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Repeat Mediastinoscopy
Repeat Mediastinoscopy Ralph J. Lewis, M.D., Glenn E. Sisler, M.D., and James W. Mackenzie, M.D. ABSTRACT Although it has been maintained that a repeat mediastinoscopy results in high morbidity and mortality, it was considered an essential staging procedure in this group of 12 patients. The results of repeat mediastinoscopy were negative in 10 patients and positive in 2. On the basis of negative findings, 6 patients underwent thoracotomy. Five of them had a possible curative resection, and the remaining patient had an unresectable invasive carcinoma. An unnecessary thoracotomy was avoided in 2 patients with positive mediastinal nodes. For various reasons, thoracotomy was not indicated in the other 4 patients. In the evaluation of a patient with a new or recurrent pulmonary lesion, repeat mediastinoscopy can be performed safely. When findings are negative, it would appear to increase the likelihood of a curative resection, whereas when findings are positive, an unnecessary thoracotomy can be avoided. In our opinion, mediastinoscopy is the best procedure available for accurate staging of lung cancer. It increases the rate of resectability to well over 90% in most series and frequently obviates needless exploratory thoracotomies with their inherent morbidity and mortality (1-41. When mediastinal metastases are present, sufficient tissue can be obtained easily to permit delineation of tumor type and, at times, a reasonable prediction of biological activity. Because of the superiority of mediastinoscopy as a staging procedure, we have utilized it routinely for all suspected cases of carcinoma of the lung regardless of the size, anatomical position, or duration of the lesion. Some surgeons maintain that mediastinoscopy should never be repeated because of the hazards posed by adhesions in the mediastinum and the high morbidity and mortality resulting from their dissection [5]. This has not been our experience.
Material and Methods Twelve patients, 10 men and 2 women ranging from 49 to 74 years old, underwent a repeat mediastinoscopy. The first mediastinoscopy revealed benign nodes in 8 patients and no nodes in the other 4. Seven patients
From the Department of Surgery, University of Medicine and Dentistry of New Jersey, Rutgers Medical School, New Brunswick, NJ.
Presented at the Nineteenth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 17-19, 1983. Address reprint requests to Dr. Lewis, Department of Surgery, UMDNJRutgers Medical School, New Brunswick, NJ 08903.
147
underwent a lobectomy and 1 a pneumonectomy for carcinoma. One had a lobectomy for benign disease. A thoracotomy was not recommended to the other 3 patients because of clearing infiltrates. A repeat or second mediastinoscopy was performed from eight months to eight years following the first procedure. Malignant nodes were found in only 2 patients. Six with benign nodes underwent a second thoracotomy leading to a possible curative resection in 5 of them. In the other patient, the results of a pulmonary biopsy confirmed invasive unresectable carcinoma. Lobectomy was done in 3 patients and pneumonectomy, segmentectomy, and wedge resection in 1 each. Because advanced disease was found in the other 6 patients, repeat thoracotomy could not be recommended to any of them. Two had recurrent advanced carcinoma on bronchoscopy; 1 repeatedly postponed surgical intervention, and eventually positive scalene nodes developed three months after a negative mediastinoscopy; 1 had bilateral oat cell carcinoma on bronchoscopy; and, as mentioned, 2 had a positive mediastinoscopy.
Technique The patient is placed in the supine position under endotracheal anesthesia with slight extension of the head. The neck is antiseptically prepared and draped. The old transverse scar and underlying subcutaneous tissue are excised. At times the strap muscles can be separated easily, but usually they are firm and fibrotic, and require sharp dissection to divide adhesions. Sometimes the muscles are so adherent to the anterior tracheal wall that a plane cannot be developed. When this occurs, dissection can be safely accomplished along the lateral tracheal wall. Usually the left side is dissected first, since the aorta can be palpated easily and used as a landmark. The right side is dissected next, and the surgical team must remember that the superior vena cava and the innominate artery can be anatomically displaced and adherent to the trachea. Even though these adhesions are very rigid, the dissection can be completed down to the main bronchi. If bleeding is encountered, packing will provide adequate hemostasis in this fixed, fibrotic mediastinum. Following exploration and biopsy, the wound is closed in one layer without drainage. Case Reports PATIENT 1. A 67-year-old woman underwent bronchoscopy, mediastinoscopy, and right lower lobectomy during April, 1981, for an alveolar cell carcinoma. She did well until January, 1982, when a new lesion was noted in the area of the right middle lobe. Evaluation including a bone scan and a computed tomographic scan revealed no other lesions. The results of bronchoscopy and repeat mediastinoscopy were negative for carcinoma. At repeat thoracotomy, a middle lobectomy was performed. No mediastinal nodes were present, and the patient had an
148 The Annals of Thoracic Surgery Vol 37 No 2 February 1984
uneventful postoperative course. Alveolar cell carcinoma again was diagnosed. PATIENT 2. A 62-year-old man underwent bronchoscopy and mediastinoscopy for a left upper lobe density in 1980. The results of biopsies were negative for carcinoma at that time, and no further therapy was recommended. The patient did well until October, 1981, when a persistent cough developed and a chest roentgenogram demonstrated an infiltrate of the right lung. Bronchoscopy utilizing the flexible and rigid scopes yielded negative results, but repeat mediastinoscopy revealed nodes with metastatic carcinoma from both the right and left paratracheal areas. Operation was not recommended.
areas of the mediastinum, we continue to perform it routinely in all patients with suspected carcinoma of the lung. When mediastinoscopy has been performed previously and a new pulmonary lesion is suspected, we strongly advocate repeat mediastinoscopy. In our experience it has proven safe, reliable, and very helpful in defining potential candidates for resection.
References 1. Ashraf MH, Milsom PL, Walesby RK: Selection by medias-
2.
Comment
3.
Since carcinoma of the lung metastasizes commonly to the mediastinal lymph nodes, the appropriate mode of therapy can be instituted best after a careful evaluation of this region. The gallium scan cannot always differentiate between malignancy and inflammation, and the CT scan does not distinguish hyperplastic, anthracotic, or granulomatous nodes from malignant nodes. Neither method can perceive intranodal metastases to lymph nodes 2 cm or less in diameter. When the thorax has been assaulted by operation or irradiation, tissue planes and interfaces become modified or obliterated. In this setting, the CT scan becomes even less reliable and repeat mediastinoscopy more important in diagnosing mediastinal metastases. In some patients who have undergone a previous mediastinoscopy and later have a left lung lesion, parasternal exploration might be recommended. Although we use this procedure when indicated, it does require more dissection than either primary or repeat cervical mediastinoscopy. On occasion, rib resection and chest tube drainage are needed. In fact, this procedure might more accurately be called a minithoracotomy and certainly has its own inherent morbidity and mortality. It has been maintained that mediastinoscopy should never be repeated because of the hazards encountered when dissecting rigid adhesions between the innominate artery and the trachea [5, 61. These firm adhesions purportedly block access to the mediastinum and prevent appropriate exploration. Yet in each of our 12 patients, the mediastinum was adequately and safely explored. Dissection was not exceedingly difficult in any patient in this group, but circumspection was necessary since all landmarks frequently had been obliterated. The findings from repeat mediastinoscopy contributed to a successful resection in 5 patients and the avoidance of an unnecessary thoracotomy in 2 others. In any patient being considered for a second thoracotomy because of a potential malignancy, a negative mediastinoscopy provides further reassurance to the patient, family, and surgeon that a curative resection is possible. Because mediastinoscopy still seems to be the best and most specific staging procedure in that it allows bilateral palpation, visualization, and direct biopsy of suspect
4.
5. 6.
tinoscopy and long-term survival in bronchial carcinoma. Ann Thorac Surg 30:208, 1980 Jolly PC, Li W, Anderson RP: Anterior and cervical mediastinoscopy for determining operability and predicting resectability in lung cancer. J Thorac Cardiovasc Surg 79:366, 1980 Kirschner PA: Transcervical approach to the superior mediastinum. Hosp I’ract 5(6):61, 1970 Paulson DL, Urschel HC Jr: Selectivity in the surgical treatment of bronchogenic carcinoma. J Thorac Cardiovasc Surg 62:554, 1971 Perciado MC, Duvall AJ 111, Koop H: Mediastinoscopy: a review of 450 cases. Laryngoscope 83:1300, 1973 Palva T, Palva A, Kaja J: Re-mediastinoscopy. Arch Otolaryngol 101:748, 1975
Discussion DR. PAUL A. KIRSCHNER (New York, NY): 1 am in complete agreement with Dr. Lewis that mediastinoscopy should be performed routinely, with rare exceptions, as a staging procedure for lung cancer before thoracotomy is done. However, in patients with metachronous carcinoma, we have not repeated mediastinoscopy if it was done the first time the patient was seen. Nevertheless, our rate of resectability is about 95%. This is probably due to the biology of these recurrent lesions and to careful patient selection. There are three questions that must be considered in regard to repeating the procedure. (1) Can repeat mediastinoscopy be done as effectively and as safely as the primary procedure? The answer is yes, and success has been demonstrated by Dr. Lewis’s group (12 patients), Palva of Finland (6), Jepsen of Denmark (3), Reynders of Holland (l),and myself (2). There are undoubtedly more examples of which 1 am not aware. In all of these instances, both the primary and the secondary mediastinoscopies were done by the same experienced surgeon. One technical point deserves mention: the fibrosis encountered appears to be increased if substances like Surgicel gauze or perhaps metal clips are left in place at the first mediastinoscopy. (2) What other methods are available for evaluating the mediastinum especially after prior mediastinoscopy? There are two indirect methods: CT and gallium scanning, and a direct surgical alternative to the Carlens procedures, namely, the parasternal anterior approach of Chamberlain, which will provide the essential confirmation. (3) Was the original mediastinoscopy accurately and adequately performed? Two case reports illustrate this point. A 62year-old man with right hilar adenopathy underwent a reportedly negative mediastinoscopy at another institution about a month before 1 saw him. At this time, a gallium scan was positive and a CT scan showed a large node in the right lower anterolateral paratracheal region, an area eminently accessible to the Carlens cervical mediastinoscopy but obviously not reached in this instance. The node, containing metastatic adenocarcinoma, was removed easily through a right Chamber-
149 Lewis, Sisler, and Mackenzie: Repeat Mediastinoscopy
lain procedure. Through the same incision, the pleura was opened, thereby allowing the identification and excision of the small 1 cm primary cancer in the right upper lobe. A 61-year-old man was seen at another institution with a large anterosuperior mediastinal mass. The surgeon conveniently marked the site of the biopsy, the results of which were negative, with a metal clip. In the lateral view, the clip lay on the anterior surface of the lower end of the trachea but there was a large anterior substernal mediastinal mass. It is apparent, based on knowledge of the anatomy of the superior mediastinum, that the tumor was not in the retrovascular pretracheal plane in which the "negative" standard mediastinoscopy was done. Rather it was located in the prevascular retrosternal compartment, anterior to the great vessels. A diagnosis of thymoma was made by parasternal needle biopsy, and the tumor subsequently was removed through a median sternotomy. In conclusion, it appears that while accurate, safe repeat mediastinoscopy can be done well by experts, there are simpler and more effective alternatives that will solve the problem. I enjoyed Dr. Lewis's paper, and I compliment him on his skill. DR. LEWIS: 1 thank Dr. Kirschner for his very interesting comments. He certainly is recognized as an early advocate of mediastinoscopy .
Because carcinoma of the lung metastasizes commonly to the mediastinal lymph nodes, we believe mediastinoscopy is the single most effective staging procedure. The procedure takes approximately fifteen to twenty minutes to do and is combined with bronchoscopy. The contralateral mediastinum is available for careful examination, and biopsy specimens are easily obtained from nodes too small to be perceived on roentgenogram or scan. The gallium scan cannot always differentiate between malignancy and inflammation, and the CT scan does not distinguish hyperplastic, anthracotic, or granulomatous nodes from malignant nodes. Once the thorax has been operated on or irradiated, tissue planes and interfaces are modified or obliterated. Under these conditions, the CT scan becomes even less reliable and repeat mediastinoscopy more important in diagnosing mediastinal metastases. Although the occasion to perform a repeat mediastinoscopy occurs infrequently, the procedure can return extremely valuable and necessary information. We have been seeing with greater frequency second new lesions of the lung occurring four to five years following the initial resection. The all-important decision concerning surgical resection in these patients can be best made after studying tissue under the microscope. On the basis of our experience, we strongly advocate repeat mediastinoscopy before repeat thoracotomy.
Notice from the Southern Thoracic Surgical Association The Thirty-first Annual Meeting of the Southern Thoracic Surgical Association will be held at the Marriott's Hilton Head Resort, Hilton Head Island, SC, Nov 1-3, 1984. There will be a $100 registration fee for nonmember physicians except for guest speakers, authors and coauthors on the program, and residents. There will be a $25 registration fee for attendees of the Postgraduate Course on Thursday, Nov 1. Members wishing to participate in the scientific program should submit abstracts in triplicate, by May 15, 1984, to Frederick L. Grover, M.D., University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284. Abstracts should be double-spaced on one
side of one sheet of paper, with a 1-inch left margin, and limited to 200 words. All slides used during the presentation must be 35 mm. Manuscripts of accepted papers must be submitted to The Annals of Thoracic Surgery prior to the 1984 meeting or to the Secretary-Treasurer at the opening of the Scientific Session. Applications for membership should be completed by September 1, 1984, and forwarded to Laman Gray, Jr., M.D., Department of Surgery, University of Louisville, 550 S Jackson St, Louisville, KY 40207.
Harvey W. Bender, j r . , M . D . Secreta y-Treasu rer
Material and Methods Twelve patients, 10 men and 2 women ranging from 49 to 74 years old, underwent a repeat mediastinoscopy. The first mediastinoscopy revealed benign nodes in 8 patients and no nodes in the other 4. Seven patients
From the Department of Surgery, University of Medicine and Dentistry of New Jersey, Rutgers Medical School, New Brunswick, NJ.
Presented at the Nineteenth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 17-19, 1983. Address reprint requests to Dr. Lewis, Department of Surgery, UMDNJRutgers Medical School, New Brunswick, NJ 08903.
147
underwent a lobectomy and 1 a pneumonectomy for carcinoma. One had a lobectomy for benign disease. A thoracotomy was not recommended to the other 3 patients because of clearing infiltrates. A repeat or second mediastinoscopy was performed from eight months to eight years following the first procedure. Malignant nodes were found in only 2 patients. Six with benign nodes underwent a second thoracotomy leading to a possible curative resection in 5 of them. In the other patient, the results of a pulmonary biopsy confirmed invasive unresectable carcinoma. Lobectomy was done in 3 patients and pneumonectomy, segmentectomy, and wedge resection in 1 each. Because advanced disease was found in the other 6 patients, repeat thoracotomy could not be recommended to any of them. Two had recurrent advanced carcinoma on bronchoscopy; 1 repeatedly postponed surgical intervention, and eventually positive scalene nodes developed three months after a negative mediastinoscopy; 1 had bilateral oat cell carcinoma on bronchoscopy; and, as mentioned, 2 had a positive mediastinoscopy.
Technique The patient is placed in the supine position under endotracheal anesthesia with slight extension of the head. The neck is antiseptically prepared and draped. The old transverse scar and underlying subcutaneous tissue are excised. At times the strap muscles can be separated easily, but usually they are firm and fibrotic, and require sharp dissection to divide adhesions. Sometimes the muscles are so adherent to the anterior tracheal wall that a plane cannot be developed. When this occurs, dissection can be safely accomplished along the lateral tracheal wall. Usually the left side is dissected first, since the aorta can be palpated easily and used as a landmark. The right side is dissected next, and the surgical team must remember that the superior vena cava and the innominate artery can be anatomically displaced and adherent to the trachea. Even though these adhesions are very rigid, the dissection can be completed down to the main bronchi. If bleeding is encountered, packing will provide adequate hemostasis in this fixed, fibrotic mediastinum. Following exploration and biopsy, the wound is closed in one layer without drainage. Case Reports PATIENT 1. A 67-year-old woman underwent bronchoscopy, mediastinoscopy, and right lower lobectomy during April, 1981, for an alveolar cell carcinoma. She did well until January, 1982, when a new lesion was noted in the area of the right middle lobe. Evaluation including a bone scan and a computed tomographic scan revealed no other lesions. The results of bronchoscopy and repeat mediastinoscopy were negative for carcinoma. At repeat thoracotomy, a middle lobectomy was performed. No mediastinal nodes were present, and the patient had an
148 The Annals of Thoracic Surgery Vol 37 No 2 February 1984
uneventful postoperative course. Alveolar cell carcinoma again was diagnosed. PATIENT 2. A 62-year-old man underwent bronchoscopy and mediastinoscopy for a left upper lobe density in 1980. The results of biopsies were negative for carcinoma at that time, and no further therapy was recommended. The patient did well until October, 1981, when a persistent cough developed and a chest roentgenogram demonstrated an infiltrate of the right lung. Bronchoscopy utilizing the flexible and rigid scopes yielded negative results, but repeat mediastinoscopy revealed nodes with metastatic carcinoma from both the right and left paratracheal areas. Operation was not recommended.
areas of the mediastinum, we continue to perform it routinely in all patients with suspected carcinoma of the lung. When mediastinoscopy has been performed previously and a new pulmonary lesion is suspected, we strongly advocate repeat mediastinoscopy. In our experience it has proven safe, reliable, and very helpful in defining potential candidates for resection.
References 1. Ashraf MH, Milsom PL, Walesby RK: Selection by medias-
2.
Comment
3.
Since carcinoma of the lung metastasizes commonly to the mediastinal lymph nodes, the appropriate mode of therapy can be instituted best after a careful evaluation of this region. The gallium scan cannot always differentiate between malignancy and inflammation, and the CT scan does not distinguish hyperplastic, anthracotic, or granulomatous nodes from malignant nodes. Neither method can perceive intranodal metastases to lymph nodes 2 cm or less in diameter. When the thorax has been assaulted by operation or irradiation, tissue planes and interfaces become modified or obliterated. In this setting, the CT scan becomes even less reliable and repeat mediastinoscopy more important in diagnosing mediastinal metastases. In some patients who have undergone a previous mediastinoscopy and later have a left lung lesion, parasternal exploration might be recommended. Although we use this procedure when indicated, it does require more dissection than either primary or repeat cervical mediastinoscopy. On occasion, rib resection and chest tube drainage are needed. In fact, this procedure might more accurately be called a minithoracotomy and certainly has its own inherent morbidity and mortality. It has been maintained that mediastinoscopy should never be repeated because of the hazards encountered when dissecting rigid adhesions between the innominate artery and the trachea [5, 61. These firm adhesions purportedly block access to the mediastinum and prevent appropriate exploration. Yet in each of our 12 patients, the mediastinum was adequately and safely explored. Dissection was not exceedingly difficult in any patient in this group, but circumspection was necessary since all landmarks frequently had been obliterated. The findings from repeat mediastinoscopy contributed to a successful resection in 5 patients and the avoidance of an unnecessary thoracotomy in 2 others. In any patient being considered for a second thoracotomy because of a potential malignancy, a negative mediastinoscopy provides further reassurance to the patient, family, and surgeon that a curative resection is possible. Because mediastinoscopy still seems to be the best and most specific staging procedure in that it allows bilateral palpation, visualization, and direct biopsy of suspect
4.
5. 6.
tinoscopy and long-term survival in bronchial carcinoma. Ann Thorac Surg 30:208, 1980 Jolly PC, Li W, Anderson RP: Anterior and cervical mediastinoscopy for determining operability and predicting resectability in lung cancer. J Thorac Cardiovasc Surg 79:366, 1980 Kirschner PA: Transcervical approach to the superior mediastinum. Hosp I’ract 5(6):61, 1970 Paulson DL, Urschel HC Jr: Selectivity in the surgical treatment of bronchogenic carcinoma. J Thorac Cardiovasc Surg 62:554, 1971 Perciado MC, Duvall AJ 111, Koop H: Mediastinoscopy: a review of 450 cases. Laryngoscope 83:1300, 1973 Palva T, Palva A, Kaja J: Re-mediastinoscopy. Arch Otolaryngol 101:748, 1975
Discussion DR. PAUL A. KIRSCHNER (New York, NY): 1 am in complete agreement with Dr. Lewis that mediastinoscopy should be performed routinely, with rare exceptions, as a staging procedure for lung cancer before thoracotomy is done. However, in patients with metachronous carcinoma, we have not repeated mediastinoscopy if it was done the first time the patient was seen. Nevertheless, our rate of resectability is about 95%. This is probably due to the biology of these recurrent lesions and to careful patient selection. There are three questions that must be considered in regard to repeating the procedure. (1) Can repeat mediastinoscopy be done as effectively and as safely as the primary procedure? The answer is yes, and success has been demonstrated by Dr. Lewis’s group (12 patients), Palva of Finland (6), Jepsen of Denmark (3), Reynders of Holland (l),and myself (2). There are undoubtedly more examples of which 1 am not aware. In all of these instances, both the primary and the secondary mediastinoscopies were done by the same experienced surgeon. One technical point deserves mention: the fibrosis encountered appears to be increased if substances like Surgicel gauze or perhaps metal clips are left in place at the first mediastinoscopy. (2) What other methods are available for evaluating the mediastinum especially after prior mediastinoscopy? There are two indirect methods: CT and gallium scanning, and a direct surgical alternative to the Carlens procedures, namely, the parasternal anterior approach of Chamberlain, which will provide the essential confirmation. (3) Was the original mediastinoscopy accurately and adequately performed? Two case reports illustrate this point. A 62year-old man with right hilar adenopathy underwent a reportedly negative mediastinoscopy at another institution about a month before 1 saw him. At this time, a gallium scan was positive and a CT scan showed a large node in the right lower anterolateral paratracheal region, an area eminently accessible to the Carlens cervical mediastinoscopy but obviously not reached in this instance. The node, containing metastatic adenocarcinoma, was removed easily through a right Chamber-
149 Lewis, Sisler, and Mackenzie: Repeat Mediastinoscopy
lain procedure. Through the same incision, the pleura was opened, thereby allowing the identification and excision of the small 1 cm primary cancer in the right upper lobe. A 61-year-old man was seen at another institution with a large anterosuperior mediastinal mass. The surgeon conveniently marked the site of the biopsy, the results of which were negative, with a metal clip. In the lateral view, the clip lay on the anterior surface of the lower end of the trachea but there was a large anterior substernal mediastinal mass. It is apparent, based on knowledge of the anatomy of the superior mediastinum, that the tumor was not in the retrovascular pretracheal plane in which the "negative" standard mediastinoscopy was done. Rather it was located in the prevascular retrosternal compartment, anterior to the great vessels. A diagnosis of thymoma was made by parasternal needle biopsy, and the tumor subsequently was removed through a median sternotomy. In conclusion, it appears that while accurate, safe repeat mediastinoscopy can be done well by experts, there are simpler and more effective alternatives that will solve the problem. I enjoyed Dr. Lewis's paper, and I compliment him on his skill. DR. LEWIS: 1 thank Dr. Kirschner for his very interesting comments. He certainly is recognized as an early advocate of mediastinoscopy .
Because carcinoma of the lung metastasizes commonly to the mediastinal lymph nodes, we believe mediastinoscopy is the single most effective staging procedure. The procedure takes approximately fifteen to twenty minutes to do and is combined with bronchoscopy. The contralateral mediastinum is available for careful examination, and biopsy specimens are easily obtained from nodes too small to be perceived on roentgenogram or scan. The gallium scan cannot always differentiate between malignancy and inflammation, and the CT scan does not distinguish hyperplastic, anthracotic, or granulomatous nodes from malignant nodes. Once the thorax has been operated on or irradiated, tissue planes and interfaces are modified or obliterated. Under these conditions, the CT scan becomes even less reliable and repeat mediastinoscopy more important in diagnosing mediastinal metastases. Although the occasion to perform a repeat mediastinoscopy occurs infrequently, the procedure can return extremely valuable and necessary information. We have been seeing with greater frequency second new lesions of the lung occurring four to five years following the initial resection. The all-important decision concerning surgical resection in these patients can be best made after studying tissue under the microscope. On the basis of our experience, we strongly advocate repeat mediastinoscopy before repeat thoracotomy.
Notice from the Southern Thoracic Surgical Association The Thirty-first Annual Meeting of the Southern Thoracic Surgical Association will be held at the Marriott's Hilton Head Resort, Hilton Head Island, SC, Nov 1-3, 1984. There will be a $100 registration fee for nonmember physicians except for guest speakers, authors and coauthors on the program, and residents. There will be a $25 registration fee for attendees of the Postgraduate Course on Thursday, Nov 1. Members wishing to participate in the scientific program should submit abstracts in triplicate, by May 15, 1984, to Frederick L. Grover, M.D., University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284. Abstracts should be double-spaced on one
side of one sheet of paper, with a 1-inch left margin, and limited to 200 words. All slides used during the presentation must be 35 mm. Manuscripts of accepted papers must be submitted to The Annals of Thoracic Surgery prior to the 1984 meeting or to the Secretary-Treasurer at the opening of the Scientific Session. Applications for membership should be completed by September 1, 1984, and forwarded to Laman Gray, Jr., M.D., Department of Surgery, University of Louisville, 550 S Jackson St, Louisville, KY 40207.
Harvey W. Bender, j r . , M . D . Secreta y-Treasu rer