Richard H. Overholt

Primary Cancer of the Lung: A 42-Year Experience

Between April, 1932, and July, 1974, 3,808 patients with primary lung cancer were studied and 1,848 underwent resection. Among untreated patients, 95% were dead with a year. Unresected cancer of the lung is so lethal that efforts to streamline surgical management should not be neglected. In good-risk patients with isolated lesions the approach can be direct. If surgical excision is indicated, regardless of a positive or negative sputum cytology, bronchoscopic biopsy, or brush biopsy, such investigations become superfluous. Needle biopsy is also inconclusive and in addition is hazardous. Preoperative investigation should focus on cardiopulmonary reserve more than on ways to obtain tissue for verification. With the passage of time, the extent of resection has become more conservative. The value of palliative resection is now better appreciated in terms of quality of life, its prolongation, and, for some, a possibility for cure.

Bilateral pulmonary resection for bronchiectasis: a 40-year experience.

Ninety-nine patients underwent bilateral pulmonary resection for severe multisegmental bilateral bronchiectasis at the Overholt Thoracic Clinic during the period 1937 to 1977. A total of 216 operations were performed, and 20 patients underwent three or more procedures. The operative mortality was 1.4% and the incidence of severe complications, 7%. Follow-up ranged from 1 to 30 years (average 10.2 years). Only 1 patient was lost to follow-up. Improvement in pulmonary symptoms was achieved in 83 patients; there was no improvement in 9 patients; and 4 patients were worse following resection. The results suggest that bilateral bronchiectasis need not be a contraindication to operation. In properly selected patients, lasting symptomatic improvement can be provided by resection.

Metastatic melanoma to the lung: Long-term results of surgical excision

The only long-term survivor of multiple bilateral pulmonary metastases from malignant melanoma after staged thoracotomies has been described, and a series of 18 patients who underwent pulmonary resection for metastatic malignant melanoma at one clinic have been reviewed. Median survival was 16.5 months and the 5 year survival rate was 11.1 percent. Forty-four percent of the patients had multiple metastases and 11.1 percent had bilateral metastases. There was no correlation between length of survival and disease-free interval, number of metastases, or the presence of unilateral versus bilateral tumor nodules. Twenty-seven percent of the patients had more metastases found intraoperatively than suspected preoperatively. Unfavorable results occurred when the extent of the disease required pneumonectomy. The current literature has also been reviewed and arguments have been made to support the surgical approach to carefully selected patients with metastatic melanoma to the lung.

XCVI Hidden or Unsuspected Bronchiectasis in the Asthmatic

Bronchiectasis, hidden and unsuspected, is often present in the asthmatic patient. Attacks of severe bronchospasm may be produced and maintained by the mere presence of bronchial deformity acting as an exciting cause. Bronchospasm can be more than a symptom of bronchiectasis-by obstruction it can produce bronchiectasis. Since it can be either cause or effect, consequently, bronchiectasis should always be suspected and looked for in bronchial asthma.

TREATMENT OF OCCULT CARCINOMA OF THE LUNG

Bronchogenic carcinoma which is invisible and undetectable by survey or by routine examination can be categorized as occult cancer of the lung. It is discovered accidentally within lung tissue removed for other reasons. The occurrence in clinical practice is extremely infrequent. There are two other categories that are close to being occult. In both groups the cancer has not announced itself by symptoms and cannot be seen bronchoscopically. They are concealed to a great degree, but do give a warning. One of these types is invisible to the eye and fails even to cast a radiographic shadow. It exfoliates cells into bronchial secretions and might be called an occulting tumor.* The other group might be called semioccult. The existence of the cancer is suspected purely on the basis of its shadow, which appears as an alteration in the radiographic pattern of the lung field. Experiences with true occult and occulting lesions are rare occurrences in treatment centers. Removal at such an early stage in the evolution of the cancer should carry the highest of cure rates. A true occult cancer is illustrated in FIGURES 1 and 2. In our Clinic, only three cases (occulting cancer) out of 2,110 have been brought to light and treated on the basis of cytologic evidence alone. Cancer was found in the removed lobes. Without the help of a radiologic shadow, it is necessary to make certain of the side of origin by individual right and left bronchial aspiration. Repeat examinations must be consistent as to positivity and as to lateralization. One patient with negative chest films was referred for exploration on the basis of a highly positive cytologic report from an excellent laboratory. Secretions aspirated bronchoscopically for double check and lateralizing failed to yield tumor cells on two subsequent occasions. Surgery was not advised on lack of evidence. The patient has remained well, is asymptomatic, and after three years an X-ray of the chest remains clear. This represents an unsubstantiated false positive, Another patient with repeatedly positive cytology from the left lower lobe was explored and resected. Bronchiectasis with mucosal metaplasia was found, but no cancer. This case represented a true false positive.

Esophageal myectomy for recurrent multiple leiomyomas of the esophagus: manometric and cineradiographic documentation.

This is a report of recurrent multiple leiomyomas of the esophagus treated initially by enucleation and subsequently by myectomy of the involved portion of the esophagus to prevent further recurrence. Experimental studies support the clinical observation that the esophagus will function as a conduit for food in the absence of an orderly progression of peristalsis. Preservation of hilar truncal vagus nerve function must be accomplished if normal lower esophageal sphincter function is to be maintained. We believe this is the first report of deliberate esophageal myectomy in a human patient with manometric and cineradiographic documentation of satisfactory function postoperatively. Limited myectomy may be considered, as circumstances require, in the treatment of multiple esophageal leiomyomas, although enucleation remains the treatment of choice.

Early diagnosis and treatment of cancer of the lung

practice shoulders part of the cancer burden. People look to us for advice and help, individually and collectively, if they fall prey to such a terrible dis ease. Until the time comes when the causes are known and preventive pro grams or specific cures are developed, progress in treatment must depend on earlier detection and the prompt and skilful use of known weapons, prin cipally excision. Cancer in any location presents a challenge. The ingenuity of both the physician who discovers it and the sur geon who removes it is taxed to the limit, especially if the original site is in one of the internal organs. A unique situation has developed, however, in regard to primary lung cancer. It is the most detectable of any internal tu mor; it is accessible for excision; and it is frequent enough to invite general familiarity and awareness.

Resection of Carotid Body for Asthma

To the Editor: —Dr. Comroes reasonable and thoughtful criticisms deserve comment. First, he would require sham operations for a control series. This, in effect, has been done. Professor Nakayama accepted 50 unrelieved patients who had been operated upon by other surgeons but with no change in their asthmatic statuses. The carotid bulb area had been previously exposed, but apparently the carotid body was overlooked. Dr. Nakayama reoperated, located the carotid body, and removed it. Relief in this group paralleled that obtained in other cases where removal was documented histologically. After our initial success with glomectomy in certain desperate asthmatic patients, we have had an increasing number of patients referred to us specifically for cartoid body removal. In balancing a negligible risk against the probable benefits of glomectomy, we could do nothing but proceed with excision of one carotid body in all those patients in whom we considered it to be

Single or double segments of the lung occupying a hemithorax; clinical and physiologic evaluation.

DISEASE may destroy all but one or two segments of a lung. Often, surgery is imperative, with a choice between pneumonectomy and conservation of the single or double segment. If there is disease on...