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Seventy-three patients (57 men and 16 women) underwent en bloc resection of lung and attached parietes between 1970 and 1982. All patients had documented malignant pleural invasion. Chest wall parietal pleura was invaded in 33 patients, pericardium in 14, phrenic or vagus nerve in nine, left atrium in five, superior vena cava in four, esophagus in two, diaphragm in one, and multiple structures in five. No patient underwent chest wall resection. Parietal pleurectomy was performed in all patients with involvement of the chest wall parietal pleura; 37 lobectomies and 36 pneumonectomies were performed. Operative mortality was 12.3%. The actuarial overall 5 year survival rate (Kaplan-Meier method) was 39.7%. We conclude that en bloc resection for primary bronchogenic carcinoma with invasion of adjacent intrathoracic structures, although associated with a significant mortality, can be performed with a reasonable likelihood of long-term survival.

Early after thoractomy, incisional chest pain may lead to a sequence of undersirable effects on respiratory function, in addition to causing patient discomfort. Pharmacologic blockade of the intercostal nerves innervating the incisional area can improve respiratory function as well as patient comfort. The postoperative production of continuous intercostal nerve blockade can be accomplished by the insertion of indwelling analgesic catheters at the time of thoracotomy closure.

We evaluated the risk of adenocarcinoma developing in Barrett's esophagus (esophagus lined with columnar epithelium). Mayo Clinic records were reviewed, and all cases that met predefined histologic criteria for the diagnosis of Barrett's esophagus in 1979 or earlier were included. In 18 of 122 such cases, adenocarcinoma of the esophagus and Barrett's esophagus were diagnosed simultaneously. The status of the remaining 104 cases was determined after a mean interval of 8.5 years. During this time, adenocarcinoma of the esophagus developed in 2 patients, and 24 died from other causes. We conclude that although the incidence of esophageal adenocarcinoma is increased in patients with symptomatic Barrett's esophagus, it does not occur in the majority of such patients.

The Mayo Lung Project (MLP) is a screening program designed to detect bronchogenic carcinoma at a curable stage. Screening tests include chest roentgenograms, three-day "pooled" sputum cytology studies, and lung-health questionnaires. These are being applied every four months to a study population of outpatients who have a high probability of developing lung cancer. Initial patient acceptance of the screening program has been excellent. Small asymptomatic lung cancers have been detected both roentgenographically and cytologically. The two procedures have complemented each other with little overlap. Chest roentgenography has proved most useful in diagnosing peripherally situated cancers, whereas sputum cytology studies have been most effective in identifying early squamous cancer involving major airways. At present, more cancers have been detected roentgenographically than cytologically, but the cytologically detected cases appear to have a better prognosis. Roentgenographically occult cancers have been localized with regularity, although the localization process is complicated. Theoretically, vigorous application of radiologic and cytologic screening, combined with optimum use of localizing procedures and treatment, could increase the five-year survival rate among lung cancer patients to nearly 50 percent. However, the actual survivorship attained will ultimately be determined by currently imponderable factors such as patient acceptance of longterm screening, frequency of multicentric respiratory cancers, and incidence of noncancerous smoking-related diseases, especially chronic obstructive pulmonary disease and ischemic heart disease.

Hematoporphyrin is preferentially concentrated by cancer tissue and therefore is a potentially useful chemical marker. This report demonstrates the effectiveness of a photoelectric hematoporphyrin fluorescence detector used simultaneously with flexible fiberoptic bronchoscopy as a means of detecting and localizing bronchogenic carcinoma. The detector generates an audio signal when fluorescence is within the visual field of the bronchoscope. Of interest is that an audio signal was generated which indicated hematoporphyrin fluorescence in areas where no mucosal abnormality had been seen. These areas proved to be carcinoma in situ.

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 surgically resectable disease. They have remained free of disease for 3, 6, 7, and 14 years. Sixty-nine patients (94.5 percent) had unresectable carcinoma with metastases. Seventeen (94 percent) of 18 patients with bloody effusions had unresectable cancer. Carcinoma was resected in one patient with cytologically negative bloody effusion, and the patient remained free of disease during the 14-year follow-up period. Unresectability must be documented surgically in these patients to exclude those in whom curative resection can be performed.

The symptoms of progressive dyspnea, hemoptysis, spontaneous pneumothorax, chylous effusions, and cough in conjunction with ventilatory obstruction and abnormal gas exchange in a young woman should prompt the diagnosis of pulmonary lymphangiomyomatosis. Cytosol steroid-receptor assays and postmortem studies were conducted in an extensive investigation of a case of this disease. A biopsy specimen of the lung disclosed evidence of nuclear translocation of [3H]progesterone and the presence of a cytosolic receptor for progesterone, an indication that this disease could be treated effectively with progestin.

The purpose of this study was to evaluate tracheal viability and to document histological changes in an autograft implanted in the abdominal wall after a 1-week period of cryopreservation. A 5-cm segment of cervical trachea was resected in 6 dogs. One-half of the segment was cryopreserved and stored in liquid nitrogen at -196 degrees C for 1 week. The other half was immediately implanted in an abdominal pouch fashioned from the rectus abdominis muscle (control). One week later, the cryopreserved segment was thawed and then implanted in a similar contralateral muscular pouch. Five weeks later, the control and cryopreserved autografts were removed and compared with the in situ trachea. Ciliary beat frequency was assessed by transmitted light technique. Histology was evaluated by light microscopy. Gross anatomy and mucus production were maintained after cryopreservation. Histologically the cryopreserved segment displayed both normal epithelium and smooth muscle cells, but the cartilage was abnormal as characterized by empty lacunae. Mean ciliary beat frequency of in situ, control, and cryopreserved segments was 13.3 +/- 1.8, 13.5 +/- 1.5, and 13.3 +/- 1.1 beats per second (+/- the standard deviation), respectively. We conclude that smooth muscle, epithelium with mucus production, and ciliary function were retained after cryopreservation and reimplantation. Histological changes, however, were suggestive of early cartilage ischemia. These findings support further evaluation of cryopreserved canine tracheal grafts.

During the first 10 years of the Mayo Lung Project, 68 roentgenographically inapparent ("occult") lung cancers were localized and apparently completely resected. A pathologic classification was developed based on depth of tumor infiltration. The five categories were (1) in situ carcinoma confined to surface epithelium or ducts of mucous glands or acini (23 cancers), (2) intramucosal invasion not greater than 0.1 cm from mucosal surface (12 cancers), (3) invasion to bronchial cartilages (11 cancers), (4) invasion to full thickness of bronchial wall (10 cancers), and (5) extrabronchial invasion (12 cancers). Multicentricity of lung cancer was studied in 54 patients, none of whom had a history of cancer of the respiratory tract, and all of whom had had "complete" surgical resection of the initial occult lung cancer (or cancers). Neoplasms that were initially multicentric occurred in 4 patients, and a subsequent primary lung cancer developed in 11. The rate of detection of second primary lesions was 42 per 1,000 person-years of observation. A high incidence of unresectable cancers and a low survival rate were noted among patients who had a subsequent primary tumor. These findings were primarily attributable to invasiveness of the subsequent primary cancer or to respiratory insufficiency that resulted from obstructive lung disease or previous pulmonary resection. Because of the high risk of development of a second primary cancer after initial surgical resection, it is important to treat the initial occult cancer as conservatively as possible consistent with "cure."

Reflux esophagitis and its complications are not only common clinical problems but also problems that can be accurately defined by careful history taking and a knowledge of the pathophysiology of the various manifestations. An element of objective assessment, however, is required to define and substantiate fully an individual patient's problem. Only when disabling subjective and intractable objective complications persist after good medical treatment should surgical intervention be considered. Various antireflux procedures are currently available and all can be effective. Surgeons should review their own experiences and make alterations that they perceive will correct the types of problems encountered. In our current technique for the surgical management of gastroesophageal reflux in the common clinical setting, normal esophageal peristalsis is present, the fundus is adequate for plication, and sufficient esophageal mobilization can be effected to permit reduction of the entire stomach and fundoplication below the diaphragm. In addition, the procedure should be restricted to patients who do not have stenosis or have stenosis that can be readily dilated to 50 French.

In a group of 47 patients with mediastinal granulomas, the most common clinical symptoms were cough, chest pain, dysphagia, hemoptysis, and dyspnea. The main laboratory findings were right paratracheal or hilar mass on chest roentgenogram, positive histoplasmin skin test, and caseating granuloma on histopathologic examination. Complications included fibrosing mediastinitis with superior vena cava obstruction, esophageal compression, and major upper airway compression. Treatment was usually surgical resection or evacuation of caseous contents. The prognosis in most patients with mediastinal granulomas appears to be good--long-term survival with minimal or no disability.

A review of 95 patients seen at the Mayo Clinic with mediastinal granuloma indicated that ten (10.5%) had esophageal involvement. The primary complaint was dysphagia. Esophageal roentgenographic features included compression, stricture, diverticulum, sinus tract formation, and tracheoesophageal fistula. An esophagogram should be included in the workup of any patient with suspected mediastinal granuloma.

Recurrent pharyngoesophageal diverticulum is uncommon after a one-stage diverticulectomy. Among 888 operations at the Mayo Clinic, recurrence has been noted after only 32 (3.6%). The present report outlines our management during a 19-year period of 44 patients operated on previously, including management of various late complications seen in 13 patients after diverticulopexy and diverticulectomy performed at other institutions. The study then focuses on the results in 31 patients in whom reoperation for symptomatic recurrent diverticulum was performed at the Mayo Clinic during the same period. Although reoperation posed a technical challenge, there was only 1 operative death (3.2%). Surviving patients experienced highly satisfactory late results, with only two recurrences. Early surgical morbidity was considerably higher than for primary operations, but this did not interfere with most patients having excellent to good late results.

Three hundred forty-six patients with post-surgical non-small cell Stage I bronchogenic carcinoma were followed from 5.0 to 10.8 years (median, 7.0 years). Recurrent cancer developed in 135 patients (39%). Seventy-five recurrences were nonregional metastases (55.6%); 35 (25.9%), a subsequent primary lung cancer; and 25 (18.5%), local recurrence only. The rate of recurrent lung cancer decreased from 15.0 patients per 100 patient-years the first postoperative year to 2.3 the seventh and subsequent years. The rate of recurrence varied among the three different types of recurrent cancer. Five years after pulmonary resection, 70.0% of patients with T1 N0 neoplasms had no evidence of recurrence compared with 58.2% of patients with T2 N0 tumors (p = 0.012) and only 31.8% of patients with T1 N1 neoplasms (p less than 0.001). There was no significant difference in overall rate of recurrence among the various cell types. Currently, 174 patients are alive. Lung cancer survival (Kaplan-Meier) was 69.1% at 5 years and 61.9% at 9 years. At 2 years following detection of subsequent lung cancer, 51.8% of patients with subsequent primary lung cancer had survived lung cancer compared with 23.4% for those with local recurrence and only 8.9% for those with nonregional metastases.

The records of all patients with spontaneous esophageal perforations who were examined between August 1966 and December 1978 were reviewed. Eleven patients (six men and five women) whose mean age was 62.8 years were treated during this period. Precipitating factors that contributed to perforation were identified in all patients. Ten patients had epigastric or low sternal pain. Chest roentgenograms were abnormal for all patients. Two patients were treated conservatively, and both died. Of the nine patients treated by thoracotomy, the two who were treated within 24 hours of perforation survived. Of the seven patients treated later than 24 hours, only three survived. Late treatment consisted of either primary closure or esophageal exclusion. Prompt surgical intervention remains the treatment of choice.

A patient with an uncalcified splenic artery aneurysm with an arteriovenous fistula and aneurysmal dilatation of the splenic vein who underwent splenectomy and resection of the fistula is described. Splenic arteriovenous fistulas are rare and are usually associated with aneurysms of the splenic artery. Patients with these fistulas frequently have signs and symptoms of portal hypertension and may often present with upper gastrointestinal hemorrhage. The patient described in this report was asymptomatic, and the only manifestation of the fistula was a loud, continuous bruit in the left flank noted on routine physical examination. Although an upper abdominal incision can be used to manage most splenic artery aneurysms, a left thoracoabdominal incision is advocated in the presence of an arteriovenous fistula, particularly in anticipation of portal hypertension or aneurysm of the splenic vein.

Two patients had both scleroderma and a columnar epithelium-lined lower esophagus (Barrett esophagus). Features of Barrett's esophagus included high esophageal strictures in both patients and ulcer craters in the columnar area of one. Biopsy confirmed columnar epithelium in the lower esophagus of each patient. In these patients, the Barrett esophagus probably was a complication of scleroderma and resulted from long-standing gastroesophageal reflux.

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.

Between 1949 and 1976, 899 patients underwent treatment for achalasia of the esophagus at the Mayo Clinic, 431 by forceful hydrostatic or pneumatic dilation and 468 by a standardized transthoracic esophagomyotomy. Esophageal leak and mediastinal sepsis was an uncommon but major complication of both types of therapy, occurring four times more often with dilation (4%) than with myotomy (1%), although no deaths resulted from this in either group. The 30-day mortality was 0.2% after myotomy and 0.5% after forceful dilation. Although there was minimal morbidity and mortality with either modality, the late results were significantly superior after myotomy. Excellent to good results were obtained by 85% of the group treated with myotomy but only by 65% of those treated with hydrostatic dilation. Late poor results were encountered three times more frequently after dilation (19%) than after myotomy (6%). Analysis of poor results after myotomy indicates that late serious complications of gastroesophageal reflux developed in only 3% of patients operated on.

A cytologic examination of pleural fluid was performed on a pleural lavage specimen collected at the completion of operation after pulmonary resection in 135 of 599 patients undergoing curative pulmonary resection for a non-small cell carcinoma of the lung between 1977 and 1982. The cytologic results of lavage was positive for malignant cells in 12 of the 135 patients (8.9%). The incidence of positive results was correlated with lymph node status (N2 greater than N1 greater than N0), cell type (adenocarcinoma greater than other non-small cell lung cancers), stage (III greater than II greater than I), and visceral pleural status (invaded greater than not invaded). No positive cytologic results were noted in 39 patients having a diagnostic excisional pulmonary biopsy prior to more definitive resection. The disease has recurred in nine of the 12 patients with positive cytologic results (only two in the ipsilateral pleural space), and eight have died. The prognostic role of pleural lavage cytology needs more study.

Fifty-two patients (31 men and 21 women) were treated for complications of broncholithiasis between 1969 and 1984. Mean age was 50.8 years (range 26 to 74 years). Indications for operation included symptoms in 49 patients and an abnormal chest x-ray film in three. Broncholithectomy was initially attempted by thoracotomy in 40 patients and by bronchoscopy in 12. In the thoracotomy group broncholithectomy was successful in all patients, 32 of whom underwent pulmonary resection. Significant postoperative complications occurred in five patients (12.8%). There was one postoperative death (2.5%). In the bronchoscopy group broncholithectomy was successful in eight patients (67%); significant complications occurred in two and there were no early deaths. Subsequent thoracotomy was done in three of the four patients in whom bronchoscopic removal was unsuccessful. Follow-up averaged 76.5 months (range 6 to 183 months). The 15 year survival rate (Kaplan-Meier) for all patients was 75.1% and did not differ from a control group of patients. No patient in the thoracotomy group had recurrent complications of broncholithiasis. In contrast, complications recurred in three of the eight patients (37.5%) successfully treated by bronchoscopy. We conclude that broncholithectomy via thoracotomy is the preferred treatment, as the risks are low and the long-term results are excellent.

Exercise-induced wheezing developed in a previously healthy 14-year-old boy. Chest radiographs revealed hyperlucency of the left lung. Bronchial tomography and bronchoscopy revealed a mass in the left mainstem bronchus, identified as a carcinoid tumor after surgical excision. The patient is now asymptomatic. Exercise-induced wheezing as the sole manifestation of this tumor has not been previously reported.

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.

Among 706 collected cases of mediastinal neurogenic tumors were 69 patients (9.8%) with extension through an intervertebral foramen, so that the composite neoplastic mass was dumbbell-shaped. Although only 10% of these dumbbell tumors were malignant, the majority of the patients presented with neurologic symptoms of spinal cord compression. In about 40% of reported cases, the intraspinal component, although present, was not clinically apparent. Such cases of asymptomatic intraspinal extension should be suspected when special roentgenologic views of the spine demonstrate erosion of the vertebral pedicle or enlargement of the intervertebral foramen adjacent to the posterior mediastinal mass. Workup of these patients should include myelographic studies to determine whether a dumbbell tumor is indeed present; if it is, surgery should be carried out by a team of thoracic surgeons and neurosurgeons in a one-stage combined resection of both the intraspinal and the mediastinal component of the tumor. With early diagnosis and surgical intervention, long-term survival is the rule. When the patient is in the pediatric age bracket, an orthopedic surgeon should be included on the team to help minimize subsequent skeletal growth deformity.

A patient who had sustained lye burns of the esophagus had undergone reconstruction with a colon interposition. Because of necrosis and stricture of the interposed colon, he was unable to manage salivary secretions and was maintained on gastrostomy feedings. The defect from the pharynx to the midmanubrial level was reconstructed with a free jejunal graft by using microvascular surgical techniques. At 18-month follow-up, barium swallow roentgenography showed flow through the jejunal and colonic segments and into the stomach. The patient gained 15.9 kg postoperatively and was able to consume a normal diet.

En bloc resection of chest wall and lung for primary non-small cell bronchogenic carcinoma with chest wall invasion, although often associated with a significant operative mortality, can be performed with a reasonable expectation of long-term survival if lymph nodes are not metastatically involved. Older age appears to decrease long-term survival, but age alone should not abrogate surgical resection. Non-small cell carcinoma cell type, tumor size, depth of chest wall invasion, and extent of chest wall or lung resection do not significantly influence survival.

Cardiac tachydysrhythmias occurred in 53 (22 percent) of 236 consecutive patients undergoing pneumonectomy. All patients had preoperative electrocardiograms which showed normal sinus rhythm. Patients did not receive digitalis before surgery. Atrial fibrillation was the most common dysrhythmia (64 percent; 34/53), followed by supraventricular tachycardia (23 percent; 12/53) and atrial flutter (13 percent; 7/53). No episodes of ventricular tachycardia were documented. Elevated concentrations of cardiac enzymes were associated with 12 (28 percent) of 43 tachydysrhythmias. Recurrent or persistent dysrhythmias were documented in 29 (55 percent) of 53 patients despite medical management or electrocardioversion (or both). Thirty-one percent (9/29) of these patients subsequently died during their hospitalization. There was no correlation between standard preoperative pulmonary function tests and the incidence of postoperative dysrhythmia. In addition, there was no correlation of dysrhythmia with postoperative diagnoses, surgical staging for lung cancer, postoperative arterial blood gas levels, or the fact that a completion pneumonectomy or chest wall resection was undertaken. An increased incidence of tachydysrhythmia was noted in patients undergoing intrapericardial dissections and those who developed postoperative interstitial or perihilar pulmonary edema. Twenty-five percent (13) of the patients experiencing tachydysrhythmias died within 30 days following their pneumonectomy. We conclude that tachydysrhythmias after pneumonectomy are associated with significant mortality, have poor correlation to preoperative pulmonary function, and occur more frequently following intrapericardial dissection and in patients who develop postoperative interstitial pulmonary edema or perihilar pulmonary edema.

Approximately 8% of all mediastinal tumors are benign teratomas. We reviewed 86 cases of benign teratoma seen at the Mayo Clinic from 1930 through 1981. The mean age of the patients was 28 years and the sex distribution was approximately equal. The most common symptoms were chest, back, or shoulder pain, dyspnea, and cough, but 36% were asymptomatic at the time of presentation. Chest roentgenograms showed a well-circumscribed anterior mediastinal mass which often protruded into one lung field. Detectable calcification was observed in 22 patients: a calcified tumor wall in seven, bone or teeth in the mediastinum of seven, and nonspecific calcifications in eight. Surgical excision remains the best means of diagnosing and treating this benign tumor. Though the tumors are histologically benign, they may present difficult surgical problems because of the vital structures involved. Since 1952 there has been a change in the clinical presentation of patients with this entity: More patients are asymptomatic and have smaller tumors and fewer complications than prior to 1952.

Thirty-one patients with mediastinal granuloma and fibrosing mediastinitis were seen at the Mayo Clinic from 1975 through 1977. Review of this series reveals that surgery is necessary to establish a diagnosis if the lesions are noncalcified and indeterminate. Fibrosing mediastinitis most likely develops after rupture of the fibrocaseous material from mediastinal lymph nodes into the mediastinum. Thoracotomy, with evacuation of the granulomas, is recommended, especially when the lesions are large, in order to prevent subsequent fibrosing mediastinitis with involvement of the contiguous structures, such as the superior vena cava, azygos vein, trachea, esophagus, and left atrium. In most patients, obstruction of the superior vena cava develops slowly, and efficient collateral venous circulation occurs, allowing long-term survival and minimal disability.

In the absence of a prospective randomized study of patients treated conservatively or with thymectomy, a computer-assisted retrospective matches study was devised. Of 563 patients treated for myasthenia gravis without thymoma up to 1965, 104 had thymectomy. With computer assistance, each surgical patient was matched with a medical patient on the basis of age, sex, and severity and duration of disease. On this basis 80 of the 104 surgical patients could be matched satisfactorily. There were 16 males and 64 females in each of the matched surgically treated and medical control groups. A complete remission was experienced by 27 of the 78 patients in the surgical group as compared to 6 of the medical group. Improvement was noted by 26 of 78 surgically treated patients and 13 of 78 receiving medical treatment. Survival for patients having thymectomy. Thirty-four patients in the medical group had died as compared to 11 in the surgical group. Comparison of survival in relation to sex, duration of symptoms, or age (less than 30 or less than 30 years) did not show a significant difference. Until more effective treatment is available for myasthenia gravis, thymectomy deserves consideration for both sexes, and with increased age or long duration of symptoms.

During a 6-yr period, 57 children and young adults less than 21 yr of age underwent 111 thoracotomies for pulmonary metastatic osteogenic sarcoma. Follow-up after the initial thoracotomy averaged 36.8 no and ranged from 1 to 78 mo. Twenty-eight patients (49%) underwent more than one thoracotomy--the number of multiple thoracotomies averaged 2.9 and ranged from two to eight. Twenty-six of the 57 patients are currently alive, and 25 of these are free of disease. Median survival was 36 mo. Actuarial survival curves demonstrated a 5-yr survival of approximately 40%. Seventy-one percent of patients who had a tumor-free interval of greater than 1 yr are currently alive, compared with 39% of patients who had a tumor-free interval of less than 1 yr. Patients with disease confined to one lobe at the initial thoracotomy had a better survival (64%) than patients with diffuse or bilateral disease (41%). An aggressive surgical approach toward osteogenic sarcoma with pulmonary metastasis thus appears to be justified.

Twenty-six cases of desmoid tumors of the wall of the chest were reviewed. These are rare lesions, which nonetheless should be considered in the differential diagnosis of all tumors of the chest wall. Although the lesion is most often palpable, several of the tumors were detectable only by means of an x-ray film of the thorax. Definitive diagnosis could not be made clinically but was easily established by pathologic examination of widely excised tumor. Like all desmoid tumors, these were locally aggressive in their growth but nonmetastatic and generally carried a good prognosis. Ideally, treatment consisted of wide local excision, but if there was encroachment of the tumor on vital structures, excision with suboptimal tumor-free margins was required. Even in the latter instance, tumefaction could be well controlled for long periods. Recurrences after an initial attempted removal were common, but most of these responded to reexcision.

During a three-year period, 53 patients with myasthenia gravis underwent transsternal thymectomy by a partial sternum-splitting technique at our institution. This procedure was carried out (1) because an x-ray film or a computed tomography scan had suggested the presence of a thymoma or (2) to manage symptoms of myasthenia gravis. In 41 patients the endotracheal tube was removed in the post-anesthesia recovery room. The remaining 12 patients were extubated in the Respiratory Care Unit--in five, after prolonged mechanical ventilation. From our experience, the only factor useful for predicting the probable need for prolonged postoperative mechanical ventilation is the degree of bulbar involvement. Patients in Osserman classification groups 3 and 4 have an extremely high incidence of postoperative respiratory failure. Consideration should be given to the use of preoperative plasmapheresis in myasthenia gravis patients who have significant bulbar symptoms.

Sixteen patients, aged 10 to 70 years, had carcinoid tumors of the lower respiratory tract treated by various resective tracheobronchoplastic procedures. These represent 8.8 percent of 181 patients with carcinoid lesions treated during a recent 20 year period. All 16 patients had respiratory symptoms, and one patient also had the carcinoid syndrome. Roentgenographic changes ranged from a mass or atelectasis (or both) through unilateral lung hyperinflation to clear lungs with subtle filling defects in major airways. All tumors were visualized endoscopically, and 13 patients had biopsies. Histopathologically, all tumors were "typical" carcinoids . Before operation, the patients had minimal or no respiratory insufficiency, although flow-volume and ventilation-perfusion abnormalities were noted when major airways were affected. Surgical management at thoracotomy was as follows: (1) simple wedge tracheobronchotomy without lung resection (five patients); (2) bronchial sleeve resection without lung resection (three patients); and (3) bronchial sleeve with upper lobe resection (eight patients). These 16 operations were performed with eight technical anatomic variations. No early or late deaths occurred. One patient had early transient atelectasis, and three patients required late endoscopic removal of suture granulation tissue. All patients were alive without recurrence of tumor or carcinoid syndrome or other respiratory complications 6 months to 19 years postoperatively. Pulmonary resection should be avoided unless there is histologic evidence of tumor extension into lung parenchyma or irreversible pulmonary suppuration distal to the obstructive tumor.

The recent surgical treatment of two patients with relatively complex esophageal problems is described. In one patient, a long segment of proximal intrathoracic esophagus was mobilized during the course of surgery, and it was noted that the esophagus was viable and had a good blood supply at the distal margin of resection. In the other, the entire cervical and intrathoracic esophagus remained viable after mobilization. The obvious viability of these long esophageal segments detached from the segmental blood supply prompted us to preserve and use them in reconstruction. These observations suggest that there is a rich intramural arterial and venous network complementing the segmental blood supply of the esophagus. Although previous studies have clearly demonstrated a rich intramural esophageal vasculature, to the best of our knowledge it had not been clearly demonstrated that such lengths of esophagus could be mobilized from their segmental blood supply and remain viable. The details of these two cases are presented and discussed to document this observation and the manner in which it was possible to modify the esophageal reconstruction favorably by the use of the mobilized segment of esophagus.

Structural polypeptides of two plaque-purified variant isolates of fowlpox virus differing in plaque morphology and size were examined by Coomassie blue-staining and immunoblot analysis of purified virions. A total of 30 structural polypeptides were observed, ranging in molecular weight from 14,100 to 122,600. A late polypeptide of 36,400 molecular weight was quite prominent in the small-plaque clone but absent in the large-plaque clone. Two other polypeptides, of 33,700 and 34,800 molecular weight, were present in virions from large-plaque virus and cell lysates of both clones but were absent in the small-plaque virions. These differences were observed whether the viruses were grown in chorioallantoic membrane or in chicken embryo fibroblast cultures. No difference was observed between the growth curves of the two virus clones. Differences observed in the polypeptides of the two viruses may be due to changes in the less conserved regions of viral DNA and may be used for differentiation of virus isolates.

Most patients with Schatzki's ring have dysphagia that can be relieved by esophageal dilation. We report an unusual case in which dysphagia caused by a Schatzki ring could not be managed conservatively. The obstructing ring was excised through a gastrotomy approached by a left-sided thoracotomy. An antireflux procedure was done after elimination of the ring. Five years later, the patient remained symptom free.

Of 53 patients with horseshoe kidney (9 in the present series), 45 underwent operation for an abdominal aortic aneurysm: 40 electively and 5 on an emergency basis. The remaining eight patients underwent revascularization for arteriosclerosis obliterans. Of the 53 patients, 35 (66%) had renal artery anomalies. The anomalous arteries prevented aortic repair in 6 patients (17%), were left undisturbed in 9 (26%), were revascularized in 7 (20%), and were ligated in 13 (37%). Partial nephrectomy was required in 2 of the 13 patients undergoing arterial ligation. Symphysiotomy was performed in 16 (30%) of the 53 patients. The following approach to management of horseshoe kidney associated with disease of the abdominal aorta is suggested. 1. Whenever a horshoe kidney is suspected, excretory urography, aortography, and, if necessary, selective renal arteriography should be obtained preoperatively. 2. Anomalous renal arteries arising from resected segments of the aorta should be revascularized whenever technically possible, usually by reimplantation of the renal artery into the aortic graft. 3. If an anomalous renal artery is ligated, the kidney should be inspected for signs of ischemia, and partial nephrectomy should be performed if ischemia occurs. 4. Symphysiotomy should be avoided. If division is necessary, symphysiectomy is preferable to symphysiotomy. In either circumstance, care need be taken lest there be fusion of the urinary collecting system and the renal parenchyma. In most patients with horseshoe kidney, aortic surgery has been accomplished without complication and with only minor alteration in surgical technique, even when the renal anomaly is first detected at surgical exploration.

Proximal cervical esophageal diversion is occasionally employed in the management of distal esophageal perforation. However, subsequent esophageal reconstruction can pose a formidable surgical challenge. The DeBakey femoral tunneling device has proven helpful in identifying the distal defunctionalized segment of esophagus during certain types of reconstruction. We describe the use of this instrument to reestablish esophageal continuity in two instances.

172 patients who had had mastectomy for breast cancer were treated by repeated adjuvant chemotherapy, either with phenylalanine mustard (P.A.M.) or a combination of cyclophosphamide, 5-fluorouracil, and prednisone (C.F.P.) with and without radiotherapy. Tumours recurred significantly more frequently and mortality tended to be higher in P.A.M.-treated patients than in patients on other treatment. The interval between surgery and disease recurrence was significantly shorter for P.A.M.-treated premenopausal but not postmenopausal patients than for patients of equivalent menstrual status treated with C.F.P. with or without radiation. The associations in premenopausal patients between the mode of treatment and both survival and the disease-free interval were significant before and after adjustment for variations between the treatment groups in the number of involved lymph nodes and the size of the primary tumour.

Of 97 patients with mediastinal granuloma, 13 had involvement of the esophagus by extension from adjacent lymph nodes or pleura. A knowledge of the anatomic relationships of these structures is important in understanding the distribution and radiologic features of these lesions. The most common manifestation was extrinsic compression, being present in 7 (54%) of the 13 patients. Three patients (31%) had either a fistula or a sinus tract. Esophageal stricture and diverticulum formation also occurred. Mediastinal granuloma should be considered in the differential diagnosis in patients with any of these findings.