Bronchogenic carcinoma complicated by ipsilateral cytologically positive effusion is considered unresectable. Bronchogenic carcinoma with cytologically negative effusion, even if bloody, has also been thought by many to be unresectable. Seventy-three patients with bronchogenic carcinoma and ipsilateral cytologically negative effusions were studied. Sixty-six underwent exploratory thoracotomy for staging or therapy; five had pleural biopsies and two had mediastinoscopies, all disclosing metastatic carcinoma. Four of the 73 patients (5.5 percent) had surgi

The Editors wish to express their deep and sincere gratitude to the large group o f colleagues who functioned as expert reviewers for the journal during 1979. Some reviewed one paper, but others were asked to review many of our contributions; all performed willingly and were o f great help to us. Your efforts are irreplaceable, without you a scientific journal cannot function, and this recognition is a small token of our thanks.

Dr Stuart Harrington, the 20th president of The American Association for Thoracic Surgery, was born in Blossburg, Pennsylvania, on April 20, 1889. He attended Pennsylvania State College in 1908-1909 pursuing premedical studies and enjoying a year of varsity football. He went on to study medicine at the University of Pennsylvania, managing his time to include varsity football for 3 years, and was named to an All-American team in 1912 as a halfback. He was always known as “Tack” to friends and associates, suggesting a position other than halfback. In 1913 he received his degree of Doctor of Medicine from the University of Pennsylvania and interned at Howard Hospital in Philadelphia. During the 1913-1914 football seasons, he served as football coach at Dickinson College in Carlisle, Pennsylvania, to supplement his meager income. Dr Harrington arrived at the Mayo Clinic in November 1914, as a Fellow in surgery in the Mayo Foundation, which was incorporated shortly after his arrival. His training included 6 months of general medical diagnoses and 5 years in various surgical sections. During this period, he earned a Master of Science degree in surgery from the University of Minnesota. In July 1920, he became head of a section of surgery at the Mayo Clinic, a post he occupied for 34 years, and ascended in the academic ranks to full professor. Early in his career, while Dr Harrington was deeply committed to gastrointestinal and urologic surgery, Dr Will Mayo suggested that he assume a primary interest in thoracic and breast surgery. Though hesitant to do this, a negative reply to Dr Will Mayo was “not in the cards.” It was promptly arranged for Dr Harrington to visit a number of pioneer thoracic surgeons such as Evarts Graham in St Louis, John Alexander in Ann Arbor, Peter Churchill in Boston, and Sauerbruch in Germany. Dr Harrington's tenacity and determined efforts with wise recruiting of associates soon established an international reputation in the diagnosis and treatment of diaphragmatic hernias and mediastinal tumors. His description of a one-stage repair of pharyngoesophageal diverticula led to a huge experience surpassing any recorded previously. A sign of the times contributed to a vast experience in managing chronic postpneumonic empyema, and pericardiectomy for chronic constrictive pericarditis. His results in surgical treatment of carcinoma of the breast were followed meticulously, producing valuable contributions in the management of this disease. He was given the highest awards by the American Medical Association for exhibits of treatment of the conditions mentioned above. In 1937, Dr Harrington was elected the 20th president of The American Association for Thoracic Surgery and later a member of the Founders Group of the American Board of Surgery, organized in 1948. He was a member of many surgical societies but he was especially proud of the “Stuart Harrington Club” organized by his former residents, which met annually at the meeting of The American Association for Thoracic Surgery. Having experienced the occasional vicissitudes while working with the “firm taskmaster,” the former residents could, in a relaxed atmosphere, appreciate and enjoy the soft and likable side of their former chief. During World War I, Dr Harrington was a First Lieutenant in the Medical Corp of the US Army and during World War II served on the Medical Advisory Board of the US Selective Service. While sometimes stern and intolerant of what he interpreted to be “less than excellent assistance,” Dr Harrington's sincere and warm care of his patients was constantly evident. He and his lovely, devoted wife, Gertrude, were not blessed with children. Dr Harrington filled the void with unusually long hours in the operating room. Mrs Harrington provided a faithful, prompt taxi service, appearing at the hospital entrance at all hours at his prompting. Aside from long hours in the operating room, automobile trips with his wife, Gertrude, provided special pleasure. Before his death in March 1975, Dr Harrington, virtually blind, enjoyed sitting in his beloved Cadillac with the garage doors open, because the running engine gave him a sense of riding. Notices of CorrectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 130Issue 4PreviewIn the March 2005 issue of the Journal, in the article by Bernatz titled, “Historical Perspectives of The American Association for Thoracic Surgery: Stuart Harrington, MD (1889-1975) (2005;129:670-1), the photograph accompanying the article is incorrect. A correct photograph of Dr Harrington is provided herewith. Full-Text PDF

The clinical and pathologic features of 283 patients with thymoma treated at the Mayo Clinic (147 female and 136 male; ages 16 years to 90 years; mean, 52 years) were examined. Forty-six percent of the patients had myasthenia gravis and 10% had other paraneoplastic phenomena. The tumors were locally invasive at operation in 32%, including 6% with metastasis to lung or pleura. Intrathoracic recurrence was noted postoperatively in 15% of those who had total excision and distant metastasis developed in 3% of patients. Thirteen percent died of their thymomas and 16% died of myasthenia. Overall 5-year survival was 67% and 10-year survival was 53%. Poor prognostic factors included presence of tumor-related symptoms, large tumor size, local invasion or metastasis in initial operation, and predominantly epithelial histologic features. Although true thymomas are composed of cytologically benign elements, they show a propensity for local invasion and intrathoracic recurrence. They rarely metastasize outside the thorax.

One hundred adult patients underwent Ivor Lewis esophagogastrectomy for documented carcinoma of the esophagus from 1980 through 1982. After operation, 7 patients were classified in Stage I, 11 in Stage II, and 82 in Stage III. Major postoperative complications occurred in 27 patients and included pulmonary problems in 11, suture line leak in 9, wound infection in 5, empyema in 4, renal failure in 4, abdominal abscess in 4, bleeding in 2, myocardial infarction in 2, and chylothorax in 1. There were 3 deaths within 30 days of operation. Five-year survival was 85.7% for patients with Stage I disease, 34.1% for patients with Stage II disease (p = .052), and 15.2% for patients with Stage III disease (p = .001). Late morbidity included weight loss in 60 patients, dysphagia in 40, gastroesophageal reflux in 14, and gastroduodenal dumping in 5. Thirty-one patients required postoperative esophageal dilations (mean, 3.4). Most patients, however, were eating without dysphagia at the time of last follow-up or death. We conclude that the Ivor Lewis esophagogastrectomy can be performed with low mortality, can provide adequate palliation, and does result in satisfactory long-term survival for those patients with more favorable postsurgical stages of cancer. These results support the continued use of the Ivor Lewis esophagogastrectomy for treatment of carcinoma of the esophagus.

Between 1955 and 1975, chest wall resection was done in 90 patients for primary chest wall tumors. Ages ranged from 8 to 96 years (mean, 44.3 years). A painful mass was the most common sign and symptom. Eighty-two tumors (91.1%) were located in the lateral chest wall and eight, in the anterior thorax. The tumor was malignant in 71 patients (78.9%) and benign in 19. All patients with benign tumors had complete excision and are currently free from disease. Malignant fibrous histiocytoma, chondrosarcoma, and rhabdomyosarcoma constituted 62% of the malignant neoplasms. Most malignancies were treated by wide resection. There were no thirty-day operative deaths. Overall 1-, 5-, and 10-year survival was 89%, 57%, and 49%, respectively. Recurrent tumor developed in 37 patients (52%); 5-year survival, however, was only 17% after recurrence. Cell type and extent of invasion significantly influenced survival. Both chondrosarcoma and rhabdomyosarcoma had a better prognosis than malignant fibrous histiocytoma (p less than 0.05). We conclude that early resection is the treatment of choice for primary malignant chest wall tumors and that development of recurrent disease is an ominous event.

Between 1953 and 1984, 53 patients (40 male and 13 female) underwent thoracotomy for treatment of pulmonary aspergilloma. The median age was 58 years (range 4 to 86 years). Either underlying lung disease or immunologic risk factors were present in 49 patients (92%). Twenty-one patients (31%) had simple aspergilloma and 32 (47%) had complex aspergilloma. The most common indication for operation was an indeterminate mass, hemoptysis, or severe cough. Lobectomy, wedge excision, and pneumonectomy were the most frequent operations. Complications occurred in 78% of patients with complex aspergilloma and in 33% of patients with simple aspergilloma (p = 0.002). Operative mortality was 5% (one death) in patients with simple aspergilloma and 34% (11 deaths) in patients with complex aspergilloma (p = 0.01). Cause of death was respiratory failure in four patients, underlying pulmonary disease in three, aspergillosis in two, and other conditions in three. At follow-up, 84% of operative survivors with simple aspergilloma were alive and well compared with 43% of those with complex aspergilloma. Although operative mortality in patients with complex aspergilloma was high, 67% of the survivors had a good long-term result in terms of absence of symptoms, but they frequently died of underlying disease. In contrast, operation in patients with simple aspergilloma was done with low risk, and approximately 90% of survivors had a good late result. Late appearance of contralateral disease did occur and argues for rigorous postoperative surveillance.

Cancers of the esophagus and cardia remain serious conditions that cause many thousands of deaths every year throughout the world. In North America, cancer of the esophagus and gastric cardia is an endemic disease of low order and stable incidence. Nevertheless, it is responsible for many deaths and considerable suffering. With current methods of treatment, substantial palliation and amelioration of patient disability are possible, and some patients gain long-term survival with comfort and even cure. A combination of surgical resection and reconstruction is the chief modern method of management of such cancers. Herein we discuss a variety of standard surgical procedures that are currently available and present detailed illustrations of these procedures. The selection of a specific operation depends largely on the site of the neoplasm. With all these procedures, function is restored and the local and regional neoplastic tissue is removed without compromising the potential for cure. Associated operative mortality is approximately 7%. The late results of the operations illustrated depend primarily on the cell type, grade, and stage of the neoplasm encountered at the time of surgical treatment. For patients who have undergone resection, 5-year survival rates have ranged from 15 to 54%, the results depending on the stage of the cancer. Of equal importance is the fact that oral diet can be maintained in 93% of patients despite recurrence of the neoplasm.

Between 1953 and 1984, 53 patients (40 male and 13 female) underwent thoracotomy for treatment of pulmonary aspergilloma. The median age was 58 years (range 4 to 86 years). Either underlying lung disease or immunologic risk factors were present in 49 patients (92%). Twenty-one patients (31 %) had simple aspergilloma and 32 (47 %) had complex aspergilloma. The most common indication for operation was an indeterminate mass, hemoptysis, or severe cough. Lobectomy, wedge excision, and pneumonectomy were the most frequent operations. Complications occurred in 78% of patients with complex aspergilloma and in 33% of patients with simple aspergilloma (p = 0.002). Operative mortality was 5% (one death) in patients with simple aspergilloma and 34% (11 deaths) in patients with complex aspergilloma (p = 0.01). Cause of death was respiratory failure in four patients, underlying pulmonary disease in three, aspergillosis in two, and other conditions in three. At follow-up, 84% of operative survivors with simple aspergilloma were alive and well compared with 43% of those with complex aspergilloma. Although operative mortality in patients with complex aspergilloma was high, 67% of the survivors had a good long-term result in terms of absence of symptoms, but they frequently died of underlying disease. In contrast, operation in patients with simple aspergilloma was done with low risk, and approximately 90% of survivors had a good late result Late appearance of contralateral disease did occur and argues for rigorous postoperative surveillance.

The mystique surrounding the esophagus has contributed to a dearth of textbooks devoted solely to this organ. In this volume, the surgical aspects of esophageal disease are emphasized, but good discussions of anatomic and physiologic features and diagnostic considerations should appeal to physicians in all medical disciplines who deal with patients who have difficulty swallowing.

The cases of 96 patients (55 male and 41 female) with primary chondrosarcoma of the chest wall were reviewed. Ages ranged from 17 to 78 years (median, 53.5 years). The tumor involved the rib in 78 patients and the sternum in 18. Seventy-two patients had treatment at the Mayo Clinic, 28 by wide resection, 25 by local excision, and 19 by palliative excision. There was 1 operative death. Follow-up ranged from 1 to 46 years. Recurrent chondrosarcoma developed in 37 patients. All had local recurrence, and 14 also had metastases. Within 10 years, recurrence had developed in 50% of patients who had local excision and in 17% of patients who had wide resection. Ten-year chondrosarcoma survival (Kaplan-Meier) for patients treated by wide resection was 96%; by local excision, 65%; and by palliative excision, 14% (p less than 0.0001). Tumor grade, tumor diameter, tumor location, and date of operation all had a significant influence on survival. This report documents the natural history of chest wall chondrosarcoma and demonstrates that early wide resection is the treatment of choice.

The cause of splenic artery aneurysms and the indications for their treatment remain controversial. Splenic artery aneurysms occur more frequently in women and are associated with pregnancy and multiparity. Whether arteriosclerosis is the cause of the aneurysm or is a secondary phenomenon is unknown. Patients not treated do well, especially if the aneurysm is less than 2 cm in diameter. The rate of rupture is approximately 3%, and it appears to be decreasing as more patients are found to have this type of aneurysm. The mortality rate for ruptured splenic artery aneurysm is greatly increased if the patient is pregnant. Indications for removal include presence of symptoms, pregnancy or plan to become pregnant, increasing size, and a diameter of 2 cm or greater. Depending on the medical condition of the patient, aneurysms that are less than 2 cm in diameter can be removed electively, or they can be left and the patient followed closely. The risk of elective removal is extremely low and has minimal morbidity. In the treatment of this type of aneurysm, the spleen should be preserved if possible; splenectomy is reserved for those aneurysms found in the hilus of the spleen or during emergency situations.

Computed tomography (with and without contrast enhancement) provides excellent diagnostic accuracy for the evaluation of the chest. Oblique (55°) and anteroposterior hilar tomography is accurate for the evaluation of hilar nodes and masses. Magnetic resonance techniques provide excellent differentiation of vascular and nonvascular structures and therefore should be useful in the hilum and mediastinum. Magnetic resonance imaging was used in 55 patients with known pathologic conditions in the mediastinum, hilum, and lungs to determine the accuracy and efficacy of this technique compared with computed and hilar tomography. The pathologic conditions included primary and metastatic neoplasms, benign masses, vascular abnormalities, and pulmonary nodules and infiltrates. Spatial resolution with magnetic resonance imaging is less than with computed tomography with our instrument (0.15 T resistive magnet). However, in the hilum and mediastinum, magnetic resonance imaging provided diagnostic information equal to that of computed tomography with contrast in 90% of patients. Vascular and nonvascular structures were more easily differentiated than with hilar tomography. Computed tomography was far superior in the evaluation of multiple pulmonary nodules. Lesions of the chest wall were better seen with magnetic resonance imaging because of the improved soft tissue contrast.

Bronchogenic carcinoma is reported to be more rapidly fatal in young persons than in older persons. We wondered whether young patients experience a more virulent form of lung cancer or whether other factors might contribute to poor survival. We reviewed the records of 113 Mayo Clinic patients younger than 40 years with histologically proven bronchogenic carcinoma diagnosed between 1956 and 1976. One hundred four patients (92%) had symptoms for a mean duration of 4 months before diagnosis. The disease was categorized as Stage I in 9 patients, Stage II in 6, and Stage III in 98. Fifty-six patients underwent thoracotomy. The procedure was curative in 17 and palliative in 14; in 25, the lesion was unresectable. Respective 1-year and 2-year survivals were 71% and 35% after curative resection and 79% and 28% after palliative resection. The 1-year survival was 82% for patients in Stage I, 40% for Stage II, and 26% for Stage III. Without resection, only 16% of patients lived 1 year or longer. Advanced disease at presentation characterized this group of young patients.

Previously reported from our institution has been a series of 63 patients with pulmonary arteriovenous fistula who were seen from Jan. 1, 1952, through Dec. 31, 1972. Subsequently, we have seen 38 additional patients during the 8 1/2-year period from Jan. 1, 1973, through June 1981. The series includes three patients with hereditary telangiectasia who had bilateral pulmonary arteriovenous fistulas removed at two separate thoracotomies. Our report also includes a brief description of five additional patients with acquired systemic artery-to-pulmonary artery fistula who underwent miniballoon occlusion of the fistula. We are including these five cases because we believe this therapeutic catheterization technique may be of particular value in patients with multiple or bilateral pulmonary arteriovenous malformations and may obviate extensive pulmonary resection and repeat thoracotomy. Pulmonary arteriovenous fistula is believed to occur most often in middle-aged women who have associated Rendu-Osler-Weber syndrome, but most of our patients did not have hereditary hemorrhagic telangiectasia. Twenty-three (36.5%) of the 63 patients in a previous Mayo Clinic series and 18 (47%) of the 38 in the present series had associated Rendu-Osler-Weber syndrome. A logical workup of a patient with pulmonary arteriovenous fistula includes, in sequential fashion based on priority, chest roentgenography and tomography, arterial blood gas measurements, contrast echocardiography with indocyanine green dye, angiography, and measurement of differential pulmonary venous oxygen content.

During the past 10 years, 54 patients, all men, were found to have roentgenographically occult lung cancer. The mean age was 61 years (range 45 to 76 years). All patients had abnormal findings on sputum cytologic study (carcinoma in 41 patients and squamous cell atypia in 13). The cancer was localized by bronchoscopy in all patients (range one to five examinations, mean 1.5). Seventy-five percent of the tumors were localized within 169 days of the abnormal sputum cytologic examination. Pulmonary resection for cure was performed in all patients: lobectomy in 38, pneumonectomy in nine, and bilobectomy in seven. Operative mortality was 5.6% (three patients). Fifty-eight cancers were resected, all squamous cell carcinomas (two had a component of large cell cancer). Tumor TNM classification (AJC) was TIS N0 M0 in 19 patients, T1 N0 M0 in 25, T1 N1 M0 in five, T2 N1 M0 in four, and T3 N0 M0 in one. Overall 5 year actuarial survival rate (lung cancer deaths only) was 90%. Five-year survival rate for the 44 patients with TIS N0 M0 and T1 N0 M0 neoplasms was 91%. Currently, 21 patients have died, but only 10 of lung cancer. Subsequent additional lung cancer developed in 12 patients (22%). Eleven of these patients had a second primary squamous lung cancer, six of which again were occult. We conclude that patients with occult lung cancer have a strong likelihood of long-term survival if treated early. Close surveillance is indicated because of the high incidence of a second primary lung cancer.

The value of computed tomography in myasthenia gravisLR Brown, Muhm, JR, PF Sheedy, 2nd, KK Unni, PE Bernatz and RC Hermann, JrAudio Available | Share

Within a 75-year period, 20 patients with primary nonteratomatous carcinomas of the thymus were seen at the Mayo Clinic. Fourteen were males and six were females, with a mean age of 48 years. Thirteen of the lesions were classified as poorly differentiated or spindling squamous cell carcinomas. One neoplasm was a sacromatoid carcinoma, and two showed both squamous cell and neuroendocrine ultrastructural features. The remaining four tumors had both light- and electron-microscopic features of neuroendocrine carcinomas. In all 20 patients, careful clinical and pathologic examinations, including autopsy in fatal cases, excluded malignant lymphomas and metastasis to the thymus from epithelial tumors in other anatomic sites. Thirteen patients underwent surgery, with or without postoperative radiotherapy; of these, one was alive and apparently disease-free 43 months after diagnosis. There were two operative deaths. The remaining patients received primary radiotherapy or chemotherapy, or both. The mean survival of the 16 patients who died (excluding operative deaths) was 18.7 months for the 14 patients with tumors of squamous cell differentiation and 36.0 months for the two patients with pure neuroendocrine carcinomas. Among patients with squamous cell carcinoma, 11 developed metastases to lungs, liver, bones, adrenal glands, or extrathoracic lymph nodes; nine of these died of massive local growth within the mediastinum. Among patients with neuroendocrine carcinomas, two of four patients died of local growth within the mediastinum; one of these also had metastases to the liver and adrenal glands. One patient with oat cell carcinoma was alive with residual thoracic tumor and cervical lymph node metastasis 18 months after diagnosis.