rate was 26% for all patients and 30% for resected patients. Those patients receiving a complete resection achieved a 41% 5-year survival. The best single group were those patients undergoing a lobectomy (versus wedge resection) and en-bloc chest wall resection (60% 5-year survival). We were unable to demonstrate an advantage for the use of intraoperative brachytherapy in those patients with complete resection. For those patients with incomplete resection, the use of brachytherapy combined with preoperative or postoperative external radiation therapy resulted in a 9% 5-year survival. Locoregional failure was significant both in patients with complete resection and in patients with incomplete resection. Adverse prognostic factors included Horner's syndrome, N2 and N3 disease, T4 disease, and incomplete resections. In superior sulcus tumors, every attempt to completely resect the tumor by en-bloc chest wall resection combined with lobectomy and adequate nodal staging remains the surgical treatment of choice together with either preoperative, postoperative, or "sandwich" external radiation therapy.

Management of non-small cell lung cancer with direct mediastinal involvement.

The results of surgical treatment were analyzed for 102 patients with non-small cell lung cancer invading the mediastinum by direct extension (T3 and T4), but those who had N2 disease were excluded to eliminate the adverse prognostic effect of this nodal subset. The histologic type was squamous cell carcinoma in 55 patients, adenocarcinoma in 40, and large cell carcinoma in 7. There were 58 T3 tumors invading the mediastinal pleura or fat, phrenic nerve, vagus nerve, pericardium, or pulmonary vessels and 44 T4 lesions invading the aorta, vena cava, esophagus, trachea, spine, or atrium. Resection included lobectomy (33 patients), pneumonectomy (32 patients), and limited resection (6 patients). Complete resection was possible in 46 patients and incomplete or no resection was possible in 56. The interstitial implantation of radioactive sources to control residual tumor also was undertaken in 43 patients. The operative mortality was 6%. The overall survival (Kaplan-Meier) was 19% at 5 years (median survival time, 18 months). Factors found to be significantly affect survival were complete resectability and the histologic type. With complete resection, the 5-year survival was 30% (p = 0.005). The 5-year survival in patients with adenocarcinoma or large-cell carcinoma was 30%, compared with 14% in patients with squamous cell carcinoma (p = 0.002). The extent of mediastinal involvement (T3 versus T4) influenced resectability and survival, and this approached statistical significance (p = 0.055). We conclude that most patients with non-small cell carcinoma and mediastinal invasion do poorly with primary surgical treatment.

Accuracy of lung imaging in metastases with implications for the role of thoracoscopy.

Thoracoscopy for wedge resection of lung metastases is rapidly increasing in frequency. This technique precludes bimanual palpation of the lung to locate additional lesions not seen on the surface. Finger palpation is inadequate. Implications regarding the failure to identify all metastases and the negative impact on long-term survival led us to review retrospectively the correlation between pathologic findings and imaging reports. One hundred forty-four patients who had resection of lung metastases from colorectal cancer were studied. All had chest roentgenograms and 72 had computed tomographic scans as well. Chest roentgenogram and computed tomographic reports differed in the number of nodules reported in 17 of 72 patients (24%). In 3 of 17 patients chest roentgenogram showed more nodules than computed tomography. Chest roentgenogram differed from pathologic findings at surgery in 57 of 144 patients (39%). Twenty-six of 57 patients (46%) had more lesions than chest roentgenogram detected and 31 had fewer. Computed tomographic scans differed from pathologic findings in 30 of 72 patients (42%). If one or two lesions were imaged, 12 patients had fewer cancers (some lesions were benign) and 18 had more cancers than computed tomography reported; computed tomographic scans erred 28% of the time. The inability to adequately palpate the entire lung using the thoracoscope alone markedly impairs the surgeon's ability to know if a resection of all lesions has been done. The validity of using thoracoscopy resection in the management of metastatic disease is seriously questioned other than for diagnosis.

Pleural mesothelioma.

Pleural mesotheliomas are uncommon tumors. Correct diagnosis of the benign variant is rarely made preoperatively, and resection is the treatment of choice and is curative. Malignant pleural mesotheliomas are locally aggressive and difficult to treat. They may be seen clinically as localized pleural tumors or as diffuse pleural disease with effusion and encasement of the lung and obliteration of the pleural space. The localized forms of malignant mesotheliomas are fibrosarcomatous. Their diagnosis and treatment do not differ from those for soft-part sarcomas seen elsewhere. Wide en-bloc excision is the treatment of choice and can be curative. The diffuse forms of malignant mesotheliomas are mainly epithelial. Treatment is generally unsatisfactory, and long-term survival is rare. Two surgical approaches are currently available: an extrapleural pneumonectomy and a pleurectomy with irradiation. The authors favor the latter approach because of its wider applicability, lower morbidity rate, and better survival advantage. Steps in selecting the best surgical mode of treatment are presented.

Thymoma: a multivariate analysis of factors predicting survival.

BACKGROUND: Despite complete surgical excision, malignant thymomas often recur with resultant death. We reviewed our series to determine which factors independently predict survival after surgical resection. METHODS: A retrospective analysis of patients operated on for thymoma between 1949 and 1993 at Memorial Sloan-Kettering Cancer Center was performed. Clinical data were collected from chart review. Only patients with a pathology report confirming the diagnosis of thymoma were included in this analysis. Kaplan-Meier survival curves were generated and comparisons of survival analyzed by log rank test. Multivariate analysis was performed by the Cox proportional hazard model. RESULTS: One hundred eighteen patients with thymoma underwent operation. There were 86 complete resections (73%), 18 partial resections (15%), and 14 biopsies (12%). By Masaoka staging, 25 patients were stage I (21%), 41 stage II (35%), 43 stage III (36%), and 9 stage IVa (8%). Overall survival was 77% at 5 years and 55% at 10 years. Tumor recurred in 25 (29%) of 86 completely resected thymomas. Stage of disease (p = 0.03) was the only independent prognostic factor affecting recurrence. By multivariate analysis, stage (p = 0.003), tumor size (p = 0.0001), histology (p = 0.004), and extent of surgical resection (p = 0.0006) were independent predictors of long-term survival. CONCLUSIONS: Patients with stage I disease require no further therapy after complete surgical resection. Neoadjuvant therapy should be considered for patients with large tumors and invasive disease.

Survival after resection of stage II non-small cell lung cancer.

From 1973 to 1989, 214 patients with stage II non-small cell lung cancer were treated by resection and complete mediastinal lymph node dissection. There were 116 adenocarcinomas and 98 squamous cancers. There were 35 T1 N1 and 179 T2 N1 tumors. Whereas T1 tumors were mainly adenocarcinomas (83%), this difference was not apparent in T2 lesions. Regardless of histology, half of the patients had a single involved N1 lymph node. Lobectomy was performed in 68% of the patients, pneumonectomy in 31%, and wedge resection or segmentectomy in 1%. Lobectomy was sufficient to encompass all disease in 34 of 35 T1 N1 tumors. Only 48 patients (22%) received postoperative external irradiation and 11 patients (5%) received chemotherapy. The overall 5-year disease-free survival was 39%. The best survival rates were in patients who had a single node involved and tumors 3 cm or less in diameter (48%). The pattern of recurrence differed by histology. Local or regional recurrence was more frequent in patients with squamous carcinoma whereas distant metastases were more commonly seen in adenocarcinomas (87%) with brain as the most frequent site (adenocarcinoma, 52%; squamous, 34%). It is concluded that in stage II carcinomas, resection remains the treatment of choice, that mediastinal lymph node dissection provides the most accurate staging, and that the best adjuvant treatment to improve survival is yet to be determined.