Relative accuracy of diagnostic method in bronchogenic carcinoma

Effective use of bronchoscopy and sputa in the diagnosis of lung cancer

The records of 134 patients who underwent bronchoscopy at the Forbes Health System hospitals between January 1, 1982 and December 31, 1983 were reviewed. The number of pre- and postbronchoscopy sputa obtained on each patient, final diagnosis, and follow-up for 6 to 30 months were obtained. Tissue obtained at bronchoscopy yielded a diagnosis of malignancy in 71 of 84 (84.5%) patients who received that final diagnosis. Addition of postbronchoscopy sputa examination increased the yield to 73 of 84 (86.9%). Prebronchoscopy sputa contributed no diagnoses beyond those made by bronchoscopically obtained material. The cost to the patient of examining pre- and postbronchoscopy sputa in addition to bronchoscopically obtained cytologic and biopsy material is 70% higher than that of examining bronchoscopically obtained material alone. Indirect costs of increased hospital stay may also be significant. We propose early bronchoscopy without prebronchoscopy sputa in cases where there is clinical suspicion of lung cancer. Postbronchoscopy sputa should be obtained, but only processed for microscopic examination if the bronchoscopically obtained material does not yield a diagnosis.

Major pulmonary resection for suspected but unconfirmed malignancy

Thoracotomy is not infrequently performed in patients with suspected pulmonary carcinoma but with no histological or cytological confirmation of malignancy. The intraoperative decision to proceed with major pulmonary resection (lobectomy or pneumonectomy) is difficult if a large or central lesion precludes total excisional biopsy. Incisional or needle biopsies violate the principles of good cancer surgery, and the results may be inconclusive if the tumor is missed and areas of associated inflammation or necrosis are sampled. Between January 1, 1970, and December 31, 1980, 303 patients underwent thoracotomy for suspected but unconfirmed malignancy. One hundred twenty-two had a minor resection only, 79 had a major resection (lobectomy or pneumonectomy) after a diagnosis was established by frozen section, and 102 had a major resection without a definitive diagnosis of cancer. Carcinoma subsequently was found in 68% (69) of this group of 102 patients, and benign lesions were identified in the remaining 32% (33), all of whom underwent lobectomy. The diagnoses in these 33 patients included seven granulomas, three hamartomas, nine instances of tuberculosis, and fourteen instances of fibrosis, inflammation, or cystic degeneration. The 2 thirty-day operative deaths in this group of 102 patients occurred among the 69 with malignant disease; 1 died of hemorrhage following pneumonectomy and 1, of respiratory insufficiency after lobectomy. In all 303 patients, there was no difference in operative mortality (p less than 0.01) between lobectomy (2%) and a lesser resection (1.6%). In a patient with a suspicious but inaccessible pulmonary lesion, lobectomy can be performed safely without violating the principles of cancer surgery. This recommendation should probably not be extended to lesions requiring pneumonectomy, because of the increased rates of morbidity and mortality associated with that procedure.