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Biomedical subjects

T W Shields

Publications and source records attributed to T W Shields.

At least 37 records · Page 2Linked to original sources
PubMed1987

Selective preoperative evaluation for possible N2 disease in carcinoma of the lung.

The efficacy of computed tomography and surgical mediastinal exploration in determining tumor resectability were retrospectively evaluated in 92 consecutive patients with non-small cell lung carcinoma. Status of mediastinal nodes was ultimately determined by surgical mediastinal exploration or thoracotomy. Patients were divided into three groups on the basis of chest roentgenography: Group I comprised 30 patients with peripheral T1 or T2 lesions with normal hilar and mediastinal shadows. Only one patient was found to have an involved node. Chest roentgenography had an accuracy rate of 96% and computed tomography, 93%. Thoracotomy is recommended without either computed tomography or surgical mediastinal exploration in this group. Group II comprised 47 patients with T1 or T2 lesions with an abnormal hilus, an abnormal mediastinal shadow, or either the hilus or mediastinum obscured by overlying parenchymal disease. Computed tomography revealed mediastinal nodes 1 cm or greater in size (abnormal node group) in 21 patients (45%) and smaller than 1 cm (normal node group) in 26 patients (55%). Surgical mediastinal exploration was performed in the abnormal node group and involved nodes were found in 17 of 21 patients (81%). In the normal node group, thoracotomy only was performed and no involved nodes were found. Computed tomography is recommended in all patients in Group II. Patients in the normal node group may be subjected to thoracotomy only and those in the abnormal node group should undergo surgical mediastinal exploration as the next diagnostic step before thoracotomy. Group III comprised 15 patients with grossly abnormal mediastinal shadows. Findings from computed tomography were abnormal in all 10 patients in whom it was done. Surgical mediastinal exploration was done in all 15 and yielded abnormal results in 14. It is recommended in this group that computed tomography is unnecessary and surgical mediastinal exploration should be the only diagnostic procedure. Thus, in potentially resectable non-small cell lung carcinoma, the use of computed tomography and surgical mediastinal exploration should be selective and should be determined by appropriate initial interpretation of the chest roentgenogram.

Carcinoma, Non-Small-Cell Lung↗
PubMed1986

Surgery of small cell lung cancer.

The role of surgical resection in the management of patients with small cell lung cancer remains to be defined. Some data suggest the potential benefit of resection in the few patients with very limited disease (peripheral T1N0 and T2N0 lesions), and there are chemotherapy regimens with 80-85% response rates in patients with more extensive but still localized disease. Interest has been reawakened in the role of adjuvant surgical resection in selected patients by 2 approaches: in patients with peripheral T1 or T2 lesions with negative mediastinal exploration, initial surgical resection followed by an adequate chemotherapeutic regimen and prophylactic cranial irradiation has resulted in an 80% disease-free survival at 30 months; initial chemotherapy in patients with only localized disease is followed by resection in the responders. Approximately 30% of the responders have undergone exploratory thoracotomy after completion of the chemotherapy. Local irradiation, as well as prophylactic cranial irradiation, generally has been used postoperatively. Early pilot studies suggest benefit of this approach in patients found to have T1-3 N0-1 disease but not in those with N2 disease. Prospective, randomized, clinical trials by the Lung Cancer Study Group in North America and its counterparts in Europe are now being carried out in hopes of supplying definitive data relative to this multi-modality therapy in small cell lung cancer. Unfortunately, no data are available to date.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1984

Multimodality approach to treatment of carcinoma of the esophagus.

We conducted a combined treatment pilot project in 17 patients with squamous cell carcinoma of the thoracic esophagus. Thirteen of the patients initially had stage I or II disease, and four had stage III disease. Each patient received three cycles of chemotherapy consisting of a high dose of cisplatin (100 mg/sq m), followed by continuous infusion of fluorouracil (1,000 mg/sq m/day for five days). Thirteen patients had a favorable response to the chemotherapy, and ten of the 11 responding patients with stage I or II disease were offered surgical resection. Total thoracic esophagectomies and cervical gastroesophagostomies were done in the six patients who accepted the surgical recommendation. Pathologically, five patients had stage I disease, and one had stage III disease (even in this patient the local tumor was confined within the wall of the esophagus). All six patients were alive, without evidence of disease, four to 34 months after diagnosis. Two patients with stage II disease had tumor progression, as did two of the four patients with stage III disease. Three of the nonresponding patients died of their disease two to seven months after diagnosis. The eight remaining patients, three of whom received irradiation after chemotherapy, were alive, but with evidence of persistent disease, one to seven months after entrance into the study.

Aged↗
PubMed1983

Prognostic significance of parenchymal lymphatic vessel and blood vessel invasion in carcinoma of the lung.

In a series of 685 men who had undergone a microscopically curative resection of a carcinoma of the lung admitted to a prospective randomized adjuvant chemotherapy trial, a review of the data relative to the prognostic implication of either parenchymal lymphatic vessel or blood vessel invasion as determined by routine histologic examination was carried out. In the patients without parenchymal lymphatic vessel invasion and without lymph node metastasis, the three year survival rate was 61.0 per cent. In those without lymphatic vessel invasion but with lymph node metastasis, the three year survival rate was 34.5 per cent. In the patients with lymphatic vessel invasion and no lymph node metastasis, the three year survival rate was 41.7 per cent and when lymph node metastasis was present, it was 33.8 per cent. In the patients without blood vessel invasion and with neither lymph node metastasis nor lymphatic vessel invasion, the survival rate was 61.9 per cent at three years. When either or one, or both, of the latter were present, the survival rate was 35.6 per cent. In the patients with blood vessel invasion, the three year survival rate in those without lymph node invasion or lymphatic vessel invasion was 58.0 per cent, and in those with either one or both, the survival rate was 34.9 per cent. It is concluded that parenchymal lymphatic vessel invasion in itself is an indication of a poor prognosis. However, blood vessel invasion when identified by routine histologic examination was found to provide little, if any, additional predictive information.

Blood Vessels↗
PubMed1982

Prolonged intermittent adjuvant chemotherapy with CCNU and hydroxyurea after resection of carcinoma of the lung.

Eight hundred sixty-five patients with a microscopically curative resection for carcinoma of the lung were accepted for study, none of whom were excluded from analysis. Adjuvant therapy was randomly assigned about the tenth to 14th postoperative day; 432 patients (treated) were to receive CCNU and hydroxyurea for one year, while 433 patients (controls) were to receive no adjuvant therapy. Toxic reactions to therapy were reported, but only 1% were severe enough to require stopping therapy. No evidence of improved survival or delayed recurrence of disease was seen in treated patients as a whole or when examined by cell type and by postsurgical TNM category. On the contrary, survival beyond the second year of follow-up may have been impaired by the drugs when administered to patients without evidence of tumor spread to the lymph nodes.

Carcinoma↗
PubMed1982

Surgical therapy for carcinoma of the lung.

Surgical resection in patients with carcinoma of the lung remains the one therapeutic modality that offers the greatest potential for long-term survival. However, it is apparent that the surgical treatment of carcinoma of the lung must be applied selectively. The selection of the appropriate patients is determined by the extent of the disease process, the cell type of the tumor, and the physical status of the patient. The operative procedure chosen in a given patient may be either conservative or extended in nature as deemed necessary to eradicate the local disease process. The morbidity and mortality must be commensurate with the potential salvage that may be expected. The latter is primarily determined by the extent of the disease process at the time of operation.

Adult↗
PubMed1982

Surgical resection in the management of small cell carcinoma of the lung.

In an attempt to define the role of initial surgical resection in patients with undifferentiated small cell carcinoma of the lung, we reviewed the experience of the Veterans Administration Surgical Oncology Group (VASOG). One hundred forty-eight patients with small cell carcinoma of the lung had undergone a potentially "curative" resection. This represented 4.7% of "curative" resections carried out in four major prospective adjuvant chemotherapy trials. In the early trials (101 patients), 16 patients (15.8%) died within the first 30 postoperative days. These patients have been excluded from the analysis of long-term survival, since in the more recent trials postoperative deaths were excluded prior to randomization. In the 132 patients remaining, the 5 year survival rate by the life-table method was 23.0%. The tumor of each was classified pathologically by the TNM system. Five-year survival rates for each category were as follows: T1 N0 M0 59.9%, T1 N1 M0 31.3%, T2 N0 M0 27.9%, T2 N1 M0 9.0%, and any T3 or N2 3.6%. The effect of postoperative adjuvant chemotherapy was evaluated in each of the trials. No beneficial effect of the adjuvant therapy was noted with a one or two course regimen of either nitrogen mustard or cyclophosphamide, but possible benefit, although not significant, was noted in a prolonged intermittent chemotherapy trial of cyclophosphamide either alone or alternating with methotrexate. In the most recent trial of prolonged intermittent courses of 1-(2-chlorethyl)-3-cyclohexyl-l-nitrosourea (CCNU) and hydroxyurea, a 5 year survival rate of 80.8% was noted in those receiving adjuvant chemotherapy as compared to a 38.1% in the control group. We conclude that resection is definitely indicated in patients with T1 N0 M0 lesions and probably indicated in those with T1 N1 M0 or T2 N0 M0 lesions. Primary surgical resection is contraindicated in patients with any other TNM category.

Antineoplastic Agents↗
PubMed1982

Unusual causes of spontaneous pneumoperitoneum.

Spontaneous pneumoperitoneum may pose a diagnostic dilemma, especially when evaluating a patient who has no or minimal abdominal or constitutional findings accompanying its presence. The free intraperitoneal air may be the result of a perforation of a hollow viscus in such instances. Under these circumstances, the air is most often from another source. The more common sites of origin are intrathoracic sites, air in the wall of the intestinal tract and the genital organs in women. Diagnostic and therapeutic procedures in or adjacent to the abdomen may result in an iatrogenic pneumoperitoneum. In each instance when the findings of an acute abdominal catastrophe are lacking, the circumstances present before the discovery of the pneumoperitoneum should give a clue to the appropriate diagnosis. When a reasonable nonsurgical cause can be discerned, continued observation may be sufficient, thus avoiding an unnecessary laparotomy.

Abdomen↗
PubMed1981

Roux-en-Y operation in the management of postoperative fistula.

Four patients had complicated gastric and duodenal fistulas. In each patient, factors including marked inflammation and dense adhesions made dissection and mobilization difficult and hazardous. As a result, the standard recommended management of the fistulas was impossible. In each of these patients a Roux-en-Y operation was used successfully as an alternative procedure to seal the fistula. A successful outcome was experienced in each patient.

Aged↗
PubMed1981

Site of recurrence in patients with stages I and II carcinoma of the lung resected for cure.

Ninety-nine patients with Stage I or II lung carcinoma that was other than the small cell type and who survived for more than 30 days after a "curative" resection were followed for five years or until death if it occurred prior to the five-year anniversary. Recurrent disease developed in 44 patients. Clinical data and data from postmortem examination were reviewed in these 44 patients in an attempt to classify each recurrence as either initially local or distinct metastatic disease. The site of the first documented recurrence was local in 18 patients and distance metastases in 26. When the patients with recurrence were separated into TNM categories, it was apparent that in those patients without lymph nodes metastases demonstrated in the resected specimen (N0), the initial recurrence tended to be a distant metastases, whereas in those with such involvement (N1), the initial occurrence was more often local. In light of these data, selection of appropriate initial adjuvant therapeutic modalities may be different for each type of patient.

Female↗
PubMed1980

Healing of the perineal wound.

The operative management of the perineal wound of 100 consecutive patients undergoing abdominoperineal resection or total proctocolectomy was readily divided into four categories: (1) left open with simple packing, (2) closed primarily with simple drainage (Penrose or red rubber), (3) closed primarily with suction drainage (airtight and watertight), or (4) closed primarily with suction drainage plus continuous irrigation. At three weeks, none of the open wounds, 11% of those closed with simple drainage, 48% closed with suction, and 60% of those closed with suction plus irrigation were healed. By three months, the cumulative figures were 20%, 44%, 88%, and 87%, respectively, and at one year, 92%, 77%, 95%, and 97%. No difference was found between the wounds closed with suction and those closed with suction plus irrigation. There was a highly significant difference in the rate of wound healing when the wounds closed with suction alone or with irrigation were compared with those left open or closed with simple drainage. At three months, the former wounds were healed in 88% of the patients, and the latter in only 30%. The method of choice of management of the perineal wound appears to be that of primary closure with immediate suction drainage with or without concomitant irrigation.

Adenocarcinoma↗
PubMed1980

Alterations in intercostal muscle morphology and biochemistry in patients with obstructive lung disease.

Twenty-two patients undergoing thoracotomy for the diagnosis or treatment of a suspected pulmonary neoplasm had separate biopsies taken from their external and internal intercostal muscles at the time of surgery. Pulmonary function abnormalities ranged from none to moderate airway obstruction. Seventeen of the twenty-two patients had morphologic changes (targeting, variation in fiber size, splitting, and atrophy) in both respiratory muscles, but not in the control latissimus dorsi. Fiber atrophy was more marked in the internal intercostal muscle and was significantly related to the degree of airway obstruction, but not to age, malignancy, or weight loss. Biochemical analyses revealed decreased adenosine triphosphate (ATP) and phosphocreatine (PC) in 47 of 52 muscles, including the latissimus dorsi. The data suggested a relation between increasing airway obstruction and decreasing amounts of phosphocreatine in both intercostal muscles. This relationship may have been enhanced by the presence of malignancy or weight loss. There was a selective decrease in muscle glycogen found only in the external intercostal muscle that was not affected by airway obstruction, malignancy, or weight loss. Intercostal muscle abnormalities are common in patients with obstructive lung disease who undergo thoracotomy, and are probably multifactorial in origin. It is possible that these abnormalities affect the natural history of lung disease in some patients.

Adenosine Triphosphate↗