164 Abstracts/Lung Cancer 14 (19%) 149-179

stage 11 disease was compared with that of stage-matched and age- matched groups having right pneumonectomy. Results: Four patients (3.5%) died postoperatively. Nonfatal complications occurred in 55 patients (49%); the most frequent problem was pleural space disease (34%). Survival studies focused on the 96 patients with non-small cell bronchogenic cancer (44 in stage I, 32 in stage II, and 20 in stage IIIA). The overall 5-year survival rate was 40%; the 5-year survival rate was similarforstage landstage II (41% forstage I, 50% for stage II. and 17% for stage IIIA). The incidence of local recurrence was significantly increased after bilobectomy for stage I cancer (chil = 5.066, p < 0.05) compared with pneumonectomy but did not affect 5-year survival. Local recurrence and survival were similar after bilobectomy and pneumo- nectomy in stage II. Conclusions: These datademonstrate an increased morbidity after bilobectomy. Survival studies demonstrate an increased risk of local recurrence in patients with stage I disease, which might be partly explained by understaging.

Randomized trial of lobectomy versus limited resection for Tl NO non-small cell lung cancer GinsbergRJ,RubinsteinLV,BenfieldJR. Thoracic-Service, Depatiment ofsurgery, Memon’alSloan-Ketten’ng Cancer Crr.. 1275 YorkAve. New York, NY 10021. AM Thorac Surg 1995;60:615-23.

Background: It has been reported that limited resection (segment or wedge) isequivalent tolobectomyinthemanagementofearlystage (TI- 2 NO) non-small cell lung cancer. Merhods: A prospective, multi- institutional randomized trial was instituted comparing limited resection with lobectomy for patients with peripheral TI NO non-small cell lung cancer documented at operation. Analysis included locoregional and distant recurrence rates, 5-year survival rates, perioperative morbidity and mortality, and late pulmonary function assessment. Results: There were 276 patients randomized, with 247 patients eligible for analysis. There were no significant differences for all stratification variables, selected prognostic factors, p&operative morbidity, mortality, or late pulmonary function. In patientsundergoing limitedresection, there was an observed 75% increase in recurrence rates (p = 0.02, one-sided) attributable toanobservedtriplingofthelocalrecurrencerate (p= 0.008 two-sided). an observed 30% increase in overall death rate (p = 0.08, one-sided). and an observed 50% increase in death with cancer rate (p = 0.09, one-sided) compared to patients undergoing lobectomy (p = 0 IO. one-sided wasthe predetined threshold for statistical significance for this equivalency study). Conefusions: Compared with lobectomy, limited pulmonary resection does not confer improved perioperative morbidity,mortality,orlatepostoperativepulmonaryfunction.Because ofthe higher death rate and locoregional recurrence rate associated with hmited resection, lobectomy still must be considered the surgical procedure of choice for patients with peripheral Tl NO non-small cell lung cancer.

A resected case of double primary lung cancers, each with coexistent metastasis in the same mediastinal lymph node Komiya T, Kusunoki Y, Yana T, Takada M, Nakagawa K, Morino H. .Swond Depl. ofInternal Medicine, Osaka PrejcwalHabikino Hospital. Owka. Jpn J Lung Cancer 1995;35:477-81.

A 65 year-old man was admitted to our hospital for a further exam- ination ofa roentgenologicaly abnormal shadow in the ipsilateral lung field during antituberculous therapy. Squamous cell carcinoma of the lung was diagnosed by preoperative examinations, and then right upper lobectomy was performed. Histological findings of the resected tumor revealeddouble primaryhmgcancers(rt.B~a: squamouscell carcinoma. rt B’b; adenocarcinoma). Metastasesof each carcinomas were detected 111 the same right tracheobronchial lymph node (4) coexisting with each other. There have been very few reports referring multiple primary

cancers showing concurrent metastases to the same lymph node, especi- ally in multiple primary lung cancers. We present this rare case and review the literature.

Airway stents: Present and future Colt HG, Dumon J-F. PSP and Nd: YAG Laser C&r, UCSD Medical Center, 200 War Arbor Drive. San Diego, CA 92103-8380. Clin Chest Med 1995;16:465- 78.

Tracheobronchial stent insertion is a relatively new technique used to palliate or cure central airways obstruction. When performed by experienced thoracic endoscopists, this procedure is both safe and effective, even if complications of indwelling stents may require repeat endoscopic intervention. Although proven clinically beneficial to many patients, airway prostheses have not yet been the subject of Large comparative case studies or randomized controlled investigations. Reports are often experiential and anecdotal. Further research is needed todetennine the effectsofstentingonsurvivalinpatientswithmalignant airway disease and its degree of success in patients with benign airway strictures. Only thenwillairwaystentstrulydeserve theirplacealongside other therapies for tracheobronchial obstruction.

Influence of heparin thromboprophylaxis on plasma leuco- cyte elastase levels following lobectomy for lung carcinoma Tian Y. Gebitekin C. Martin P. Satur CMR, Meams A, Walker DR. lfr~~~l~rm~nt 01‘ (~tirdiotho~ucic Swgqv. Killingbeck Hospizui. York Koud. Lrrrl.5 LS14 6UQ. Blood Coagul Fibrinolysis 1995:6:527-30.

Recent in vitro studlesand animal investigations indicate that plasma leucocyte elastase (PLE) can dissolve pulmonary structural proteins, such as elastin. and produce lesions in the lung similar to that seen in adultrespiratorydistresssyndrome(ARDS)andemphysema. Incontrast. heparin strongly inhibits PLE and protects elastin from elastolysis. On the basis ofthese findings, PLE levels were monitored in 24patients with non-small cell lung carcinoma (NSCLC) undergoing lobectomy. Ten patients from lllingbeck Hospital (Group 1) received 5000 IU sub- cutaneous (s.c.) heparin commenced 2 h prior to surgery and continued at 8 h intervals unnl the patient was fully ambulatory. Fourteen patients from Bradford Royal Infirmary (Group 2) received no heparin as standard policy. There was no significant difference in pre-operative PLE levels between groups. The post operative PLE levels in both groups increased significantly (PC 0.02) on the first post operation day (POD). However, PLE levels of Group 2 were 2.5 to 5.3 times higher than those of Group I at each postoperative interval (first. third, and seventh POD) respectively (0.002 < PC 0.02). There was no difference in blood loss between groups (P = 0.17). These results indicate that post operative PLE activity IS elevated in NSCLC patients following lobec- tomyand s.c heparinadministrationasthromboprophylaxismay inhibit PLE activity post operatively without increasing blood loss. Therefore, heparin may have a role to play in protecting lung tissue against the pulmonary lesions caused by proteolytic activity of PLE, and theoreti- callyreducepostoperativecomplications,suchasARDSoremphysema.

Modality of failure following resection of stage I and stage II non-small cell lung cancer Ramacciato G, Paolini A, Volpino P, Aurello P, Balesh AM, D’ Andrea N et al. Lsrifuro di Clinica Chirurgica, Univ degli Studi Roma ‘La Sapienza’, VialedelPoliclinico. 00161 Roma.Int Surg 1995;80: 156-61.

The pattern and sites ofrecurrence were studied in 270 patients with resected Stage l(N0) or Stage II (NI) non-small cell lung cancer (NSCLC). Survival, incidence, and type of intrathoracic locoregional recurrence versusdistantextm-thoracicrecurrence~ersurgicalexcision were analyzed. Prognostic parameters, such as postsurgical stage,

Abstracts/Lung Cancer 14 (19%) 149-179 16.5

histologic type, degreeofcellulardifferentiation, andsurgical approach. were examined to discern their influence on tlunor recurrence. The total incidence ofrecurrence in patients with stage 1 and II twnors was high, with a radical surgical approach often resulting ineffective, because of incomplete locoregional neoplastic extirpation due tomicrometastases. Lymph node metastases worsened prognosis, with Nl tumors demon- strating a significantly higher recurrence rate at 5 years (63%) than NO neoplasms (48%) @ < 0.01). Stage I tumors showed an elevated incidence of local recurrence (45%), with tumor T-factor making a significant contribution in such cases. NI-factor combined with an elevated T-factor (Stage II Subclass pT2NI neoplasms) promoted a higher incidence of distant rather than local recurrence. A shorter disease-free interval was observed inpatients with N tllfnors as opposed to NO neoplasms. Histologic type did not play a statistically significant role (p =ns) in the total incidenceofrecurrence. A similar total incidence ofrecurrence wasobservedinStageIandIItwnorstreatedbylobectomy (51%)orpneumonectomy(56%),withlocoregionaIrecurrenceapp~ring more frequently after lobectomy.

Good results of surgical treatment of elderly patients with stage I lung cancer Damhuis RAM, Schutte PR, Kho GS, Maat APWM. Inregraal Kankercmtnmm. Postbus 289, 3000 AG Rotterdam. Ned Tijdschr Geneeskd 1995;139:1781-5.

Objective. To determine the influence ofage on survival ofpatients undergoing resection for lung cancer. Design. Retrospective. Setting. South-western partofthe Netherlands. Methods. Follow-upinformation was gathered on patients who had undergone resection for stage I non- small cell lung cancer from 1984 through 1990 and had been registered by the Rotterdam Cancer Registry. Operative mortality, 2-year and 5- year survival in the age groups 20-59,60-69 and 70 yearsand older were compared. Results. Of the 630 patients (median age of 66 years) one- third was 70 years or older. Operative mortality was mainly determined by the type of operation: 6% after pnewnonectomy versus 1% after lesser resections. Five-year survival declined with age from 65% to48% and43%(p<0.01). Afteradjustment fornon-related causesofdeath this difference decreased: 68%, 55%. 61% @ = 0.15). The main prognostic factor was tumow size. Conclusion. Chronological age has a limited influence on the survival of patients with lung cancer and does not preclude surgical treatment.

Pulmonary function 3-12 months after pneumonectomy, lobectomy or bilobectomy for lung cancer Hjalmarsen A, Aasebo U, Lie M. DeptofPulmonaryMedicine, Universiry Hospital of Tromso. N-9038 Tromso. Stand J Thorac Cardiovasc Surg 1995;29:71- 4.

Pulmonary fimction was studied 3 and 12 months &er pulmonary resection for lung cancer in 37 patients, ten of whom had wdergone pneumonectomy, 19 lobectomy and eight bilobectotiy. The resection was right-sided in 25 cases and left-sided in 12. Tumour site and diameter were registered, arterial blood gases measured and spirometry performed. Three monthsafierall types ofresection there was significant decrease in forced vital capacity (FVC), and forced expiratory volume/ I second(FEV,),butnotiFEV,/FVC%.At 12monthspneumonectomy had reduced FVC to 58% of predicted values, FEV, to 50% and FEV,/ FVC% to 70%. After lobectomy the corresponding figures were 86%. 73% and 67% and after bilobectomy they were 88%. 78% and 70%. Between 3 and 12 months postoperatively, FVC increased in all groups, significantlyinthosewithlobectomyorbiIobectomy@<0.01 and0.05, respectively).

Stage l nonsmall cell lung cancer: A multivariate analysis of treatment methods and patterns of recurrence Harpole DH Jr, Hemdon JE II, Young WG Jr. Wolfe WG, Sabiston DC Jr. Division of Thoracic Surgey, Brigham and Women’s Hospiral, 75 Francis Street. Boston, MA 02115. Cancer 1995;76:787-96.

Background. Nonsmall cell lung cancer (NSCLC) has become the leading cause of cancer-related deaths in women and men in the United States, with more than 157,000 estimated deaths m 1995. Surgical resection remains the mainstay of therapy in Stage I and II disease. However, local and distant recurrence account for the disappointing survivalratesafierresection. Appropriateselectionofsurgicalprocedures and effective use ofadjuvant therapies will depend upon the elucidation of prognostic factors that predict for recurrence. Mefhods. A detailed analysis was undertaken to evaluate surgical therapy and to define risk factors associated with recurrence and cancer death in 289 consecutive patients with NSCLC who were diagnosed, resected and followed at the Duke University Medical Center from January I, 1980, until December 3 1, 1988. These patients had no evidence of me&stases on head and chest/abdominal computed tomograms and radionuclide bone scans before resection. Resected specimens from these patients pathologic verification of Stage I disease. Follow-up was complete in all cases through 8/l/94 (median, 61 months). Variables analyzed included age, sex, smoking history, presenting signs and symptoms, operative procedure, histopathology, hospital course including complications, and the time and location ofany recurrence or cancer death. Results. The 30-day mortality rate was 5 of 289 (1.7%), with minor and major morbidity rates of 17% and 9%, respectively. Statistical comparison of lobectomy( 193)wedgeresection(75)andpneumonectomy(21)revealed significantly (P < 0.04) smaller tumors (T,), more comorbidity. and fewer complications for wedge resection patients. A trend (P < 0.09) toward an increased rate of local/regional recurrence and no difference in survival was also observed for wedge resection. One hundred five patients died of cancer (I 3-month median time to recurrence) for an actual 5-year survival of63%. Significant univtiate predictors ofearly recurrence and decreased survival (P < 0.01) were: male sex, the presence ofsymptoms, hemoptysis, chest pain, type ofcough. tumor size in cm and by T- classification, visceral pleural invasion, high mitotic index, and vascular invasion. Significant (P < 0.05) multivariate independent variables for early recurrence and cancer death were the presence ofsymptoms, vascularinvasion,pleural invasion, highmitotic index, and tumor size greater than 3 cm. Conclusion. Current surgical therapy for stage I NSCLC has an acceptable morbidity and mortality rate. The current dataalso stratify patients with Stage 1 NSCLC into high and low risk populations that can be used in future randomized trials of adjuvant therapy.

Changes of ventilator-y and respiratory function of the lungs after pneumonectomy Mayer M, Strmen J, Holly P, Mayerova S, Dubrava I, Petrik V. Novozamocka 32, 960 01 Zvolen. Stud Pneumol Phtiseol 1995;55: 186- 95.

Authorsanalyse the reduction ofventilatory and respiratory functions of the: lungs after pneumonectomy in 132 patients. 96 % of patients suffered from primary bronchogenic carcinoma. Pneumonectomy led to anaveragedecreaseofVC(1.791,43%),FEVl(1.161,39%),MMV (36.4 I/min, 37 %) and ERV (0.47 I, 34 %), Static volumes, examined by whole body plethysmography, decreased as follows: TLCb (2.76 I, 37 %), TGV (1.44 1, 32 %) and, Rvb (0.96 1, 27 %). Static volumes examined by the nitrogen washout method decreased as follows: TLC (39 %), FRC (34 %) and RV (26 %). Lung diffusion capacity for CO decreased about 25 % (single breath method) and about 21 % (steady state method). The values of Raw, FEVI/VC % and RV/TLC %