L. Penfield Faber

Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma: Five-year survival and patterns of intrathoracic recurrence

One hundred seventy-three patients with stage I (T1 N0, T2 N0) non-small-cell lung cancer underwent either a segmental pulmonary resection (n = 68) or lobectomy (n = 105) from 1980 to 1988. Four patients were lost to follow-up, but the remaining 169 patients were followed up for 5 years. Survival and the prevalence of local/regional recurrence were assessed. Although no survival advantage of lobectomy over segmental resection was noted for patients with tumors 3.0 cm in diameter or smaller, a survival advantage was apparent for patients undergoing lobectomy for tumors larger than 3.0 cm. The rate of local/regional recurrence was 22.7% (15/66) after segmental resection versus 4.9% (5/103) after lobectomy. A review of histologic tumor type, original tumor diameter, and segment resected revealed no risk factors that were predictive of recurrence. An additional resection for recurrence was performed in four patients. Lobectomy is the preferred operative procedure for patients with stage I tumors larger than 3.0 cm. Because the rate of local/regional recurrence was high after segmental resections, diligent follow-up of these patients is mandatory.

Preoperative chemotherapy and irradiation for stage III non-small cell lung cancer

Surgical therapy for stage III non-small cell lung cancer (NSCLC) has not resulted in substantial long-term survival. Neoadjuvant treatment programs that could down-stage the tumor and achieve increased long-term survival would be of obvious benefit. We have used preoperative simultaneous chemotherapy and irradiation in 85 patients with clinical stage III non-small cell lung cancer considered candidates for surgical resection. One group of 56 patients was treated with cisplatin, 5-fluorouracil, and simultaneous irradiation for five days every other week for a total of four cycles. After treatment, 39 patients underwent resection, and the operative mortality was 2 (5%) of 39. A second trial was undertaken in which etoposide (VP-16) was added because of its synergism with cisplatin. In this group, 29 patients were considered to have potentially resectable disease, and 23 underwent thoracotomy with 1 operative death (4%). Of the total of 62 patients having thoracotomy, 60 underwent resection (97%). Complications were major, and there were four bronchopleural fistulas. For the 85 patients eligible for surgical intervention in these two groups of patients, the Kaplan-Meier median survival estimate is 40% at 3 years. The median survival of the 62 patients having thoracotomy is 36.6 months. Combination preoperative chemotherapy and irradiation is feasible with acceptable toxicity and operative mortality in patients with clinical stage III non-small cell lung cancer. Prospective randomized studies are suggested for further evaluation of this treatment program.

Segmental Resection for Bronchogenic Carcinoma

Segmental resection was performed on 168 patients with peripheral, Stage I bronchogenic carcinoma from 1957 to July 1, 1978. Seventy-four patients (44%) had adenocarcinoma, 58 (34%) had an epidermoid type, 28 (17%) had an unadifferentiated tumor, and 8 (5%) had a bronchoalveolar variety. Ninety-five resections were done on the left lung, the most frequent procedure being removal of the superior division of the left upper lobe (38 patients). On the right side, 73 resections were done. The anterior segment was removed most frequently (19 patients). There were 3 surgical deaths, for a mortality of less than 2%. Complications requiring prolonged hospitalization were associated with air leak in 10 (6%) of the 168 patients. Survival by actuarial curve is 53% at 5 years, 33% at 10 years, and 25% at 15 years. Forty-five patients (27%) died of metastatic carcinoma. Patients with epidermoid lesions have the most favorable prognosis.

Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage

BACKGROUND Optimal management of cardiac tamponade resulting from pericardial effusion remains controversial. METHODS Cardiac tamponade in 117 patients was treated with either subxiphoid pericardiostomy (n = 94) or percutaneous catheter drainage (n = 23). Percutaneous catheter drainage was used for patients with hemodynamic instability that precluded subxiphoid pericardiostomy. Effusions were malignant in 75 (64%) of 117 patients and benign in 42 (36%) of 117. RESULTS Subxiphoid pericardiostomy had no operative deaths and a complication rate of 1.1% (1 of 94). In contrast, percutaneous drainage had significantly (p < 0.05) higher mortality and complication rates of 4% (1 of 23) and 17% (4 of 23), respectively. Patients with an underlying malignancy had a median survival of 2.2 months, with a 1-year actuarial survival rate of 13.8%. In comparison, patients with benign disease had a median survival of 42.8 months and a 1-, 2-, and 4-year actuarial survival rate of 79%, 73%, and 49%, respectively (p < 0.05). Effusions recurred in 1 (1.1%) of 94 patients after subxiphoid pericardiostomy compared with 7 (30.4%) of 23 patients with percutaneous drainage (p < 0.0001). CONCLUSIONS Benign and malignant pericardial tamponade can be safely and effectively managed with subxiphoid pericardiostomy. Percutaneous catheter drainage should be reserved for patients with hemodynamic instability.

Simultaneous Cisplatin Fluorouracil Infusion and Radiation Followed by Surgical Resection in Regionally Localized Stage III, Non–Small Cell Lung Cancer

Sixty-four patients with stage III (M omicron) non-small cell lung cancer were treated with cisplatin fluorouracil infusion chemotherapy and simultaneous radiation therapy for 5 days every other week. A total of 4 cycles (40 Gy) was followed by attempted surgical resection. Clinical response to the preoperative treatment included 5 (8%) complete and 32 (48%) partial responses. Thirty-nine (61%) underwent the planned operation, and in 9 (23%) of these patients the resected specimens were histologically negative. Clinical assessment failed to predict histological response. With 17 months median follow-up (range, 2.4-29 months), estimated 1-year survival was 61% and median survival was 16 months for all patients.

Extrapleural Pneumonectomy for Diffuse, Malignant Mesothelioma

Extrapleural pneumonectomy for malignant mesothelioma is a radical procedure that entails en bloc removal of the parietal pleura, lung, pericardium, and diaphragm. Minimal tumor remains after this procedure; palliation and occasional long-term survival may be achieved in properly selected patients. Extrapleural pneumonectomy for diffuse, malignant mesothelioma was done in 33 patients (27 male and 6 female) with 18 procedures on the left side and 15 on the right. There was a history of exposure to asbestos in 16 (48%) of the patients. Histological classification revealed that 20 tumors were epithelial, 10 were mixed, and 3 were sarcomatous. Good palliation, defined as survival for 24 months with a return to fairly normal activities, was obtained in 8 patients (24%) and survival for 36 months was achieved in 5 patients. Three patients died of the disease at 59 months, 60 months, and 82 months. There were 3 operative deaths (9.1%), and serious postoperative complications occurred in 8 patients (24%). Postoperative adjunctive therapy consisting of chemotherapy or irradiation or both was given to approximately one-half of the patients. These findings indicate that extrapleural pneumonectomy for malignant mesothelioma can be done with an acceptable morbidity and mortality. Palliation is achieved in 24% of patients, and there may be an occasional long-term survivor.

Subxiphoid pericardial drainage for pericardial tamponade

As a result of recent reports and enthusiasm for video-assisted thorascopic pericardiectomy, we reviewed our experience with subxiphoid pericardial drainage. From August 15, 1988, to June 7, 1993, 155 patients underwent subxiphoid pericardial drainage for pericardial effusion associated with pericardial tamponade. The group comprised 85 female (55%) and 70 male patients whose ages ranged from 5 weeks to 88 years. The procedure was carried out with general anesthesia in 113 patients (72%) and with local anesthesia and sedation in 42 patients. Underlying cancer was present in 82 patients; 73 patients had benign disease. Follow-up is complete in all patients. The overall 30-day mortality was 20%; in patients with cancer it was 32.9% (27/82) versus 5.4% (4/73) for patients with benign disease. No postoperative death was attributed to the surgical procedure. Recurrent pericardial tamponade necessitating further surgical intervention occurred in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). Median survival after subxiphoid pericardial drainage in patients with benign disease was more than 800 days versus 83 days in patients with cancer (p < 0.01). Median survival after pericardial drainage in patients with cancer who had malignant pericardial effusion was 56 days compared with 105 days for patients with cancer who did not have tumor in the pericardium (p < 0.05). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients.

Bronchopleural fistula after stapled closure of bronchus

The incidence of bronchopleural fistula after stapling among 2,243 pulmonary resections at the Rush-Presbyterian-St. Lukes Medical Center has been reviewed. There were 35 fistulas in 1,773 stapled and in 470 sutured bronchi (segmentectomy, 2; lobectomy, 1; bilobectomy, 9; and pneumonectomy, 23). We have found that the stapler is expedient and simple to use, and that it produces a hermetic and uniform closure. The stapler is contraindicated when the bronchus is thickened, inflamed, or of insufficient length. The overall incidence of bronchopleural fistula was 1.6%. Approximately two thirds of the patients with bronchopleural fistula had preoperative radiation therapy or chemotherapy or both.

Results of Sleeve Lobectomy for Bronchogenic Carcinoma in 101 Patients

Sleeve lobectomy for bronchogenic carcinoma is an alternative to pneumonectomy. The extent and location of the tumor must be such that a sleeve procedure is feasible. The conservation of lung tissue benefits both compromised and uncompromised patients. From 1961 to 1982, 101 patients underwent sleeve lobectomy for bronchogenic carcinoma of the lung. There were 58 procedures on the right side and 43 on the left. Life-table analysis of 94 of the patients shows a 5-year survival of 30% and a 10-year survival of 22%. Preoperative irradiation was utilized in 51 patients with a 5- and 10-year survival of 25% and 16%, respectively. The sleeve lobectomy group that did not have radiation therapy demonstrated a 5-year survival of 36% and a 10-year survival of 28%. There were 2 operative deaths (2%). Completion pneumonectomy was required in 7 patients because of anastomotic dehiscence in the early postoperative period in 6 and tumor at the margin in 1. Other major complications included empyema and granulation tissue at the anastomosis that were successfully managed by bronchoscopic dilation and suture removal. Tumor recurred locally in the area of the anastomosis in 9 patients. Sleeve lobectomy is a safe procedure and when technically feasible can be considered the procedure of choice for bronchogenic carcinoma.

Pulmonary Venoocclusive Disease

Pulmonary venoocclusive disease has been established as a definite clinical entity characterized by congestive cardiac failure with pulmonary arterial hypertension, chronic interstitial pulmonary edema, and normal wedge pressure on cardiac catheterization. This disease was diagnosed and confirmed in a patient during life. A review of the 32 patients reported earlier has been done in an attempt to fine possible etiological agents. Early recognition and treatment with anticoagulants, methylprednisolone, aspirin, and dipyridamole may improve the prognosis.