Takashi Iwa

AGGRESSIVE SURGICAL INTERVENTION IN N2 NON-SMALL CELL CANCER OF THE LUNG

An aggressive attitude toward surgical treatment was taken in patients with N2 non-small cell lung cancer in the past 10 years. Computed tomographic scanning was employed in the diagnosis of N2 disease, and had a true-positive rate of 57%. Among patients with N2 disease detected by computed tomographic scanning, surgical intervention was attempted except for those with unresectable disease. Of 190 patients with clinical N2 disease, 115 underwent surgical exploration: 9 patients had only an exploratory thoracotomy, 53 patients underwent a curative operation, and 53 had a noncurative operation. The overall 5-year survival rate of these patients was 16% and that of curatively resected patients was 20%. There were 47 patients whose N2 disease was not recognized before operation. The 5-year survival rate of this group was 20% overall and 33% in curatively resected cases. The overall 5-year survival rate of patients with N2 disease who underwent resection (106 with clinical N2 disease and 47 with clinically unrecognized N2 disease) was 17%, and that of the 84 patients undergoing curative operations was 24%. An aggressive attitude toward surgical intervention can be advocated for patients with N2 disease on the basis of our present results.

Clinical value of immunotherapy for lung cancer by the streptococcal preparation OK‐432

A streptococcal preparation, OK‐432 was employed as the adjuvant immunotherapeutic agent for lung cancer. To evaluate the clinical efficacy of the OK‐432, patients admitted between 1975 and 1979 were randomized into two groups: (1) an immunochemotherapy group and (2) a chemotherapy, or control, group. For evaluation of long‐term survival, there were 108 cases in the immunochemotherapy group and 103 cases in the chemotherapy group. When comparing the prognosis of the two groups, the survival rate was statistically higher in the immunochemotherapy group than the control group. The resected cases in Stages I and II showed better prognosis with immunochemotherapy than the cases in the same stages treated with chemotherapy alone. Among the resected cases in the more advanced stages, mostly Stage III and a few cases in the Stage IV, the cases treated with immunochemotherapy also showed more favorable prognosis than the cases treated with chemotherapy alone. In terms of the cell type of the lung cancer, the cases with epidermoid carcinoma in Stages I and II showed significantly better prognosis with immunotherapeutics than the control group. The cases with positive reaction to the streptococcal polysaccharide skin test apparently showed better prognosis than those with negative reaction.

Results in 104 patients undergoing bronchoplastic procedures for bronchial lesions

Bronchoplastic procedures were used in 104 patients with various bronchial disorders. Ten had benign lesions and 94, malignant tumors. The principal operative procedures were sleeve lobectomy and sleeve pneumonectomy for bronchogenic carcinoma, but 11 limited bronchial resections were performed in patients with benign lesions, minute bronchogenic carcinomas, and low-grade malignant tumors. Of the 94 patients with malignant tumors, 79 underwent a bronchoplastic procedure without carinal resection (sleeve lobectomy in 75 and limited bronchial resection in 4), and there was one operative death (1.3%). The overall 5-year survival rate for the patients with bronchogenic carcinoma in this group was 45% and that for patients undergoing curative resection, 57% (survival of patients in stages I, II, and IIIA was 79%, 55%, and 30%, respectively). A bronchoplastic procedure with carinal resection was performed in 15 patients. Twelve in this group underwent sleeve pneumonectomy. There were two operative deaths, and 1 patient has survived for longer than 4 years. Two patients with low-grade malignant tumors underwent carinal resection without lung resection and are still alive. We believe that bronchoplasty is a safe and valuable procedure and that limited bronchial resection appears to be the procedure of choice for localized bronchial lesions.

Surgical correction of idiopathic paroxysmal ventricular tachycardia possibly related to left ventricular false tendon

Abstract Ventricular tachycardia (VT) can occur in healthy subjects.1,2 We have reported a high prevalence of the coexistence of left ventricular false tendons or fibromuscular bands in the left ventricular cavity, and ventricular arrhythmias in apparently healthy subjects.3,4 In this report, we describe a patient with paroxysmal sustained VT, which indicates a QRS morphology of right bundle branch block and left axis deviation. It has been completely suppressed by the surgical resection of the false tendon and the partial cryocoagulation of the left ventricular myocardium where the false tendon was attached.

Second Surgical Intervention for Recurrent and Second Primary Bronchogenic Carcinomas

Second operations were performed in 1961–1990 on 23 patients with non-small cell bron-chogenic carcinoma, constituting 2.5% of 906 who had undergone pulmonary resection for such tumor and 3.6% of the 641 with apparently curative surgery. The second operation was performed for recurrent tumor in 15 cases and for second primary tumor in eight. Five-year survival after the first operation was 30% in the former group and 88% in the latter (significant difference). Among the total 23 patients, this survival rate was 51%. The study indicates that an aggressive attitude to second surgical intervention is warranted. For early detection of second lesions, follow-up at maximally 6-month intervals should be continued for more than 5 years after the first operation.

Nuclear tomographic phase analysis: Localization of accessory conduction pathway in patients with Wolff-Parkinson-White syndrome

The purpose of this study was to evaluate the usefulness of tomographic phase analysis in detecting the site of the accessory conduction pathway (ACP) in patients with Wolff-Parkinson-White (WPW) syndrome. Gated emission computed tomography and planar gated blood pool scintigraphy were performed in 20 patients with WPW syndrome, 14 with delta waves and six without delta waves (two intermittent types and four concealed types). The abnormal initial contractions in both planar and tomographic phase images were compared with the sites of ACPs confirmed by epicardial mapping and surgery. The atrioventricular ring was divided into eight segments on each side, and the identification of the initial phase in the segment in which the ACP was located, or that adjacent to it, was considered to be the correct diagnosis. In planar phase analysis, the abnormal initial phase was identified correctly in 8 of 14 patients (57%), whereas in tomographic phase analysis, the site of the ACP was detected in 12 of 14 patients (86%). Tomographic phase analysis can be a helpful adjunctive method in patients with WPW syndrome.

Interruption of multiple accessory conduction pathways in the Wolff-Parkinson-White syndrome

Of 35 patients with Wolff-Parkinson-White syndrome operated on, 5 were seen with two accesory conduction pathways each; all of these were successfully interrupted. In one patient, one accessory conduction pathway each was located in the right and left side of the heart; in the other 4, both pathways were confined to the right side. In 2 patients with unilateral (right side) multiple accessory conduction pathways, Ebsteins anomaly was also present. In 1 patient with Ebsteins anomaly, the second unilateral accessory conduction pathway was discovered intraoperatively and was successfully interrupted. The remaining 4 patients required a second operation to interrupt the other pathway. A delta wave completely different from the preoperative one appeared 4 to 10 days after interruption of the first major pathway, and the second operation was performed 14 days, 42 days, four months, or five years after the first operation. All 5 patients survived, and long-term follow-up revealed no signs of morbidity.

Comparative study of eight sets of ECG criteria for the localization of the accessory pathway in Wolff-Parkinson-White syndrome

Eight sets of electrocardiographic (ECG) criteria for the localization of accessory conduction pathway (ACP) were evaluated on 182 patients with a single ACP. The Rosenbaum criteria identified 78.6% of the left-sided and 94.0% of the right-sided ACPs. Four of the other seven sets of criteria demonstrated a sensitivity higher than 70.9% and six showed a specificity higher than 74.9% in the 4-region ACP localization. The ECG feature of the delta wave polarity in lead V1 correctly localized the ACP to one of three broad regions in 162 of 182 patients with an overall specificity of 94.5%. The study indicates that (1) the 12-lead ECG is of practical value for initial ACP localization; (2) a type A ECG is almost invariably associated with a left-sided ACP, while type B may occur with any ACP location; (3) the polarity of the delta wave is the most important ECG feature, and the polarities of the delta wave and main QRS complex in lead V1 play an important role in ACP localization.

The histological effects of cryocoagulation on the myocardium and coronary arteries.

The effects of epicardial and endocardial cryolesions were histologically studied in 29 dogs. To produce epicardial lesions, hypothermic exposure was applied at −60°C for 3 minutes, over or adjacent to the left anterior descending coronary artery. To produce endocardial lesions, exposure was applied at −60°C for 2 minutes, using the inflow occlusion technique over the ventricular septum. The dogs were killed 30 minutes to 6 months later. The cryolesions were sharply demarcated from the surrounding tissues and showed similar healing processes. The lesions showed no tendency to form aneurysms or rupture, although moderate intimal thickening of the coronary artery subjacent to the probe was observed. Our results indicate that cryocoagulation may greatly contribute to the surgical treatment of cardiac arrhythmias.

The clinical value of high-frequency jet ventilation in major airway reconstructive surgery

High-frequency jet ventilation (HFJV) via a catheter with internal diameter 2.4 mm was employed in 21 patients to facilitate airway reconstructive surgery. Tracheal reconstruction was performed in six cases, sleeve lobectomy in six and sleeve pneumonectomy in nine. An HFO-Jet-Ventilator was used at individually selected settings of 0.5-2.4 kg/cm2 for driving gas pressure and 4-10 Hz frequency. Intermittent positive pressure ventilation (IPPV) was used initially, with switch to HFJV at the time of tracheobronchial reconstruction. The time during which HFJV was employed ranged from 25 to 65 min. Except for transient hypoxia or hypercapnia in a few patients, the results of blood gas analyses during HFJV were satisfactory. The most appropriate HFJV settings for each surgical procedure and the advantages of HFJV over IPPV are discussed.