Joseph W. Lewis

Surgical approach to lung cancer with solitary cerebral metastasis: twenty-five years' experience

From 1960 to 1985, 41 patients underwent resection of a lung cancer and one or more brain metastases. There were 24 men and 17 women ranging in age from 40 to 71 years (average, 56 years). Cell type was adenocarcinoma in 19 patients, squamous in 16, small cell in 4, and large cell in 2. Wedge resection was performed in 4 patients, lobectomy in 20, pneumonectomy in 14, and bilobectomy in 3. Brain irradiation was used for 25 patients (61%). To date, the longest survival is 18.3 years after craniotomy; mean survival is 2.3 years +/- 3.8 (+/- standard deviation). Survival was 55 +/- 7.9% (+/- standard error) at 1 year, 31 +/- 7.4% at 2 years, 21 +/- 6.5% at 5 years, and 15 +/- 6.0% at 10 years. Using multivariate analysis, we evaluated possible significant predictors of improved survival. Only wedge resection was a significant predictor (p less than .01), which suggests better results with a small peripheral lung tumor. Results of our 25 years experience using an aggressive approach to lung cancer with solitary cerebral metastasis indicate significantly improved patient survival that justifies its widespread use.

Carcinoid tumors of the thymus

Carcinoid tumors arising in the thymus are rare. Since Rosai and Higa in 1972 distinguished these neoplasms from thymomas, fewer than 100 cases have been reported in the world literature. In a 38-year review (1950 to 1988) of surgically treated thymic tumors at Henry Ford Hospital, only 7 cases of thymic carcinoids were identified. These 6 men and 1 woman ranged in age from 27 to 70 years (mean, 48 years) at diagnosis. Follow-up was available in all patients with the longest survival being 12 years in 2 patients, and the shortest, 1 year, in 1. Recurrences and/or metastases developed in 4 of 7 patients between 1 and 9 years after initial resection. Recurrences were treated by reexcision in addition to radiation treatment and chemotherapy in 3 patients and reexcision with radiation treatment alone in 1 patient. A review of the literature along with our experience suggests that thymic carcinoids have a biological behavior distinct from thymoma in terms of cell origin, associated syndromes, neoplastic behavior, and prognosis. An aggressive surgical approach with complete initial excision of the tumor and of subsequent recurrences, along with radiation and probably chemotherapy, is the best available treatment today.

Spontaneous Degeneration of Porcine Bioprosthetic Valves

From October, 1971, to October, 1979, 490 patients with 560 porcine bioprosthetic valves were discharged from the hospital. During these 8 years, 23 valves were removed because of failure due to spontaneous degeneration. Bioprosthetic valve survival without degeneration was at 4 years, 98.9% +/- 86 (standard error); at 5 years, 96.4% +/- 1.3; at 6 years, 90.8% +/- 2.4; and at 7 years, 84.2% +/- 3.7. There was no difference in degeneration observed with regard to sex, valve position, or whether the valves were rinsed with antibiotics prior to implantation. There was an increase in degeneration in patients 35 years old and younger compared with those more than 35 years old (p = 0.0001). Valve failure was gradual, and valve changes were noted by echocardiogram and phonocardiogram prior to actual failure. Specific factors leading to degeneration require further investigation.

The utility of a double-lumen tube for one-lung ventilation in a variety of noncardiac thoracic surgical procedures

To determine the utility of one-lung ventilation (OLV) in a variety of noncardiac thoracic surgical procedures, 200 patients were studied to document the ease of double-lumen tube (DLT) placement, associated complications, intraoperative respiratory changes, and methods for managing hypoxic events. Most tubes could be placed, repositioned when necessary, and secured within 12 minutes. By defining tube position with fiberoptic bronchoscopy, auscultatory assessment of placement was found to be incorrect in 38.0% of patients. The tip occluded the respective upper lobe orifice in 40.5% of this subgroup, the endobronchial cuff was at or above the carina in 38.7%, and in the wrong mainstem bronchus in 20.8%. During OLV, PaO2 initially fell to approximately 200 mmHg in most patients but gradually rose during the balance of the operation. Hypoxia (PaO2 less than 80 mmHg) during OLV developed in 28.5% of patients. Preoperative spirometry and arterial blood gases had no predictive value for this complication. Pulse oximetry values between 95% and 100% reliably reflected systemic arterial oxygen saturation. Hypoxia occurring during OLV was successfully reversed in 40.0% of instances by positive end-expiratory pressure (PEEP) to the ventilated lung. The addition of continuous positive airway pressure (CPAP) to the nonventilated lung reversed persistent hypoxia in virtually all cases. There was no difference in oxygenation, carbon dioxide elimination, airway pressures, or intraoperative complications noted between right and left double-lumen tubes. In conclusion, a DLT for OLV can expeditiously and safely be placed. Because auscultation for tube position is unreliable, bronchoscopic assessment of final position should be performed in every instance. Hypoxia during OLV can be detected reliably by pulse oximetry.(ABSTRACT TRUNCATED AT 250 WORDS)

Can computed tomography of the chest stage lung cancer?—Yes and no

To determine the accuracy of computed tomography (CT) of the chest in the staging of lung cancer, we studied 418 patients with primary pulmonary carcinoma between 1979 and 1986. Each had a preoperative scan performed before detailed operative staging. Each CT scan was analyzed for components of the current TNM staging system. Computed tomography sensitivity and specificity for mediastinal lymph node metastasis were 84.4% and 84.1%, with corresponding positive and negative predictive accuracies of 68.7% and 92.9%, respectively. When TNM stages were derived from CT scans, only 190 of 418 (45.4%) completely agreed with operative staging. An additional 53 of 418 (12.7%) predicted the correct stage, although components of the TNM system were incorrect. In 94 of 418 scans (22.5%) CT overestimated the stage, whereas in 81 (19.4%) CT downgraded the stage. Computed tomography suggested metastatic lesions in liver, lung, adrenal gland, bone, or abdominal lymph nodes in 40 of 373 scans (10.7%); only five of 40 (12.5%) had documented metastasis. In summary, CT of the chest cannot accurately stage primary lung carcinoma according to the TNM classification. Because the negative predictive accuracy for mediastinal lymph node metastasis remains high (92.9%), invasive staging can be deferred for definitive thoracotomy when no lymphadenopathy is evident on CT. The high negative predictive accuracy for scans of the chest and upper abdomen makes CT a useful tool for exclusion of metastatic disease.

The Porcine Bioprosthetic Heart Valve: Experience at 15 Years

The porcine bioprosthetic valve has been in use at Henry Ford Hospital since 1971. In this review, 980 patients with 1,081 porcine bioprosthetic valves were examined from 1 month to 16.4 years after implantation with a 99% complete follow-up. Patient survival was 59% +/- 2.2% (+/- standard error of the mean) at 10 years and 38% +/- 4.0% at 15 years. Factors associated with decreased survival after hospital discharge were age greater than 35 years and New York Heart Association functional class IV. Freedom from thromboembolism was 92% +/- 1.2% at 10 years and 89% +/- 3.2% at 15 years. Freedom from endocarditis was 93% +/- 1.2% at 10 years and 92% +/- 1.3% at 15 years. Freedom from structural valve degeneration for all valves was 71% +/- 2.6% at 10 years and 31% +/- 5.6% at 15 years. Factors associated with increased risk of structural valve degeneration were age younger than 35 years, female sex, and preoperative cardiac index greater than 2 L/min/m2. Among a total of 172 patients undergoing removal of a degenerated valve, mortality was 12.5%, and significant risk factors for death at reoperation were emergency operation and functional class IV. Experience with the porcine bioprosthetic valve after 15 years suggests that its use be confined to older patients or patients with a contraindication of anticoagulation.

Comparison of three treatment strategies for esophageal cancer within a single institution

Fifty-seven patients with esophageal cancer were treated with curative intent between January 1979 and June 1985. Seventeen were treated with radical radiation therapy alone (TD 4000-6500 cGy in 200-250 cGy fractions). Twenty-five were treated using radiation therapy (3000 cGy in 200 cGy fractions, day 1-19, and 2600-3000 cGy in 200 cGy fractions, day 50-68) and concomitant chemotherapy (5-FU and Cis-platinum). Fifteen were treated preoperatively by radiation therapy (3000 cGy at 200 cGy fractions) and concomitant chemotherapy (5-FU and Cis-platinum) followed by esophagectomy in 2-3 weeks. Chi square tests showed no significant baseline differences between the patients in the three different treatment groups with respect to A.J.C. stage, T status, location of tumor or histology. Median survival and 2-year survival for the three treatment groups were RT alone: 5 months and 0%, RT and chemotherapy: 12 months and 37%, RT, chemotherapy and surgery 13 months and 38%. A Cox multivariate analysis revealed significant predictor variables for increased survival were treatment strategy, RT dose delivered and T status. Increased local control was seen with either multimodality approach compared to radiation therapy alone. Our data suggests that a multimodality approach is superior as a curative treatment strategy, compared to RT alone, in esophageal cancer. In our series no significant differences were seen with respect to treatment outcome between the two multimodality approaches used.

The increased need for a permanent pacemaker after reoperative cardiac surgery

OBJECTIVEnThe requirement for permanent pacemaker implantation after most initial cardiac surgical procedures generally is less than 3%. To identify the incidence and factors related to permanent pacemaker need after repeat cardiac surgery, we retrospectively studied 558 consecutive patients undergoing at least one repeat cardiac operation.nnnMETHODnUnivariable and multivariable analyses of comorbidity, preoperative catheterization values, and operative data were performed to identify factors related to pacemaker implantation.nnnRESULTSnIn this group, 54 patients (9.7%) required a permanent pacemaker. A multivariable model showed a relationship between a permanent pacemaker and tricuspid valve replacement/annuloplasty associated with aortic/mitral valve replacement, preoperative endocarditis, increasing number of reoperations, the degree of hypothermia during cardiopulmonary bypass, and advanced age. Additional univariable predictors of pacemaker need included multiple valve replacement, increased cardiopulmonary bypass and aortic crossclamp times, and aortic valve replacement. Over 90% of patients who have or have not received permanent pacemaker implantation were in New York Heart Association class I to II, with a mean follow-up time of 6 years. Kaplan-Meier survival curves were statistically similar for both groups at 5 and 10 years after the operation.nnnCONCLUSIONnPermanent pacemaker implantation was required in 9.7% of patients undergoing repeat cardiac surgery. This represented approximately a fourfold increase compared with similar primary operations reported in other series. Factors strongly related to this need included valve replacement, preoperative endocarditis, number of reoperations, advanced age, and degree of hypothermia during cardiopulmonary bypass. The need for a permanent pacemaker after reoperations did not result in significant long-term impairment of functional status or longevity compared with those who did not require a permanent pacemaker.

Is the Hancock Porcine Valve the Best Cardiac Valve Substitute Today

Valve replacement with the Hancock stabilized glutaraldehyde porcine aortic valve has been accomplished in 454 patients. Hospital mortality (influenced by a high proportion of patients in New York Heart Association Functional Class IV) was 17.6% (80/454). The first 221 patients discharged from hospital were followed for 36 to 75 months after valve replacement. There have been 26 late deaths among these patients; 88% (195/221) are alive. Of these 221 patients, 185 had single-valve replacement, (125 mitral and 60 aortic), and 36 underwent multiple-valve replacement. There have been 260 valves at risk up to 6 1/4 years, which is equivalent to 12,984.5 valve-months or 1,082 valve-years. Average follow-up is 4.16 years. There have been 13 valve failures in 10 patients. In 4 patients endocarditis was proved to be the cause of failure, and in 5 it was suspected; in 1 patient the failure the failure is unexplained. The pathological similarity between those in whom infection was documented and the other 5 is remarkable and raises the question of whether low-grade infections may be the cause of certain types of valve failure.

The Value of Radiographic and Computed Tomography in the Staging of Lung Carcinoma

Abstract A prospective double-blind study was undertaken to compare computed tomography (CT) and conventional radiographic tomography (RT) in the staging of lung carcinoma. Seventy-five patients had CT and RT of the mediastinum and hilum prior to operation. The presence or absence of metastasis to lymph nodes documented at the time of operation was the standard applied to the studies. CT correctly predicted the presence or absence of mediastinal lymphadenopathy in most cases (sensitivity 91%, specificity 94%), while RT was less helpful (sensitivity 61%, specificity 86%). Metastatic mediastinal lymph nodes in those patients with false negative CT and RT studies averaged only 0.8 cm in diameter, probably accounting for the negative radiographic findings. Both CT and RT had poor predictive values in detecting hilar lymphadenopathy (sensitivity 73% and 47%, specificity 87% and 72%, respectively). The predictive value of CT in the evaluation of mediastinal lymphadenopathy equaled that of mediastinoscopy or mediastinotomy. When CT of the mediastinum demonstrates no lymphadenopathy, invasive staging can be deferred for definitive thoracotomy. Since false positive values were seen with both CT and RT scans of the mediastinum (4% and 8%, respectively), invasive staging will still be necessary in those patients with positive studies.