J. Gordon Scannell

Basis for new strategies in postoperative radiotherapy of bronchogenic carcinoma

In order to improve our understanding of the role of postoperative radiotherapy and to search for new strategies in the management of N1 N2 T3 stage carcinoma of the lung, we analyzed results of treatment in 148 of 166 patients who were registered at the Massachusetts General Hospital Tumor Registry from 1971–1977 with a pathological diagnosis of N1 N2, T3 carcinoma of the lung after pulmonary resection. Ninety-three patients received postoperative radiotherapy and another 55 were followed without further treatment. Patients with adenocarcinome showed significant improvement of survival by postoperative radiotherapy; actuarial NED (no evidence of disease) survival rates were 85 % and 51 % at 1 year, and 43 % and 8 % at 5 years for S + RT (patients treated with surgery plus postoperative radiotherapy) and S (patients treated with surgery only) groups, respectively, (P < 0.01). The brain was the most common site of failure in adenocarcinoma, 53 % and 58 % of all failures occurred in the brain in S and S + RT groups suggesting elective whole brain irradiation in a future trial. For the sguamous cell carcinoma group, there was no improved survival in the irradiated patients, actuarial NED survival rates were 63 % for both S + RT and S groups at 2 years, and 42 % and 33 % for S + RT and S groups at 4 years. These figures should be considered in the light of the following: In 52 % (24/46) of S + RT vs. 27% (8/29) of S group, disease was in N2, T3 stages. Regional recurrence was the most common failure in squamous cell carcinoma; 76% (13/17) and 45% (10/22) of all failures were in the regional area in S and S + RT groups. Regional failure in S + RT group was noted with radiation dose up to 5000 rad (TDF 82) which suggests radiation dose higher than 5000 rad in future trial.

Role of staging in prognosis and management of thymoma

Eighty-five patients operated on for thymoma from 1972 to 1989 were evaluated, 32 with myasthenia gravis and 53 without. Masaoka staging revealed stage I disease in 45 (53%), stage II in 23 (27%), stage III in 14 (16%), and stage IVa in 3 (4%). There was no operative mortality. Actuarial survival at 10 years was 63.7% for all patients: 78.3% for those in stage I, 74.7% for those in stage II, and 20.8% for those in stage III. There was no recurrence in patients in stage I. Mediastinal recurrence developed in 4 patients in stage II considered to have noninvasive disease by the surgeon. It is recommended that all patients be followed up for a minimum of 10 years and that all patients in stages II and III receive postoperative radiotherapy. The presence of myasthenia gravis is no longer considered as an adverse factor in survival.Eighty-five patients operated on for thymoma from 1972 to 1989 were evaluated, 32 with myasthenia gravis and 53 without. Masaoka staging revealed stage I disease in 45 (53%), stage II in 23 (27%), stage III in 14 (16%), and stage IVa in 3 (4%). There was no operative mortality. Actuarial survival at 10 years was 63.7% for all patients: 78.3% for those in stage I, 74.7% for those in stage II, and 20.8% for those in stage III. There was no recurrence in patients in stage I. Mediastinal recurrence developed in 4 patients in stage II considered to have noninvasive disease by the surgeon. It is recommended that all patients be followed up for a minimum of 10 years and that all patients in stages II and III receive postoperative radiotherapy. The presence of myasthenia gravis is no longer considered as an adverse factor in survival.

Thromboembolic Complications of Prosthetic Cardiac Valves

Our experience with thromboembolism in 283 patients surviving at least 1 week following insertion of Starr-Edwards valves is reported here. Of these patients, 155 underwent aortic valve replacement, 21 had aortic valve replacement with mitral commissurotomy, 80 had mitral replacement, and 27 had both aortic and mitral valve replacement. Complete follow-up data were obtained on all patients, from 3 to 49 months following surgery (mean, 20 months).Thromboembolic episodes developed in 68 of the 283 patients (24%). Seventeen of these 68 patients died (25%), three had serious neurological residual (4%), but the majority of survivors recovered completely.Use of long-term anticoagulant therapy appeared to reduce incidence of embolic episodes only in patients with aortic valve replacement. Control of anticoagulant therapy (good, fair, or poor) bore no relationship to incidence of embolism within this group. Anticoagulant therapy in untreated patients with emboli reduced the incidence of subsequent thromboembolism. Hemorrhagic complications occurred in 23 patients (8%); one died.Thromboembolism is a serious complication of prosthetic valves. Its incidence in some patients is reduced but not eliminated by anticoagulant therapy.

Combined Approach to “Dumbbell” Intrathoracic and Intraspinal Neurogenic Tumors

The unexpected finding of an extension of a neurogenic tumor from the thorax through the spinal foramen into the neural canal complicates its removal. Serious neurological complications may result from a two-stage approach, whether done first through the thorax or neural canal. Vertebral tomography or computed tomographic scanning reveals enlargement of a spinal foramen in advance of operation. Myelography confirms the probable presence of an intraspinal component. Four patients have been operated on using an approach designed to allow wide posterolateral thoracotomy and concomitant laminectomy for single-stage removal of the entire tumor. In 3 patients the diagnosis was schwannoma and in 1, neurofibroma. All had good results.

Severe Mitral Regurgitation Secondary to Ruptured Chordae Tendineae

Fifteen cases of severe mitral regurgitation secondary to ruptured chordae tendineae have been reviewed, eight of whom underwent open-heart surgery to correct their lesions. Three patients are living at this time with two being markedly improved. Cardiac catheterization was performed in six prior to surgery.Progressive deterioration within the year following the onset of difficulty or sudden worsening of previous cardiac symptoms characterized the usual clinical course. The apical systolic murmur, always loud, was conspicuously harsh and radiated to the base of the heart, simulating aortic stenosis when the mural cusp was ruptured. Although strongly suggesting the diagnosis, the sudden onset of an apical systolic murmur could be documented in only three instances. The presence of a small left atrium radiographically with tall left atrial “v” waves and marked reflux of contrast material into a paradoxically pulsating left atrium also pointed to the correct diagnosis.Various technics of surgical repair and problems influencing survival of patients in the present series are discussed.

Survival After Starr-Edwards Aortic Valve Replacement

A series of 507 patients who underwent Starr-Edwards aortic valve replacement is reported. Four hundred fifty-five of these patients were adequately followed an average of 36 months. Of this number, 339 patients (75%) are alive, and 116 (25%) have died. There was an operative mortality of 10.8% and a late mortality of 13.4%. Patients with mixed aortic stenosis and regurgitation had a significantly lower cumulative mortality than patients with pure stenosis or regurgitation. Complications related to the valvular prosthesis itself were frequent. Although the great majority were minor, prosthetic complications caused a significant number of deaths and considerable morbidity. Myocardial disease was the other significant limiting factor in survival. Preoperative cardiac index and functional classification were valuable in predicting long-term survival, but age at time of surgery and type of preoperative symptoms were of lesser prognostic value.

Fever, splenomegaly and atypical lymphocytes. A syndrome observed after cardiac surgery utilizing a pump oxygenator.

DURING the past year we have encountered 6 examples of an unusual syndrome characterized by fever, splenomegaly and atypical lymphocytes, occurring in patients who have undergone openheart operatio...

Pulmonary resection for metastases from gynecologic cancers: Massachusetts General Hospital experience, 1943-1982.

Fifteen patients with pulmonary metastases from gynecologic cancers have been evaluated and treated surgically at the Massachusetts General Hospital from 1943 to 1982. These women have had primary tumors involving the cervix (6), endometrium (3), and ovary (2) as well as uterine sarcomas (2) and choriocarcinomas (2). Two-year Kaplan-Meier survival for this group was 71%; the corresponding survival at 5 years was 36%. No hospital mortality was encountered. Patients with solitary lesions of less than 4 cm diameter appeared to have the most favorable prognosis in the group. A prolonged time to initial recurrence (latent period) of greater than 36 months was associated with improved survival and there was a 60% survival among patients with latent periods of 60 months or more. An aggressive approach to resection of pulmonary metastases in selected patients provides gratifying palliation for the majority of women and long-term cure in a significant minority.

Atypical patent ductus arteriosus with absence of the usual aortic-pulmonary pressure gradient and of the characteristic murmur.

Abstract The clinical criteria for the diagnosis of patent ductus arteriosus are well known and are, in the vast majority of cases, sufficient to establish the diagnosis without recourse to cardiac catheterization or to angiocardiography. Of these criteria, a continuous machinery murmur best heard at the left of the upper sternum has been considered typical of patent ductus and is rarely of other origin (i.e., arteriovenous aneurysm in the same area). However, the earlier insistence that this typical murmur must be present in order to justify surgical exploration1,2 has proved untenable. Furthermore, it has been pointed out3,4 that in infancy or with congestive heart failure a patent ductus may be present with-out murmurs. Several proved cases3,5 have been reported in which only systolic murmurs not continuing into diastole were found. Why does a patent ductus arterious occasionally fail to give rise to a continuous murmur? Burchell5 suggested that in these cases the usual aortic-pulmonary pressure gradient may be absent during diastole or during the entire cardiac cycle. However, no data bearing on this point have thus far been available. In this paper we present two cases of patent ductus arteriosus in children who did not exhibit the classic machinery murmur. In the preoperative evaluation of these patients, cardiac catheterization was helpful in making the diagnosis and, in one of the cases, furnished data which satisfactorily explained the lack of typical physical signs.

Respiratory and Circulatory Studies of Patients with Mitral Stenosis

Sixteen patients with severe mitral stenosis have been studied by means of cardiac catheterization, ventilatory and respiratory tests. A decrease in the oxygen diffusing capacity and an increase in venous admixture were observed in a majority of the cases. The degree of pulmonary arterial and arteriolar abnormality observed in lung biopsies failed to correlate with the pulmonary arteriolar resistances calculated from the hemodynamic data. It is suggested that reversible vasoconstriction plays an important role in the pathogenesis of the pulmonary hypertension associated with mitral stenosis.