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Surgical palliation for lung cancer
Surgical Palliation for Lung Cancer Tno~Ias C, KING, M.D., Chicago, Illinois, A. G. RA~IOS, M.D., and J. M, ZIMMERMAN, M.D.,
Kansa.s City, Missouri From the Departments of Surgery, the Kansas University School of Medicine, Kansas City, Kansas, and the Veterans Administration Hospital, Kansas City, Missouri.
PATIENTS with nmlignant disease follow F EWa nmre predictable or distressing course than those with lung cancer advanced beyond resectability. In many other malignant diseases efforts are made to remove the primary tumor whenever possible even though evidence nlay exist of remaining ttunor, in the hope that the patient's life, either in length or quality, will be beneficially affected. Most clinicians believe, however, that in the presence of incurability as manifested by positive scalene nodes, m a l i g n a n t effusions, positive carinal nodes, or other evidences of gross extension beyond the resectable specimen, removal of a hmg lesion should not be undertaken because of the hopeless outlook for the patient. Whenever the problem of palliation is considered, a complexity of attitudes and philosophie issues present themselves. Since this is largely a matter of value judgment, there can be no " r i g h t " answer and generally the question "What is palliation?" is one which nmst be answered by individual physicians. Particularly pertinent to the patient with hmg cancer, however, are several aspects to this question which form the rationale for the material to be presented in this paper. In considering the issues of palliation, several important factors should be taken into account. First among these is the problem of qtmntity of life. It is hard? to turn our backs on any procedure which may, w i t h reasonable probabilify, extend the length of life; however, in our concern to extend life we often find ourselves merely I)rolonging the act of dying and consequently can never consider quantity of life alone. In the patient with incurable disease the quality of remaining life is of vital ira432
portance and selection of therapy nmst keep this in clear focus. The conventional approach towards qualitative palliation has been to treat complications and symptoms of disease rather than anticipating ttmm, and it is an approach to terminal illness which we have generally supported. Little information is available in the literature about the way in which patients with lung cancer die despite" several reviews [1-4] relating the natural history of the disease and the longevity course of the patient with a nonresectable or unresected lesion. In ahnost all reviews it is evident that the vast majority of these patients will be dead within a year. It has been our experience that these patients generally die a distressing and miserable death with pulmonary sepsis, increasing respiratory insufficiency, and usually a prolonged and costly terminal illness, costly in terms of not only fmnily financial resources but also, even more importantly, emotional resources. It is the primary purpose of this study to provide some descriptive information regarding the course of the patient with lung cancer with tumor beyond the limits of resectability in whom, once the risks of a thoraeotomy with its accompanying morbidity have already been undertaken, all reasonable efforts were made to resect the primary tumor even at tile expense of leaving cancer in the bronchial stump, pericardium, or chest wall. This study is not a comparative study and we do not intend to compare the course of these highly selected patients with that of other hmg cancer pa, tients not treated or treated by any other means including x-ray therapy or chemotherapy. It is our purpose only to describe our experience in extending the indications for resection in the hope that the'place for primary surgical extirpation of lung lesions without hope of cure can be more adequately assessed. American Journal of Surgery
Surgical Palliation for Lung Cancer TABLI~ 1 SURVIVAL PATTERNS
Time after Surgery (,no.) Sample 1
3 6 12 18 24 36 48 60
Reseeted for "Cure"
Proved Tumor Remaining
Possible Survivors
Survivors
Per cent Surviving
Possible Survivors
50 50 50 50 43 36 30 24. 16 ll
50 40 34 31 19 12 6 4 2 2
100 80 68 62 44 33 20 16 12 18
13 13 13 13 13 12 12 9 6 3
F r o m t h e s p r i n g of 1959 t o t h e s p r i n g of 1964, s i x t y - t h r e e p a t i e n t s u n d e r w e n t r e s e c t i v e p r o c e d u r e s f o r p r i n m r y l u n g t u m o r s in t h e Kansas City Veterans Administration Hospital. T h e g e n e r a l m a k e - u p of t h i s p o p u l a t i o n of t u m o r p a t i e n t s is n o t u n l i k e t h a t of o t h e r rep o r t e d series in t e r m s of age, s m o k i n g h i s t o r y , histologie t u m o r t y p e , o r d e l a y f r o m first s y m p t o m s Lo s u r g e r y ; d a t a r e f e r a b l e to t h o s e f a c t o r s will n o t be p r e s e n t e d . All p a t i e n t s in w h o m it was t e c h n i c a l l y possible u n d e r w e n t r e s e c t i o n , w h e t h e r or n o t all r e c o g n i z a b l e t u m o r was rem o v e d w i t h t h e s p e c i m e n . I n v a s i o n of t h e puhnonary artery, positive superior medias t i n a l (scalene) l y m p h nodes, m a l i g n a n t effusion, a n d e a r i n a t n o d e i n v o l v e m e n t w e r e n o t c o n s i d e r e d c o n t r a i n d i c a t i o n s to r e s e c t i o n if the p r i m a r y t u m o r could be removed, w i t h o u t requiring reconstructive procedures to the remaining vital structures (superior vena cava, esophagus, and t r a c h e a ) . Patients with demons t r a b l e d i s t a n t m e t a s t a s e s (we h a v e c o n s i d e r e d t h e s c a l e n e n o d e as p a r t of t h e r e g i o n a l l y m phatic system) were not operated nor resected unless " t r a p p e d l u n g " a n d u n c o n t r o l l a b l e l ) u h n o n a r y sepsis b e h i n d a r e m o v a b l e t u m o r m a s s was e x p e c t e d . CASE REPORTS
CASe I. T h e patient (M. B.), a sixty-six year old man, h a d severe myositis and massive weight loss which left him u n a b l e to feed himself or sit without support. At operation an adenoearcinonm invading chest wall was reseeted with tunmr left in the chest wall. T h e patient was discharged two weeks postoperatively with remarkable improvement; relief of myositis was noted on the operative day. The Vol. 109, APril 1965
Survivors 13 12 12 7
4 3 3 1 1 1
Per cent Surviving 100 92 92 54 31 25 25 11 17 33
patient died suddenly five months and seventeen days after surgery while on a fishing trip of what was prestoned to be cerebral metastasis or a vascular accident CASE II. The patient (W. L.), sixty-nine years of age, had lobectomy aceomplished for a large hilar mass with " t r a p p e d lung" after positive scalene node biopsy. Pathologic report described an anaplastic bronchogenic carcinoma with extensive nodal metastases. Patient's postoperative recovery allowed a transurethral resection fourteen days after tile thoracotomy. T h e patient returned to full activity with stable weight and no symptoms for two full years when increasing dysphagia developed clue to tumor constriction of the esophagus. This was treated by an endoscopically inserted tube (Souttar tube [7]) with relief of dysphagia and restabilization of weight. The esophageal obstruction recurred within the next few months and the patient died of aspiration pneumonia after a t w e n t y day terminal hospitalization, twenty-nine months, fourteen days after a "palliative" procedure. CaSE IIL T h e patient (T. W. K . ) , thirty-six years of age, required extensive resection of the chest wall to remove an adenocarcinoma of the right upper lobe after four months of aggressive weight loss and malaise. He returned to work three months after his operative procedure, having gained 16 pounds, and died six months after th e procedure with the sudden onset of coma after having missed only four days of work during his last three months of life.
Comment: E v e n t h o u g h t h e t o t a l l e n g t h 0f survival was p r o b a b l y not m a t e r i a l l y changed in t h i s y o u n g m a n , t h e r e m a r k a b l e s u b j e c t i v e i m p r o v e m e n t in t h i s p a t i e n t a n d h i s a b i l i t y t o r e t u r n in f u n c t i o n a l l y g o o d h e a l t h t o h i s y o u n g 433
King, Ramos,
and Zimmerman
%
".['ABLE I I l NONCURATIVE
! e.o >
~= u
801~,\ 1\ I
J ~ut"-~ m
r ........................
~,
~
-
Data
Number
-
Average age a t operation Operative d e a t h s Left hospital within 16 days Employable at 8 months T e r m i n a l hospitalization < 3 0 days T e r n f i n a l narcotics < 7 days"
59.6 years 1 of t3 patients 7 of 12 patients 6 of 7 patients 10 of I2 patients 9 of 12 patients
o "cuR,~r,ve~
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.
i_
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"PALLIATIVE"
_
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24
36
48
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MONTHS
F I G . 1. C o m p a r a t i v e
survival
RESECTIONS
t i o n d o n o t allow a n y s t a t i s t i c a l l y v a l i d inf e r e n c e s t o b e m a d e f r o m t h e s e differences.
of patients at risk. Pallia-
t i r e cases had biopsy proof of residu'fl tumor. QUALITY OF LIFE
fanfily, e v e n f o r a s h o r t t i m e , w a s m o s t g r a t i f y ing. RESULTS
Table I and Figure 1 present the survival p a t t e r n s of t h e s i x t y - t h r e e p a t i e n t s , f i f t y of w h o m w e r e r e s e c t e d w i t h h o p e of c u r e a n d t h i r t e e n of w h o m h a d b i o p s y - p r o v e d t u m o r r e m a i n i n g w i t h i n t h e chest. E l e v e n p a t i e n t s d i e d w i t h i n t h e first t h i r t y d a y s a f t e r t h e o p e r a t i o n ( o p e r a t i v e m o r t a l i t y r a t e : 17 p e r c e n t ) ; o n l y o n e of t h e s e d e a t h s was in t h e p a l l i a t i v e g r o u p . I t will be n o t e d t h a t while o n l y 30 p e r c e n t of p a t i e n t s w i t h n o n c u r a t i v e resections s u r v i v e d b e y o n d t h e first y e a r , o n e patient survived sixty-three months after the t u m o r h a d b e e n left in t h e m e d i a s t i n u m a n d t h e n d i e d of a c e r e b r o v a s c u l a r a c c i d e n t . T a b l e ii p r e s e n t s i n f o r m a t i o n r e l a t i v e t o t h e q u a n t i t y of life w h i c h f o l l o w e d t h e r e s e c t i v e procedure. T h e small samples and high variaTABLE RESULTS
II
OF RESECTIVE
Data
N u m b e r of p a t i e n t s S u r v i v i n g (April 1964)
Average period of survival Dead Average survival of deaths Survived 30 days 30 day (operative) mortality rate Average survival of patients excluding operative deaths
PROCEDURE
Proved Tumor Remaining
13 patients 0
13 patients 14.3 mo. 12 p a t i e n t s 7.7%
15.5 too.
Reseeted for "(2ure" 50 p a t i e n t s 15 p a t i e n t s
23.6 too. 35 patients 7.6 too. 40 patients
S i n c e o u r m a i n aim in u n d e r t a k i n g t h i s s t u d y w a s t o a l l e v i a t e t h e s u f f e r i n g a s s o c i a t e d with t h e u n r e s e e t e d lesion r a t h e r t h a n to e x t e n d t h e p e r i o d o f life, we w e r e m o r e i n t e r e s t e d in t h e q u a l i t a t i v e a s p e c t s of t h e r e m a i n i n g life a f t e r t h e n o n c u r a t i v e r e s e c t i o n s . In p r e s e n t i n g his m a t e r i a l o n s u r g e r y in t h e t r e a t m e n t of l o c a l l y a d v a n c e d lung c a r c i n o m a , A b b e y S m i t h h a s s u g g e s t e d [5,6] as c r i t e r i a f o r a successful o u t c o m e , a s u r v i v a l of at least e i g h t m o n t h s a n d t h e p a t i e n t ' s a c h i e v i n g sufficient well b e i n g t o allow him t o r e t u r n to w o r k o r t o his r e g u l a r a c t i v i t i e s . E x a c t l y h a l f of o u r t w e l v e p a t i e n t s w h o s u r v i v e d t h e o p e r a t i o n a r e successes b y these criteria. Other objective measures which p r o v i d e s o m e i n f o r m a t i o n as t o t h e v a l u e of t h e p r o c e d u r e a r e leng-th of t i m e s p e n t in t h e hospital after the operation before the patient c o u l d r e t u r n to his f a m i l y in a s a t i s f a c t o r y s t a t e of h e a l t h , l e n g t h of t e r m i n a l h o s p i t a l i z a tion r e q u i r e d , a n d t h e l e n g t h of t i m e p r i o r to d e a t h during which the patient required narc o t i c m e d i c a t i o n s . T h e s u m m a r y of this d a t a as it r e l a t e s t o o u r p a t i e n t s is p r e s e n t e d in T a b l e m . We were quite surprised b y the short tenninal hospitalizations and shortt e r m n a r c o t i c n e e d s of t h e p a t i e n t s in r e l a t i o n t o t h e t e r m i n a l illnesses we w e r e a c c u s t o m e d to s e e i n g in p a t i e n t s w i t h n o n r e s e c t e d l u n g cancer. SUMMARY
T h e r e s u l t s of r e s e c t i n g i n c u r a b l e l u n g c a n c e r in an e f f o r t t o i m p r o v e t h e t e r m h m l c o u r s e of a small n u m b e r of p a t i e n t s a r e b r i e f l y p r e s e n t e d . T h i s is n o t a c o m p a r a t i v e s t u d y a n d n o inf e r e n c e s or c o n c l u s i o n s a r e j u s t i f i e d r e g a r d i n g t h e c h o i c e of t h i s f o r m of t h e r a p y as p a l l i a t i o n
20.0% 10.6 too. 434
American Journal of Surgery
Surgical Palliation for I.ung Cancer in preference to o t h e r forms of palliative thera p y ; h o w e v e r we do believe t h a t the terminal course of the t)atient with h m g cancer is beneficially effected by removal of the p r i m a r y t u m o r w h e n e v e r this is technically feasible.
5.
REFERENCES
1. CIIA.MIIERLAIN, J. M., NIcNglI.L, T. M., PARNASSA, P., and I~DSALI., J. |~.. Bronchogenie carcinoma: an aggressive surgical attitude. J. Thoracic Surg., 38: 727, 1959. 2. I~bIERSON, (~. L., EMERSON, i'~. S., all(| SIlI~RWOOD, C. E. The natural history of carcinoma of the hlug. J. Thoracic Surg., 37: 291, 1959. 3. HUGItES, F. A., JR., PATZ, J. W., and CAMPBELL, l~.
Vol. 109, A pril 1965
4.
435
6. 7.
E. Bronchogenie carcinoma: eoml)arison of natttral course •11(| treattucllt with resection, xradiation, and nitrogen mustard. J. Thoracig Surg., 39: 409, 1960. OCnSNER, A., DEBAKVA', M., DUNLAP, C. E., and RICIIMAN, I. Primary puhnonary malignancy. J. Thoracic Surg., 17: 573, 1948. SMITH, R. A. Tile resuhs of raising tile reseetability rate in operations for lung carcinoma. Thorax, 12: 79, 1957. S.~UTH, P,. A. Surgery in tile treatment of locally adwmced lung carcinoma. Thorax, 18: 21, 1963. ZIM,~IF-RMAN,J. M., KING, T. C., and CANTRELI.,J. R. The
use of
all
endoseopically inserted intra-
luminal tube in the nianagement of ineurahle esophageal c-treiuoma. J. Kansas 31. Soc., 65: 275, 1964.
Kansa.s City, Missouri From the Departments of Surgery, the Kansas University School of Medicine, Kansas City, Kansas, and the Veterans Administration Hospital, Kansas City, Missouri.
PATIENTS with nmlignant disease follow F EWa nmre predictable or distressing course than those with lung cancer advanced beyond resectability. In many other malignant diseases efforts are made to remove the primary tumor whenever possible even though evidence nlay exist of remaining ttunor, in the hope that the patient's life, either in length or quality, will be beneficially affected. Most clinicians believe, however, that in the presence of incurability as manifested by positive scalene nodes, m a l i g n a n t effusions, positive carinal nodes, or other evidences of gross extension beyond the resectable specimen, removal of a hmg lesion should not be undertaken because of the hopeless outlook for the patient. Whenever the problem of palliation is considered, a complexity of attitudes and philosophie issues present themselves. Since this is largely a matter of value judgment, there can be no " r i g h t " answer and generally the question "What is palliation?" is one which nmst be answered by individual physicians. Particularly pertinent to the patient with hmg cancer, however, are several aspects to this question which form the rationale for the material to be presented in this paper. In considering the issues of palliation, several important factors should be taken into account. First among these is the problem of qtmntity of life. It is hard? to turn our backs on any procedure which may, w i t h reasonable probabilify, extend the length of life; however, in our concern to extend life we often find ourselves merely I)rolonging the act of dying and consequently can never consider quantity of life alone. In the patient with incurable disease the quality of remaining life is of vital ira432
portance and selection of therapy nmst keep this in clear focus. The conventional approach towards qualitative palliation has been to treat complications and symptoms of disease rather than anticipating ttmm, and it is an approach to terminal illness which we have generally supported. Little information is available in the literature about the way in which patients with lung cancer die despite" several reviews [1-4] relating the natural history of the disease and the longevity course of the patient with a nonresectable or unresected lesion. In ahnost all reviews it is evident that the vast majority of these patients will be dead within a year. It has been our experience that these patients generally die a distressing and miserable death with pulmonary sepsis, increasing respiratory insufficiency, and usually a prolonged and costly terminal illness, costly in terms of not only fmnily financial resources but also, even more importantly, emotional resources. It is the primary purpose of this study to provide some descriptive information regarding the course of the patient with lung cancer with tumor beyond the limits of resectability in whom, once the risks of a thoraeotomy with its accompanying morbidity have already been undertaken, all reasonable efforts were made to resect the primary tumor even at tile expense of leaving cancer in the bronchial stump, pericardium, or chest wall. This study is not a comparative study and we do not intend to compare the course of these highly selected patients with that of other hmg cancer pa, tients not treated or treated by any other means including x-ray therapy or chemotherapy. It is our purpose only to describe our experience in extending the indications for resection in the hope that the'place for primary surgical extirpation of lung lesions without hope of cure can be more adequately assessed. American Journal of Surgery
Surgical Palliation for Lung Cancer TABLI~ 1 SURVIVAL PATTERNS
Time after Surgery (,no.) Sample 1
3 6 12 18 24 36 48 60
Reseeted for "Cure"
Proved Tumor Remaining
Possible Survivors
Survivors
Per cent Surviving
Possible Survivors
50 50 50 50 43 36 30 24. 16 ll
50 40 34 31 19 12 6 4 2 2
100 80 68 62 44 33 20 16 12 18
13 13 13 13 13 12 12 9 6 3
F r o m t h e s p r i n g of 1959 t o t h e s p r i n g of 1964, s i x t y - t h r e e p a t i e n t s u n d e r w e n t r e s e c t i v e p r o c e d u r e s f o r p r i n m r y l u n g t u m o r s in t h e Kansas City Veterans Administration Hospital. T h e g e n e r a l m a k e - u p of t h i s p o p u l a t i o n of t u m o r p a t i e n t s is n o t u n l i k e t h a t of o t h e r rep o r t e d series in t e r m s of age, s m o k i n g h i s t o r y , histologie t u m o r t y p e , o r d e l a y f r o m first s y m p t o m s Lo s u r g e r y ; d a t a r e f e r a b l e to t h o s e f a c t o r s will n o t be p r e s e n t e d . All p a t i e n t s in w h o m it was t e c h n i c a l l y possible u n d e r w e n t r e s e c t i o n , w h e t h e r or n o t all r e c o g n i z a b l e t u m o r was rem o v e d w i t h t h e s p e c i m e n . I n v a s i o n of t h e puhnonary artery, positive superior medias t i n a l (scalene) l y m p h nodes, m a l i g n a n t effusion, a n d e a r i n a t n o d e i n v o l v e m e n t w e r e n o t c o n s i d e r e d c o n t r a i n d i c a t i o n s to r e s e c t i o n if the p r i m a r y t u m o r could be removed, w i t h o u t requiring reconstructive procedures to the remaining vital structures (superior vena cava, esophagus, and t r a c h e a ) . Patients with demons t r a b l e d i s t a n t m e t a s t a s e s (we h a v e c o n s i d e r e d t h e s c a l e n e n o d e as p a r t of t h e r e g i o n a l l y m phatic system) were not operated nor resected unless " t r a p p e d l u n g " a n d u n c o n t r o l l a b l e l ) u h n o n a r y sepsis b e h i n d a r e m o v a b l e t u m o r m a s s was e x p e c t e d . CASE REPORTS
CASe I. T h e patient (M. B.), a sixty-six year old man, h a d severe myositis and massive weight loss which left him u n a b l e to feed himself or sit without support. At operation an adenoearcinonm invading chest wall was reseeted with tunmr left in the chest wall. T h e patient was discharged two weeks postoperatively with remarkable improvement; relief of myositis was noted on the operative day. The Vol. 109, APril 1965
Survivors 13 12 12 7
4 3 3 1 1 1
Per cent Surviving 100 92 92 54 31 25 25 11 17 33
patient died suddenly five months and seventeen days after surgery while on a fishing trip of what was prestoned to be cerebral metastasis or a vascular accident CASE II. The patient (W. L.), sixty-nine years of age, had lobectomy aceomplished for a large hilar mass with " t r a p p e d lung" after positive scalene node biopsy. Pathologic report described an anaplastic bronchogenic carcinoma with extensive nodal metastases. Patient's postoperative recovery allowed a transurethral resection fourteen days after tile thoracotomy. T h e patient returned to full activity with stable weight and no symptoms for two full years when increasing dysphagia developed clue to tumor constriction of the esophagus. This was treated by an endoscopically inserted tube (Souttar tube [7]) with relief of dysphagia and restabilization of weight. The esophageal obstruction recurred within the next few months and the patient died of aspiration pneumonia after a t w e n t y day terminal hospitalization, twenty-nine months, fourteen days after a "palliative" procedure. CaSE IIL T h e patient (T. W. K . ) , thirty-six years of age, required extensive resection of the chest wall to remove an adenocarcinoma of the right upper lobe after four months of aggressive weight loss and malaise. He returned to work three months after his operative procedure, having gained 16 pounds, and died six months after th e procedure with the sudden onset of coma after having missed only four days of work during his last three months of life.
Comment: E v e n t h o u g h t h e t o t a l l e n g t h 0f survival was p r o b a b l y not m a t e r i a l l y changed in t h i s y o u n g m a n , t h e r e m a r k a b l e s u b j e c t i v e i m p r o v e m e n t in t h i s p a t i e n t a n d h i s a b i l i t y t o r e t u r n in f u n c t i o n a l l y g o o d h e a l t h t o h i s y o u n g 433
King, Ramos,
and Zimmerman
%
".['ABLE I I l NONCURATIVE
! e.o >
~= u
801~,\ 1\ I
J ~ut"-~ m
r ........................
~,
~
-
Data
Number
-
Average age a t operation Operative d e a t h s Left hospital within 16 days Employable at 8 months T e r m i n a l hospitalization < 3 0 days T e r n f i n a l narcotics < 7 days"
59.6 years 1 of t3 patients 7 of 12 patients 6 of 7 patients 10 of I2 patients 9 of 12 patients
o "cuR,~r,ve~
°k ~
.
i_
\°~' \\
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_
]
o00f X i \ . 12
24
36
48
6(
MONTHS
F I G . 1. C o m p a r a t i v e
survival
RESECTIONS
t i o n d o n o t allow a n y s t a t i s t i c a l l y v a l i d inf e r e n c e s t o b e m a d e f r o m t h e s e differences.
of patients at risk. Pallia-
t i r e cases had biopsy proof of residu'fl tumor. QUALITY OF LIFE
fanfily, e v e n f o r a s h o r t t i m e , w a s m o s t g r a t i f y ing. RESULTS
Table I and Figure 1 present the survival p a t t e r n s of t h e s i x t y - t h r e e p a t i e n t s , f i f t y of w h o m w e r e r e s e c t e d w i t h h o p e of c u r e a n d t h i r t e e n of w h o m h a d b i o p s y - p r o v e d t u m o r r e m a i n i n g w i t h i n t h e chest. E l e v e n p a t i e n t s d i e d w i t h i n t h e first t h i r t y d a y s a f t e r t h e o p e r a t i o n ( o p e r a t i v e m o r t a l i t y r a t e : 17 p e r c e n t ) ; o n l y o n e of t h e s e d e a t h s was in t h e p a l l i a t i v e g r o u p . I t will be n o t e d t h a t while o n l y 30 p e r c e n t of p a t i e n t s w i t h n o n c u r a t i v e resections s u r v i v e d b e y o n d t h e first y e a r , o n e patient survived sixty-three months after the t u m o r h a d b e e n left in t h e m e d i a s t i n u m a n d t h e n d i e d of a c e r e b r o v a s c u l a r a c c i d e n t . T a b l e ii p r e s e n t s i n f o r m a t i o n r e l a t i v e t o t h e q u a n t i t y of life w h i c h f o l l o w e d t h e r e s e c t i v e procedure. T h e small samples and high variaTABLE RESULTS
II
OF RESECTIVE
Data
N u m b e r of p a t i e n t s S u r v i v i n g (April 1964)
Average period of survival Dead Average survival of deaths Survived 30 days 30 day (operative) mortality rate Average survival of patients excluding operative deaths
PROCEDURE
Proved Tumor Remaining
13 patients 0
13 patients 14.3 mo. 12 p a t i e n t s 7.7%
15.5 too.
Reseeted for "(2ure" 50 p a t i e n t s 15 p a t i e n t s
23.6 too. 35 patients 7.6 too. 40 patients
S i n c e o u r m a i n aim in u n d e r t a k i n g t h i s s t u d y w a s t o a l l e v i a t e t h e s u f f e r i n g a s s o c i a t e d with t h e u n r e s e e t e d lesion r a t h e r t h a n to e x t e n d t h e p e r i o d o f life, we w e r e m o r e i n t e r e s t e d in t h e q u a l i t a t i v e a s p e c t s of t h e r e m a i n i n g life a f t e r t h e n o n c u r a t i v e r e s e c t i o n s . In p r e s e n t i n g his m a t e r i a l o n s u r g e r y in t h e t r e a t m e n t of l o c a l l y a d v a n c e d lung c a r c i n o m a , A b b e y S m i t h h a s s u g g e s t e d [5,6] as c r i t e r i a f o r a successful o u t c o m e , a s u r v i v a l of at least e i g h t m o n t h s a n d t h e p a t i e n t ' s a c h i e v i n g sufficient well b e i n g t o allow him t o r e t u r n to w o r k o r t o his r e g u l a r a c t i v i t i e s . E x a c t l y h a l f of o u r t w e l v e p a t i e n t s w h o s u r v i v e d t h e o p e r a t i o n a r e successes b y these criteria. Other objective measures which p r o v i d e s o m e i n f o r m a t i o n as t o t h e v a l u e of t h e p r o c e d u r e a r e leng-th of t i m e s p e n t in t h e hospital after the operation before the patient c o u l d r e t u r n to his f a m i l y in a s a t i s f a c t o r y s t a t e of h e a l t h , l e n g t h of t e r m i n a l h o s p i t a l i z a tion r e q u i r e d , a n d t h e l e n g t h of t i m e p r i o r to d e a t h during which the patient required narc o t i c m e d i c a t i o n s . T h e s u m m a r y of this d a t a as it r e l a t e s t o o u r p a t i e n t s is p r e s e n t e d in T a b l e m . We were quite surprised b y the short tenninal hospitalizations and shortt e r m n a r c o t i c n e e d s of t h e p a t i e n t s in r e l a t i o n t o t h e t e r m i n a l illnesses we w e r e a c c u s t o m e d to s e e i n g in p a t i e n t s w i t h n o n r e s e c t e d l u n g cancer. SUMMARY
T h e r e s u l t s of r e s e c t i n g i n c u r a b l e l u n g c a n c e r in an e f f o r t t o i m p r o v e t h e t e r m h m l c o u r s e of a small n u m b e r of p a t i e n t s a r e b r i e f l y p r e s e n t e d . T h i s is n o t a c o m p a r a t i v e s t u d y a n d n o inf e r e n c e s or c o n c l u s i o n s a r e j u s t i f i e d r e g a r d i n g t h e c h o i c e of t h i s f o r m of t h e r a p y as p a l l i a t i o n
20.0% 10.6 too. 434
American Journal of Surgery
Surgical Palliation for I.ung Cancer in preference to o t h e r forms of palliative thera p y ; h o w e v e r we do believe t h a t the terminal course of the t)atient with h m g cancer is beneficially effected by removal of the p r i m a r y t u m o r w h e n e v e r this is technically feasible.
5.
REFERENCES
1. CIIA.MIIERLAIN, J. M., NIcNglI.L, T. M., PARNASSA, P., and I~DSALI., J. |~.. Bronchogenie carcinoma: an aggressive surgical attitude. J. Thoracic Surg., 38: 727, 1959. 2. I~bIERSON, (~. L., EMERSON, i'~. S., all(| SIlI~RWOOD, C. E. The natural history of carcinoma of the hlug. J. Thoracic Surg., 37: 291, 1959. 3. HUGItES, F. A., JR., PATZ, J. W., and CAMPBELL, l~.
Vol. 109, A pril 1965
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435
6. 7.
E. Bronchogenie carcinoma: eoml)arison of natttral course •11(| treattucllt with resection, xradiation, and nitrogen mustard. J. Thoracig Surg., 39: 409, 1960. OCnSNER, A., DEBAKVA', M., DUNLAP, C. E., and RICIIMAN, I. Primary puhnonary malignancy. J. Thoracic Surg., 17: 573, 1948. SMITH, R. A. Tile resuhs of raising tile reseetability rate in operations for lung carcinoma. Thorax, 12: 79, 1957. S.~UTH, P,. A. Surgery in tile treatment of locally adwmced lung carcinoma. Thorax, 18: 21, 1963. ZIM,~IF-RMAN,J. M., KING, T. C., and CANTRELI.,J. R. The
use of
all
endoseopically inserted intra-
luminal tube in the nianagement of ineurahle esophageal c-treiuoma. J. Kansas 31. Soc., 65: 275, 1964.