Bronchoplastic Procedures for Bronchial Carcinoma

147 Copenhagen, Denmark. Clin. Exp. Immunol. 67: 425-432, 1987. Modification of beta-2microglobulin has been shown to occur in vitro in serum of patients suffering of small cell lung cancer, where it clearly correlated to the clinical course of disease. The cause of serum beta-2-microglobulin modification occuring in these patients is investigated in the present study. This revealed that modification of beta-2microglobulin is due to cleavage by a serine protease, which is dependent on divalent cations and has a trypsin-like specificity. The process showed the following characteristics: pH optimum at 8.5, heat inactivation by incubation at 56 degr. C for 20 min and temperature optimum at 20 degr. C. Comparison of CT and Fiberoptic Bronchoscopy in the Evaluation of Bronchial Disease. Naidich, D.P., Lee, J.-J., Garay, S.M. et al. Department of Radiology, New York University Medical Center-Bellevue Hospital, New York, NY 10016, U.S.A. Am. J. Roentgenol. 148: 1-7, 1987. CT was compared to fiberoptic bronchoscopy in a large series of patients to study the value of CT for visualizing bronchial disease. CT scans were available for review in 64 cases in which focal airway disease was identified with fiberoptic bronchoscopy and in 38 patients in whom the airways appeared normal at bronchoscopy. CT was positive in 59 of 64 cases in which lesions were detected endoscopically. If the results are analyzed according to the extent of involvement of individual bronchi, CT successfully identified 88 (90%) of 98 lesions. CT correctly excluded disease in 35 (92%) of 38 cases that were subsequently verified to be normal by fiberoptic bronchoscopy. In no case was the diagnosis of malignancy missed by CT. While extremely accurate in detecting focal lesions. CT was inaccurate in predicting whether a given abnormality was endobronchial, submucosal, or extrinsic (peribronchial). In three cases CT failed to detect submucosal extension into the left mainstem bronchus, which has important implications concerning the value of CT in staging bronchial malignancy. It is concluded that CT is helpful when bronchoscopy is contraindicated or refused. CT may also be used in selected cases when there is low clinical suspicion of endobronchial disease and as a complementary procedure to fiberoptic bronchoscopy for outlining the exact location of major mediastinal and hilar vessels, lymph nodes, and tumor in relation to adjacent airways. Mediastinal

Lymph Node Metastases From

Bronchogenic Carcinoma: Detection With MR Imaging and CT. Poon, P.Y., Bronskill, M.J., Henkelman, R.M. et al. Department of Radiology, University of Toronto, Toronto, Ont., Canada. Radiology 162: 651-656, 1987. Magnetic resonance (MR) imaging and computed tomography (CT) were compared in a prospective study of 48 patients for the detection of metastatic mediastinal lymphadenopathy from bronchogenic carcinoma. The images were interpreted by three experienced radiologists using a five-point rating scale, enabling receiver operating characteristic (ROC) analysis. Imaging results were evaluated against 'truth' data based on analysis of surgical specimens from mediastinoscopy and thoracotomy. All MR images were cardiac gated to reduce cardiac motion artifacts in the mediastinum. MR and CT both performed well, as indicated by similar areas under the ROC curves of 0.779 + or 0.039 for MR imaging and 0.781 + or 0.038 for CT scanning. No strong correlation between nodal size and metastatic involvement could be found for either MR or CT results. As long as nodal size remains the sole criterion in the detection of metastatic mediastinal lymphadenopathy, MR imaging is unlikely to enable better interpretations than CT scanning. 6.

SURGERY

Bronchoplastic Procedures for Bronchial Carcinoma. Roder, O.C., Christensen, J.B., Andersen, C. et al. Surgical Department T, Odense University Hospital, Odense, Denmark. Scand. J. Thorac. Cardiovasc. Surg. 21: 109-111, 1987. In a 22-year period from 1962 to 1984, 51 patients with malignant lung disease had a sleeve resection performed. In 33% of the patients, pneumonectomy was contraindicated because of limited lung function. The operative mortality was 8%. Six per cent of the patients developed complications after the operation. The 5year survival of the total group of patients was 30%. Patients with lesions classified as stage 1 and stage 2 had the best prognosis, with a 5- and 10year survival of 43.5% and 27%, respectively. In patients classified as stage 3 and stage 4, the 5- and 10-year survival was 20%. A postoperative measurement of regional ventilation and perfusion indicated that the function of the remaining lung was presumably undisturbed by the operation. Also, the vital capacity and FEV 1 were only minimally reduced as a result of the operation. The amount of functional lung tissue spared by the operation compared to pneumonectomy was estimated

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to 39%. Because of these functional results and the promising 5-year survival figures, we suggest that sleeve lobectomy should be the operation of choice for tumors localized to the upper lobe orifice involving the main bronchus. Thoracic Computed Tomography in the Preoperative Evaluation of Primary Bronchogenic Carcinoma Matthews, J.I., Richey, H.M., Helsel, R.A., Grishkin, B.A. Pulmonary Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, U.S.A. Arch. Intern. Med. 147: 449-453, 1987. One hundred seventy-four patients with bronchogenic carcinoma underwent computed tomography (CT) as part of their preoperative evaluation. Overall, CT had a sensitivity of 86%, a specificity of 78%, and an accuracy of 81% in identifying mediastinal lymph node metastases. In patients with a central tumor, the sensitivity was 93%, the specificity 74%, and the accuracy 83%. In patients with a peripheral tumor, the respective percentages were 55%, 82%, and 77%. Only ii of 66 patients with a peripheral tumor had mediastinal metastases, and five of these patients had a normal CT scan. Conversely, 43 of 64 patients with a central tumor and mediastinal lymph node enlargement on the CT scan had unresectable disease, compared with only one of 44 patients without such enlargement. We conclude that CT is not useful in the evaluation of patients with a peripheral tumor; however, it is useful in determining which patients with a central tumor do not require a surgical staging procedure prior to thoracotomy. Selective Preoperative Evaluation for Possible N2 Disease in Carcinoma of the Lung. Backer, C.L., Shields, T.W., Lockhart, C.G. et al. Department of Surgery, Veterans Administration Lakeside Medical Center, Chicago, IL 60611, U.S.A. J. Thorac. Cardiovasc. Surg. 93: 337343, 1987. The efficacy of computed tomography and surgical mediastinal exploration in determining tumor resectability were retrospectively evaluated in 92 consecutive patients with non-small cell lung carcinoma. Status of mediastinal nodes was ultimately determined by surgical mediastinal exploration or thoracotomy. Patients were divided into three groups on the basis of chest roentgenography: Group I comprised 30 patients with peripheral T1 or T2 lesions with normal hilar and mediastinal shadows. Only one patient was found to have an involved node. Chest

roentgenography had an accuracy rate of 96% and computed tomography, 93%. Thoracotomy is recommended without either computed tomography or surgical mediastinal exploration in this group. Group II comprised 47 patients with T1 or T2 lesions with an abnormal hilus, and abnormal mediastinal shadow, or either the hilus or mediastinum obscured by overlying parenchymal disease. Computed tomography revealed mediastinal nodes 1 cm or greater in size (abnormal node group) in 21 patients (45%) and smaller than 1 cm (normal node group) in 26 patients (55%). Surgical mediastinal exploration was performed in the abnormal node group and involved nodes were found in 17 or 21 patients (81%). In the normal node group, thoracotomy only was performed and no involved nodes were found. Computed tomography only was performed and no involved nodes were found. Computed tomography is recommended in all patients in Group II. Patients in the normal node group may be subjected to thoracotomy only and those in the abnormal node group should undergo surgical mediastinal exploration as the next diagnostic step before thoracotomy. Group III comprised 15 patients with grossly abnormal mediastinal shadows. Findings from computed tomography were abnormal in all i0 patients in whom it was done. Surgical mediastinal exploration was done in all 15 and yielded abnormal results in 14. It is recommended in this group that computed tomography is unnecessary and surgical mediastinal exploration should be the only diagnostic procedure. Thus, in potentially resectable non-small cell lung carcinoma, the use of computed tomography and surgical mediastinal exploration should be selective and should be determined by appropriate initial interpretation of the chest roentgenogram. Bronchial Sleeve Resection With and Without Pulmonary Resection. Frist, W.H., Mathisen, D.J., Hilgenberg, A.D., Grillo, H.C. Department of Surgery, Division of General Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114, U . S . A . J . Thorac. Cardiovasc. Surg. 93: 350-357, 1987. Sleeve resection with and without pulmonary resection is safe, effective and appropriate treatment for a wide range of endobronchial lesions including neoplasms of low-grade malignant potential and selected cases of bronchogenic carcinoma. Sixty-three patients underwent 64 sleeve resection procedures (47 with concomitant pulmonary resection and 17 without) at the Massachusetts General Hospital between 1962 and 1986 with a 30 day mortality