Roentgenographically occult lung cancer

The influence of lung cancer mass screening on surgical results

BACKGROUND

After the introduction of the mass screening program for lung cancer, the number of patients detected by mass screening increased as well as the number of early staged patients. Therefore, we examined the influence of lung cancer mass screening on surgical results.

METHODS

A total of 1177 primary lung cancer cases, who underwent surgery from 1963 to 1992, were retrospectively reviewed. They were grouped according to the changes in the mass screening system: the first period (1963-1977) before lung cancer screening started, the second period (1978-1986) when mass screening was conducted by the local government, and the third period (1987-1992) after the launching of the national screening program.

RESULTS

The rate of cases detected by mass screening increased over time and the 5-year survival rate improved significantly, from 33.7% in the first period, to 51.8% in the second period and finally, to 58.4% in the third period. The improvement is attributable to a relative increase of rate of stage I cases and better stage I survival rate. Specifically, in stage I cases, improvement resulted from a relative increase of stage IA in peripheral type and roentgenographically occult lung cancer cases and from better survival rate of these two groups.

CONCLUSION

As lung cancer screening has come into widespread use, detection of peripheral small-sized lung cancer and roentgenographically occult lung cancer have increased and consequently, surgical results have improved.

Early diagnosis of lung cancer

Recent advances in computer-assisted image analysis, tumor biology, PCR-based assays, fluorescence bronchoscopy, spiral CT, endobronchial treatment modalities, and chemoprevention make it possible to re-examine the strategy of early detection in the comprehensive management of lung cancer.

A case of long-term survival with stage IV small cell lung cancer and early-stage central-type squamous cell lung cancer treated by photodynamic therapy

The present report is on a 67-year-old man with stage IV small cell lung cancer and early-stage centrally located squamous cell cancer of the lung. He was diagnosed as small cell lung cancer with multiple metastasis to the ipsilateral lung and was found to have a central-type early-stage squamous cell cancer by bronchoscope. After obtaining a complete response to the small cell lung cancer with chemotherapy and radiotherapy, photodynamic therapy was applied to the squamous cell carcinoma, resulting in complete disappearance of the tumor. Recurrence of small cell cancer occurred at the ipsilateral lung and this patient died of small cell cancer 8 years after initiation of treatment. Post mortem examination confirmed complete disappearance of squamous cell cancer treated by photodynamic therapy. This is a rare case of long-term survival with stage IV small cell lung cancer and early-stage central-type squamous cell lung cancer successfully treated by photodynamic therapy.

Localization of bronchial intraepithelial neoplastic lesions by fluorescence bronchoscopy

BACKGROUND

In the treatment of lung cancer, the best outcome is achieved when the lesion is discovered in the intraepithelial (preinvasive) stage. However, intraepithelial neoplastic lesions are difficult to localize by conventional white-light bronchoscopy (WLB).

OBJECTIVE

To determine if autofluorescence bronchoscopy, when used as an adjunct to WLB, could improve the bronchoscopist's ability to locate and remove biopsy specimens from areas suspicious of intraepithelial neoplasia as compared with WLB alone.

METHOD

A multicenter clinical trial was conducted in seven institutions in the United States and Canada. WLB followed by fluorescence examination with the light-induced fluorescence endoscopy (LIFE) device was performed in 173 subjects known or suspected to have lung cancer. Biopsy specimens were taken from all areas suspicious of moderate dysplasia or worse on WLB and/or LIFE examination. In addition, random biopsy specimens were also taken from other parts of the bronchial tree.

RESULTS

The relative sensitivity of WLB + LIFE vs WLB alone was 6.3 for intraepithelial neoplastic lesions and 2.71 when invasive carcinomas were also included. The positive predictive value was 0.33 and 0.39 and the negative predictive value was 0.89 and 0.83, respectively, for WLB+LIFE and WLB alone.

CONCLUSION

Autofluorescence bronchoscopy, when used as an adjunct to standard WLB, enhances the bronchoscopist's ability to localize small neoplastic lesions, especially intraepithelial lesions that may have significant implication in the management of lung cancer in the future.

Photodynamic therapy for early stage squamous cell carcinoma of the lung

OBJECTIVE

To study the effectiveness of photodynamic therapy (PDT) as a therapeutic strategy in roentgenographically occult squamous cell carcinoma of the lung.

MATERIAL AND METHODS

A carefully selected group of 21 patients (with 23 cancers) who had early stage squamous cell carcinoma of the lung and were eligible for surgical treatment were offered PDT as an alternative to resection. Patients underwent close follow-up with bronchoscopic surveillance and were offered resection if cancer persisted after no more than two sessions of PDT.

RESULTS

A complete response was identified in 15 patients (16 cancers) after an initial PDT session. A complete response that lasted longer than 12 months was noted in 11 patients (52%). After PDT, the minimal follow-up period was 24 months. A subsequent primary lung cancer developed in 5 of the 21 patients (24%). Ten patients ultimately had surgical treatment, in 3 (30%) of whom N1 disease was identified at the time of resection. Two patients refused a surgical procedure and received alternative therapy. Therefore, nine patients (43%) were spared an operation (95% confidence interval, 21.8 to 66.6%). The mean duration of follow-up for these nine patients was 68 months (range, 24 to 116).

CONCLUSION

On the basis of this investigation, we can conclude with 95% confidence that at least 22% of patients with early stage squamous cell lung cancer who are candidates for PDT can be spared surgical resection.

Histopathologic diagnosis made in lung tissue resected from patients with severe emphysema undergoing lung volume reduction surgery

STUDY OBJECTIVES

This study reports histopathologic findings in a group of emphysema patients who underwent thoracoscopic lung volume reduction surgery (75) or sternotomy (five) with the purpose to induce functional improvement and relief of dyspnea. Immediate outcome and complications were correlated to histologic patterns.

DESIGN

Histopathologic material obtained in lung volume reduction surgery in 80 consecutive patients was analyzed. Thirty patients who had other histopathologic diagnoses in addition to emphysema were grouped and compared with 50 patients found to have emphysema exclusively. Postoperative outcome and preoperative lung function variables were compared.

MEASUREMENTS AND RESULTS

All patients had severe obstructive lung disease and significant air trapping preoperatively documented by pulmonary function testing. All had severe exertional dyspnea. All had chest radiographs, CT, and nuclear medicine lung scans consistent only with emphysema. All portions of resected lung tissue were weighed, lung volume was estimated, and routine histopathologic studies were made. Thirty patients (37.5%) had unsuspected findings such as interstitial fibrosis, noncaseating granulomatosis, chronic inflammation, and unsuspected neoplasia (three carcinomas, one carcinoid). Retrospective review of imaging studies in these patients failed to show infiltrative processes. The average lung weight resected in this group was significantly heavier (65+/-18 g) compared with the other group (56+/-13 g), although both had the same estimated lung volume. Average number of days requiring chest tubes and length of hospitalization was also significantly higher (12.8+/-19 vs 6.4+/-5 days with chest tubes and 17.4+/-22 vs 8.5+/-6 days of hospitalization, respectively). None of the preoperative pulmonary function tests variables were different between the two groups. Serious postoperative complications were more frequent in these patients compared with those who showed only emphysema.

CONCLUSIONS

A significant portion of patients diagnosed as having severe emphysema will have other unsuspected histologic findings. When subjected to lung volume reduction surgery, this subgroup will have more serious complications and longer periods of air leaks, requiring longer hospitalization time. Retrospective review of imaging studies and preoperative pulmonary function tests used to select patients for lung volume reduction failed to identify this subgroup.

Synchronous and metachronous multicentric squamous cell carcinomas in the upper aerodigestive tract

A rare case is presented of a 57-year-old Japanese male with synchronous and metachronous multicentric squamous cell carcinomas (SCC) in the upper aerodigestive tract. During a 9-year-period from the appearance of first primary SCC to autopsy, 14 foci of primary SCC and one severe dysplasia developed in succession in the thoracic esophagus, oral floor, soft palate, uvula, lingual radix, piriform recess, hypopharynx, cervical esophagus, trachea and lingual body. The patient died of severe bronchopneumonia due to Gram-negative bacterial infection that developed as a result of recurrent nerve paralysis. Human papilloma virus and Epstein-Barr virus, which are risk factors, were not detected by immunohistochemistry or by the polymerase chain reaction method. Genetic analysis revealed the absence of point mutations in K-ras codon 12. Heavy consumption of alcohol and excessive smoking may have been responsible for the multicentric carcinogenesis. This is the first case report in the literature of the development of so many primary SCC lesions in the upper aerodigestive tract during such a short period.

Roentgenographically occult small-cell lung cancer: case report and review of the literature

This report describes a rare case of roentgenographically occult small-cell lung cancer in a 73-year-old man with hemoptysis. Fiberoptic bronchoscopy disclosed a 5-mm dome-shaped lesion; a biopsy established the diagnosis of small-cell lung cancer. The patient received a combination of chemotherapy and radiotherapy. More than 10 years later, he is still alive without recurrent disease. A review of the literature of roentgenographically occult small-cell lung cancer revealed the following: (1) a history of heavy smoking was common; (2) double primary bronchogenic carcinoma was noted; (3) hemoptysis or bloody sputum was an initial common symptom; (4) the sensitivity of sputum cytologic analysis was relatively low; (5) the tumor, which was shiny, smooth, and covered with bronchial epithelium, was often located at the bifurcation; and (6) lymph node metastatic involvement occurred.

Treatment of roentogenographically occult endobronchial carcinoma with external beam radiotherapy and intraluminal low dose rate brachytherapy

PURPOSE

A prospective Phase II study was done to investigate the treatment results of combined external beam and intraluminal radiotherapy in roentogenographically occult inoperable endobronchial carcinoma.

METHODS AND MATERIALS

In 41 patients (all male) with roentogenographically occult endobronchial carcinoma, a combination of external beam radiotherapy using linac x-ray and intraluminal low dose rate brachytherapy via 192Ir thin wire (1.48 GBq) was performed. External beam radiotherapy comprised of 40 Gy in 20 fractions over 4 weeks was carried out, whereas intraluminal brachytherapy consisted of 25 Gy in five fractions over 2.5-5 weeks. The dose reference point for brachytherapy varied (3-9 mm) according to a diameter of the bronchus.

RESULTS

Excluding two cases in which bronchoscopy was refused (1) and was still being treatment (1), 39 patients were treated according to plan. By the last intraluminal brachytherapy, no tumor was endoscopically identifiable in all cases. The follow-up period ranged from 1-41 months, with a median of 24.5 months. Recurrence occurred in two cases, with subsequent surgery: one is alive without cancer and the other died of uncontrolled lung cancer at 35 months. Radiation pneumonitis was observed in two cases for whom glucocorticoid and antibiotics were administered. Both recovered and resumed work. Other recurrences or severe complications from irradiation have not been observed so far. Two or more separate primary cancers were observed in 19 (lung, 10; other organs, 10) of the 41 patients.

CONCLUSIONS

The combination treatment of external beam radiotherapy and intraluminal brachytherapy is effective for roentogenographically occult endobronchial carcinoma with acceptable complications.

Treatment of multiple primary squamous cell carcinomas of the lung

BACKGROUND

The prevalence of multiple primary bronchogenic cancers, especially squamous cell carcinoma, has been increasing as a result of improvements in early detection and cancer therapy.

MATERIALS

We treated 14 patients with multiple squamous cell carcinoma of the tracheobronchial tree and lung, which corresponded to 2.3% of all squamous cell carcinoma patients undergoing resection.

RESULTS

Two patients had peripheral secondary tumors and underwent segmentectomy or partial resection of the lung with good results. The secondary lesions were superficial and minute (less than 5 mm) in 3 patients, and treated with neodymium-yttrium aluminum garnet laser ablation. Five patients had endobronchial tumors of the nodular or polypoid type with suspected deep invasion or invasion extending beyond the bronchial wall based on the bronchoscopic findings. They underwent parenchymal-sparing limited bronchoplasty with excellent results. Three patients had more advanced tumor with massive invasion outside the bronchial wall without lymph node metastases, 1 patient underwent sleeve lobectomy with long survival, and the other 2 patients without operation died of bleeding or had recurrence. One patient with stage IIIA (T2 N2) secondary cancer who underwent lobectomy died 14 months after the second operation.

CONCLUSIONS

The surgical treatment of multiple squamous cell carcinoma is justified and limited operation using bronchoplastic techniques provides superior results.

Endoscopic criteria of early squamous cell carcinoma of the bronchus

BACKGROUND

Early lung cancer, not extending beyond the bronchial cartilaginous layer without regional lymph node involvement is considered curable by endoscopic laser therapy or limited surgery. The endoscopic criteria for early squamous cell carcinoma of the bronchus, however, have not yet been determined.

METHODS

For 44 resected lesions of roentgenographically occult bronchogenic squamous cell carcinomas, the relationship between endoscopic findings and the degree of histologic extent of tumor was examined.

RESULTS

The lesions were divided into three types: polypoid or nodular (PN), flatly spreading (FS), and mixed. Thirty-three lesions arising from the central bronchus included 7, 19, and 7 of the PN, FS, and mixed types, respectively. In the central lesions, the degree of transmural invasion and the greatest dimension correlated, but the degree of intramural invasion of PN-type lesions was higher than that of the FS type. The PN-type lesions smaller than 10 mm and the FS type smaller than 15 mm in greatest dimension were found within the cartilaginous layer without regional lymph node involvement. All lesions of the mixed type were larger than 20 mm. Three of the lesions larger than 20 mm had regional lymph node involvement. All 11 lesions originating in the peripheral bronchus were of the FS type, and a lesion of only 5 mm in greatest dimension had extracartilaginous invasion.

CONCLUSIONS

The endoscopic criteria of early squamous cell carcinoma of the bronchus may be applied to central PN lesions smaller than 10 mm and central FS lesions less than 15 mm in greatest dimension. Any lesions of mixed type should be excluded from the criteria.

Multicentricity in resected occult bronchogenic squamous cell carcinoma

The frequency and the treatment of multicentricity in 127 patients with resected roentgenographically occult bronchogenic squamous cell carcinoma were studied. The cumulative rate and the incidence of postoperative metachronous multiple primary lung cancer were 0.11 at 5 years after initial operation and 0.022 per patient-year, respectively. The cumulative rate and the incidence of second primary lung cancer, which includes synchronous and subsequent metachronous cancer in patients with initial lung cancer, were 0.17 at 5 years after the initial operation and 0.041 per patient-year, respectively. The cumulative rate and the incidence of third primary lung cancer in patients with second primary lung cancer were 0.47 at 5 years, which was significantly higher (p = 0.05) than that of second primary lung cancer, and 0.11 per patient-year, respectively. In all 12 patients with synchronous multiple primary lung cancer, no recurrence was observed after treatment, but 3 had subsequent multiple primary lung cancer. Among the 13 patients with postoperative metachronous multiple primary lung cancer, recurrence was observed in 1 of the 6 patients who underwent resection and in 2 of the 4 patients treated with laser or radiation therapy or both. The overall survival rate at 5 years after initial operation in patients with solitary and those with multicentric occult bronchogenic squamous cell carcinomas was 0.90 and 0.59, respectively.

Detection and sequencing of p53 gene mutations in bronchial biopsy samples in patients with lung cancer

We demonstrated the feasibility of detection of p53 gene mutations in bronchial biopsy samples from patients with lung cancer. Following DNA extraction from two to three pieces of bronchial tissue obtained by fiberoptic bronchoscopy, p53 gene mutations were screened using polymerase chain reaction/single-strand conformation polymorphism technique. We examined four bronchial biopsy specimens from patients with squamous cell carcinoma of the lung and detected one point mutation at codon 130 (C to G, Leu to Val). This technique will be very useful for studies on early detection of lung cancers or for an analysis of a suspected premalignant lesion. Furthermore, this technique enables us to know the status of oncogene or tumor suppressor gene at the time of diagnosis, which may be very useful for a treatment of patients with cancer in the not too distant future.

Ancillary therapies in the management of lung cancer: photodynamic therapy, laser therapy, and endobronchial prosthetic devices

Endoscopic therapy for cancer that involves the tracheobronchial tree is currently available for two distinct types of lesions: radiographically occult superficial squamous cell carcinoma and advanced malignant tumors that cause severe airway obstruction. Photodynamic therapy, which uses a photosensitizing agent, is effective for managing early superficial squamous cell carcinoma. Neodymium:yttrium-aluminum-garnet laser therapy has been effective in the palliative management of patients with advanced or recurrent malignant obstructive airway lesions, either alone or in combination with intraluminal radiation therapy. Most recently, endobronchial prosthetic devices (stents) have been used in patients with advanced airway obstruction. The use of each of these modalities in the management of lung cancer is reviewed.

Detection and localization of early lung cancer by imaging techniques

Two new technologic developments may have a significant impact on the detection and localization of early lung cancer. These two developments work together in a complementary way. The first is a solid-state microscope that can be applied in the prescreening of sputum cytology specimens. The finding that malignancy-associated changes (MACs) are present in ostensibly normal bronchial epithelial cells may be used to improve the sensitivity of sputum cytology to detect cancer. Once abnormal or MAC cells are found, a second device, a fluorescence bronchoscope, can be employed to localize the source of the abnormal cells. Fluorescence bronchoscopy is also a potentially useful tool for procuring premalignant tissue for molecular biology studies and for monitoring the progress of patients in chemoprevention studies.

Photodynamic therapy in the management of early superficial squamous cell carcinoma as an alternative to surgical resection

Photodynamic therapy has been used since 1980 at our institution for the management of cancer of the tracheobronchial tree. We identified 13 patients (14 cancers) who were thought to be surgical candidates but who elected to have photodynamic therapy. Thirteen cancers (93 percent) had a complete response to hematoporphyrin-derivative phototherapy. Ten cancers (71 percent) showed a complete response after single treatment, and three (21 percent) required a second course of therapy to achieve a complete response. Ten (77 percent) of 13 cancers have shown no local recurrence. Three patients with persistent cancer underwent surgical resection and were found not to have nodal involvement. We concluded that photodynamic therapy is an alternative to surgical resection in the management of early superficial squamous cell carcinoma.

Early hilar lung cancer: its clinical aspect

Early hilar lung cancers are rare, but are curable if they are properly diagnosed and treated. In the past 14 years, we have treated 27 patients with early hilar cancers that fulfilled the criteria proposed by the Japanese Lung Cancer Society (JLCS). Eighteen patients presented with symptoms and 9 were detected by the mass screening examination of sputum cytology. All lesions in both groups were finally diagnosed by bronchoscopy. Twenty patients (74%) had positive sputum cytology, whereas only 7 (26%) had positive chest X-ray findings. All the patients underwent surgery, and bronchoplasty was the most frequent operative procedure. The 5-year survival rate was 100%, and the 10-year survival rate was 91.7%, as one patient died of a second primary lung cancer in the 6th postoperative year. In conclusion, the definition of early hilar lung cancer proposed by the JLCS is thought to be reasonable, and early hilar lung cancer is a curable disease, if it is properly diagnosed and treated.

Localization of occult bronchogenic carcinoma by bronchography

Bronchography is seldom recommended today to localize radiographically and bronchoscopically occult bronchogenic carcinoma. We report a case in which bronchography promptly localized such a tumor that had been occult to multiple bronchoscopies and chest computed tomograms (CTs). The patient is free of recurrence 32 months after lobectomy. Bronchography should be considered when bronchoscopies and CT fail to reveal a radiographically occult carcinoma.

Non-small cell lung cancer. Part I: Biology, diagnosis, and staging

Squamous, large cell, and adenocarcinoma, collectively termed non-small cell lung cancer (NSCLC), are diagnosed in approximately 75% of patients with lung cancer in the United States. The treatment of these three tumor cell types is approached in virtually identical fashion because, in contrast to small cell carcinoma of the lung, NSCLC more frequently presents with localized disease at the time of diagnosis and is thus more often amenable to surgical resection but less frequently responds to chemotherapy and irradiation. Cigarette smoking is etiologically related to the development of NSCLC in the great majority of cases. Genetic mutations in dominant oncogenes such as K-ras, loss of genetic material on chromosomes 3p, 11p, and 17p, and deletions or mutations in tumor suppressor genes such as rb and p53 have been documented in NSCLC tumors and tumor cell lines. NSCLC is diagnosed because of symptoms related to the primary tumor or regional or distant metastases, as an incidental finding on chest radiograph, or rarely because of a paraneoplastic syndrome such as hypercalcemia or hypertrophic pulmonary osteoarthropathy. Screening smokers with periodic chest radiographs and sputum cytologic examination has not been shown to reduce mortality. The diagnosis of NSCLC is usually established by fiberoptic bronchoscopy or percutaneous fine-needle aspiration, by biopsy of a regional or distant metastatic site, or at the time of thoracotomy. Pathologically, NSCLC arises in a setting of bronchial mucosal metaplasia and dysplasia that progressively increase over time. Squamous carcinoma more often presents as a central endobronchial lesion, while large cell and adenocarcinoma have a tendency to arise in the lung periphery and invade the pleura. Once the diagnosis is made, the extent of tumor dissemination is determined. Since most NSCLC patients who survive 5 years or longer have undergone surgical resection of their cancers, the focus of the staging process is to determine whether the patient is a candidate for thoracotomy with curative intent. The dominant prognostic factors in NSCLC are extent of tumor dissemination, ambulatory or performance status, and degree of weight loss. Stages I and II NSCLC, which are confined within the pleural reflection, are managed by surgical resection whenever possible, with approximate 5-year survival of 45% and 25%, respectively. Patients with stage IIIa cancers, in which the primary tumor has extended through the pleura or metastasized to ipsilateral or subcarinal lymph nodes, can occasionally be surgically resected but are often managed with definitive thoracic irradiation and have 5-year survival of approximately 15%.(ABSTRACT TRUNCATED AT 400 WORDS)

Detection of early lung cancer using low dose Photofrin II

Fluorescence imaging using hematoporphyrin derivative (HpD) or Photofrin II as a tumor marker has been used for localization of early bronchogenic carcinoma. Wider clinical application of HpD or Photofrin II as a cancer imaging agent has been hampered by the potentially serious and prolonged skin photosensitivity. Using a sensitive fluorescence bronchoscope system with a ratio fluorometer probe, carcinoma in situ was detected in four patients with low dose Photofrin II (0.25 mg/kg) with no apparent skin phototoxicity to 30 J/cm2 visible light on skin photosensitivity test.

Diagnosis of squamous-cell carcinoma of the lung by sputum cytology: with special reference to correlation of diagnostic accuracy with size and proximal extent of resected tumor

Sputum cytology was performed in 179 cases of squamous-cell carcinoma of the lung; 134 cases were diagnosed as positive. There were no significant differences in diagnostic accuracy of sputum cytology between tumors sizes. In cases with tumors extending proximally into the main, lobar, or segmental bronchi, the diagnostic accuracy of sputum cytology was significantly higher than in cases where the proximal invasion of tumor was limited to the peripheral bronchi. In cases with tumors 3 cm or less in diameter, when tumors extended proximally into main, lobar, or segmental bronchi, the diagnostic accuracy of sputum cytology was significantly higher than in cases with tumors extending proximally into subsegmental or subsubsegmental bronchi. In peripherally located squamous-cell carcinoma, in cases in which the tumor arose in subsegmental or subsubsegmental bronchi, carcinoma could be detected by sputum cytology even when it was roentgenographically occult.

Bronchoscopic localization and treatment of occult lung cancer

The flexible fiberoptic bronchoscope is currently the standard tool for localization of radiographically occult carcinomas of the tracheobronchial tree. It allows direct inspection of proximal airways and can establish the location of most occult lung cancers. A small percentage of patients present with bronchoscopically as well as radiographically occult carcinoma, particularly challenging because definitive localizations is required before a therapeutic plan can be outlined. Selective cytologic brushing of each lobar segment, taking random biopsy specimens, has been used to assist in localization of these early cancers. Recently, fluorescent compounds have been used to assist in localizing early lung cancers and in the treatment of radiographically occult carcinoma. We review the current methods of bronchoscopic localization and treatment of radiographically occult lung cancer.

The development of small cell lung cancer in the contralateral lung of a patient surviving 8 years after the original diagnosis of small cell lung cancer

The development of non-small cell lung cancer in patients successfully treated for small cell lung cancer has been previously described. Many of these non-small cell tumors appear to be second primary lung tumors. However, the development of second primary small cell lung cancers has not been clearly delineated. In this report, a patient with limited stage small cell lung cancer who had a complete response to chemotherapy plus chest radiotherapy and remained cancer-free for 8 years is described. Small cell lung cancer developed in this patient's contralateral lung with no evidence of recurrence at the original primary site. Clinical evidence suggests that a second primary small cell lung cancer developed in this patient.

Management of malignant airway compromise with laser and low dose rate brachytherapy. The Mayo Clinic experience

Between January 1983 and October 1985, 65 patients with malignant airway compromise have had 93 flexible bronchoscopic placements of a nylon afterloading catheter for low dose rate iridium-192 temporary intraluminal brachytherapy. All patients received prior (59 patients) and/or concurrent (13 patients) external beam irradiation to "tolerance" and were not candidates for surgery. Forty of these patients also received neodymium-YAG laser treatment prior to brachytherapy in a planned combined approach to provide immediate symptomatic relief and facilitate catheter placement. A dose of 3,000 cGy is prescribed to 5 mm and 10 mm radii over 20-40 hours in the bronchus and trachea, respectively. Of 59 patients treated with palliative intent, 40 patients (68 percent) have had follow-up bronchoscopy, 18 patients have had clinical follow-up only, and one patient was lost to follow-up. Of 40 patients examined by bronchoscope in follow-up, 24 (60 percent) responded, eight were stable, and eight progressed. Lack of progression after prior external beam radiation for periods of greater than 12 months, six-12 months and less than six months yielded response rates to brachytherapy in 83 percent, 50 percent and 31 percent, respectively. Most patients with clinical follow-up only expired at early intervals with airway palliation from extra-airway disease progression. Four of five patients treated with curative intent are disease-free at a median of 16 months. Eleven patients have experienced fistula and/or hemorrhage, of which seven instances (11 percent of all patients) appear to be treatment-induced. This brachytherapy technique is simple, well tolerated, and convenient for the patient providing airway palliation in the significant majority of patients with acceptable risk.

Predictive value of sputum cytology

A 60 year old woman non-smoker with bronchial asthma of 6 years' duration, treated with aminophylline, salbutamol, and oral corticosteroids, was admitted because of increasing dyspnoea and productive cough. On examination she was in moderate respiratory distress with inspiratory and expiratory wheezes. Her chest radiograph was interpreted as normal. Two consecutive sputum examinations requested by a junior doctor reveal "malignant" cells.

Bronchoscopic phototherapy with hematoporphyrin derivative for treatment of localized bronchogenic carcinoma: a 5-year experience

Between December 1980 and April 1986 at our institution, 38 patients with cancer that involved the tracheobronchial tree (a total of 40 carcinomas) completed at least one course of hematoporphyrin derivative phototherapy. A complete response occurred in 13 patients (with 14 carcinomas). Eleven of these carcinomas did not recur during follow-up periods that ranged from 3 to 53 months. Three carcinomas recurred at 9, 12, and 35 months, respectively. For 26 carcinomas, the response was less than complete, and alternative therapy was necessary. The carcinomas in patients with a complete response were radiographically occult, were less than 3 cm2 in surface area, and appeared superficial at bronchoscopy. Our experience supports the use of hematoporphyrin derivative phototherapy as an alternative to surgical resection in carefully selected patients.

Computed chest tomography in the evaluation of hemoptysis. Impact on diagnosis and treatment

The results of computed chest tomograms (CT) and chest roentgenograms (CR) were compared in 32 patients who presented with hemoptysis. The CT demonstrated roentgenographic abnormalities more often than CR (p less than 0.01), providing new diagnostic information in 15 patients (46.9 percent), and clarifying CR abnormalities in five (15.6 percent) others. In addition, CT correctly localized sources of bleeding in 23 (88.5 percent) of the 26 patients in whom a site was identified at bronchoscopy, while CR localization was correct in 17 (65.4 percent) (p less than 0.05). Despite this augmentation of roentgenographic yield, information derived from CT scans influenced the management of only six patients, did not obviate the need for bronchoscopy, and supplemented the combined diagnostic yield of CR and bronchoscopy in only two. Outcome was changed in one patient in whom CT had demonstrated an otherwise unrecognized malignant solitary pulmonary nodule. The chest roentgenogram and fiberoptic bronchoscopy provided all the information essential for diagnosis and therapeutic recommendations in 93.7 percent of these patients. Although the CT provided additional information in over one half of our patients, its overall impact on clinical management was small and does not support routine use of this imaging procedure in evaluation of hemoptysis. The possible role of chest CT in evaluating carefully selected patients with hemoptysis requires further study.

Non-small-cell lung cancer. Major cause of late mortality in patients with small cell lung cancer

Among 360 patients with small cell lung cancer treated in National Cancer Institute therapeutic trials from 1973 to 1982, 40 were two-year cancer-free survivors. Of these 40 patients, six had later development of non-small-cell lung cancer at 3.5 to 8.0 years (median 5.1) after the diagnosis of small cell lung cancer. Three had the second malignant tumor in the contralateral lung, one in a different lobe, and two in the same lobe as the initial small cell lung cancer. Ten patients had relapses of small cell lung cancer at 2.1 to 6.2 years (median 3.2) from diagnosis. Three recurrences were in the same site or lobe as the initial lesion, four in the same lobe and in sites outside the thorax, and three solely in sites outside the thorax. It is concluded that these non-small-cell lung cancers usually represent second primary lung tumors and that most late small cell lung cancers represent relapses occurring up to 6.2 years from diagnosis. In this study, the risk of development of non-small-cell lung cancer after two years of disease-free survival following small cell lung cancer is 4.4 percent per person-year, approximately 10 times higher than the rate of 0.5 percent previously determined in screening studies of men at high risk for lung cancer. Non-small-cell lung cancer represents more than a third of lung cancer deaths in patients with small cell lung cancer surviving beyond two years from diagnosis and more than half of lung cancer deaths beyond three years. It is recommended that all patients treated for small cell lung cancer discontinue smoking.

Endobronchial management of lung cancer

Bronchoscopic phototherapy is available now for 2 distinct categories of tracheobronchial cancer: roentgenographically occult superficial squamous cell carcinoma and advanced malignancy causing significant airway obstruction. Laboratory and clinical experience show that the photodynamic effect of hematoporphyrin derivative phototherapy (HpD-PT) may be useful for treating superficial cancers that penetrate less than 5 mm into bronchial mucosa. The larger, obstructing cancers are better managed by high-power laser sources, such as the YAG laser, which are effective by hyperthermal photocoagulation, thermal necrosis, and tissue vaporization.

Photodynamic therapy with hematoporphyrin derivative in cancer of the upper gastrointestinal tract

An historical overview is given of the development of photodynamic therapy (PDT) with hematoporphyrin derivative for the treatment of malignant tumors. Results in patients with superficial, and non-superficial esophageal cancer and with early gastric cancer is described, with case illustrations and follow-up. Due to the difficulty in early stage diagnoses and in determining all cases of lymph node involvement, this form of treatment should be employed primarily in inoperable early-stage cancer, to reduce the extent of resection, or to render previously inoperable cases operable. Combination with other treatment modalities and the effects of PDT on histologically different tumor types, need to be further examined.

Postsurgical stage I bronchogenic carcinoma: morbid implications of recurrent disease

Three hundred forty-six patients with post-surgical non-small cell Stage I bronchogenic carcinoma were followed from 5.0 to 10.8 years (median, 7.0 years). Recurrent cancer developed in 135 patients (39%). Seventy-five recurrences were nonregional metastases (55.6%); 35 (25.9%), a subsequent primary lung cancer; and 25 (18.5%), local recurrence only. The rate of recurrent lung cancer decreased from 15.0 patients per 100 patient-years the first postoperative year to 2.3 the seventh and subsequent years. The rate of recurrence varied among the three different types of recurrent cancer. Five years after pulmonary resection, 70.0% of patients with T1 N0 neoplasms had no evidence of recurrence compared with 58.2% of patients with T2 N0 tumors (p = 0.012) and only 31.8% of patients with T1 N1 neoplasms (p less than 0.001). There was no significant difference in overall rate of recurrence among the various cell types. Currently, 174 patients are alive. Lung cancer survival (Kaplan-Meier) was 69.1% at 5 years and 61.9% at 9 years. At 2 years following detection of subsequent lung cancer, 51.8% of patients with subsequent primary lung cancer had survived lung cancer compared with 23.4% for those with local recurrence and only 8.9% for those with nonregional metastases.