Thomas W. Shields

Preoperative radiation therapy in the treatment of bronchial carcinoma

Three hundred and thirty‐one selected male patients with biopsy‐proven bronchial carcinoma were randomized into two groups: 166 patients received preoperative radiation therapy and subsequent surgery and the other 165 patients underwent surgery alone. One hundred and six operations were performed in the pretreatment group and 153 in the control group; of these, 20 and 63 patients, respectively, underwent thoracotomy only. All patients are now eligible for 4‐year survival or more, and no increase in survival is noted in the pretreatment group. In those patients in each group who underwent successful resection, survival again was not increased in the pretreatment group; in fact, the survival rate in the preoperative treatment group was significantly less during the first 12 postoperative months than in those patients who only underwent operative removal of their tumor. The survival rate continues to be less in the pretreatment group, 12.5% vs. 21%, although the difference is not statistically significant. Thus, it has been concluded that the routine use of preoperative irradiation in patients with bronchial carcinoma is not beneficial and indeed may well be harmful.

Cisplatin and 5-fluorouracil in the primary management of squamous esophageal cancer

A combined treatment program consisting of chemotherapy with cisplatin and infusion 5‐fluorouracil (5‐FU) for three cycles followed by esophagectomy or radiation, or both, has been conducted in 26 patients with squamous cancer of the esophagus localized to the primary site. Eleven patients had objective evidence of partial or complete response to the chemotherapy. Fourteen patients were operated on and ten underwent total esophagectomy. Drug toxicity was considerable with severe mucositis and myelosuppression occurring in 11 and seven patients, respectively. There were no drug‐related deaths. Median survival is 17.8 months. Ten patients have lived more than 2 years. Six of these patients have undergone total thoracic esophagectomy after the induction chemotherapy. Determination of the ultimate benefits of combined modality therapy may require prospective randomized trials isolating the major treatment components but our data suggest that chemotherapy contributes to improved results in this disease and that drug therapy is emerging as an integral component of combined therapy.

Fiber Size and Energy Metabolites in Five Separate Muscles from Patients with Chronic Obstructive Lung Disease

The purpose of this study was to examine whether morphologic abnormalities in human respiratory muscles are related to increased airway obstruction. 43 patients who were undergoing thoracotomy for suspected neoplasm had biopsies taken from one or more of the following muscles: external intercostal (EXT), internal intercostal (INT), diaphragm (DIA), latissimus dorsi (LAT), and quadriceps femoris (LEG). Mean FEV1/FVC was 65% of predicted (range 43–90%). 21 of the 43 patients had a malignancy. Atrophy of type I fibers was found in 27% of respiratory and 11 % of nonrespiratory muscles. Type II fiber atrophy was more common, being found in 58% of all muscles studied. The degree of type II fiber atrophy correlated significantly with the amount of weight loss, but not with age or the presence of malignancy. A unique and significant relationship was found between type II fiber atrophy in the INT (an expiratory muscle) and all measured indices of airway obstruction. This relationship did not exist in the DIA, EXT, or LAT, ordinarily considered muscles of inspiration. The percentage of type I and type II fibers bore no relationship to indices of airway obstruction. Depletion of muscle metabolites was common to all muscles and could not be related to airway obstruction or fiber atrophy. These data suggest that fiber atrophy and metabolite depletion occur commonly in both respiratory and nonrespiratory muscles in patients with stable obstructive lung disease. These changes probably reflect a generalized disease process and may predispose to muscle fatigue. Whether or not airway obstruction produces fiber atrophy in expiratory muscles requires further investigation.

Primary Malignant Melanoma of the Esophagus

Primary malignant melanoma of the esophagus is a rare disease. A case is reported and the newer diagnostic techniques of immunohistologic identification of the tumor by positive reaction to the HMB-45 antigen, as well as immunoscintigraphy with Technetium-99m-labeled melanoma monoclonal antigen for the demonstration of distant metastasis, is presented. A current review of the literature on this uncommon tumor is presented, and treatment options are discussed. A total esophagectomy remains the treatment of choice. Four long-term (> 5 years) survivors after adequate surgical removal have been recorded in the literature.

Neurogenic Tumors of the Thorax

Neurogenic tumors of the thorax are observed in all age groups, although they are rare in the elderly. They are more likely to be malignant in the child than in the adult. Tumors of the autonomic system are common in children, whereas the nerve sheath tumors are more likely to be found in adults. The malignant lesions are almost always symptomatic and the benign lesions asymptomatic, except in the child, in whom a benign lesion may result in symptoms because of its size relative to the volume of the childs thorax. Intraspinal canal extension, although relatively infrequent, should be sought for in all paravertebral tumors, for a significant percentage of these may be initially asymptomatic. Excision of such an hourglass tumor without foreknowledge of such extension may lead to serious spinal cord complications. Surgical excision of most of these tumors is sufficient except for the malignant lesions, especially in infancy and childhood, for which the addition of postoperative irradiation and chemotherapy may be beneficial. The prognosis after the removal of benign neurogenic tumors of the thorax is excellent. In the infant or child with Stage III or IV neuroblastoma, ganglioneuroblastoma, or an Askin tumor, the prognosis is poor. In the adult with a malignant neurogenic sarcoma or a malignant paraganglioma, the prognosis likewise is grave.

Relationship of Cell Type and Lymph Node Metastasis to Survival After Resection of Bronchial Carcinoma

In the completed adjuvant chemotherapy lung trials conducted by the Veterans Administration Surgical Group, the cell type was recorded in 2,341 of 2,349 curative resections; extent of lymph node involvement was known in all cases. Nodes were normal in 1,231 patients. Five- and ten-year survival computed by the life-table method was 33.7% and 20.4%, respectively. These rates were significantly greater than the 16.2% and 8.8% recorded in 1,118 patients whose nodes showed metastases. Among patients whose cell type was known, five-year survival in 484 with hilar node involvement was 17.4% and was not significantly different from 20.1% in 364 patients in whom only lobar nodes were involved. The survival was 8.9% in 268 patients with cancer in the mediastinal nodes; this was significantly worse than either of the aforementioned groups. A five-year survival of 26.8% in 1,482 patients with squamous cell carcinoma was greater than the 24.3% in 359 with adenocarcinoma and 22.4% in 500 with undifferentiated cell types, but the differences were not significant. Variations between these groups remained nonsignificant when nodes were normal and were of only borderline significance, at the 5% level, when they showed metastasis. When a curative resection has been accomplished, cell-type as classified in this study has little bearing on long-term survival, whereas the presence of node metastasis as well as its location is of the utmost importance.

Mediastinal parathyroid cysts revisited

BACKGROUND A case of a functioning mediastinal cyst is presented. METHODS A comprehensive review of the literature found 93 patients in whom a parathyroid cyst or cysts extended into, or was completely contained within, the mediastinum. Including our patient, there were 46 men and 45 women, and the gender was not recorded in three. RESULTS The cysts were located in the anterosuperior region in 56 patients, in the middle region of the mediastinum in 26, and in the anterior, prevascular region in 12. Thirty-nine patients had functioning cysts associated with hyperparathyroidism of varying severity; seven patients presented with a hypercalcemic crisis. Local symptomatology consisted of a neck mass, respiratory distress, and occasional dysphagia or chest pain. Recurrent laryngeal nerve paresis was present in nine patients, and innominate vein compression or thrombosis was present in two. The cysts in all but four patients were treated by open surgical excision; two were treated by thoracoscopy, and two patients only had fine-needle aspiration of the cyst. The cyst was excised via a cervical approach in 67 patients and by a thoracotomy or median sternotomy or a variation thereof in 23. There was no operative mortality and morbidity was minimal. CONCLUSION Surgical resection was successful in all and remains the treatment of choice for mediastinal parathyroid cysts.

Thoracic esophageal diverticula

SummaryA review of intrathoracic esophageal diverticula has been presented. Diverticula are considered either epibronchial or epiphrenic by their point of origin in the intrathoracic esophagus. The pathogenesis, symptomatology, complications, and methods of diagnosis of each has been presented. The surgical treatment of epibronchial diverticula is indicated for complications. Small, asymptomatic epiphrenial diverticula are treated conservatively; diverticula that are symptomatic or large and retain barium should be removed surgically. The treatment of choice is a transpleural diverticulectomy. The technical details of this procedure as performed by the authors has been recorded.

Adjuvant Therapy for Large Bowel Cancer: Update of Veterans Administration Surgical Oncology Group Trials

The results of eight clinical trials are reported. In two trials radiotherapy was the adjuvant modality, five used chemotherapy, and one used a combination of chemotherapy and nonspecific immunotherapy. There is evidence of a modest but definite survival benefit from both adjuvant chemotherapy and radiotherapy.

Lymphoepithelioma-like carcinoma of the lung

Primary lymphoepithelioma-like carcinoma of the lung is rare; only 26 case reports have been identified in the literature. The present report presents a case of a 67-year-old white man with a T1 N1 M0 lymphoepithelioma-like carcinoma of the lung. He presented with severe arthritic complaints that resolved after resection of the tumor. The majority of these tumors have occurred in Asian patients who have shown evidence of previous exposure to the Epstein-Barr virus.