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One hundred three consecutive patients undergoing 106 thoracotomies for primary lung carcinoma were reviewed to determine factors associated with the development of postoperative pulmonary complications. Pulmonary complications occurred in 40 of 104 (39 percent) patients. Minor complications occurred in 17 of 104 (16 percent) patients and major in 23 of 104 (22 percent). There were six deaths in the entire series of 103 patients (6 percent), two of which were directly caused by a pulmonary complication and one where it was a contributing factor. Extended surgical resections were associated with an increased risk of complications. Pulmonary complications occurred in 9 of 11 (82 percent) patients undergoing extended resections involving chest wall resection. The use of neoadjuvant chemotherapy also was associated with an increase in the rate of major complications. Poor nutritional status as measured by a history of weight loss and preoperative serum albumin levels also was associated with an increased risk of any pulmonary complication. Cardiac complications were significantly increased in the group of patients having pulmonary complications. Pulmonary complications continue to present a major source of morbidity and mortality for patients undergoing thoracotomy for lung carcinoma. Determination of factors associated with increased risk is important in order to identify patients who might be predisposed to the development of these complications.

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Tracheal obstruction and superior vena cava (SVC) syndrome are rare complications of retrosternal goiter. These two conditions present a difficult diagnostic and therapeutic challenge. Malignancy is the most common cause of SVC syndrome. Determining whether SVC syndrome is due to a benign or malignant process is imperative before instituting treatment, but this determination may be difficult. We present a case of a patient presenting with upper airway obstruction and SVC syndrome with a large mediastinal mass. The mass was determined to be a multinodular goiter. The patient was managed by surgical removal of the goiter with complete resolution of symptoms. This case illustrates the need for careful preoperative evaluation and the importance of establishing a histologic diagnosis prior to initiating treatment for SVC syndrome.

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In this retrospective review of 58 patients (12 females and 46 males) with pulmonary metastases of squamous cell carcinoma of the head and neck treated between January 1, 1970, and December 31, 1989, we evaluated their clinical courses and analyzed the outcomes of those who underwent pulmonary resection. For the entire group of patients, factors predictive of survival in those patients with a diagnosis of pulmonary metastases included pulmonary resection of metastases (p = 0.0001), locoregional control of the head and neck primary tumor at the time of diagnosis of pulmonary metastases (p = 0.007), TNM stage of the head and neck primary tumor (p = 0.02), a single nodule seen on the chest radiograph (p = 0.02), and disease-free interval (DFI) from the primary tumor of the head and neck of 2 years or more (p = 0.05). Twenty-four of 58 patients underwent thoracotomy for resection of metastases. Four (17%) were found to have a second primary tumor of the lung. Of the 20 remaining patients who underwent explorative surgery for possible pulmonary resection, 18 (90%) underwent complete resection of all malignant disease with an estimated 5-year survival of 29%. In these patients, a DFI of less than 1 year was associated with a 5-year survival rate of 0%, whereas a DFI of 1 to 2 years was associated with a 5-year survival rate of 43% and a DFI of 2 years or longer had a 5-year survival rate of 33%. The number of malignant pulmonary nodules that were resected ranged from one to five and was not significant in predicting survival (p = 0.19). Of eight patients who underwent the resection of more than one malignant pulmonary nodule, 50% survived 2 years, but none survived 5 years. Resection of a solitary pulmonary metastasis from squamous cell carcinoma of the head and neck resulted in long-term survival in selected patients. Important prognostic factors included locoregional control of the head and neck primary tumor, the number of nodules seen on chest radiograph, the TNM stage of the primary tumor, and the DFI from the head and neck primary tumor. The value of resection in patients with more than one malignant pulmonary nodule remains to be defined for this group of patients.

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From 1970 through 1986, 78 patients underwent 162 thoracotomies for removal of lung metastases from soft-tissue sarcomas. A multivariate analysis showed that the presence of a local recurrence, an incomplete pulmonary resection, and a shorter disease-free interval were poor prognostic factors. Patients who underwent multiple thoracotomies survived longer from the time of initial thoracotomy. The histologic type of sarcoma and the number of metastases resected showed no statistical significance. The median survival of the 61 patients who had a complete resection was 21 months. Patients with five or fewer metastases resected had an overall 5-year survival of 22% compared with 21% for patients who had six or more metastases resected. However, patients with five or fewer metastases showed a trend toward a higher 10-year disease-free survival. A complete resection of pulmonary metastases from soft-tissue sarcoma can prolong survival even if multiple metastases are present, although patients with fewer metastases may have a longer disease-free survival.

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The ultrasonic surgical aspirator was originally developed for neurosurgical procedures and hepatic resections. Ultrasonic vibration at the tip of the instrument results in lysis of the parenchymal cells, leaving more resistant fibrous tissue such as blood vessels and bronchi intact and, thus, minimizing blood loss. We have studied the feasibility of applying the ultrasonic surgical aspirator for segmental and subsegmental lung resection for primary and metastatic neoplasms of the lung. Over the past 5 years, 27 patients underwent segmental or limited lung resection using the ultrasonic surgical aspirator. Except for prolonged air leak in 6 patients postoperatively, no other serious morbidity was noted. We observed several advantages: (1) the ultrasonic surgical aspirator dissects out the pulmonary vessels and bronchi, allowing the surgeon to perform segmental and subsegmental resections with minimal blood loss, (2) it permits lung-sparing operation for centrally located tumors that would otherwise have required lobectomy, and (3) it allows direct visualization of lung parenchyma during dissection, thus assuring grossly adequate margins.

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Carcinoma of the cecum, the third most common location for malignancy of the large bowel, was examined with attention centered upon cecal cancers producing obstruction. Reviewing 136 patients revealed 11 obstructing lesions (8.1%) presenting as distal small bowel obstructions. The mean age of the patients was 74 years. All but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy. There was no operative mortality or significant morbidity. Bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment.

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Total sialic acid (TSA), total protein (TP), TSA normalized to total TP (TSA/TP), and carcinoembryonic antigen levels were determined in 146 consecutive colorectal patients. These results were compared with results from 73 people with nonmalignant gastrointestinal disease, and with results from 96 normal controls. All malignancies were staged according to the Astler-Coller modification of Dukes' classification for colorectal cancer. All blood samples were drawn before surgical therapy. The TSA/TP ratio for colorectal cancer was 13.4 (mg/gm) in contrast to 12.1 (mg/gm) for pathologic controls, and 9.7 (mg/gm) for normal controls. Student's t test showed a P value less than 0.001 for normal controls and a P value less than 0.001 for pathologic controls. The TSA/TP also showed statistical significance in Dukes A, B2, C, and D subgroups when compared with normal controls. There were only four patients with stage C1 carcinoma, thus statistical analysis would be questionable. In contrast, carcinoembryonic antigen levels showed no significant elevations until Dukes C2 tumors were encountered. These preliminary findings suggest that TSA/TP ratio may detect colorectal cancer patients with less tumor burden and be more beneficial as a tumor marker than CEA for monitoring patients with colorectal cancer.

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We have developed a simple and reliable procedure for determining serum levels of lipid-associated sialic acid (LASA) in crude preparations. This method extracts essentially all gangliosides, excludes glycoprotein-bound sialic acid, and gives LASA values (0.5-1.0 mg/dL) in good agreement with values for isolated serum gangliosides. The procedure was used to determine serum levels of LASA in patients with colorectal cancer, in patients with nonmalignant diseases (pathological control subjects), and in normal control subjects. The results indicated that the percentages of total sialic acid (TSA) comprised by LASA (LASA/TSA X 100) were elevated in patients with the earliest stages of colorectal cancer, compared with percentages in normal control subjects (P less than .001) and pathological control subjects (P less than .01).

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A 55-year-old white man with an extensive retrorectal tumor died after transrectal needle biopsy. The indications and methods for biopsy of tumors in this location are controversial and are not well delineated in the literature. When resection seems unlikely or risky, or if a neoplasm is suspected which could be treated by nonsurgical means, biopsy is indicated. Antibiotics with aerobic and anaerobic coverage should be given prophylactically. When CT scan or sigmoidoscopic findings suggest a necrotic tumor, the transrectal approach should be avoided.

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