The detection and treatment of early lung cancer

Lung cancer detection. Results of a randomized prospective study in Czechoslovakia

A randomized prospective study of lung cancer detection was begun in 1976 to evaluate semiannual screening by radiologic and sputum cytologic study in comparison to screening at a 3-year interval, and to no screening. In a high-risk population of 6364 men (aged 40 to 64 years), the initial prevalence of lung cancer was 0.28% (18 cases), the annual incidence was 0.35% per year (66 cases during 3 years), the proportion of Stage I cases was 31% (26/84), and Stage II was 17% (14/84), "curative" resections were 27% (23/84), and 5-year survival was 23% (19/84). The study confirmed the ability of radiologic screening to detect lung cancer at an earlier stage when treatment by resection can be accomplished. The fate of a high-risk population submitted to screening was better than that of a population with no screening where lung cancer was discovered by symptoms, accidental x-rays, or at autopsy. A matter of lesser importance was the frequency of screening. The absolute numbers of 5-year survivors detected by screening were practically the same for either compared screening frequency.

Bronchofiberscopy with curette biopsy and bronchography in the evaluation of peripheral lung lesions

Flexible bronchofiberscopy using a double-hinged curette biopsy and under fluoroscopic guidance was performed on 46 patients with peripheral lung carcinomas smaller than 2 cm. Prior mapping of the location of the lung lesion was achieved with selective peripheral bronchography. With these diagnostic tools, a positive cytologic diagnosis for lung carcinomas was made in 45 of 46 patients, a yield of 97.8 percent. Complications associated with the curette biopsy included minor bleeding in three cases and pneumothorax requiring a chest tube in one case.

Lung cancer

Only patients with localized lung cancer benefit from curative resection. Curative radiotherapy is recommended in patients with a resectable tumor in whom surgery is precluded for medical reasons. Adjuvant preoperative or postoperative therapy of any type does not improve the results of surgery except in patients with Pancoast tumor. Therapy for nonlocalized tumors does not affect survival. Radiotherapy has a palliative effect in 50 to 75 per cent of patients presenting with symptoms from either a primary lesion or metastases and should therefore be recommended in symptomatic patients. The palliative effect of chemotherapy is limited in lung cancers other than small cell carcinomas. However, chemotherapy alone or in association with radiotherapy produces remarkable tumor regression and some improvement of survival in small cell carcinoma. The use of immunotherapy in the treatment of lung cancer is still under evaluation.

The coin lesion story: update 1976. Twenty years' experience with thoracotomy for 179 suspected malignant coin lesions

We reviewed 179 patients who had undergone thoracotomy and resection of a suspected malignant coin lesion of the lung over the past 20 years to see if a policy of early thoracotomy was therapeutically valid. The average diameter of all lesions was 1.6 cm; the average diameter of 27 malignant lesions (15 percent) was 1.8 cm. Follow-up of the 27 patients with malignant neoplasms was 100 percent. The present survival rate of the 19 patients with primary lung cancer is 89 percent (17/19). Of 12 cases of primary lung cancer followed for five years, ten (83 percent) survived. The five-year survival of the eight patients with metastatic lesions was 25 percent (2/8). There were no postoperative deaths and few serious postoperative complications (four patients or 2 percent). Very small primary lung cancers detected and treated early do have the same poor prognosis as larger primary cancers.

The clinical assessment of selected patients with bronchogenic carcinoma

This paper describes the clinical management of patients with malignant cells in their sputum and a normal chest roentgenogram and those with asymptomatic peripheral pulmonary masses. The source of malignant cells in the sputum of patients with no roentgenographic abnormalities can be localized by tantalum bronchography and fiberoptic bronchoscopy. Peripheral pulmonary masses can be diagnosed preoperatively by needle biopsy or transbronchial fiberoptic bronchoscopy with little morbidity and no mortality. These procedures are not necessary, however, if there is firm clinical and roentgenographic evidence of malignancy. Bronchogenic carcinomas presenting as asymptomatic circumscribed peripheral pulmonary masses have a 25% incidence of occult mediastinal lymph node metastases. In view of this relatively high incidence of metastasis, we think mediastinoscopy should routinely be performed prior to thoracotomy is asymptomatic patients with a peripheral pulmonary mass and no roentgenographic evidence of mediastinal widening.

Delayed clearance of tantalum by radiologically occult cancer

The best current treatment of bronchogenic carcinoma is prompt surgical excision of early lesions before mediastinal and extrathoracic spread occurs. Bronchoscopy, in a patient with a positive cytology and a negative chest radiograph, is a long, time-consuming procedure. Tantalum bronchography done prior to the bronchoscopy will significantly reduce the time necessary for bronchoscopy. Tantalum is cleared solely by mucociliary action. Early bronchogenic carcinoma, when sufficiently large enough, will destroy the ciliated epithelium, thus impairing mucociliary clearance and altering mucus secretion. Tantalum bronchography has localized these early x-ray negative lesions, both by minimal mucosal irregularity and by delayed clearance. In the past three years we have localized the radiologically occult malignancy in four out of five patients.

Diagnostic fiberoptic bronchoscopy: Techniques and results of biopsy in 600 patients

Six hundred patients underwent diagnostic flexible fiberoptic bronchoscopy (FFB). The two diseases most frequently encountered were bronchogenic carcinoma in 330 patients (55 percent) and bacterial infection in 94 (16 percent). A positive cytology on biopsy material was obtained in 279 of 330 patients (85 percent) with primary lung cancer. Fluoroscopy was a valuable aid in diagnosing bronchogenic carcinoma, since 42 percent of the tumors were not visible endoscopically and required fluoroscopic control for placement of the biopsy instrument. Of the 55 patients with hemoptysis and negative chest x-ray films, nine (15 percent) had fiberoptically visible endobronchial carcinomas! In addition, two patients with carcinoma of the larynx and one with carcinoma of the nasopharynx were discovered. Transbronchial biopsy (TBB) in 68 patinets with diffuse and localized disease achieved an overall 69 percent diagnostic success, including a correct diagnosis in each of four patients with Pneumocystis carinii pneumonia. Brush biopsy provided additional valuable laboratory data in bacterial, mycobacterial and cytomegalovirsu infectious but had a poor yield in Pneumocystis infection. Complications as a result of forceps biopsy were minimal, except for brisk bleeding in six patients.

The Mayo Lung Project for early detection and localization of bronchogenic carcinoma: a status report

The Mayo Lung Project (MLP) is a screening program designed to detect bronchogenic carcinoma at a curable stage. Screening tests include chest roentgenograms, three-day "pooled" sputum cytology studies, and lung-health questionnaires. These are being applied every four months to a study population of outpatients who have a high probability of developing lung cancer. Initial patient acceptance of the screening program has been excellent. Small asymptomatic lung cancers have been detected both roentgenographically and cytologically. The two procedures have complemented each other with little overlap. Chest roentgenography has proved most useful in diagnosing peripherally situated cancers, whereas sputum cytology studies have been most effective in identifying early squamous cancer involving major airways. At present, more cancers have been detected roentgenographically than cytologically, but the cytologically detected cases appear to have a better prognosis. Roentgenographically occult cancers have been localized with regularity, although the localization process is complicated. Theoretically, vigorous application of radiologic and cytologic screening, combined with optimum use of localizing procedures and treatment, could increase the five-year survival rate among lung cancer patients to nearly 50 percent. However, the actual survivorship attained will ultimately be determined by currently imponderable factors such as patient acceptance of longterm screening, frequency of multicentric respiratory cancers, and incidence of noncancerous smoking-related diseases, especially chronic obstructive pulmonary disease and ischemic heart disease.

Local ablative procedures designed to destroy squamous-cell carcinoma

In a series of experiments in dogs, the bronchial mucosa was either excised or destroyed prior to closure of a bronchial stump following a lobectomy or the reanastomosis of a divided bronchus. The experiments were designed to simulate the clinical situation in which focal areas of squamous-cell carcinoma in situ in the bronchial margin would be managed by local ablation of the mucosa rather than by excision of additional bronchus. The experiments demonstrated that the bronchial mucosa is not necessary for bronchial healing. They also demonstrated that functionally and morphologically normal bronchial epithelium regenerates across the denuded bronchus. The source of this regenerated epithelium appears to be the submucosal glands which remain in the bronchial wall after a variety of local ablative procedures. Since our clinical experience has demonstrated that these submucosal glands frequently contain small foci of squamous-cell carcinoma in situ, we have concluded that either excision or thermal destruction of the bronchial mucosa has very limited clinical application and should be considered only in patients who cannot tolerate excision of more than one lobe of the lung.