Brain tumors do not affect thiopental dosing requirements

We used the biphasic electroencephalographic (EEG) response to increasing concentrations of thiopental to measure regional brain responses to thiopental. Eight patients with cortical parietal brain tumors, 3.3 (SD 1.3) cm in diameter, and eight control patients with lung cancer and normal brain computed tomography scans received thiopental by infusion (50-75 mg/min) until burst suppression (50% isoelectric activity) on the EEG occurred. Infusion lasted 10.7 (SD 2.4) min, and the average dose of thiopental administered was 810 (SD 170) mg [11.2 (SD 1.9) mg/kg]. During infusion the EEG was continuously recorded from the F3, F4, P3, and P4 electrodes. On-line power spectral analysis was performed, and data were saved for later analysis. Four EEG parameters [log beta (15-30 Hz) power, percent beta power, spectral edge 95% and spectral edge 70%] were plotted against calculated brain concentration of thiopental [using an assumed plasma-effect site rate constant (ke0) of 0.58] for each individual. Three points were measured on each curve (50% upslope, peak, and zero intercept) to quantitate the EEG response. Statistical comparisons were performed between the following sets of data: EEG response at electrode closest to brain tumor versus electrode farthest from tumor (in the same patient); and electrodes closest to brain tumors (parietal P3 and P4) versus same electrode pair in control patients (patients with thoracic tumors) using analysis. No differences were found in any comparison. Thus, the presence of a brain tumor does not affect the response of the brain in this region to thiopental as measured using EEG.

A region of primer binding variation at the D6S265 locus associated with HLA-A25 and HLA-A26 antigens

D6S265 is a polymorphic dinucleotide repeat, mapped within 70 kb centromeric of HLA-A, on chromosome 6p21.3. While genotyping families for genetic linkage analysis, allele non-amplification resulting in apparent non-Mendelian inheritance was observed at the D6S265 locus in 15 individuals, on chromosomes carrying the HLA-A25 and HLA-A26 antigens. The D6S265 locus was sequenced in a variant individual homozygous for allele non-amplification, and in a non-HLA-A25/-A26 individual, homozygous for D6S265 allele 1. Five base changes were identified in the reverse primer binding region of the variant individual, effectively preventing annealing of the 3' primer to the template.

Survival after surgical treatment of brain metastases from lung cancer: a follow-up study of 231 patients treated between 1976 and 1991

The authors reviewed the records of 231 patients who underwent resection of brain metastases from nonsmall-cell lung cancer between 1976 and 1991. Data regarding the primary disease and the characteristics of brain metastasis were retrospectively collected. Median survival in the group from the time of first craniotomy was 11 months; post-operative mortality was 3%. Survival rates of 1, 2, 3, and 5 years were 46.3%, 24.2%, 14.7%, and 12.5%, respectively. One hundred twelve women survived significantly longer than 119 men (13.8 vs. 9.5 months, p < 0.02). Patients with single metastatic lesions (200 patients) survived longer than those (31 patients) with multiple metastases (11.1 vs. 8.5 months, p < 0.02). Patients with supratentorial tumors survived longer than patients with cerebellar lesions. A high Karnofsky performance scale score before surgery also indicated increased survival. In multivariate analyses, incomplete resection or no resection of primary lung tumor, male gender, infratentorial location, presence of systemic metastases, and age older than 60 years were significantly correlated with shorter survival. Approximately one-third of the patients died of neurological causes, one-third of systemic disease, and one-third of a combination of both. The results of this series confirm that the overall prognosis for patients with even a single resectable brain metastasis is poor, but that aggressive therapy can prolong life with quality of life preserved and can occasionally permit long-term survival.

Resection of brain metastases from sarcoma

BACKGROUND

Brain metastases from sarcoma are rare, and data concerning the treatment and results of therapy are sparse.

METHODS

We retrospectively reviewed 25 patients with brain metastases from sarcoma of skeletal or soft-tissue origin, surgically treated in a single institution during 20 years.

RESULTS

In 18 patients the brain lesion was located supratentorially, and in 7 patients infratentorially. Median age at brain metastasis diagnosis was 25 years. Median time from primary diagnosis to diagnosis of brain metastasis was 26.7 months. Lung metastases were present in 19 patients and in 8 patients they were synchronous with the brain lesion. Pulmonary metastases were resected in 12 patients (48% of total, and 63% of those with pulmonary lesions). The overall median survival from diagnosis of the primary sarcoma was 38 months and from craniotomy was 7 months. The presence or absence of lung lesions did not alter the median survival as calculated from diagnosis of brain metastasis. Overall percent survival was 40% at 1 year and 16% at 2 years.

CONCLUSIONS

Because brain metastases from sarcoma are refractory to alternative treatment, surgical excision is indicated when feasible. Brain metastases from sarcoma are uncommon, usually occurring with or after lung metastasis. Long-term survival is possible in some patients.

The treatment of patients with recurrent brain metastases. A retrospective analysis of 109 patients with nonsmall cell lung cancer

BACKGROUND

Brain metastases represent a major source of morbidity in patients with cancer.

METHODS

Treatment outcomes were analyzed retrospectively in 214 patients with brain metastases from nonsmall cell lung cancer (NSCLC) who underwent resection at Memorial Hospital (New York, NY) between January, 1976, and December, 1990.

RESULTS

The study group included 109 patients (51%) with symptomatic recurrent brain tumors (median, 5.0 months after complete resection). Recurrence in the brain was at the original site in 62% of patients and at other sites in 38%. The median survival (MS) was 11.3 months in the recurrence group compared with 9.5 months (P < 0.5) in the nonrecurrence group (N = 105). Thirty-two patients had further surgery after recurrence; their median relapse time was 5.2 months. In these patients, survival (MS, 15.0 months) calculated from the time of their first operation, was significantly different (P < 0.001) from that of patients who did not undergo a second procedure (N = 77) (MS, 10.0 months). In the 32 patients who underwent reoperation, MS from the time of the second operation was 10 months, whereas the median interval from the first operation was 5 months (average, 5.7 months). Eight of these 32 patients had a third operation, after a median relapse time of 4 months; their MS was 42 months. There was a significant difference (P < 0.02) between the MS of 39 patients synchronously diagnosed with lung cancer and brain metastasis (MS, 9.0 months) and 70 metachronously diagnosed patients (MS, 14.6 months). Women (N = 55) survived longer than men (N = 54) (14.4 months vs. 9.7 months, P < 0.01). Univariate analysis showed that histology, disease stage, and completeness of resection of the primary tumor also affected survival (P < 0.02, P < 0.014, and P < 0.001, respectively). Although no significant difference was found between survival of patients with recurrence in the supratentorial space and patients with recurrence in the posterior fossa (MS, 11.4 months vs. 11.2 months, P < 0.13), no one from the latter subgroup survived 3 years.

CONCLUSIONS

If technically feasible, further surgery is effective in prolonging the survival of patients with NSCLC who have recurring brain metastases.

Clinical and echocardiographic correlates of symptomatic tachydysrhythmias after noncardiac thoracic surgery

BACKGROUND

Supraventricular tachydysrhythmias (SVTs) following thoracic surgery occur with significant frequency and may be associated with increased morbidity. Prospective data on the etiology and importance of these dysrhythmias are sparse.

METHODS

In 100 patients undergoing pulmonary resection without history of atrial dysrhythmias or previous thoracic surgery, we examined the effects of predefined risk factors by history, pulmonary function, and echocardiography on the incidence of postoperative SVT. Serial echocardiograms were performed preoperatively, on postoperative day 1, and again between postoperative days 2 to 6 (median = 3) to evaluate cardiovascular function and to estimate right ventricular systolic pressure (RVSP) by the tricuspid regurgitation jet (TRJ) Doppler velocity method.

RESULTS

Symptomatic postoperative SVT occurred in 18 (18%) of the 100 patients studied at a median of 3 days after surgery and was disabling in 12 of 18 (67%). Digoxin loading was ineffective in controlling the ventricular response in 16 of 17 episodes. In the patients developing SVT, postoperative echocardiography revealed significant elevation of TRJ Doppler velocity (2.7 +/- 0.6 m/s vs 2.3 +/- 0.6 m/s, p < 0.05) but not right atrial or ventricular enlargement or right atrial pressure increase when compared with patients without SVT. Independent correlates of SVT determined in a stepwise logistic regression included intraoperative blood loss > or = 1 L (p = 0.0001) and a postoperative TRJ Doppler velocity > or = 2.7 m/s (p < 0.05). Patients who developed SVT had a higher rate of intensive care unit admission (p < 0.004), a longer hospital stay (p < 0.02), and higher 30-day mortality (p < 0.02).

CONCLUSIONS

These prospective data suggest that increased right heart pressure but not fluid overload or right heart enlargement predisposes to clinically significant SVT after pulmonary resection. SVT may be an important marker of poor cardiopulmonary reserve in patients who develop significant morbidity after thoracic surgery. Early interventions to reduce right heart pressure may decrease the incidence of postoperative SVT and potentially improve overall surgical outcomes.

Tumor necrosis factor alpha stimulates gluconeogenesis from alanine in vivo

An increase in gluconeogenesis contributes to the cachexia seen in severe injury, sepsis, and malignancy by converting amino acids from skeletal muscle to glucose. Since tumor necrosis factor alpha (TNF alpha) may mediate this cachexia, we examined the effect of this cytokine on gluconeogenesis. Twenty-eight male Fischer rats were injected intraperitoneally with TNF alpha (250 micrograms/kg) or saline, and after 4 hours, isolated hepatocytes were obtained by in situ collagenase liver perfusion. Hepatocytes were incubated with alanine (10 mM), and rates of gluconeogenesis were determined. Plasma lactate, glucose, insulin, glucagon, cortisol, and amino acids were measured. TNF alpha administration resulted in a 50% increase in gluconeogenesis from alanine (P < 0.05) and a three-fold increase in plasma glucagon (P = 0.01). Total and glucogenic plasma amino acids decreased with TNF alpha injection (P < 0.05). In vivo TNF alpha causes an increase in hepatic gluconeogenesis associated with increased plasma glucagon.

Altered glutathione metabolism in the tumor-bearing state

BACKGROUND

Because glutathione (GSH) appears to be important for tumor growth and many tumors contain the capacity (gamma-glutamyltranspeptidase) to transport GSH, we examined GSH metabolism in MCA sarcoma-bearing rats (TB).

METHODS

Tumor, liver skeletal muscle, kidney, and serum were collected from 47 MCA sarcoma (TB) rats and 26 normal (CTL) rats. Amino acids, GSH, gamma-glutamylcysteine synthetase (GCS), and gamma-glutamyl transpeptidase (GGTP) were determined.

RESULTS

Significant activity of GGTP (117.8 +/- 16.0 mU/min/mg protein) was present in tumors. Liver GCS activity (nanomolar per hour per milligram protein) in TB rats (106.6 +/- 37.7) was increased (p < 0.01) compared with CTL rats (57.5 +/- 12.3) and correlated positively with tumor burden (R = 0.77). Muscle GGTP was decreased (p = 0.001) in TB rats (1.7 +/- 1.1) compared with controls (6.8 +/- 1.1). Serum GSH concentrations (microM) were lower (p < 0.05) in TB rats (14.97 +/- 1.72) versus control rats (16.82 +/- 1.54) and correlated negatively with tumor burden (R = -0.83).

CONCLUSIONS

In this tumor-bearing model, tumor has significant capacity (GGTP) for the uptake of GSH. Serum GSH is depleted in TB rats and correlates negatively with tumor burden. Liver GCS is increased in TB rats and skeletal muscle GGTP is decreased, which may preferentially benefit the tumor by increasing the bioavailability of glutathione for its own use.

Hypoglycemia with glycerol salvage: a role in anti-neoplastic therapy?

Most tumors are obligate glucose consumers and severe glucose depletion has anti-neoplastic effects. However, an alternate energy source is necessary to support the host. Since glycerol is utilized by all hypoglycemic sensitive normal tissues but not tumors, glycerol may be an ideal alternate energy source. The effects of glycerol on tumor growth, animal survival during systemic hypoglycemia induced by 3-mercaptopicolinic acid (3-MP, a gluconeogenesis inhibitor), and effects of 3-MP on gluconeogenesis from glycerol were studied. Experiment 1-glycerol effect on tumor cell growth; and glycerokinase activity assay. Methylcholanthrene-induced (MCA) sarcoma cells were plated in either glucose free, glucose or glycerol containing medium. Cell counts and viabilities were recorded daily. Cells in glucose group had normal growth pattern and cell viability, while cell counts and viabilities in control and glycerol groups decreased markedly. F344 rats were injected with MCA-sarcoma cells in the flank. Glycerokinase activities in tumor and host liver were assayed on day 20. Activities were 12.3 +/- 2.8, 148.2 + 17.5 assayed on day 20. Activities were 12.3 +/- 2.8, 148.2 +/- 17.5 mumol/g protein/min in tumor and liver, respectively. Experiment 2-glycerol effect on animal survival during hypoglycemia induced by 3-MP. Following a 48 hour fast, 12 Fischer 344 rats were injected (ip) with 3-MP (200mg/kg) and randomized to saline or glycerol perfusion (100mg/kg/hr) groups. Four of 6 rats in the saline group died of hypoglycemia. All rats in the glycerol group survived, but blood glucose levels were increased as compared to the saline group. Experiment 3-3-MP effect on gluconeogenesis from glycerol as compared to lactate. 5 x 10(6) hepatocytes were incubated in glucose-free HBSS containing glycerol (20mM) or lactate (20mM) in the presence (0.5mM) or absence of 3-MP. Glucose production was assayed every 30 minutes for 2 hrs. Glucose production from glycerol was not significantly inhibited in the presence of 3-MP as compared to lactate.

CONCLUSION

Glycerol does not support MCA-sarcoma growth and promotes animal survival during severe systemic hypoglycemia induced by 3-MP. However, glycerol also led to increased gluconeogenesis in this model. The use of hypoglycemic agents with glycerol protection of host tissues warrants further study.

Perioperative growth hormone improves wound healing and immunologic function in rats receiving adriamycin

Administration of perioperative growth hormone may reverse alterations in wound healing and immunologic function in animals receiving chemotherapy. F344 rats were randomized into three groups: Control (n = 12), Chemo (n = 13), and Chemo + GH (n = 12). Human growth hormone (GH) (3 mg/kg sc bid) was begun on Day 0 and continued for 2 weeks. On Day 7, all animals underwent a standardized midline laparotomy, gastrotomy, and placement of a subcutaneous wound sponge. In addition, a single dose of adriamycin (5 mg/kg i.v.) was administered to those animals receiving chemotherapy. On Day 12, right hindlimb footpads were challenged with 50 micrograms of dinitrochlorobenzene. On Day 14, bursting strengths of the laparotomy and gastrotomy were measured. The wound sponge and gastric anastomosis were analyzed for hydroxyproline (OH-Pro) content. Animal spleens were weighed and splenocytes harvested for NK cell activity. Delayed type hypersensitivity (DTH) is reported as percentage of hind-limb foot pad swelling (%FPS). Data are expressed as means +/- SD and comparisons by ANOVA. The laparotomy bursting strength (mm Hg) in the Chemo + GH group (81 +/- 14) was significantly higher than that in the Chemo group (66 +/- 15, P < 0.05). The anastomotic tissue OH-Pro levels (mumole/g dry tissue) in the Chemo + GH group (107.9 +/- 15.2) were significantly higher than those in the Chemo group (62.9 +/- 8.5, P < 0.001). GH increased splenic weights (mg) over those of Chemo (0.50 +/- 0.13 vs 0.37 +/- 0.05, P < 0.05). NK cell activity (% killing) was significantly elevated in the Chemo+GH group compared to that in Chemo.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of enteral and parenteral nutrition on amino acid levels in cancer patients

BACKGROUND

The syndrome of cancer cachexia can have a significant impact on response to therapy as well as on survival in cancer patients. Therapies directed at metabolic perturbations in cachectic patients are dependent on nutritional repletion and maintenance of adequate amino acid substrate levels. This study compares the ability of oral feeding, enteral nutrition, and total parenteral nutrition to alter plasma amino acid levels in cancer patients.

METHODS

Patients with esophageal cancer were stratified by weight loss. Patients with < 20% weight loss were randomized to continue an ad libitum oral diet (group I) or to receive total parenteral nutrition (group II) for 2 weeks; patients with > 20% weight loss were randomized to receive either enteral nutrition (group III) or total parenteral nutrition (group IV) for 2 weeks. Plasma amino acid levels were measured before the study and again after 2 weeks of nutrition support.

RESULTS

Before therapy, there was no difference between the groups in total or essential amino acid levels; however, patients in all groups had significantly lower total amino acid levels compared with those of normal controls. After 2 weeks of treatment, patients in group I and III showed no difference in individual, essential, or total amino acid levels. However, patients in groups II and IV showed significant increases in a number of individual amino acids as well as in essential and total amino acid levels after 2 weeks of TPN.

CONCLUSIONS

Patients with esophageal cancer demonstrated significant alterations in amino acid profiles compared with those of normal controls. Total parenteral nutrition was superior to ad libitum oral feeding and jejunostomy feeding in repleting plasma amino acid levels.

Echoplanar MR imaging for characterization of adrenal masses in patients with malignant neoplasms: preliminary evaluation of calculated T2 relaxation values

OBJECTIVE

We undertook this study to assess the utility of echoplanar MR imaging for distinguishing benign from malignant adrenal masses in patients with known malignant neoplasms.

MATERIALS AND METHODS

Thirty consecutive patients with 31 adrenal masses and a known malignant neoplasm underwent breath-hold echoplanar MR imaging with a repetition time of 6000 msec and four echo times (40, 80, 120, 160 msec) on a 1.5-T unit before biopsy. Subsequently, 10 masses were shown to be malignant at histologic examination, 12 masses were benign at histologic examination, and nine were thought to be benign because they had not changed in size at follow-up imaging. Mean lesion size was 2.4 +/- 2.1 cm. T2 calculations using regions of interest in the liver and adrenal mass were performed in each patient.

RESULTS

The mean calculated T2 value of benign adrenal masses was 70.3 msec (SD, 11.6 msec) versus 104.6 msec (SD, 35.2 msec) for malignant adrenal masses (p = .013). Using a cutoff T2 value of 84 msec, 19 (90%) of 21 benign masses and nine (90%) of 10 malignant masses were correctly classified. The mean adrenal/liver T2 ratio was 1.4 (SD, 0.25) for benign lesions, and 2.1 (SD, 0.78) for malignant lesions (p = .017). Using a cutoff ratio of 1.60, 19 (90%) of 21 benign lesions and eight (80%) of 10 malignant lesions would have been correctly classified.

CONCLUSION

This preliminary work suggests that obtaining T2 calculations from echoplanar MR images of adrenal masses is a useful technique for distinguishing benign from malignant adrenal masses in patients at risk for adrenal metastasis.

Surgical access to tumors of the cervicothoracic junction

BACKGROUND

Surgical resection of tumors of the cervicothoracic junction is often problematic due to the limitations imposed by the thoracic cage and adjacent neurovascular structures. The majority of surgical approaches to this region have been designed with the intent of providing adequate exposure for vertebrectomy with tumor resection and vertebral column stabilization. These approaches do not provide adequate exposure for a heterogeneous group of tumors which also involve the cervicothoracic junction. We used a combined cervicothoracic surgical approach to determine its efficacy in tumor resection.

METHOD

Seventeen patients with a heterogeneous group of malignancies arising in a variety of soft tissues underwent combined cervicothoracic resection. The approach consisted of anterior cervical access, median sternotomy, and anterior thoracotomy.

RESULTS

Complete gross tumor resection was accomplished in all 17 patients, 15 of whom had negative microscopic margins. Extensive reconstruction was employed in 6 patients. Three patients received intraoperative brachytherapy implants and 5 patients received external-beam postoperative radiotherapy. Local tumor control was obtained in 12 patients, and 10 patients are currently alive, free of disease (median: 12 months; range: 3-47 months). There was no inadvertent sacrifice of neurovascular structures. The sternoclavicular joint was maintained in all patients. There were 4 major complications, and no perioperative mortality associated with the surgical procedure.

CONCLUSION

The combined "trap door" technique provides sufficient exposure for resection of cervicothoracic tumors. Surgery is performed with limited morbidity with the sparing of uninvolved neurovascular structures. The sterno-clavicular joint was maintained in all patients. Preliminary results using this approach for resections of tumors of the cervicothoracic junction are encouraging.

Interleukin-6 stimulates gluconeogenesis in primary cultures of rat hepatocytes

Tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and IL-1 have been shown to stimulate the synthesis of acute-phase proteins; however, few studies have examined the effect of these cytokines on gluconeogenesis. We investigated the effects of these cytokines on gluconeogenesis in primary cultures of rat hepatocytes. Incubation of hepatocytes for 24 hours with TNF-alpha or IL-1 alpha did not affect gluconeogenesis. Hepatocytes incubated with 100 pmol/L and 1 nmol/L IL-6 had a dose-dependent increase (P < .05) in gluconeogenesis (2.6 +/- 0.1 and 3.2 +/- 0.1 pmol/10(6) cells/min, respectively) as compared with controls (2.0 +/- 0.1).

Carcinoma of the esophagus. Prognostic significance of histologic type

Previous investigators have reported that in patients with esophageal carcinoma tumor cell type affects prognosis. A retrospective analysis of 258 patients, from 1985 to 1991, undergoing curative esophagogastrectomy for adenocarcinoma (n = 134) or squamous cell carcinoma (n = 124) was performed to test the hypothesis that histologic cell type is an independent prognostic factor and to identify other predictors of survival after resection. The actuarial overall survival (p = 0.16) and disease-specific survival (p = 0.68) were similar for adenocarcinoma (median overall survival = 27 months) and squamous cell carcinoma (median overall survival = 22 months). Univariate analysis identified T stage, N stage, number of diseased nodes, tumor differentiation, tumor site, and blood transfusions as significant (p < 0.05) variables in predicting overall survival. The presence of Barrett's esophagus was not predictive of survival. Multivariate analysis demonstrated that T stage (p = 0.006), N stage (p = 0.01), and number of diseased lymph nodes (p = 0.03) were independent predictors of overall survival. This analysis demonstrated that histologic type is not an independent variable for overall survival in patients undergoing curative esophagogastrectomy for carcinoma of the esophagus and gastroesophageal junction. Outcome is most strongly influenced by extent of disease defined by T and N stage.

Esophageal carcinoma. The unusual variants

The clinical behavior and response to therapy of rare histologic variants of esophageal carcinoma are unclear. To evaluate the results of therapy in this group the records of 29 patients treated between 1949 and 1991 with primary rare histologic variants of esophageal carcinoma were retrospectively reviewed. This group represented 1.2% of 2454 cases of esophageal carcinoma treated between 1949 and 1991 and included mucoepidermoid (n = 14), small-cell (n = 12), adenoid cystic (n = 2), and carcinosarcoma (n = 1) carcinomas. Treatment for localized disease consisted of esophagectomy in five of seven patients with mucoepidermoid carcinoma, two of six patients with small-cell carcinoma, two of two patients with adenoid cystic carcinoma, and one of one patient with carcinosarcoma. Patients with stage IV mucoepidermoid carcinoma were treated predominately with radiation therapy (5/7). The majority of small cell carcinomas were treated with multiagent chemotherapy (10/12). The 1- and 3-year disease-specific survivals were 54% and 9% for mucoepidermoid carcinoma (median survival, 5 months) and 16% and 0% for small-cell carcinoma (median survival, 7 months), respectively. Patients with stage III mucoepidermoid carcinoma (median survival, 20.5 months) compared with those with stage III small-cell carcinoma (median survival, 6.2 months) had a significantly longer duration of survival (p < 0.05). Distant disease was present in 86% of patients in whom recurrence developed after esophagectomy Esophagectomy is standard therapy for localized carcinomas of the esophagus. Small-cell carcinoma appears to be a more aggressive variant of carcinoma and is most commonly treated with chemotherapy.

Unilateral pulmonary artery occlusion inhibits growth of metastatic sarcoma in the rat lung

Tumors depend on their blood supply for growth. The blood supply to metastatic neoplasia of lung is usually from the pulmonary circulation or both the pulmonary and systemic circulation. The antineoplastic effect of pulmonary artery occlusion was investigated in a rat model of methylcholanthrene-induced metastatic pulmonary sarcoma. Left pulmonary artery ligation was performed on day 7 after tumor inoculation, and animals were sacrificed on day 14. The tumor burden of the left lung decreased 44% when compared with the control group. The survival of non-tumor-bearing rats undergoing left pulmonary artery ligation for 24 hours followed by right pneumonectomy after 2 weeks was also studied. No significant lung damage after a period of left pulmonary artery ligation was seen, as evidenced by both survival after contralateral right pneumonectomy and histology. Balloon occlusion of pulmonary artery, together with regional chemotherapy for patients with lung metastases, may warrant investigation.

Postoperative radiation for lung cancer metastatic to the brain

PURPOSE

Although resection of single brain metastases and postoperative whole-brain radiation therapy (WBRT) improves survival, compared with treatment using WBRT alone, the value of postoperative WBRT after resection of brain metastases is controversial. We analyzed the largest reported series of lung cancer patients with resected brain metastases to evaluate the impact of postoperative WBRT.

MATERIALS AND METHODS

Between 1974 and 1989, 185 patients with non-small-cell lung cancer (NSCLC) underwent resection of brain metastases. Patients who had received preoperative WBRT (23%, 42 of 185) were excluded. The remaining patients were divided into group A (no WBRT; n = 32), group B (patients received WBRT and were prognostically matched to group A; n = 32), and group C (all other WBRT patients; n = 79). Most patients received postoperative doses of 30 Gy in 10 fractions. Higher doses were used in 16% of group B and 18% of group C patients.

RESULTS

Overall 5-year survival rates were as follows: group A, 12%; B, 8%; C, 16%. Overall brain failures occurred in 38% of patients in group A, 47% in group B, and 42% in group C. The use of WBRT (group A v groups B plus C) had no apparent impact on survival or on overall brain failure rates. In particular, no improvement in either of these parameters could be demonstrated when group B was compared with group A. Focal failure (defined as failure within the brain adjacent to the site of the resected brain metastases) occurred as follows: group A, 34% (11 of 32); groups B plus C, 23% (25 of 111) (P = .07). WBRT significantly reduced focal failure for patients with adenocarcinoma (group A, 33% [eight of 24]; groups B plus C, 14% [11 of 79]; P = .05). Nonfocal failure (anatomically distinct from the resected metastasis) occurred in 9% of patients in group A (three of 32), 21% in groups B plus C (23 of 111) (P = .07).

CONCLUSION

Long-term survival is possible when NSCLC brain metastases are resected. Postoperative WBRT as used in this series only had an impact on the focal control of brain metastases and this effect was of borderline significance. The lack of conclusive benefit supports the need for ongoing randomized trials to test the value of adjuvant postoperative WBRT. Brain failures were relatively common in all three groups of patients, which suggests that doses greater than 30 Gy need to be studied.

Acute metabolic effects of human recombinant tumor necrosis factor beta in the rat

BACKGROUND

Cancer cachexia is associated with several alterations in host metabolism, including hypoaminoacidemia and an increase in gluconeogenesis (GLC) and lipolysis. Tumor necrosis factor beta (TNF beta), a lymphokine released by mitogen-activated T lymphocytes and several cancer cell lines, causes an increase in lipolysis in 3T3L1 adipocytes. Since little is known about the metabolic effects of TNF beta in vivo, we examined its acute effects in the rat.

METHODS

Twenty-eight male Fischer rats were injected intraperitoneally with TNF beta (250 micrograms/kg) or saline (CTL), and after 4 h, isolated hepatocytes were obtained (by in situ collagenase liver perfusion [n = 12]) or aortic blood was collected (n = 16). Hepatocytes were incubated with 10 mM alanine (ALA) or 10 mM lactate (LAC), and glucose production was measured. Rates of GLC (nmol glucose/10(6) cells/min) were determined by linear regression. Plasma lactate, glucose, insulin, and amino acids (AA) (nmol/ml) were measured, and values were expressed as means +/- SEM. Comparisons between groups were made by unpaired t test or Mann-Whitney U test, and significance was defined as p < 0.05.

RESULTS

TNF beta caused a 130% increase in gluconeogenesis from alanine (2.7 +/- 0.5 vs 1.2 +/- 0.2 nmol glucose/10(6) cells/min, TNF vs CTL), and a 60% increase from lactate (7.5 +/- 1.0 vs 4.6 +/- 0.5 nmol glucose/10(6) cells/min, TNF vs CTL). Plasma insulin levels in TNF treated rats were 1.2 +/- 0.2 ng/ml compared to 1.1 +/- 0.2 ng/ml in CTL. Total amino acid levels in TNF treated rats were 3,175 +/- 111 nmol/ml compared to 3,190 +/- 103 nmol/ml in CTL.

CONCLUSION

In vivo TNF beta causes an increase in hepatic gluconeogenesis from alanine and lactate with no change in plasma insulin or amino acids.

Effect of systemic insulin on protein kinetics in postoperative cancer patients

BACKGROUND

Cancer cachexia is a significant cause of postoperative morbidity and mortality in patients with tumors of the upper gastrointestinal tract. Standard parenteral nutrition (TPN) has failed to alter this. The anabolic effect of insulin has been well documented, and its positive effect on protein economy in cancer patients has been recently demonstrated. This study examines the effect of high-dose insulin and parenteral nutrition on protein kinetics in postoperative cancer patients.

METHODS

Eleven patients underwent surgery for pancreatic, esophageal, or gastric carcinoma. Postoperatively, patients received standard TPN for 4 days (1 g/kg/day amino acids, 1,000 kcal/day dextrose, 100 g/day lipid), and hyperinsulinemic parenteral nutrition for 4 days (same as standard TPN plus 1.44 U/kg/day regular human insulin) in a crossover design. All patients received both treatments, and the order of treatment was determined randomly. Euglycemia was maintained during insulin infusion via a variable 30% dextrose infusion. Patients underwent protein metabolic studies after each treatment period and rates of whole body and skeletal muscle protein synthesis, breakdown, and net balance were determined by radioisotopic tracer methods using 14C-leucine and 3H-phenylalanine.

RESULTS

Compared with standard TPN (STD), hyperinsulinemic TPN (INS) resulted in a significant increase in skeletal muscle protein synthesis (INS: 52.04 +/- 10.22 versus STD: 26.06 +/- 6.71 nmol phe/100 g/min, p < 0.05) and net balance of protein (INS: 7.75 +/- 4.61 versus STD: -15.10 +/- 6.44 nmol phe/100 g/min, p < 0.01), but no difference in skeletal muscle protein breakdown (INS: 44.29 +/- 11.54 versus STD: 41.17 +/- 5.89 nmol phe/100 g/min). Whole-body net balance of protein also significantly increased with insulin-based TPN, compared with standard TPN (INS: 0.04 +/- 0.05 versus STD: -0.08 +/- 0.07 mumol leu/kg/min, p < 0.05), but no difference in whole-body protein synthesis (INS: 2.52 +/- 0.15 versus STD: 2.49 +/- 0.15 mumol leu/kg/min) or whole-body protein breakdown (INS: 2.48 +/- 0.16 versus STD: 2.58 +/- 0.19 mumol leu/kg/min) was observed. Patients received significantly more calories during the hyperinsulinemic TPN period than during the standard TPN period. There was no difference in total, essential, or branched-chain amino acids, and no difference in serum free fatty acids, triglycerides, or cholesterol was observed between the two treatment periods.

CONCLUSION

High-dose insulin in conjunction with hypercaloric parenteral nutrition causes improved skeletal muscle protein synthesis, skeletal muscle protein net balance, and whole-body protein net balance compared with standard TPN in postoperative cancer patients.

Effect of growth hormone on tumor and host in an animal model

BACKGROUND

The relative effects of growth hormone on tumor versus host growth and protein metabolism are not known. This study examines the influence of recombinant rat growth hormone (r-rGH) on host and tumor growth, host body composition, and protein synthesis of tumor and host in tumor-bearing rats.

METHODS

After left flank implantation of methylcholanthrene-induced sarcoma, 28 Fischer rats with palpable tumor were treated with s.c. saline or 1 mg/kg/day r-rGH for 11 days. At death, fractional protein synthetic rates (FSRs) of tumor, liver, and gastrocnemius muscle were determined. In a separate experiment, 27 tumor-bearing rats received saline or 1 mg/kg/day r-rGH for 2 weeks. Tumor and host growth and host body composition were analyzed.

RESULTS

Animals treated with r-rGH had significantly higher liver FSR than did controls (233 +/- 27%/day vs. 110 +/- 4%/day, respectively). No significant differences were associated with growth hormone administration with respect to tumor growth, host composition, or FSR of tumor or muscle.

CONCLUSIONS

Growth hormone stimulates liver protein synthesis, without changing tumor growth, protein synthesis, or host composition in this rat sarcoma model. Further investigation of growth hormone as an anticachectic agent is warranted.

A phase II trial of pleurectomy/decortication followed by intrapleural and systemic chemotherapy for malignant pleural mesothelioma

PURPOSE

This study investigated the feasibility of a novel approach to the treatment of malignant pleural mesothelioma by combining surgical resection with immediate postoperative intrapleural chemotherapy and subsequent systemic chemotherapy.

PATIENTS AND METHODS

Patients with biopsy-proven, resectable malignant pleural mesothelioma underwent pleurectomy/decortication immediately followed by intrapleural chemotherapy with cisplatin 100 mg/m2 and mitomycin 8 mg/m2. Systemic chemotherapy was started 3 to 5 weeks postoperatively and included cisplatin 50 mg/m2 on days 1, 8, 15, 22, 36, 43, 50, and 57, and mitomycin 8 mg/m2 on days 1 and 36. Patients were then monitored by serial chest and abdominal computed tomographic (CT) scans every 3 months until death or for a minimum of 18 months, whichever occurred first.

RESULTS

Of 36 patients entered onto the study, 28 had pleurectomy/decortication and intrapleural chemotherapy. There was one postoperative death, and two episodes of grade 4 renal toxicity after intrapleural chemotherapy. The 23 patients who also had systemic chemotherapy received a median of 80% and 87% of the planned total cisplatin and mitomycin doses, respectively. No grade 3 or 4 toxicities were observed. The overall survival rate of the 27 patients who were originally candidates for systemic chemotherapy was 68% at 1 year and 40% at 2 years, with a median survival duration of 17 months. Locoregional disease was the most common form of relapse (16 of 20 patients).

CONCLUSION

This short but aggressive combined modality regimen was generally well tolerated, but should not be used outside of a protocol setting because of the potential for serious toxicity. Overall survival was as good or better than with previously reported multimodality approaches, but other strategies are needed to improve local control.

A simplified method for endotracheal intubation in the rat

Endotracheal intubation in small laboratory animals is often necessary for survival experiments. Methods of airway control have included tracheostomy, blind intubation, and intubation under direct vision. Most of these methods are unsatisfactory and associated with high failure and complication rate. We developed an easy method of endotracheal intubation in the rat that requires simple material that is easily available to any research facility. The animals were anesthetized with pentobarbital sodium, the tongue was pulled out, and an otoscope was introduced into the oropharynx. By direct vision, a guide wire was inserted into the trachea and a 16-gauge intravenous catheter was glided over the wire. The first group of 70 rats underwent left thoracotomy with endotracheal intubation and mechanical ventilation at our laboratory as part of a study on isolated lung perfusion. The second group of five rats was anesthetized with pentobarbital, and a left carotid catheter and an endotracheal tube were inserted. Animals were ventilated with 100% O2. Arterial blood gases were sampled before intubation, 30 min after ventilation, and 60 min after extubation. In the first group, 94.3% (66 of 70) of the animals survived surgery and mortality was not directly related to the intubation and/or ventilation. All five animals of the second group survived the procedure to be extubated. Arterial PO2 before intubation, 30 min after intubation and ventilation, and 60 min after extubation was 77.1 +/- 8.5, 465.0 +/- 55.6, and 98.9 +/- 12.8 Torr, respectively. PCO2 at the same time points was 42.5 +/- 10.1, 35.1 +/- 6.3, and 32.7 +/- 6.5 Torr, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

"Trap door" exposure of the cervicothoracic junction. Technical note

This report describes a "trap door" exposure of the cervicothoracic junction. The method combines a standard anterior approach to the spine along the medial border of the sternocleidomastoid muscle with both a partial median sternotomy and an anterolateral thoracotomy. Transection of the clavicle is not required and the sternoclavicular joint is preserved. With this method, all important ventral paravertebral vessels, nerves, and associated soft tissue are fully identified and readily mobilized as needed. The method provides full bilateral anterior exposure from the C-4 through at least the T-3 vertebral levels, as well as unilateral anterolateral access to the upper thoracic spine.

Primary malignant tumors of the chest wall. The Memorial Sloan-Kettering Cancer Center experience

Primary malignant tumors of the chest wall are relatively uncommon. During the 40-year period from 1949 to 1989, 418 primary malignant tumors of the chest wall were evaluated at Memorial Sloan-Kettering Cancer Center. Because the treatment depends on the histology of these tumors, the five different types of tumors are discussed separately in the article. The results from Memorial Sloan-Kettering during the 40-year period are stressed, with comparisons to other studies included when appropriate.

Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer. Impact of magnetic resonance imaging

We designed a prospective study to evaluate the accuracy of magnetic resonance imaging in distinguishing a benign from a malignant adrenal mass in patients with otherwise operable non-small-cell lung cancer.

METHODS

Potentially operable non-small-cell lung cancer was prospectively staged. If a unilateral adrenal mass was found by computed tomographic scanning, respiratory compensated and cardiac gated thin section magnetic resonance imaging of the adrenal glands was done. One radiologist interpreted the magnetic resonance imaging scan blinded and, on the basis of the relative signal strengths of the T1- and T2-weighted images, judged whether the adrenal mass was benign or malignant. The patients then underwent a percutaneous needle biopsy of the adrenal mass, if technically feasible. If the result of the needle biopsy was nondiagnostic or if the biopsy was not feasible, an adrenalectomy through a posterior approach was performed.

RESULTS

Twenty-seven patients with a unilateral adrenal mass entered the study-11 men and 16 women whose ages ranged from 42 to 75 years (median 58 years). Four patients had epidermoid and 23 adenocarcinoma of the lung. The clinical locoregional stage was I in 9, II in 1, IIIA in 16, and IIIB in 1. Twenty-five completed the magnetic resonance imaging procedure. Five adrenal masses (19%) were metastatic non-small-cell lung cancer (adenocarcinoma = 4, epidermoid = 1); 22 masses (81%) were benign (adenoma = 20, hyperplasia = 2). There were no significant differences in age, sex, histologic type, or locoregional stage between those with a benign versus a malignant mass. However, the malignant masses were significantly larger (3.8 +/- 1.9 cm; range 2.5 to 7.1; median 3.1) than the benign masses (2.0 +/- 0.4 cm, range 1.2 to 2.8; median 2.0) (p < 0.001). Among those having magnetic resonance imaging (n = 25), the technique correctly predicted a malignant mass in the four patients with a histologically confirmed metastasis from non-small-cell lung cancer. However, among the 21 histologically benign masses, the magnetic resonance imaging was interpreted as benign in 5, malignant in 14, and indeterminate in 2. Therefore, although the false-negative rate was 0%, the false-positive rate was 67%.

CONCLUSION

Most adrenal masses in patients with otherwise operable non-small-cell lung cancer are benign. Currently available magnetic resonance imaging methods cannot replace biopsy.

Isolated single lung perfusion with doxorubicin is effective in eradicating soft tissue sarcoma lung metastases in a rat model

The only effective therapy for patients with metastatic soft tissue sarcoma in the lung is surgical resection, with a 5-year survival of approximately 25%. Because systemic chemotherapy has not significantly affected survival in these patients, we began to investigate locoregional chemotherapy. We have previously shown that isolated single lung perfusion with doxorubicin in the rat results in higher lung tissue levels and lower systemic toxicity than does high-dose intravenous therapy. In the present study, we examined the safety of isolated lung perfusion with doxorubicin and its efficacy in the treatment of experimental pulmonary metastases from soft tissue sarcoma. In experiment 1, 15 F344 rats were randomized into three groups (n = 5): group I had isolated left lung perfusion with doxorubicin 320 micrograms/ml in saline solution; group II had left isolated lung perfusion with doxorubicin 480 micrograms/ml and group III with doxorubicin 640 micrograms/ml. All perfusions with doxorubicin were at 0.5 ml/min for 10 minutes followed by perfusion of saline solution for 5 minutes. On day 21, all animals underwent right (contralateral) pneumonectomy and were observed for over 10 days. In experiment 2, two groups of F344 rats were injected intravenously with 10(7) viable methylcholanthrene-induced sarcoma cells on day 0. On day 7, group I (n = 12) had left isolated lung perfusion with saline solution only and group II (n = 15) had isolated lung perfusion with doxorubicin 320 micrograms/ml. On day 21, all animals were killed, and their lungs were stained for metastases. Routine histologic sections from three animals from group II were examined. In experiment 1, 80% of the animals in group I survived contralateral pneumonectomy. There were no survivors in groups II and III. In experiment 2, three animals died after isolated lung perfusion (one from group I and two from group II), and one animal (group I) was excluded because of mediastinal tumor. All animals in both groups had massive tumor replacement of the right (untreated) lung. Group I animals had massive tumor replacement of the left (treated) lung, whereas animals in group II had eradication of metastases in nine of ten cases; no microscopic evidence of tumor was detected in all three animals evaluated for microscopic disease. Isolated lung perfusion with doxorubicin 320 micrograms/ml is safe and effective in eradicating experimental pulmonary sarcoma metastases in this model.

Growth hormone administration preserves lean body mass in sarcoma-bearing rats treated with doxorubicin

Cachexia and malnutrition play a significant role in the morbidity associated with antineoplastic chemotherapy regimens. Conventional nutritional support during cancer therapy has shown little benefit in terms of reducing morbidity and mortality. We examined the anabolic properties of growth hormone (GH) that preserve normal body composition in sarcoma-bearing animals treated with doxorubicin. On day 0, 40 male Fischer 344 rats were inoculated with 10(6) methylcholanthrene-induced sarcoma cells s.c. in the left flank. On day 9, animals were randomized into 3 groups: control (CTL, n = 13); doxorubicin (DOX, n = 13); and doxorubicin plus GH (DOX-GH, n = 14). Two CTL animals were excluded due to tumor invasion into the peritoneal cavity. From day 9 to day 23, the DOX-GH group received daily s.c. recombinant rat GH injection (1 mg/kg). On day 13, DOX and DOX-GH groups received 7 mg/kg of DOX i.v. while the CTL group received sham i.v. sterile saline injection. Body weight and tumor dimensions were measured daily. On day 23, all animals were weighed and sacrificed. Tumors were resected and weighed. Body composition analysis was performed. Plasma GH levels were measured by radioimmunoassay and insulin growth factor 1 levels were measured by chondrocyte proliferation bioassay. The DOX-GH group had a significantly higher mean body weight, carcass weight, total fat free body mass, insulin growth factor 1, and GH plasma levels as compared to the DOX group. No difference in total food intake was observed between the DOX and DOX-GH groups. There was no difference in final tumor weight and tumor growth rate between DOX and DOX-GH groups. Exogenous growth hormone can attenuate weight loss and preserve host body composition in tumor-bearing rats treated with doxorubicin without stimulating tumor growth.

Parathyroid carcinoma: diagnosis and clinical history

BACKGROUND

Parathyroid carcinoma is often over-diagnosed based on histologic appearance alone. We limited the definition of the disease to patients with recurrence, metastases, or frank capsular invasion on histologic examination.

METHODS

With these criteria, fourteen cases of parathyroid carcinoma seen at our institution from 1955 to the present were identified.

RESULTS

All patients presented with hypercalcemia, and all deaths were due to hypercalcemia. Two patients have been free of disease after initial operation for 31 and 180 months. Six other patients had a prolonged course with a median survival more than 80 months. Two of these patients have undergone one reexcision each for local recurrence, and four have undergone multiple resections for local recurrence or metastases. These reoperations usually resulted in satisfactory, albeit temporary, control of hypercalcemia. Finally, six patients died of disease after an aggressive course, with a short median survival (47 months). Four of these patients were seen in the 1950s before an aggressive approach to metastatic disease was adopted.

CONCLUSIONS

The types of clinical courses observed in this study may be more reflective of the varied biologic features of parathyroid carcinoma and the approach to recurrence than of the initial operations. For patients with recurrent or distant disease, an operation appears to prolong survival and palliate the symptoms of hypercalcemia.

Transcutaneous cardiac pacing during thoracic surgery. Feasibility and hemodynamic evaluation by transesophageal echocardiography

BACKGROUND

Occasionally, emergency perioperative pacing is necessary. Transcutaneous cardiac pacing is noninvasive, safe, and readily available. Its feasibility and hemodynamic effects during thoracic surgery and one-lung ventilation have not been established.

METHODS

Twenty anesthetized patients (aged 25-70 yr) without cardiac disease undergoing elective pulmonary resection (right n = 10, left n = 10) were studied in normal sinus rhythm and during transcutaneous cardiac pacing. Patients were paced in supine and lateral decubitus positions (with closed and opened chest) at the minimal current necessary to produce ventricular capture. Invasive arterial monitoring permitted calculation of mean arterial pressure, and transesophageal echocardiography was used to assess atrial and ventricular wall motion and the evaluation of transmitral flow. Twelve patients underwent Doppler analysis of pulmonary venous flow.

RESULTS

Pacing was achieved in all patients, with a mean threshold of 86.9 +/- 20.6 mA for the right thoracotomy group, and 106.7 +/- 16.2 mA for the left thoracotomy group. The mean paced heart rates for the right and left thoracotomy groups were 101.6 +/- 18.2 and 105.4 +/- 11.5 beats/min, respectively. During pacing, all patients sustained reversible transient decrements in mean arterial pressure (9-19%) from baseline, the loss of AV synchrony, and the development of paradoxical ventricular septal wall motion. No patient had significant mitral regurgitation during sinus or paced rhythms. Decreased systolic pulmonary venous flow velocity and abnormal systolic flow reversal were seen during pacing in 11 of the 12 patients studied.

CONCLUSIONS

Transcutaneous cardiac pacing is effective in patients undergoing thoracotomy and one-lung ventilation. Its use in patients in normal sinus rhythm induces reversible decrements in mean arterial pressure because of the effects of altered atrioventricular association, ventricular wall motion, and pulmonary venous return.

Esophagogastrectomy: reoperation for complications

From 1961 to 1991, a total of 1,452 esophagectomies were performed for esophageal cancer at Memorial Sloan-Kettering Cancer Center. Of these patients, 40 (2.7%) developed complications requiring a second operation during the same hospitalization. The majority of the carcinomas were located in the midesophagus or the gastroesophageal junction. The pathologic diagnosis was squamous cell carcinoma in two-thirds of the patients. Few comorbid factors could be identified. Twenty-nine patients (72%) had a standard Ivor-Lewis resection, 5 (12%) had a transhiatal resection, 5 (12%) had a transabdominal approach, and 1 (3%) had a cervical approach only. Complications requiring reoperation were the following: respiratory failure in 13 patients, anastomotic leak in 6, bowel obstruction in 5, major bleeding in 4, wound dehiscence in 4, tracheo-esophageal fistula in 3, feeding tube malposition in 2, empyema in 1, chyle leak in 1, a positive margin in 1. Twelve of these same patients had a persistent or second complication and required a third operation. Among the 40 patients in this study, the mortality was 40%.

Pulmonary metastases from adrenal cortical carcinoma: results of resection

Adrenal cortical carcinoma is uncommon. There is little controversy concerning treatment of the primary tumor. However, data concerning the treatment of pulmonary metastases are sparse. In order to assess the results of therapy, we reviewed our 14-year experience. Records of 24 patients admitted to our institution from 1973 to 1991 with the diagnosis of adrenal cortical carcinoma and pulmonary metastases were reviewed. Ten patients underwent pulmonary resection, 12 received chemotherapy, and 2 no therapy. In the pulmonary resection group, treatment consisted of wedge resection in 8 patients and lobectomy in 2. For the 10 patients undergoing resection of their pulmonary metastases, the 5-year survival was 71% (median not reached at 5 years). This was significantly longer than those not resected, with no one alive at 3 years (median survival 11 months). Our data suggest that those patients who are able to have their pulmonary metastases resected survive significantly longer than those who do not.

NR-LU-10 monoclonal antibody scanning. A helpful new adjunct to computed tomography in evaluating non-small-cell lung cancer

Computed tomographic scanning has improved the noninvasive staging of lung cancer but has the deficiency of not distinguishing benign from malignant lesions. This prospective trial evaluated the usefulness of a new radiolabeled monoclonal antibody, NR-LU-10, as an adjunct to computed tomography by assessing its clinical applicability and accuracy in detecting malignancy in primary lung tumors and mediastinal nodes. NR-LU-10 is a technetium 99m-labeled Fab fragment of a murine immunoglobulin G2b monoclonal antibody that recognizes a 40 kD glycoprotein expressed in lung and other epithelial cancers.

METHODS

(1) Patients with potentially resectable non-small-cell lung cancer were eligible; (2) all patients had computed tomographic scans of the chest; (3) whole body and single photon emission computed tomographic imaging were performed 14 to 17 hours after intravenous infusion of 20 to 30 mCi of NR-LU-10; (4) subsequent mediastinoscopy or thoracotomy with complete mediastinal nodal mapping provided pathologic correlation.

RESULTS

Twenty-four patients were entered, 14 men and 10 women. No allergic reactions or other adverse effects were seen. Interference from a prior ventilation-perfusion scan precluded adequate imaging in 1 patient, but high-quality images were obtained in the other 23 patients. The 22 primary malignant tumors all had uptake and there was no uptake in 1 lung nodule found to be benign. In 21 patients who had surgical correlation of mediastinal nodal involvement, NR-LU-10 was false-positive in 5 and false-negative in 1; results of computed tomography were false-positive in 6 and false-negative in 1. In this preliminary study, NR-LU-10 antibody scanning was safe and easily performed, it produced high-quality images of the lung and mediastinum, and it was accurate in detecting primary non-small-cell lung cancers. Further evaluation of its value in staging the mediastinum is needed, in particular, its role as an adjunct to computed tomography to help distinguish benign from malignant lesions.

Cerebral metastases in pleural mesothelioma: case report and review of the literature

A case of malignant mesothelioma metastatic to the brain is described. A 52-year old woman, with no known exposure to asbestos, presented with a biphasic mesothelioma of the left parietal pleura. Following resection, the thorax was irradiated with 4000 cGy, and all symptoms subsided. Three months later, a left temporal lobe tumor was diagnosed and subsequently resected. Despite neurological improvement, she died 10 days post-operatively from constrictive pericardial disease. The authors have reviewed the 54 reported cases of brain metastases from mesothelioma and have noted that the histologic appearance of brain metastases from mesothelioma may be similar to glioblastoma multiforme. Because brain metastasis from mesothelioma is rare, procedures to clarify the nature of the tumor should be performed.

Normal human mesothelial cells and mesothelioma cell lines express insulin-like growth factor I and associated molecules

Insulin-like growth factor (IGF) I has important growth regulatory functions in normal growth and development. IGF-I is also a mitogen for a number of cancer cell lines; however, its autocrine effect has not been well established. In this study, the expression of IGF-I, its receptor, and its major serum-binding protein were examined in 5 normal human mesothelial (NHM) cell samples and 11 pleural mesothelioma cell lines. All NHM cells and mesothelioma cell lines expressed IGF-I, IGF-binding protein 3 (IGFBP-3), and IGF-I receptor mRNA by either Northern blot or reverse transcription polymerase chain reaction analysis. IGF-I (0.136 +/- 0.024 ng/ml, mean +/- SEM) and IGFBP-3 (18.5 +/- 3.2 ng/ml) proteins were readily detected in the conditioned medium of mesothelioma cell lines but were not greater than corresponding measurements in that of NHM cells (IGF-I, 0.120 +/- 0.080 ng/ml; IGFBP-3, 15.9 +/- 1.3 ng/ml). Exogenous recombinant IGF-I stimulated cell proliferation of NHM cells, demonstrating the presence of a functional IGF-I receptor. Our results suggest that IGF-I may function as an autocrine growth stimulus in normal proliferating mesothelial cells, which may contribute to their malignant transformation.

Isolated single lung perfusion in the rat: an experimental model

To evaluate isolated single lung perfusion with chemotherapy in a rat lung metastasis model, we developed a model of in vivo isolated single lung perfusion. Twenty male rats were anesthetized with pentobarbital sodium (50 mg/kg) and intubated endotracheally. A left thoracotomy was performed with an operating microscope (x16 magnification), the left pulmonary artery was cannulated, and a left pulmonary venotomy was performed. Isolated left lung perfusion was performed for 10 min at 0.5 ml/min with heparinized whole blood (n = 10) or 0.9% normal saline (n = 10). Pulmonary vein effluent was collected by suction. Nineteen of the 20 (95%) animals survived isolated left single lung perfusion. Twenty-one days after isolated left lung perfusion right pneumonectomy was performed. Fifteen of the 19 animals (78%) survived right pneumonectomy. Postoperatively, animals that survived surgery recovered preoperative body weight. In vivo isolated single lung perfusion in rats is feasible with low mortality and morbidity and may be useful in the study of isolated perfusion with chemotherapy and in diverse physiological and pharmacological experiments.

Medical tumors of the chest wall. Solitary plasmacytoma and Ewing's sarcoma

Primary solitary plasmacytoma and Ewing's sarcoma of the chest wall are relatively uncommon tumors, and data concerning treatment and results are sparse. To assess the results of therapy we reviewed our 40-year experience.

METHODS

Records of 24 patients with solitary plasmacytoma and 62 with Ewing's sarcoma arising in the chest wall who were admitted to our institution from 1949 to 1989 were reviewed.

RESULTS

In the group with plasmacytoma (n = 24), ages ranged from 35 to 75 years (median 59 years); male/female ratio was 2.4:1. The presenting complaint was pain or mass or both in 92% (22/24). Primary therapy was local only in 5 (resection in 3, radiotherapy in 2), chemotherapy in 16 (resection in 5, radiotherapy in 10, and chemotherapy alone in 1); 3 patients did not receive therapy. Multiple myeloma developed subsequently in 75% (18/24). Overall 5-year survival was 38% (median 56 months). Age, sex, site of primary tumor, and local therapy did not significantly impact on survival. Ages in the patients who had Ewing's sarcoma (n = 62) ranged from 2 to 39 years (median 16 years); male/female ratio was 1.6:1. Presenting complaint was pain or mass or both in 98% (61/62). Primary therapy was local in 17 (resection in 7, radiotherapy in 7, resection plus radiotherapy in 3) and chemotherapy in 45 (plus resection in 29, resection and radiotherapy in 10, and radiation therapy alone in 3). Overall 5-year survival was 48% (median 57 months). Age, sex, and site of primary tumor did not significantly impact on survival. Patients in whom distant metastases developed (n = 48) had a significantly decreased survival (5 year, 28%) compared with those who did not have metastases (n = 14; 5 year, 100%).

CONCLUSION

Plasmacytoma of the chest wall, even if solitary at presentation, should be considered a systemic disease, and therapy should be directed as such. For Ewing's sarcoma, although resection or radiotherapy may offer local control, because of the prevalence of distant metastases (77%), systemic therapy should be considered an integral part of treatment.

Resection of hepatic and pulmonary metastases from colorectal cancer

Resection of hepatic metastases of colorectal origin has gained wide acceptance, but when patients have synchronous or metachronous pulmonary metastases, they are often considered incurable and are offered systemic therapy only. We performed a retrospective review of the patients at Memorial Sloan-Kettering Cancer Center who underwent resection of both hepatic and pulmonary metastases of colorectal origin between 1970 and 1990. Ten patients were identified who met the above criteria. Median survival after hepatic and pulmonary resections were 34 and 18 months, respectively. Actuarial 1-, 3- and 5-year survivals are 89%, 78% and 52%, respectively. With a median of 18 months after second operation, three patients have no evidence of disease (NED), four are alive with disease (AWD) and three are dead of disease (DOD). In the absence of effective chemotherapy, selected patients with hepatic and pulmonary metastases of colorectal origin should be considered for resection as it offers the only possibility for long-term survival.

Transhiatal esophagectomy

THE is a versatile procedure that has become indicated for a variety of disease processes over the past two decades; amongst these indications are to treat many benign and malignant esophageal diseases, as well as for use in restoring gastrointestinal continuity after extensive pharyngeal or laryngopharyngeal resections. Careful and meticulous handling, formation, and transposition of the gastric tube are essential to the development of a well-perfused neo-esophagus. Present studies indicate acceptable morbidity and mortality of THE compared with transthoracic resections for carcinoma of the esophagus. There appears to be no significant detriment in overall long-term survival when THE is used as primary resection therapy for malignant esophageal disease.

Desmoid tumors of the chest wall. A locally recurrent problem

Desmoid tumors, in general, are known for their propensity to recur. To evaluate treatment and results, we reviewed the records of 32 patients admitted to our institution with a chest wall desmoid tumor from 1948 to 1988. There were 13 men and 19 women whose ages ranged from 12 to 67 years (median 36 years). Four patients had Gardner's syndrome. Treatment was wide resection. Median follow-up was 110 months. The overall 5-year survival was 93%; 5-year disease-free survival was 71%. The 5-year local recurrence rate was 29%. Since death from disease is uncommon after resection, but local recurrence is common, we recommend aggressive wide resection in patients who have desmoid tumors of the chest wall when seen initially.

Primary bony and cartilaginous sarcomas of chest wall: results of therapy

Primary bony and cartilaginous sarcomas of the chest wall are uncommon, and data concerning treatment and results are sparse. To assess the results of therapy, we reviewed our 40-year experience. Records of 38 patients with osteosarcoma and 88 with chondrosarcoma arising in chest wall admitted to Memorial Sloan-Kettering Cancer Center from 1949 to 1989 were reviewed. The 88 patients with chondrosarcoma ranged in age from 5 to 86 years (median age, 49 years); the male/female ratio was 1.3:1. Presenting complaint was mass, pain, or both in 93%. Primary therapy was resection (n = 84), radiation therapy (n = 3), or chemotherapy (n = 1). Overall 5-year survival was 64%. Significant adverse prognostic factors included metastases at initial presentation (n = 9), metastases at any time during the course of disease (n = 23), age greater than 50 years (n = 42), incomplete or no resection (n = 13), and local recurrence (n = 24). Sex, grade, and tumor size were not prognostic factors. The 38 patients with osteosarcoma ranged in age from 11 to 78 years (median age, 42 years); the male/female ratio was 1.5:1. Presenting complaint was mass, pain, or both in 95%. Primary therapy included resection (n = 31; alone in 13, with radiation therapy in 3, with chemotherapy in 15), radiation therapy (n = 3), radiation therapy and chemotherapy (n = 2), chemotherapy (n = 1), or no treatment (n = 1). Overall 5-year survival was 15%. Significant adverse prognostic factors included presence of synchronous metastases (n = 13) and metastases at any time during the course of disease (n = 26).(ABSTRACT TRUNCATED AT 250 WORDS)

Resection of brain metastases from non-small-cell lung carcinoma. Results of therapy. Memorial Sloan-Kettering Cancer Center Thoracic Surgical Staff

The treatment of patients with a solitary brain metastasis has been evolving, with most centers recommending resection in patients with good performance status. To evaluate the results of resection of brain metastases from non-small-cell lung cancer, we reviewed our 16-year experience with 185 consecutive patients undergoing resection of brain metastases from 1974 to 1989, inclusive. There were 89 men and 96 women; ages ranged from 34 to 75 years (median 54). Sixty-five (35%) had synchronous and 120 (65%) metachronous brain metastases. Discounting the brain metastasis, 68 patients (37%) had stage I, 13 (7%) stage II, 62 (33%) stage IIIA, 30 (16%) stage IIIB, and 12 (6%) stage IV carcinoma. There was no significant difference in age, locoregional stage (TN), or histologic features in patients with synchronous versus metachronous lesions. The overall survival rates (n = 185) were as follows: 1 year, 55%; 2 years, 27%; 3 years, 18%; 5 years, 13%; and 10 years, 7% (median 14 months). There was no significant difference in survival between patients with synchronous and metachronous lesions. To evaluate the impact of locoregional stage and treatment of the primary site, we analyzed only those patients with synchronous brain metastases. Multivariate analysis demonstrated that locoregional stage had no significant effect on survival (p = 0.97), but complete resection of the primary disease significantly prolonged survival (p = 0.002). Therefore complete resection, and not stage, of the locoregional primary lesion is the primary determinant of survival in patients undergoing resection of brain metastases from non-small-cell lung cancer.

Postthoracotomy respiratory muscle mechanics during incentive spirometry using respiratory inductance plethysmography

We undertook this study to characterize the postthoracotomy compartmental displacement and respiratory mechanical changes occurring during and after the performance of the incentive spirometry maneuver. We also evaluated the effect of recumbency angle on compartmental recruitment. Sixteen patients were randomized to perform incentive spirometry either at 30 degrees or 60 degrees recumbency angle. They were studied using respiratory inductance plethysmography to measure tidal volume, respiratory frequency, inspiratory time, rib cage motion/tidal volume ratio, inspiratory duty cycle, and inspiratory flow. Patients were studied before surgery and on postoperative days 1 and 3. Statistical analysis was accomplished using multiple measures ANOVA with post-hoc Student's t-tests when appropriate. Preoperative incentive spirometry augmented VT by increasing both VT/TI and TI. Postoperatively, the incentive recruitment of VT was reduced, a result of a decrease in TI and TI/TTOT; VT/TI was unchanged. There was postoperative decrease of AB and AB/VT during incentive spirometry, greatest in the 60 degrees group. Our results characterize the nature of the respiratory recruitment afforded by incentive spirometry, before and after thoracotomy. We also found evidence of postthoracotomy diaphragmatic derecruitment during incentive spirometry exacerbated by a high recumbency angle.

Malignant esophagorespiratory fistula: management options and survival

The development of a malignant esophagorespiratory fistula is a devastating complication. Data comparing various treatment options in a large group of patients are sparse. To assess the results of therapy, we reviewed our experience in 207 patients with malignant esophagorespiratory fistula. Records of 207 patients admitted to our institution with malignant esophagorespiratory fistula from 1926 to 1988 were reviewed and results of management analyzed. Age ranged from 21 to 90 years (median, 59 years); the male/female ratio was 3:1. Primary tumor site was esophagus in 161 (77%), lung in 33 (16%), trachea in 5 (2%), metastatic nodes in 4 (2%), larynx in 3 (1%), and thyroid in 1. Symptoms and signs of malignant esophagorespiratory fistula included cough in 116 (56%), aspiration in 77 (37%), fever in 52 (25%), dysphagia in 39 (19%), pneumonia in 11 (5%), hemoptysis in 10 (5%), and chest pain in 10 (5%). Respiratory location of fistula included trachea in 110 (53%), left main bronchus in 46 (22%), right bronchus in 33 (16%), lung parenchyma in 13 (6%), and multiple sites in 5 (2%). The percentage of patients alive at 3, 6, and 12 months by treatment modality was 13%, 4%, and 1% for supportive care (n = 104); 17%, 3%, and 0% for esophageal exclusion (n = 29); 21%, 14%, and 0% for esophageal intubation (n = 14); 30%, 15%, and 5% for radiation therapy (n = 20); and 46%, 20%, and 7% for esophageal bypass, respectively. Patients treated with radiation therapy and esophageal bypass had a significantly prolonged survival compared with patients treated with the other modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple primary lung carcinomas: prognosis and treatment

From 1955 to 1990, 111 patients have been treated for multiple primary lung carcinomas. Criteria for diagnosis were: (1) different histology (n = 44); or (2) same histology, but disease-free interval at least 2 years (n = 39), origin from carcinoma in situ (n = 19), or metachronous disease in different lobe (n = 9) with no cancer in common lymphatics or extrapulmonary metastasis at the time of diagnosis. The second cancer was synchronous in 33 patients (30%) and metachronous in 78 (70%). Metachronous disease developed at a median interval of 48 months. Five-year survival for patients with metachronous and synchronous disease from the time of initial diagnosis of cancer was 70% and 44%, and 10-year survival was 42% and 23%, respectively. Survival after the development of a metachronous lesion was 23% at 5 years. Survival from the time of initial diagnosis was significantly better for metachronous versus synchronous, late (24 month disease-free interval) versus early metachronous disease, and adenocarcinoma versus epidermoid carcinoma. The first cancer was completely resected in 103 patients (93%), but complete resection of a metachronous tumor was possible in only 54 patients (69%). Complete resection of second primary cancers resulted in significantly (p less than 0.0001) prolonged 5-year survival compared with incomplete resection (38% versus 9%). Excluding patients requiring pneumonectomy, initial resection limited subsequent resection in only 7 patients (9%) with metachronous disease. We conclude that patients surviving treatment of primary lung cancers require lifelong screening for multiple primary lung carcinoma, and complete resection is recommended whenever possible.