Biomedical subjects
Publications and source records attributed to W A Fry.
Skeletal muscle hemangiomas are uncommonly described in a variety of locations. This report details the diagnosis and management of a 39-year-old woman with a right chest wall mass detected on physical examination. After a negative diagnostic evaluation, exploratory thoracotomy revealed an intercostal hemangioma, undescribed in recent literature. The lesion was excised.
Although radiologic assessment of pleural tumors may be accomplished with several imaging modalities, the standard noninvasive techniques include chest radiography and computed tomography (CT). These examinations may be supplemented with magnetic resonance imaging and occasionally with ultrasound. Depending on the location, size, and underlying histologic features, pleural tumors may produce a spectrum of findings. CT is particularly useful in defining the location and extent of these masses. The authors present a review of basic pleural anatomy and imaging features of both benign and malignant pleural neoplasms. The pleural may be involved by one of several primary or metastatic tumors. Specific cell types are diffuse malignant mesothelioma (the most common plain radiographic findings are unilateral pleural effusion and pleural thickening), localized fibrous tumor (circumscribed, spherical or ovoid, noncalcified lesions arising in the pleural surface), metastatic disease (radiographic findings may mimic those of malignant mesothelioma), and uncommon neoplasms including thymoma and lymphoma. Among these various pleural tumors, metastatic disease represents the most common neoplasm.
Solitary or multifocal pulmonary pseudolymphoma developed in two men and two women between 59 and 76 years of age. The lesions were detected incidentally in three patients and following a respiratory infection in the fourth. Follow-up radiographs and chest CT revealed gradual expansion of the opacities without cavitation, calcification, or pleural involvement. Histopathologic sections from open lung biopsies or resected segments showed dense alveolar and peribronchial infiltration by numerous mature lymphocytes and plasma cells surrounding reactive lymphoid follicles with true germinal centers. Their benign nature was confirmed by immunofluorescent studies showing polyclonal cell populations. No recurrence or malignant change occurred during 4- to 9-year periods of observation. The clinical and radiologic features of pulmonary pseudolymphoma are presented with a brief review of 54 previously reported cases.
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The axillary thoracotomy should be the incision of choice for most uncomplicated general thoracic surgical procedures. It can be performed rapidly, avoids major muscle transection, and by employing a double lumen endotracheal tube will permit segmental resection as well as lobectomy without technical problem. One hundred consecutive, elective axillary thoracotomies were performed with minimal morbidity and only one mortality. Twenty-five of the patients were of high surgical risk. The larger posterolateral thoracotomy is reserved for repeat thoracotomy, Pancoast tumors, difficult procedures such as bronchoplasty and/or radical pneumonectomy, and when pleural symphysis is expected. Sometimes called lateral thoracotomy or mini-thoracotomy, the axillary thoracotomy is our most common incision.
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A technique to close small defects in lung tissue resulting from local excision of lung lesions is described. The technique, called the spiral funnel stitch, is a conical suture started in the depth of the defect and tied at the surface. It minimizes air leaks.
Rapid cytologic diagnosis of thoracic lesions by intraoperative fine-needle aspiration is a valuable aid to the surgeon at the time of thoracotomy or mediastinoscopy, especially for lesions which are difficult or hazardous to biopsy by standard methods. The technique is simple, quick, and accurate and aids in determining the immediate surgical management of suspicious lesions. One hundred fifty-four IOFNAs of thoracic masses performed over an 8-year period were evaluated. Diagnostic accuracy was 97.7% for the diagnosis of benign lesions, 95.4% for the diagnosis of malignancy, and 100% for the differentiation of small cell carcinoma from non-small cell carcinoma of the lung.
Malignant pericardial effusion can result in acute cardiac tamponade with serious hemodynamic compromise. This condition requires prompt pericardial decompression for relief of symptoms; however, the risks of general anesthesia in this setting are considerable. In a series of 12 patients, all operated on under local anesthesia without operative mortality, there were six patients with malignant pericardial effusion secondary to lung carcinoma; four patients, secondary to breast carcinoma; one patient, secondary to squamous cell carcinoma of the oral cavity; and one patient, secondary to an unknown primary. The clinical presentation of each was abrupt and echocardiography was definitive. The procedure is performed through an upper abdominal midline incision. The xiphoid process is excised, the diaphragm is visualized, and a pericardial window is created through which two chest tubes are placed through separate stab incisions. The tubes are removed when the drainage has subsided, usually 3-7 days. No medication or irritant is instilled. There was no recurrence following this treatment. The average survival time was 27 weeks with a range of 2-153 weeks. This operation should be part of the repertoire of the general surgeon who treats breast cancer and of the thoracic surgeon who treats lung cancer.
We measured the cellular and humoral autoimmune response to carcinoma (CA)-associated T antigen in patients with the earliest clinical stages of lung (T1N0M0) and breast (Tis) CA. We used desialylated MN glycoprotein from healthy human erythrocytes in a single measurement of 1) delayed-type skin hypersensitivity response (DTHR-T) and 2) humoral anti-T response with a solid-phase immunoassay (SPIA-T). DTHR-T detected 19/20 lung CA and 10/12 ductal and 7/10 lobular breast CA patients. Sixteen of 18 stage T1N0M0 lung CA patients had a positive SPIA-T as did 7/8 patients with Tis breast CA. Two of 35 patients with benign lung and 11/144 with benign breast disease had a positive DTHR-T. None of 160 persons with either other non-CA diseases or healthy had a positive DTHR-T. Three of 68 such control subjects had a positive SPIA-T. The difference between CA patients and control populations is statistically highly significant.
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A solitary pulmonary nodule appearing in a patient with breast cancer, either past or present, is most likely to be a second primary cancer originating in the lung rather than a metastasis from the breast cancer. Between 1970 and 1983 there were at this institution 1416 patients with breast cancer and 579 patients with bronchogenic cancer, 198 of whom were women. Among the patients with breast cancer, 42 (or 3% of all of the patients with breast cancer) had a solitary pulmonary nodule either at the time of presentation of their breast cancer or during the follow-up period. Fifty-two percent of the solitary pulmonary nodules proved to be a primary lung tumor, 5% proved to be benign lesions, and only 43% proved to be metastatic breast cancer. Patients with breast cancer with solitary pulmonary nodules should have a diagnostic workup appropriate for lung cancer. Since adenocarcinoma has become the most common lung cancer cell type, the usual diagnostic tests may not allow a firm differentiation between primary lung and secondary breast cancer. Therefore if malignancy is proved or suspected, thoracotomy with appropriate resection is the treatment of choice in most patients with breast cancer, even at the initial appearance of the breast cancer.
The usefulness of T antigen in the diagnosis of lung cancer (LCA), including early, was assessed by determining the in vitro delayed type hypersensitivity response to T(DTHR-T), and by measuring with a solid phase immunofluorescent assay the serum anti-T IgM response. Sensitivity of DTHR-T was 89% for 73 patients with LCA including 8/9 with Stage T1N0M0 disease, overall specificity was 95% for 212 healthy persons and those with non-CA disease. The humoral immune assay detected 31/35 (89%) LCA patients including 4/5 Stage T1N0M0 patients. Overall specificity was greater than 90% among 116 persons without CA.
Modern postoperative mortality rates for resectional operations for lung cancer are not readily available. In recent publications estimating the risk factors for surgical resection, mortality rates of 10% to 15% for pneumonectomy and 5% to 7% for lobectomy are frequently quoted. In order to determine modern operative mortality rates (up to 30 days postoperatively), the Lung Cancer Study Group (LCSG) analyzed the surgical mortality rates of the various participating centers during the years 1979 to 1981. A total of 2,200 resections for lung cancer were available for analysis. Of the 2,220 resections performed, 1,058 were lobectomies, 569 were pneumonectomies, and 143 were lesser resections (segmental or wedge). Eighty-one postoperative deaths occurred from among the 2,220 resections (3.7%). The mortality rate for pneumonectomy was 6.2% and for lobectomy, 2.9%. Lesser resections carried a 1.4% mortality rate, not statistically different from lobectomy. In patients under the age of 60 years, the mortality rate was 1.3%, 60 to 69 years, 4.1%, and over 70 years, 7.1%, all significantly different (p less than 0.01). The postoperative mortality rate for patients 70 years or older was 7.1% (pneumonectomy 5.9% and lobectomy 7.3%). It is obvious that greater care was taken in selection among the older pneumonectomy patients. The striking similarity of postoperative mortality rates for resectional operations for lung cancer among the various centers of the LCSG and among the various institutions within these centers suggest that these data are a reasonably accurate analysis of modern surgical mortality rates in the treatment of lung cancer.
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We report here sensitive and specific measurement of immune responses of patients with certain kinds of carcinoma toward the physically and chemically well defined T antigen isolated from healthy human erythrocytes. Over 90% of adenocarcinoma tissues tested possess T-specific immunoreactive structures as determined with human antisera, in contrast to healthy tissues and benign lesions. Adenocarcinoma patients recognize the carcinoma-associated T antigen as foreign. Delayed-type skin hypersensitivity reaction to T antigen (DTHR-T) was positive in all 25 lung adenocarcinoma patients tested, in 88% of 101 patients with ductal, in 43% of 30 patients with lobular or tubular breast carcinoma and in 9/9 patients with adenocarcinoma of body cavities. Patients of all Stages reacted positively. All 7 patients with small cell lung carcinoma and 3/5 with malignant melanoma had a positive DTHR-T. None of 17 patients with malignant brain tumors, leukemia or Hodgkin's disease, sarcoma or thyroid carcinoma reacted. The DTHR-T was specific in that all 77 healthy persons and 48/49 with other diseases, including 23/24 with non-cancer lung disease were negative; one patient with organizing interstitial pneumonitis was positive. This points to a possible source of false positive reactions. 91% of 149 patients with histologically benign breast disease had a negative DTHR-T; the histology of some of the positive ones was reexamined, 2 proved to have carcinoma in situ.
Ninety-nine patients with Stage I or II lung carcinoma that was other than the small cell type and who survived for more than 30 days after a "curative" resection were followed for five years or until death if it occurred prior to the five-year anniversary. Recurrent disease developed in 44 patients. Clinical data and data from postmortem examination were reviewed in these 44 patients in an attempt to classify each recurrence as either initially local or distinct metastatic disease. The site of the first documented recurrence was local in 18 patients and distance metastases in 26. When the patients with recurrence were separated into TNM categories, it was apparent that in those patients without lymph nodes metastases demonstrated in the resected specimen (N0), the initial recurrence tended to be a distant metastases, whereas in those with such involvement (N1), the initial occurrence was more often local. In light of these data, selection of appropriate initial adjuvant therapeutic modalities may be different for each type of patient.
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