[Radiologic diagnosis of silicotic cicatricial cancer. Incidence and correlation with pathologic-anatomic results]

Out of 1,200 patients with irradiated bronchogenic carcinomas, 487 men worked as coal miners and were exposed to silicon dioxide dust. Of these 212 patients showed radiological signs of pulmonary silicosis. The patients with a bronchogenic carcinoma and silicosis showed no significant dependence upon the grade of silicosis or working time underground concerning histology, age at disease onset, or localization in comparison to people with a bronchogenic carcinoma but without silicosis. Seven patients suffered from cicatricial carcinomata, the tumorous features and means of formation of which are discussed in comparison to pathological-anatomical results.

Vacuole sign and nodule sign in early peripheral bronchogenic carcinoma. Diagnostic value and pathologic correlation

We analyzed the radiological and pathological characteristics of 30 peripheral lung masses 1.5-3 cm in diameter. We describe the vacuole and the nodule sign. Retrospective examination of 100 conventional tomograms of peripheral pulmonary masses and comparison with the histological diagnoses allowed us to determine the usefulness of these two signs in differentiating small peripheral bronchogenic carcinomas from tuberculomas.

[Mediastinal staging of non-small cell bronchial carcinoma. The place of computed tomography and mediastinoscopy]

Sixty patients with a potentially resectable non-oat-cell lung carcinoma were examined by computed tomography and cervical mediastinoscopy. The sensitivity of computed tomography as opposed to mediastinoscopy was 74% versus 58% and the specificity in 85% versus 100%. Considering the limitations of both methods and the varying prevalence of mediastinal lymph-node metastases associated with peripheral and central lesions, three different situations can be distinguished: 1. with peripheral lesions and a normal mediastinal CT, preoperative mediastinoscopy is unnecessary. 2. With an abnormal mediastinal CT, mediastinoscopy is always indicated irrespective of the location of the tumor. 3. With large central lesions, mediastinoscopy is necessary even when the CT is normal. Using these rules, 37 of 60 mediastinoscopies in our patient group could have been avoided without influencing the resection rate (98%).

[Staging of non-small cell bronchial carcinoma using CT and MRT]

The TNM Classification was rewritten by UICC in 1987. For non-small-cell bronchogenic carcinoma, stages T4 and N3 were redefined. Controversy exists in the literature regarding the clinical merits of CT and MRI examinations for staging. For the evaluation of very small tumors and lung parenchyma CT is superior to MRI. MRI, however, permits direct imaging of sagittal and coronal projections. This is favorable in the diagnosis of "superior sulcus tumors" and tumors with chest wall invasion. For the evaluation of T4 tumors and mediastinal lymph-node involvement, no additional contrast medium is necessary if MRI is used. Up to now, the main limitations for the application of MRI in thoracic imaging have been and still are the availability of the equipment, the costs, the necessary technical support, and the extensive study time.

[Testing bronchogenic carcinoma cells for sensitivity to cytostatics in vitro and in cell cultures]

The authors submit the first experience assembled in Czechoslovakia with testing of the sensitivity of bronchogenic carcinoma cells to cytostatics by the HTCA method (Human Tumor Clonogenic Assay). Based on work by A. W. Hamburger, S. L. Salmon and others the authors elaborated their own modification of the method of cell cultivation in a double layer of soft agar, which can be used in small laboratories attached to clinical departments. The sensitivity tests were made in eight bronchogenic carcinomas--four adenocarcinomas and four epidermoid carcinomas. For the tests five cytostatics were used: 5-fluorouracil, methotrexate, cis-platinum, vincristine and vinblastine. Because of contamination the results in three tested adenocarcinomas could not be evaluated. The evaluated specimen of adenocarcinoma was sensitive to 5-fluorouracil and methotrexate, but was resistant to the remaining tested cytostatics. In the group of epidermoid carcinomas one specimen was completely resistant and one completely sensitive to all tested cytostatics. In one specimen the test with 5-fluorouracil could not be evaluated, and the specimen was resistant to the remaining cytostatics. The last specimen in this group was resistant to cis-platinum and sensitive to the remaining cytostatics.

[Diagnostic strategy and treatment planning in bronchial cancer]

In carcinoma of the lung, the treatment design and the prognosis are dependent on the histological type and anatomical spread of the tumor and also on the general condition of the patient. Evaluation of these parameters requires an extensive clinical staging program that is nonetheless slanted to the individual subjective status of each patient. We generally distinguish a standardized basic diagnostic procedure from a specialized, more detailed individual diagnostic procedure. The pretherapeutic diagnostic assessment also includes evaluating the risk of therapy for each individual patient, especially in the case of surgical intervention. Posttherapeutic complications should not cause any great problem if the risk factors have been carefully evaluated before treatment.

[Bronchogenic carcinoma in women]

A total of 440 women with morphologically tested primary bronchogenic carcinoma were hospitalized in 1961-1987. The patients' average age was 57 years, 22% persons were under 50 years. In 32% women carcinoma was found accidentally in the asymptomatic stage of the illness, 4% women had subjective complaints which they considered insignificant, however, subjective complaints in 64% patients helped to diagnose it. The most frequent complaints were temperature, breathlessness, chest pain and loss of weight. In 2% women, the first sign was hemoptysis found most frequently as an isolated symptom. The history of 9.5% patients showed pulmonary TB, in 27% women bronchogenic carcinoma was first regarded as pulmonary TB and treated with anti-tuberculotics. The family history of 32% patients showed malignant diseases, most frequently gastric carcinoma, while bronchogenic carcinoma was found in 5.7%, of family members. The group consisted of 46% smokers and 54% non-smokers. The women smokers had smoked for 29 years on average, had smoked 205 thousand cigarettes on average, the average daily amount was 20 cigarettes. Regardless of their smoking habits, the most frequent histological type was found to be adenocarcinoma in 47% cases, with the squamous-cell type prevailing in the smokers (37%), and adenocarcinoma in non-smokers (59%). 36% of the patients underwent surgery, the most frequent contraindication for surgery were generalization of the process and lymph node metastases. Lobectomy was the most common operation performed (62%). 5 patients died within the first post-operative month.

The role of adjuvant surgery in the combined modality therapy of small-cell bronchogenic carcinoma after a chemotherapy-induced partial remission

Twenty-six patients with a limited-disease presentation of small-cell bronchogenic carcinoma (SCBC) had surgery after achieving a partial remission with three cycles of chemotherapy. Persistent SCBC was found in 15 patients (58%), non-small-cell bronchogenic carcinoma (NSCBC) in six patients (23%), and no malignancy in five patients (19%). Twelve patients have died since surgery. Tumor-node-metastasis (TNM) staging prior to or after chemotherapy was not predictive of outcome, but an N0 status found at pathological examination of the surgical specimen was predictive of long-term survival. Median survival for this group of patients was 25 months. Adjuvant surgery is feasible and may be beneficial.

Intrathoracic lymph node evaluation by CT and MRI with histopathologic correlation in non-small cell bronchogenic carcinoma

Twenty patients with non-small cell bronchogenic carcinoma were prospectively studied for intrathoracic lymphadenopathy using computed tomography (CT) and magnetic resonance imaging (MRI). The CT and MRI results were correlated with the surgical histopathology results of 103 harvested lymph nodes. Based on node dimension (utilizing a 1-cm cutoff value), neither imaging modality was accurate in predicting the histopathology of the nodes. CT had a sensitivity of 21%, specificity of 95%, and an overall accuracy of 85%; MRI had a sensitivity of 14%, specificity of 97%, and an overall accuracy of 85%. Moreover, CT and MRI detected preoperatively only 17% and 14%, respectively, of the harvested nodes. In summary, lymph node sizes measured by CT and MRI are inaccurate in predicting the benignity or malignancy of lymph nodes. Lymphadenopathy can be present even with a "negative" CT or MRI scan of the thorax.

[Peripheral round lesion of the lung: diagnosis, therapy, prognosis]

A total of 407 patients were hospitalized on account of a peripheral round lesion in the lungs (PR); 176 of these patients were inoperable for a wide range of different reasons. In 32.9% of the cases, a peripheral bronchial carcinoma presented, in 26.9%, the lesions were metastases, and in 2% malignant growths that were not further classified. All the remaining PR were benign. The following surgical procedures were performed: 39.8% lobectomies, 19.2% wedge resections, 20.6% enucleations, 6.4% segmental resections, 5.1% bilobectomies, 2.2% pneumonectomies, 6.7% various other procedures. The surgical mortality rate was 1.7% (0% in the case of the benign lesions); the re-thoracotomy rate for complications was 4.5%. The five-year survival probability for all bronchial carcinoma patients was 36%, and for all meta patients 47%. The poorest prognosis was seen in patients with PR when a small cell carcinoma or adenocarcinoma presented, and also in T3 tumours.

[The status of computerized tomography and conventional tomography in the assessment of endobronchial growth and extension of central bronchial cancer]

In comparison with endoscopy, computed tomography can produce excellent results with respect to the endobronchial spread of central bronchial carcinomas. Used for the same purpose, conventional tomography of the central bronchial system is greatly inferior. With respect to an evaluation of the endobronchial tumour growth configuration, computed tomography of the chest showed agreement with the endoscopic findings in only 56 per cent of all cases. This would seem to indicate that for the planning of palliative bronchological measures, such as, for example, laser therapy and afterloading treatment, prior endoscopic inspection is indispensable. By themselves, the results obtained with the imaging procedures described in this article are not adequate.

[Staging of bronchogenic cancer. Determination of mediastinal lymphatic involvement using magnetic resonance]

Twenty-five patients with bronchogenic carcinoma were prospectively studied by both CT and MR during 10 days preceding thoracotomy. MR scans included contiguous axial and coronal slices. Results of CT and MR studies were compared with the surgical and pathological findings. Although no significant difference was found between the two imaging methods for the evaluation of mediastinal nodes. MR appear to be superior to CT in the aortopulmonary and subcarinal node areas.

[Mediastinal lymph node metastases in bronchial cancer--CT analog horizontal section of an autopsy patient sample]

On the basis of horizontal sections through the entire heart-lung preparation, the size relationships and topographical features of mediastinal lymph node metastases of lung carcinomas are presented. This sectioning technique is more suitable for the determination of the lymphatic metastasization pattern than the conventional postmortem technique. The detection of multiple areas with focal consolidated lymphatic tissue in the mediastinal fatty tissuereveals additional possibilities for lymphopatic tumour spread in the mediastinum.

Cellular and molecular biological aspects of human bronchogenic carcinogenesis

This is a time of rapid progress in the field of human bronchogenic carcinogenesis due to recent advances in cellular and molecular biology. Important developments over the last 10 years include establishment of methods for culturing NHBE cells under defined conditions, and molecular biological and biochemical epidemiological techniques for identifying genetic changes that are associated with malignant transformation of these cells. Most progress in defining genes associated with human carcinogenesis has been due to discoveries related to oncogenes and more recently, tumor suppressor genes. As was described in Section II.B.3.a, we now know that oncogene products serve as growth factors, growth factor receptors, and cytosolic and nuclear regulatory proteins. In addition, although the actions of putative tumor suppressor genes are less well understood, the first isolated tumor suppressor gene Rb, interacts with the products of DNA viruses which, in turn, are involved in regulation of transcription as was described in Section II.B.3.b. Thus, not surprisingly, both oncogenes and tumor suppressor genes code for classes of proteins that are known to play an important role in regulation of cell proliferation. Recently, a second gene that appears to possess tumor suppression activity (p53) has been identified on the short arm of chromosome 17 (17p). The initial data suggesting a possible tumor suppressor gene on chromosome 17p came from cytogenetic and RFLP studies associating loss of heterozygosity in the chromosome 17p13 region with tumor cells and tissues. Since the p53 gene is located in this region it was evaluated and found to be frequently or always altered in several types of tumor cells. Recently, it was determined that introduction of the wild-type p53 gene into NIH3T3 cells will inhibit subsequent malignant transformation. Thus, the preponderance of evidence now supports the hypothesis that while mutated p53 acts as an oncogene, the wild-type p53 gene codes for a tumor suppressor function. The role of balance between oncogenes and tumor suppressor genes in control of proliferation is presently an active area of investigation. As discussed, introduction of a chromosome containing a tumor suppressor gene will suppress tumorigenicity of a malignant cell line, even though that cell line possesses an active c-Ha-ras oncogene. Whether or not the level of expression of an activated oncogene is related to tumorigenicity is presently being investigated.(ABSTRACT TRUNCATED AT 400 WORDS)

[NMR evaluation of neoplastic invasion of the pulmonary artery]

Bronchial tumors that invade the mediastinum are not necessarily inoperable. Whether surgery is possible depends, among other things, on the extent of pulmonary artery invasion. The authors have studied the value of cardiac-gated MRI and compared it with CT and venous DSA for staging tumor invasion. CT demonstrated the areas of contact between tumor and mediastinum. The MRI planes were transverse and also in the main axis of the pulmonary arteries. Twenty-one patients were studied and in 16 the findings could be checked during surgery. In all cases the findings on MRI were confirmed. In eight patients MRI provided more information than CT and DSA combined and thereby showed its superiority for evaluating arterial invasion.

Serum leucine-enkephalin in bronchial carcinoma and its relation to tumour location

Serum concentrations of the opioid peptide leucine-enkephalin were measured by radioimmunoassay in 30 patients with histologically confirmed bronchial carcinoma and 10 control subjects. This peptide, which is present in greatest amounts in the central and autonomic nervous systems, has previously been found in bronchial neoplasms. The mean serum concentration of leucine-enkephalin was significantly greater in the patients with carcinoma (1035 pg/ml) than in the control subjects (426 pg/ml). In the 23 patients with a tumour in non-apical regions of the lung, however, the mean concentration of the peptide (422 pg/ml) did not differ significantly from that in control subjects; serum concentrations in the seven patients with an apical neoplasm (mean 3050 (range 1259-5820) pg/ml) were significantly greater than values in either the control subjects or the patients with non-apical lung tumours. All seven subjects with an apical tumour had one or more features of Horner's syndrome and the three with all four components of the syndrome had the highest serum concentrations. Serum concentrations of leucine-enkephalin were unrelated to tumour type or presence of metastatic disease. No patient had evidence of metastases in the central nervous system or adrenal glands. Raised serum concentrations of leucine-enkephalin in patients with an apical tumour probably reflect invasion of cervical sympathetic ganglia with release of the peptide into the circulation rather than elaboration of the peptide by the neoplasm.

Lymphocyte subsets in bronchoalveolar lavage fluid and in circulating blood in epidermoid bronchogenic carcinoma

Alveolar macrophages, lymphocyte and granulocyte percentages, together with OKT3+, OKT4+, OKT8+ lymphocyte subsets and OKT4+/OKT8+ ratio, were evaluated in bronchoalveolar lavage (BAL) fluid and in peripheral venous blood (PVB) of neoplastic and nonneoplastic subjects, in order to assess these aspects of immunity in neoplastic disease and to find out if the modifications in the bronchoalveolar environment are correlated to the ones in the circulation blood. BAL was performed in 30 patients undergoing fiberoptic bronchoscopy to ascertain the presence of lung cancer. Twelve of them had positive findings for epidermoid bronchogenic carcinoma, while in the remaining subjects the diagnosis was not confirmed. The 30 examined subjects were then grouped according to their smoking habit. In PVB, no significant difference was seen between neoplastic and nonneoplastic subjects, whereas in BAL the neoplastic patients showed a significant increase of lymphocytes OKT3+ and OKT8+. This tends to confirm that PVB is not a good indicator of organ immunity and may justify the reduced activity of alveolar macrophages in subjects affected by bronchogenic neoplasia. Between smokers and nonsmokers, lymphocyte subsets showed more significant differences than between neoplastic and nonneoplastic subjects (decrease of T4+ lymphocytes, increase of T8+ lymphocytes and, therefore, reduction of T4/T8 ratio); there were also scalar variations in the three groups (smokers with cancer, smokers without cancer and nonsmokers without cancer). Thus, the possible autonomous role of cigarette smoke and the presence of neoplasia in the immunity alterations of the alveolar environment with final joint effects were confirmed. These data may indicate a possible correlation between cigarette smoking, immunological alterations in BAL and the onset of bronchogenic carcinoma.

En bloc resection for bronchogenic carcinoma with chest wall invasion. Value of pre-operative radiotherapy

A small number of patients with lung cancer will have a tumour invading the chest wall. Pre-operative radiotherapy and surgical resection provide the best results in patients with Pancoast's tumours, although chest wall invasion is often considered to indicate incurability. We reviewed the outcome in 46 patients with bronchogenic carcinoma and non-apical chest wall invasion and have tried to clarify the role of adjuvant pre-operative radiotherapy. All patients underwent combined chest wall and lung resection for treatment of lung cancer which had extended grossly and microscopically into the chest wall. In this retrospective study, we identified two groups of patients, those (n = 21) who received and those (n = 25) who did not receive pre-operative radiotherapy. Curative resection had been possible in 80% of the patients. There was one early post-operative death, due to pneumonia. The survival in all 46 patients is 32% at 5 years. In the most favourable cases, those without nodal involvement and who received pre-operative radiotherapy, the 5-year survival is 56%. In our series, there was a notable difference in 5-year survival between irradiated and non-irradiated patients at every stage of disease.

[Pericardial and pulmonary vascular involvement]

Over five hundred lung resections were considered, out of a series of 1570 cases of lung cancer. Histology of resected patients resulted squamous (348), adenocarcinoma (107), large cells (21) and small cells carcinoma (37). According to Mountain staging, 41% of patients were related to stage Ist, 12% to the IInd, 40.9% to the IIInd A: in such a group, a special class T3N0M0 was considered, due to the better follow-up observed in such cases. Lobectomies and minor resections were performed in 321 cases, pneumonectomies in 192. An analysis was done of differences in Histology, staging, early mortality, complications and late results after pneumonectomy which was traditional in 117 patients and required an intrapericardial section of great vessels in 68 cases: 16 patients had some pericardial resection, specific ECG disturbances, early mortality and recurrence within five years proved to be higher in the patients who had some pericardial operation: also as far as no connection was recognized with histology, the responsibility of such results can be attributed to the stage, that in those patients required a more aggressive operation.

[Choice of examination methods in bronchial cancer]

The techniques used for the investigation of a patient with lung carcinoma are determined by the mode of presentation of the disease. The first step is based on the clinical examination and the chest X-ray (frontal and lateral view). The pathological examination of the tumor represents the second step. Depending on the operability of the patient at this stage of the investigation, further evaluation will (or will not) be performed to determine the extension of the tumor, using TNM staging system. Any candidate for surgery has to be bronchoscoped in order to evaluate the endobronchial spread of the tumor and to look for additional lesions. Transverse tomography of the thorax is the central part of any staging procedure. The choice among the other methods of investigation depends on the site of the tumor in the thorax. Mediastinoscopy is only needed in case of a lesion of unknown nature located in the anterior mediastinum or in addition to CT scan when there is a suspicion of mediastinal involvement. Transthoracic needle aspiration is best performed on peripheral lesions. In small cell lung carcinoma, the preoperative work-up should be very systematic even in the absence of clinical or laboratory abnormality. Whereas in certain cases the investigation of a patient with lung carcinoma can be limited to a clinical examination and a chest X-ray, any candidate for surgery has to be submitted to a detailed TNM staging.

Bronchial stump recurrence after surgery for bronchial carcinoma

In 10 out of 295 patients (3.4%), followed-up after radical resection for non-small cell bronchial carcinoma in the period from 1980 until 1986, bronchial stump recurrence developed. A good relationship was found between relapse time (4-52 months) and distance between the primary tumour and bronchial resection line (1-7 cm) (i.e. 5-8 months.cm-1) in 8 of the patients (p less than 0.01). The mean survival time after detection of the recurrence was 10 months (range 1-15 months), and was not clearly influenced by the therapy applied (resurgery, chemotherapy, radiation), nor by the TNM stage of the bronchial stump recurrence.

Computed tomography and the TNM classification of lung cancer

Computed tomography (CT) of the thorax and upper abdomen was prospectively evaluated in 84 patients with potentially operable lung cancer. Invasion into the thoracic wall and the mediastinal structures was not accurately demonstrated by CT. For metastatic mediastinal lymph nodes, the sensitivity and specificity of CT were, respectively, 86% and 61% and the positive and negative predictive indices 49% and 91%. For T1, T2 and T3 tumours the negative indices were 100%, 96% and 71%. Positive predictive index did not differ between squamous cell carcinoma and adenocarcinoma. Adrenal metastases were CT-suspected in 17 cases and liver metastases in eight, but were verified by ultrasonography in only one and four cases. CT should be used in preoperative investigation of lung cancer, irrespective of stage. Demonstration of thoracic-wall or mediastinal invasion need not exclude tumour resection. Preoperative mediastinoscopy is indicated if CT shows nodal metastases or if there are signs of tumour invasion, but not in CT-negative T1 or T2 tumour. Abdominal metastases indicated by CT should be investigated with CT-guided needle biopsy.

Isoenzyme(s) of glutathione transferase (class Mu) as a marker for the susceptibility to lung cancer: a follow up study

Glutathione transferase are divided into three classes: Alpha, Mu and Pi. Isoenzyme(s) from one of these classes, class Mu, is dominantly inherited and can be determined by activity measurements directed towards the substrate trans-stilbene oxide. The frequency of this phenotype has been measured in patients with bronchial carcinoma and in control subjects matched for age and smoking history. After combining an earlier study from our laboratory (Carcinogenesis, 7, 751-753, 1986) with the additional material presented here (control smokers, n = 114, lung cancers, n = 125) non-cancer smokers had an increased number of subjects who expressed class Mu isoenzymes (58.3% of total n = 192) compared with lung cancer patients (36.6% of total n = 191; P less than 0.0001). The pathology of lung tumors related to the lack of class Mu isoenzymes which occurred most frequently in patients with adenocarcinomas. It is concluded that the gene expressing class Mu isoenzymes may be a host determinant of genetic susceptibility to lung cancer among smokers.

[Bronchus cancer: pathologic-anatomic principles]

The various types of bronchial carcinoma are derived from pluripotent precursor cells of the respiratory epithelium. The direction of tumor differentiation depends on the locus of the genic mutation and therefore on the cancerogenic substance, on epigenetic gene amplification, and on autocrine regulations of the tumor cell population. The growth rate is the resultant of cell proliferation and cell loss by apoptosis. The formation of metastasis is determined by surface properties and implantation ability of the tumor cells. Age and state of lymph nodes are only loosely correlated with the biological behaviour of the tumors. It is possible to check the proliferative capacity of an individual tumor by immunocytochemistry and cytophotometry before any operative therapy. The extend of the preneoplastic lesions of the bronchial epithelium outside of the bronchial tumor, however, remains unknown. This explains why programs of early detection of bronchial cancer could not really improve long time survival and why surgical resection remain a palliative measure in most if not all cases.