Ninety-four patients with malignant pleural mesothelioma were treated at Southern California Permanente Medical Group Facilities between 1965 and 1988. This retrospective analysis of survival in these patients is compared according to surgical and/or supportive management. Group I patients received supportive care only, including pleurodesis as needed. This group included the majority of patients. Group II patients were managed largely with debulking procedures including decortication and pleurectomy. Group III patients received extrapleural pneumonectomy. This group included the two long-term survivors of the entire group. This study of survival points out the need for a cooperative protocol as well as the consistent use of proper modern preoperative staging in an attempt to select patients who benefit from extrapleural pneumonectomy.

Twenty-two patients were irradiated using two different dose schedules of intracavitary irradiation for palliation of locally advanced or metastatic carcinoma of the esophagus. Irradiation was given solely with either manually afterloaded low/intermediate dose Cesium-137 (LDR) or high dose rate Iridium-192 (HDR) delivered via remote afterloader. This study was designed to test the effectiveness of HDR intracavitary brachytherapy in the relief of dysphagia and the maintenance of esophageal patency and to compare with our previous experiences with LDR intracavitary brachytherapy. Accelerated treatments were especially suited for patients with poor physical condition or short life expectancy unlikely to complete a full course of external beam irradiation without treatment interruption. Two thousand cGY in three fractions of LDR was compared with 1,250 cGY in one fraction HDR with essentially equal results.

In a prospective study, 14 patients with primary non-oat cell lung carcinoma were treated with intraoperative Iodine125 (I125) implantation of the lung tumor via lateral thoracotomy or median sternotomy. Staging mediastinal node dissection was performed in each case. Patients were selected when wedge or segmental resections were not technically feasible, such that lobectomy or completion pneumonectomy would have been required or pulmonary function studies were poor. Doses ranged from 8,000 cGy at the periphery to 20,000 cGy at the center. With a minimum 12 month follow-up, mean and median survivals were 16.7 and 15.1 months, respectively. Local control was achieved in 10 of 14 patients (71%) with all local failures occurring in pathologic stage III patients. When separated according to tumor size, local control was obtained in six of seven tumors of less than 3 cm and four of five tumors of 3-5 cm. Both cases with masses greater than 5 cm failed locally. There was one operative mortality and two postoperative complications. All other patients were discharged within one week of surgery. There was no radiation pneumonitis. I125 lung brachytherapy is an excellent alternative treatment for T1 and T2 tumors when medical conditions preclude curative resection.

A survival study for squamous carcinomas of the distal esophagus treated by the Southern California Permanente Medical Group in the interval of 1954 to 1988 was undertaken. We found radiation therapy and surgery equally efficacious in terms of cure for patients without distant disease and performance status sufficient to tolerate treatment. We did not find survival benefit for patients treated with palliative surgery, and plan less invasive endoscopic means along with chemotherapy and radiation for palliation, reserving surgery for special circumstances.

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