Occult carcinomas of the lung

Endobronchial squamous cell carcinoma presenting as localized, long, continuous bronchial thickening on CT

OBJECTIVE

To report pulmonary squamous cell carcinomas presenting as localized, long, continuous, bronchial thickening on computed tomography (CT).

MATERIALS AND METHODS

This study comprised five men (mean age, 66 years; range, 60-79 years) with pulmonary squamous cell carcinoma, including two (0.6%) selected from 310 consecutive patients with the diagnosis. Inclusion criteria were as follows: histological diagnosis obtained from thickened bronchi; continuous bronchial thickening >5cm in longitudinal extension on CT. CT scans were retrospectively reviewed, focusing on bronchial abnormalities. They were correlated with histopathological findings in four patients who underwent lobectomy.

RESULTS

On initial CT, bronchial thickening was continuous without skip area (n=5), measured 56-114mm in maximum longitudinal length, involved lobar (n=3) or segmental and distal bronchi (n=5) of the right upper (n=4) or lower (n=1) lobe, and was focally bulbous (n=2). Follow-up CT before treatment, available in two, showed progression of bronchial thickening in its thickness and longitudinal length (n=2) and a new bulbous portion (n=1) and peribronchial nodules (n=1) along the thickened bronchi. Cancer recurred after lobectomy in two, one of which manifested as continuous bronchial thickening extending from the bronchial stump on CT. On CT-histopathological correlation, bronchial thickening was mostly due to tumor spreading along the bronchus. A focal or short segmental tumor outgrowth from the thickened bronchi corresponded to a nodule or bulbous portion along thickened bronchi on CT, respectively.

CONCLUSION

Pulmonary squamous cell carcinoma may present as localized, long, continuous, bronchial thickening on CT, simulating benign infectious or inflammatory diseases.

Early central airways lung cancer

Early central airways lung cancer accounts for very small percentage of all lung cancers. Given this fact, it is much difficult to carry out a prospective randomized comparative clinical trial. Even retrospective studies can offer important information. Early central airways lung cancer is usually detected by sputum cytology. If sputum cytology shows atypical epithelial cells implying malignancy, the next thing we have to do is bronchoscopy. Both autofluorescence bronchoscopy and white light bronchoscopy were superior to white light bronchoscopy alone in detecting this type of lung cancer. Natural history of this cancer showed about the two-thirds of the patients die from original disease within 10 years. If the tumor length is 10 mm or less, photodynamic therapy is a first-line modality. After photodynamic therapy, a 5-year overall survival of about 80 % and a 10-year overall survival of 70 % can be expected. If a cancer does not meet the criteria for photodynamic therapy, surgical resection is recommended, and 5-year overall survival of about 80 % can be expected. Segmentectomy should be considered because of pulmonary function preservation if a tumor is located at segmental bronchi or beyond it. The frequency of multicentricity is high. Treatment strategy for subsequent primary lung cancer is an important key for the prognosis of patients with treated early central airways lung cancer. Surgical resection is still the most reliable treatment of subsequent primary lung cancer, except for in situ or microinvasive carcinoma located centrally, which could be cured by photodynamic therapy.

A prospective evaluation of transbronchial ultrasonography for assessment of depth of invasion in early bronchogenic squamous cell carcinoma

In order to determine the appropriate treatment modality for roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC), it is essential to evaluate the depth of invasion, because ROSCC invading beyond the cartilaginous layer cannot be effectively treated by photodynamic therapy (PDT) due to spread of disease. Transtracheal endoscopic ultrasonography (TUS) was useful for predicting the depth of invasion in some ROSCCs. In order to assess the actual significance of TUS as a diagnostic tool for predicting the depth of carcinoma invasion, we have conducted a prospective trial with 22 lesions of ROSCCs. We ultrasonographically classified the degree of the depth of invasion into two groups; A: "invasion does not reach cartilaginous layer" and B: "invasion involves cartilaginous layer". Then the patients were treated by irradiation, PDT, or surgical resection. Pathological findings were also classified into A or B. In order to calculate the sensitivity for evaluating the depth of invasion by TUS, the cases without any tumor and/or malignant cells after PDT were regarded as pathological A. In the evaluation of the depth of carcinoma invasion staying inside the cartilaginous layer, the sensitivity and the positive predictive value were 85.7%, the specificity was 66.7%, and the accuracy was 80.0%. With TUS, preoperative evaluation of the depth of invasion would be more accurate, and the decision of treatment modality would be more appropriate, compared with the conventional bronchoscopic observation alone.

Diagnostic dilemmas in pulmonary cytology

BACKGROUND

Diagnostic difficulties in pulmonary cytology may be compounded by other medical problems, lack of pertinent information, and the presence of rare tumors. In the current study, the authors describe six cases of lower respiratory tract cytology that presented particular diagnostic challenges or pitfalls.

METHODS

Three lung fine-needle aspiration biopsies (FNAB) from three patients, four bronchoalveolar lavages from two patients, and one bronchial washing from one patient, each with histologic confirmation, were reviewed. Cytologic material included direct smears, ThinPrep slides, and cell blocks. Cytologic findings were compared with established cytologic criteria for each final diagnosis.

RESULTS

Two cases with Aspergillus infection that demonstrated reactive atypical cells were misinterpreted as squamous cell carcinoma and nonsmall cell carcinoma. Two cases diagnosed as significant atypia and negative, respectively, subsequently were found to show bronchioloalveolar carcinoma (as well as lymphangioleiomyomatosis, which was suspected clinically) and bronchogenic adenocarcinoma, respectively. One lung FNAB from a patient subsequently confirmed to have bronchiolitis obliterans-organizing pneumonia (BOOP) showed reactive pneumocytes that initially were misinterpreted as being suspicious for carcinoid. These reactive pneumocytes were identified histologically in the area of BOOP. The last case was an FNAB of a well differentiated fetal-type adenocarcinoma, an unusual variant of adenocarcinoma that to the authors' knowledge rarely is described in the cytology literature.

CONCLUSIONS

Cytomorphologic features of lower respiratory tract pathology combined with appropriate clinical information and diagnostic discretion usually allow accurate diagnoses and should decrease both false-positive and false-negative result rates. Clinical information and radiologic findings may be invaluable, but may not always parallel the cytologic diagnosis.

Diagnostic results before and after introduction of autofluorescence bronchoscopy in patients suspected of having lung cancer detected by sputum cytology in lung cancer mass screening

For the purpose of early detection, we have conducted population-based mass screening for lung cancer by sputum cytology since 1982. Although detection of lung cancer in its early stage is important for a good prognosis, it is often difficult to localize lesions in roentgenographically occult cancer. To clarify the role of autofluorescence bronchoscopy in localizing tumors in patients with roentgenographically occult cancer, we analyzed our diagnostic results. Fifty patients who had been detected by sputum cytology were screened by the light-induced fluorescence endoscope (LIFE)-Lung System from November 1997 to April 1999. We compared the results according to the screening methods: conventional bronchoscopy alone versus LIFE with conventional white-light bronchoscopy (November 1997 to April 1999). Twenty-eight cancerous lesions and 39 borderline lesions were detected by LIFE. Of the 39 borderline lesions, nine were detected only by LIFE. Multicentric lesions including cancer or dysplasia were also detected in 21 of the 50 patients by LIFE. The sensitivity by white-light bronchoscopy alone was 85.3%, whereas that of the LIFE-Lung System with white-light bronchoscopy was 94.1% (P=0.078). There were no cancerous lesions in the area observed as normal by LIFE. We also compared the diagnostic results of two localization methods: brushing of all bronchi (September 1986 to December 1990) and the LIFE-Lung System (November 1997 to April 1999). Although this was a historical comparison, the number of detected borderline lesions increased, which led to a high detection rate in patients with suspected-positive sputum (P=0.0006) by the LIFE-Lung System. In conclusion, the LIFE-Lung System is a safe and non-invasive system for detecting small intraepithelial lesions of the tracheobronchial tree. Autofluorescence bronchoscopy is more efficacious for localizing intraepithelial lesions and places fewer burdens on the patient than brushing of all bronchi.

Segmentectomy for roentgenographically occult bronchogenic squamous cell carcinoma

BACKGROUND

Roentgenographically occult bronchogenic squamous cell carcinomas (ROSCCs) are early squamous cell lung cancers of central type. Some of them cannot be treated with intrabronchial therapy. Although surgical treatment was performed for such tumors, it was unknown whether lobectomy was indispensable or not.

METHODS

The clinicopathologic information of the 58 patients who underwent segmentectomy for ROSCCs were collected from 16 hospitals and reviewed retrospectively, compared with 98 patients who underwent lobectomy for ROSCCs.

RESULTS

Five-year survival rate of the 58 patients based on lung cancer deaths was 96.8%, and 82.6% including all causes of death. The duration of chest tube drainage in the segmentectomy group was slightly longer than in the lobectomy group. Operative mortality and the frequency of postoperative complications were not statistically different in both groups. Postoperative/preoperative vital capacity and forced expiratory volume in 1 second were higher in the segmentectomy group.

CONCLUSIONS

These results suggest that segmentectomy may be an alternative for surgical therapy of carefully selected ROSCCs. More prospective studies are required to fully demonstrate clinical benefit.

External irradiation and intraluminal irradiation using middle-dose-rate iridium in patients with roentgenographically occult lung cancer

PURPOSE

Therapeutic results were analyzed in 39 patients with roentgenographically occult lung cancer (ROLC), and the significance and optimal dose of this therapy were evaluated.

METHODS AND MATERIALS

The subjects were 39 patients who underwent intraluminal irradiation between May 1987 and August 1999. Radiotherapy was performed by combining external irradiation with intraluminal irradiation using middle-dose-rate iridium (four 370-MBq wires) through a catheter with a spacer, which held the source in the center of the bronchus. The doses of radiation were 22-66 Gy (median value 45 Gy) by external irradiation and 10-46 Gy (median value 28 Gy) by intraluminal irradiation.

RESULTS

The therapeutic effect was CR in 38 patients and PR in 1, and local recurrence was observed in a PR case and 3 of the 38 patients who showed CR. The 3-year and 5-year relapse-free survival rates were both 87%. No severe radiation injury was observed.

CONCLUSIONS

Considering that ROLC often occurs as multiple cancers and that many patients with ROLC have reduced lung function, radiation therapy by a combination of intraluminal irradiation and external irradiation is expected to replace surgery as the first choice for the treatment of this disease in the twenty-first century.

Surgical results for centrally-located early stage lung cancer

BACKGROUND

With the increasing use of mass screening programs for lung cancer, and especially the use of sputum cytology, the incidence of roentgenographically occult lung cancer has been increasing. These occult cancers comprise mainly histologically centrally-located early stage lung cancers. This study examined the clinicopathologic characteristics and surgical results of centrally-located early stage lung cancer.

RESULTS

From 1980 to 1998, there were 98 patients and 99 lesions of centrally-located early stage lung cancer resected. A total of 64 patients were detected by mass screening. Histologic examination revealed that 96 lesions were squamous cell carcinoma, and in these patients, there were 10 lesions of carcinoma in situ. The 5-year survival rate was 81.4% in all patients, and 88.9% in carcinoma in situ patients. In the postoperative follow-up period, a second lung cancer occurred in 13 patients.

CONCLUSIONS

The surgical results for centrally-located early lung cancer were good. However, sometimes these cancers are accompanied by a second centrally-located primary lung cancer, so it is necessary to follow-up with sputum cytology to allow early detection of additional centrally-located lung cancer.

The treatment results of 40 patients with localized endobronchial cancer with external beam irradiation and intraluminal irradiation using low dose rate (192)Ir thin wires with a new catheter

BACKGROUND AND PURPOSE

While bronchial intraluminal irradiation is valued highly as a useful palliative treatment for lung cancer, its role as a curative treatment is unclear. The treatment results of 40 localized enbobronchial tumors (including tracheal cancer) who underwent external beam irradiation (EBR) and intraluminal irradiation (IR) as a curative treatment is reported, and the role of combined EBR and IR as a curative potential treatment is examined.

MATERIALS AND METHODS

Forty patients, including 22 with roentgenographically occult lung cancer (ROLC), 14 (18 lesions) with postoperative recurrent lung cancer (PORLC) and four with tracheal cancer, who underwent EBR and IR from February 1987 to August 1996, were studied. IR was conducted using low dose rate (1.48 GBq) (192)Ir thin wires at a bronchial mucosal dose of 4-6 Gy per fraction, with a total dose of 10-57 Gy (median 28 Gy). All patients were also given combined external Linac X-ray irradiation for a total dose of 30-77 Gy (median 52 Gy).

RESULTS

As for the primary effect, complete response (CR) was obtained in all 22 ROLC cases; CR was obtained in 12 (16 lesions), partial response (PR) in one and minor response (MR) in one of the PORLC cases; and CR was obtained in three and PR in one of the tracheal cancer cases. The 3-year and 5-year local control rate by Kaplan-Meier method was 75 and 65%, respectively. Twenty-two patients survived for 3 years or longer. Complications included one case each of fatal tracheal hemorrhage, bronchial mucosal ulcer and bronchial stenosis.

CONCLUSIONS

Combined EBR and IR is useful as a curative potential treatment, and long-term survival can be expected in ROLC, tracheal cancer and a portion of PORLC cases.

Diagnosis and staging of lung cancer

Lung cancer is the biggest cancer killer among men and women in the United States. Lung cancer can present in a myriad of ways and the goal of prompt diagnosis and staging requires that the clinician be able to knowledgeably choose from a variety of tools available for such purpose. Review of some of these tools and general strategies with regard to staging is provided. Many new technologies are becoming available and much evaluation needs to be done before their proper roles become well defined. Little has changed with regard to staging of small cell lung cancer in recent years. The International System for Staging Non-Small-Cell Lung Cancer was revised for a second time in 1997. Although the revisions have largely corrected the shortcomings of the 1985 version, some controversies persist. Whenever possible, a multidisciplinary approach to diagnosis, staging, and therapy should be utilized. This should include incorporating the services of the pulmonologist, the thoracic surgeon, the medical oncologist, the radiologist, the radiation therapist, the pathologist, the respiratory therapist, and the social worker.

Synchronous roentgenographically occult lung carcinoma in patients with resectable primary lung cancer

OBJECTIVE

To assess the prevalence of synchronous roentgenographically occult lung carcinoma (ROLC) in patients with resectable roentgenographically visible lung cancer (RVLC).

METHODS

Patients undergoing surgery for RVLC in the same University Hospital were prospectively evaluated before surgery by fluorescence bronchoscopy under local anesthesia to detect synchronous ROLC. All abnormal areas, with the exception of the RVLC, had biopsies made.

RESULTS

From June 1996 to January 1999, 43 patients (male/female ratio: 1.7/1.0) were evaluated before lobectomy (n = 34) or pneumonectomy (n = 10) for 44 primary RVLC. There were 10 T1N0, 19 T2N0, 1 T1N1, 9 T2N1, 1 T3N0, 3 T1N2, and 1 T3N1 lesions. The histologic type was mainly squamous carcinoma (n = 21) and adenocarcinoma (n = 14). All but two patients were smokers or ex-smokers (mean +/- SD, 48 +/- 28 pack-years). A total of 177 endobronchial biopsies were performed (4.1 +/- 2.5); 8 were too small to be informative, 43 showed non-preneoplastic alterations, and 50 were normal. There were 7 basal cell hyperplasias, 56 metaplasias, 9 dysplasias, and 4 carcinomas in situ (CIS). All the dysplasias and CIS lesions were observed in eight subjects. The synchronous CIS were treated by surgery (n = 1) or localized therapeutic modalities (n = 3).

CONCLUSIONS

The high prevalence of synchronous early lung cancers (9.3%) as well as metaplasia and dysplasia in this series of patients with resectable RVLC suggests that fluorescence bronchoscopy may be a useful adjunct in the preoperative evaluation of lung cancer.

Radiation therapy for roentogenographically occult lung cancer by external beam irradiation and endobronchial high dose rate brachytherapy

PURPOSE

We investigated the clinical usefulness of radiation therapy by external beam irradiation and endobronchial brachytherapy for the treatment of roentogenographically occult lung cancer.

PATIENTS AND METHODS

From 1995 to 1996, five patients were treated with radiation therapy. We analyzed their treatment outcomes. The follow-up period varied from 3.0 to 3.8 years or until death. External beam radiation (40 Gy/20 fractions/4 weeks) was delivered to the tumor site alone, and not prophylactically given to the mediastinum. Endobronchial brachytherapy using high dose rate iridium (Ir)-192 was concurrently administered principally to a total dose of 18 Gy on the bronchial mucosa in three weekly fractions of 6 Gy each.

RESULTS

Complete remission was obtained in all patients. Two patients died of intercurrent diseases at 12 and 21 months without any evidence of recurrence. The disease has been also controlled in the other three cases. With the above doses, three small tumors < 1 cm were controlled without adverse effect. In two tumors, the dose reference points were set 2-7 mm beneath the mucosa, and larger doses were administered by brachytherapy. An applicator acting as a spacer was not used in these cases. The tumors were controlled, although the irradiated bronchi showed severe stenosis in 6 months following the treatment. However, the patients were asymptomatic and did not need further intervention.

CONCLUSION

External beam irradiation combined with endobronchial brachytherapy was useful for the treatment of roentogenographically occult lung cancer as an alternative to surgery. Further investigation is needed to determine the optimal doses of radiation therapy.

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.

Occult lung cancer beyond bronchoscopic visibility in sputum-cytology positive patients

Sputum cytology is useful for screening and diagnosis of centrally located lung cancer in Japan. On the other hand, cancer beyond the range of bronchoscopic visibility in X-ray negative patients can be detected only with difficulty. Of 265 patients detected by sputum cytology in mass screening, 85 had an abnormal chest roentgenogram and the remaining 180 were roentgenographically occult. A total of 200 roentgenographically occult squamous cell carcinoma lesions were detected in the above 180 patients. A total of 45 of the 200 lesions were bronchoscopically occult. Twenty-two of the above 45 lesions were beyond the range of bronchoscopic visibility with a standard bronchoscope. The data obtained show that a sputum cytology positive, X-ray negative squamous cell carcinoma may lie outside the reach of a flexible bronchoscope. Thus, when it is difficult to localize a cancer, brushing of the peripheral bronchi beyond bronchoscopic visibility and chest computed tomography should be performed.

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.

The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling

Despite a plethora of technologic advances, there has been only minimal improvement in the surgical treatment of carcinoma of the lung during the past 15 years. The advent of video-assisted thoracic surgical (VATS) techniques, however, is opening up new vistas and providing unimagined options for more accurate diagnosis, more precise staging, and more specific resections of lung tumors. Currently, a voluminous surgical literature supports tissue conservation, in selected patients, for the curative resection of peripheral malignant nodules less than 2 cm in diameter. Because these lesions are very accessible to a VATS resection, such procedures can be satisfactorily performed to meet the individual needs of the patient (ie, wedge, subsegmental, segmental, and sublobar resections, as well as traditional or SIS-lobectomy [simultaneous individual stapling of hilar structures]). As the technology advances, members of other specialties are beginning to develop a keen interest in the treatment of carcinoma of the lung. If thoracic surgeons are to prevail in the treatment of carcinoma of the lung, for the benefit of their patients, they must remain vigilant, informed, and versatile in their approach to this disease. This involves learning, understanding, and incorporating these new technologic advances into their armamentarium.

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.

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.

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.

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.

Screening for early lung cancer. Results of the Memorial Sloan-Kettering study in New York

The Memorial Sloan-Kettering lung cancer screening program was begun in 1974 to evaluate sputum cytology as a supplement to the annual chest x-ray examination for early detection and diagnosis. The 10,040 adult, male cigarette smokers who enrolled were randomly assigned to receive annual chest x-ray examinations only or a dual screen with annual chest x-ray examination and four monthly sputum cytology evaluation. Over 40 percent of the 288 who developed lung cancer were diagnosed in stage I, and their survival was 76 percent at five years; overall survival was 35 percent. Nearly one third of the lung cancers detected on first examination on the dual screen, and 14 percent of those on subsequent examinations were found by cytologic examination. The same number of cancers developed in the x-ray screen only group, and were diagnosed at a later date. Despite the delay, survival and mortality were the same, suggesting that the squamous carcinomas detected by cytologic examination alone are very slow growing and tend to remain localized until detectable by x-ray examination.

Thoracic neoplasms: imaging requirements for diagnosis and staging

This article reviews the pathophysiology of thoracic neoplasms and discusses current imaging recommendations for diagnosis and staging of these tumors. Particular emphasis is given to primary lung cancers, which comprise a variety of tumors of differing histologic type and behavior. The development of cost-effective diagnostic/staging sequences with continually changing imaging technology continues to be a challenging goal. Our recommendations are based on the TNM system and data from the current literature employing the experience from our institution.

Recent advances in pulmonary cytopathology

During the past five years, advances in pulmonary cytopathology have made possible the achievement of several goals, including the diagnosis of pneumonias in immunocompromised hosts, the detection and localization of occult lung cancers in high-risk cigarette smokers, the diagnosis of lesions of the lungs and chest wall by fine-needle aspiration, and the detection of asbestos exposure by sputum cytologic studies. Significant progress has also been made in the application of cell image analysis to the detection of premalignant bronchial epithelial cells in sputum. For the most part, these advances are based on such well-known cytologic procedures as the preparation of thin and evenly distributed smears, prompt fixation, properly controlled and monitored Papanicolaou staining, and thorough screening of slides. Such diligence in laboratory techniques remains the backbone of excellence in pulmonary cytopathology. Cytologic findings should be interpreted with the clinical features of each case in mind, for the practice of pulmonary cytopathology remains an art as well as a science.