Accelerated idioventricular rhythm was observed in three newborn infants with congenital heart disease. This ventricular arrhythmia in all of our patients did not alter the clinical features of the congenital heart disease, and it disappeared at the ages of 84 days, 40 days, and 45 days, respectively. This arrhythmia is generally considered to be benign, which also appears to be the case with the newborn infant with congenital heart disease.

Familial arrhythmogenic right ventricular dysplasia is a rare cardiomyopathy that is usually diagnosed on postmortem examination or on presentation with progressive congestive heart failure. We present a patient in whom an automatic implantable cardioverter-defibrillator was inserted prophylactically. A review of the condition and possible therapies is included.

We describe a North American human immunodeficiency virus (HIV)-positive patient with Strongyloides stercoralis infection of the gastrointestinal tract, who required repeated "standard" courses of thiabendazole. Pulmonary infection with numerous roundworms developed, as suspected by bronchoalveolar lavage, and while he was receiving therapy, dissemination occurred. On autopsy, S stercoralis was recovered in the gastrointestinal tract, liver, lung, and heart. After a literature review, we conclude that HIV-positive patients have a higher risk of dissemination and "standard" treatment failure. This may occur without elevation of IgE or eosinophilia. Those patients may require prolonged courses of thiabendazole or alternatively ivermectin therapy.

The English-language literature was reviewed to evaluate a possible relationship between asbestos-related pleural plaques and lung cancer in the absence of parenchymal asbestosis. There were six cohort studies in which the comparison group was limited to unexposed persons or the general population, four lung cancer case-control studies, and three autopsy studies. Of the 13 investigations, only 3 supported the hypothesis that lung cancer risk is elevated among persons with pleural plaques over the risk in unexposed people: 2 cohort studies from the same city in England with much the same data and 1 case-control study. These three studies had the most defects in design. The other ten studies failed to confirm the hypothesis. Thus, the weight of the evidence favors the conclusion that persons with asbestos-related pleural plaques do not have an increased risk of lung cancer in the absence of parenchymal asbestosis.

To compare complications after and outcome from surgical procedures between patients with human immunodeficiency virus (HIV) disease and a matched control population.

Using current immunosuppressive protocols, rejection is common after lung transplantation. Most recipients have at least one episode of acute rejection, and approximately 25 percent of recent long-term survivors have developed chronic rejection. Acute rejection has usually been reversible with treatment, but chronic rejection has responded poorly, relapsed frequently, and been one of the leading causes of late morbidity and mortality. Appropriate management of rejection is predicated on timely, accurate diagnosis. Clinical criteria for the diagnosis of acute rejection are useful but nonspecific, and TBB has emerged as the procedure of choice for diagnosing acute rejection and infection. Chronic rejection is manifested by OB and is characterized physiologically by the development of airflow obstruction. Although histologic confirmation is preferable, the sensitivity of TBB for the detection of OB has been inconsistent, and the specificity has been low. Lung transplantation has indeed come of age, but understanding the immunopathogenesis and improving the clinical management of rejection remain major challenges for the next decade.

Lung cancers exhibit multiple genetic lesions including mutations activating the dominant cellular proto-oncogenes as well as those inactivating the recessive or "tumor suppressor" genes. Candidate tumor suppressor genes include those on chromosomes 1p, 1q, 3p14, 3p21.3, 3p25 (VHL gene), 5q21 (APC/MCC gene cluster), 9p21-22 (interferon gene cluster), 11p, 13q (rb gene), 16p24, and 17p (p53 gene). Mutations in p53 inactivate its transcriptional activity, while replacement of a wild-type p53 in lung cancer cells inhibits growth and tumorigenicity suggesting that p53 acts as a master growth regulatory switch. Lung cancer cells exhibit several positive autocrine growth factor loops and express nicotine receptors which could function as tumor promoting systems. In addition, they express a negative autocrine loop involving opioids and their receptors which is reversed by nicotine acting through nicotinic acetylcholine receptors. The presence of nicotine receptors suggests nicotine or its metabolites may play a direct role in lung cancer pathogenesis.

In patients with lung cancer, the goals of limited resection procedures of the lung and major airways are to provide an adequate cancer operation while preserving functioning lung tissue. Discussed in this article are sleeve lobectomy, an alternative to pneumonectomy in patients with cancer in a lobar orifice; segmentectomy or wedge resection, an alternative to lobectomy in those with a peripheral lung cancer; and thoracoscopy, an alternative to open thoracotomy for various chest malignancies.

Surgical treatment of cancer of the esophagus is influenced by two issues: use of surgical resection within a multimodality treatment approach and selection of the correct surgical approach. Selecting the correct surgical approach should be individualized and determined by the intent of surgery (curative or palliative), the anatomic location of the tumor (cervical or thoracic), the preferred method of reconstruction (colonic interposition or gastric pull-up), and whether surgery is the only therapeutic modality to be used or will be combined with neoadjuvant chemotherapy and/or radiotherapy. A discussion of the efficacy of treatment within a multimodality setting and a description of the surgical approach follow.

Transhiatal esophagectomy with mobilization of the stomach to replace the esophagus has been used to provide palliation of dysphagia at the University of Michigan for more than 15 years. The subtotal esophageal resection is believed to be preferable to the transthoracic approach that has been considered the standard for this surgery. As experience with the technique has increased, complications have decreased. Most patients are discharged, able to swallow, by the 10th or 11th postoperative day. Survival in these patients is no worse than that reported after more traditional transthoracic esophagectomy, and the transhiatal route has reduced postoperative pulmonary complications and the incidence of mediastinitis from anastomotic leak, which is fatal in 50% of patients. In a phase II trial of preoperative combined radiation therapy and chemotherapy with cisplatin, vinblastine, and continuous-infusion 5-fluorouracil in 45 patients, survival after esophagectomy seemed considerably better than in our historical control subjects treated with transhiatal esophagectomy alone. The 3-year survival of the 43 patients was 46% compared with 23% of those who received only surgery. Considering only the 27% of those patients who had no cancer in their resected specimens, ie, the complete responders, the 5-year survival is 70%. A phase III trial is now accruing patients in an attempt to confirm these results.

Squamous cell carcinomas of the esophagus, while still frequent in many locations throughout the world, now comprise a smaller percentage of esophageal cancers in the United States than was previously believed. Such tumors occur most often in black men and in association with tobacco and alcohol abuse. Adenocarcinomas of the distal esophagus represent an increasing proportion of esophageal tumors. These neoplasms arise in columnar epithelium (ie, Barrett's esophagus) or extend into the esophagus from their site of origin in the proximal stomach. Esophageal adenocarcinomas appear more often in white than black subjects and in men more than women. The clinical features and diagnostic approaches to squamous cell tumors and adenocarcinomas of the esophagus are similar.

Despite a great deal of literature on pulmonary metastectomy, the treatment of pulmonary metastases remains somewhat controversial. However, review of the literature does allow the development of certain algorithms to approach this problem, and these are discussed.

Synchronous primary lung cancers (SPLCs) occur in up to 0.5% of patients with lung cancer. They are first diagnosed intraoperatively or upon pathologic examination of resected tissue in up to 40% of patients with SPLCs. Complete surgical resection is possible in over 90% of patients, with an operative mortality of 2.1%. Despite a high frequency of early stage disease (two thirds of patients have either stage I or II tumors), surgical therapy yields an overall 5-year survival of only 20%, far lower than expected. These findings suggest that the biology of SPLCs is different from that of ordinary lung cancers, or that the diagnosis of SPLCs is being made too often, and that in some patients the second cancer focus actually represents metastatic disease. The use of newer techniques of identifying the molecular and biologic characteristics of these cancers, including analysis of DNA ploidy patterns, may more accurately define SPLC patients. Optimal interventional and preventive therapies remain to be determined.

Obstruction of the superior vena cava (SVC), a thin-walled vessel that carries blood at low pressure, may result from compression by tumor or intraluminal thrombus formation. The SVC syndrome that ensures may be the cause of significant morbidity. This article reviews the pathogenesis of SVC syndrome, appropriate radiologic imaging procedures, and the issue of obtaining a tissue diagnosis. The management of SVC syndrome with chemotherapy, radiotherapy, and surgery is also discussed.

Asbestos exposure constitutes the primary cause of pleural and peritoneal mesothelioma in humans. Risk relates to the duration and intensity of exposure. Thus, those exposed at younger ages are at higher lifetime risk. Families of asbestos workers exposed to asbestos on hair and clothing as well as to asbestos items brought home from the workplace are also at risk, as are employees working in the same vicinity as asbestos workers. The public health significance of exposure from asbestos in public and private buildings remains controversial. Malignant mesothelioma is difficult to diagnose and carries a poor prognosis. Chemotherapy with single or multiple agents has thus far been disappointing, but doxorubicin and cisplatin or mitomycin and cisplatin are probably most active with response rates in measurable disease of 25%. Palliative radiotherapy is also problematic since differences between tumor cytotoxicity and pulmonary tolerance are small and radiation pneumonitis may significantly impair quality of life.