·Publicanon Number III
THE JOHN ALEXANDER MONOGRAPH SERIES
on Various phases of Thoracic Surgery
A Memorial to John Alexander (1891-1954)
Professor of Surgery, University of Michigan
Ednor
JOHN D STEELE, MD
San Fernando, California
Editorial Board
HOWARD T BARKLEY, MD HIRAM T. LANGSTON, MD
Houston Texas
Chicago, Illinois
CAMERON HAIGHT, MD HERBERT C MAIER, MD
Ann Arbor, Michigan
New York, New York
JOHN W STRIEDER, MD
Brookline, Massachusetts

·THE TREATMENT
OF BRONCHIAL
NEOPLASMS
By
ROBERT R. SHAW, M.D
and
DONALD L. PAULSON, M.D.
with a chapter on
BRONCHIAL ADENOMA
by
JOHN LESTER KEE, JR, MD
BOKS
THOPLASS
MIBOL
CHARLES C THOMAS PUBLISHER
Springfield . Illinois • U.S.A.

·CHARLES THOMAS PUBLISHER BANNERSTONE HOUSE 301 327 East Lawrence Avenue, Springfield Illinois, USA Published simultaneously in the British Commonwealth of Nations by BLACKWELL SCIENTIFIC PUBLICATIONS LTD, OXFORD, ENGLAND Published simultaneously in Canada by THE RYERSON PRESS TORONTO This book is protected by copyright No part of it may be reproduced in any manner with out written permission from the publisher © 1959, by CHARLES C THOMAS PUBLISHER Library of Congress Catalog Card Number 59 8509 With THOMAS BOOKS careful attention is given to all details of manu facturing and design It is the Publishers desire to present books that are satisfactory as to their physical qualities and artistic possibilities and appropriate for their particular use THOMAS BOOKS will be true to those laws of quality that assure a good name and good will Printed in the United States of America

·Authors
ROBERT R SHAW, MD
Clinical Professor of Surgery
Southwestern Bledical School of the
University of Texas
Chief Section of Thoracic Surgery
Baylor University Ilospiral
Dalias Teras
DONALD L PAULSON, MD
Clinical Associate Professor of Surgery
Southwestern Afedical School of the
Unis ersity of Teras
Atrending Surgeon
Baylor Unnersity Hospital
Dallas Teras
JOHN LESTER KEE, JR, MD
Instructor in Surgery
Southnestern Medical School of the
University of Texas
Assistant Attending Surgeon
Baylor Unnerszty Hospital
Dallas Texas

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·Dedicated with sincere appreciation
to Stuart W Harrington, friend, and
Cameron Haight, colleague, of John
Alexander

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·Preface THE INCREASING MAGNITUDE of the prob chogenic carcinoma has remained at the lem of bronchial neoplasms particularly same level for all patients as well as being cancer of the lung, prompts those who practically the same for those who came have treated patients having these tumors early and those who arrived late for treatto evaluate their past experience It is ment It would appear that the temporal only through such evaluations that future factor is of lesser importance than the bioapphcation of treatment using available logic factors in determining the prognosis of methods can be improved Increasing ex- patients with bronchogenic carcinoma perience is beginning to show that slavish The authors hope in presenting their adherence to the traditional radical ap proach to the surgery of cancer may actually combined experience of 1180 patients havphilosophy of treatment evolved from a be resulting in the shortening of lives of ing bronchogenic carcinoma that they can some of the victims of this disease It has contribute to an improvement in the results now been a quarter of a century since of the surgical and nonsurgical treatment of Graham's first successful surgical removal this disease They feel that this can be done of a total lung for bronchogenic carcinoma The bright promise of this brilliant achievenot so much through a contribution to the ment, both for resectability and satisfactory technique of resection or the management long term survival has not been realized in of the patient undergoing surgery, but the vast majority of patients having this rather by a better selection of patients for disease The results of surgical treatment surgical excision, and to an improvement make it evident that surgical removal for in the quality of survival through applica bronchogenic carcinoma has not measured tion in patients with suitable lesions of seup to the heavy burdens placed upon it in lective resections of the lung It is realized most instances, and emphasize the need for that this attitude may represent a departure are evaluation of the rationale of treatment from the ideal of the traditional radical apbased on the temporal factor alone proach to the surgery of cancer of an in To date it has been impossible to corre ternal organ It is believed, however, that late better end results with early treatment the traditional concept must be tempered solely from the standpoint of time Since in the case of bronchogenic carcinoma by surgery has been available for treatment, practical considerations of function there has been an intensive campaign both Because surgical therapy can be applied Within the medical profession and in the only to approximately one third of the field of lay education to detect malignancies patients having malignant bronchial neo. of the lung in a stage when they are still plasms, many patients become candidates localized to the primary site However, for irradiation or drug therapy These over the years, the operability rate for bron modalities may be effectively used to con ·THE TREATMENT OF BRONCIUAL NEOPLASMS trol distressing symptoms and prolong useful other means, which will be benefited by living radical resections, and which may be treated The challenge to the surgeon today is to by more conservative resections without learn more about the biologic characteristics sacrifice of survival time but with the atten of the various types of bronchial neoplasms dant advantages of a better quality of sur so that he will know which lesions are vival operable, and which are treated better by ·Acknowledgments THE AUTHORS wish to express their appreciation to Drs Roy T Lester, Miton V Davis, J Walter Park III, Robert Wilkens, Eldon K Siebel, ES Crossett, Pill C Hong, Ben F Mitchel, Richard Ernst, Charles T Meadows, and George lwen, former residents who ably assisted in the care of the patients who formed the basis of this clinical study, to Dr Lewis Waters Robert Sage and Ruth Sanders of the Medical Art Department of Southwestern Medi cal College for the preparation of tables, drawings and photographs, and to Mrs Antoinette Long and Mrs Charmon Hanby for theit aid in care of records and preparation of the manuscript RRS DLP

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·Contents Page IX PREFACE ACKNOWLEDGMENTS INTRODUCTION Xi 3 THE RATIONALE OF TRFATMENT Classical temporal theory Biologic Predeterminism Carcinoma in situ Operative approach It radiation and chemotherapy Summary 8 8 9 12 15 16 16 SELECTION OR PATIENTS FOR SURGERY Biologic Factors Absolute Signs of Inoperability Distant Metastases Lymphatic Extension Scalene Node Biopsy Vocal Cord Paralysis Vena Caval Obstruction Involvement of Esophagus Pleural Effusions Associated with Bronchial Neaplasmas Brachial Plexus Involvement Bronchoscomic Observations Questionable Signs of Inoperability Signs of extension beyond Jung Invasion of chest wall Poor pulmonary function Age and coronary artery disease Sutrimary 18 18 19 19 21 23 24 24 24 24 26 26 26 26 23 22 28 29 31 34 35 38 SELECTION OF OPERATION Segmental Resection Indications for Pacumonectomy Bronchoplastic Procedures Resection for Lesions of Unprorer Erology Palliative Resection Palliative Surgery Other than Resection Summary 14 46 47 ·X]V Page 49 51 IRRADIATION THERAPY Irradiation Therapy in Relation to Cell Type Indications for Irradiation Therapy in Inoperable and Nonresectable Patients Mediastinal invasion Pleural effusion Distant metastases Inadequate Pulmonary and Cardiac Function Following Resection Irradiation for Local Recurrence Following Resection Irradiation Therapy Prehminary to Resection Treatment of Metastases Contraindications to Irrndration Therapy Complications of Irradiation Therapy Results of Irradiation Therapy Summary 52 53 56 56 57 57 S8 62 65 66 66 67 69 70 70 72 71 CHEMOTHERAPY Available Chemotherapeutic Agents Mechlorethamine Hydrochloride and Related Drugs Dosage and Method of Administration Objective Evidence of Value Combined with Irradiation Combined with Surgery Chemotherapy Following Exploratory Thoricotomy Chemotherapy for Malignant Pleural Effusion Complications of Chemotherapy Repetition of Chemotherapy Conclusion 73 74 75 75 76 77 77 79 79 80 81 81 81 TERMINAL CARE What Shall the Patient be Told? The Family s Role The Role of the Family Physician The Role of the Consulting Physician Treatment of Symptoms Cough Dyspnea Para Hemoptysis General Debility The Rewards of Terminal Core 82 82 83 84 81 ·xv RESULTS Operability and Resectability Reporting the Results Reports of Other Authors Authors' Series Five Year Survivors Quality of Survival Survival Rates in Inoperable Patients Survival Following Exploratory Thoracotomy Survival Following Resection Factors Affecting Survival Following Resection Influence of Pathologic type on type of surgery and survival Chest wall invasion Bronctopizstic Procedures Pulmonary Nodules Summary Page 85 85 86 86 90 91 91 92 92 92 95 95 95 96 99 100 103 103 104 BRONCHIAL ADENOMA by John Lester Kee, Jr, MD Introduction and History Theories of Ongiti Malignancy Incidence Location Gross Pathological and Bronchoscopic Appearance Microscopic Appearance Classcal Signs, Symptoms and Diagnosis Roentgen Appearance Treatment Irradiation Therapy Results Operative Deaths and Complications Summary CONCLUSION INDEX 104 105 105 106 107 108 110 110 111 112 114 114 116 123

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·The Treatment of Bronchial Neoplasms

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·Introduction THE RAPIDLY RISING incidence of bron observation of the irritating effects on the chogenic carcinoma presents a challenging bronchial mucosa of various inhaled ulti problem to the entire medical profession tants Statistical studies have pointed con The fact that the rising incidence is a real sistently to an association between heavy one and is not due to increased interest in cigarette smoking and carcinoma of the and more accurate diagnosis of this malig lung (Fig 1) It is also recognized that nancy is accepted almost universally by inhalation of tobacco smoke is only one physicians who have dealt extensively with factor - although probably the most imthis disease Doctor Lester Breslow,' Chief portant one Inhaled fumes from the peof the Bureau of Chronic Diseases of the troleumn industry the exhaust of automo California Department of Public Health, biles, coal tar products on roads, gases states that there has been an increase of from the welding process, radioactive gases 400 per cent of carcinoma of the lung in BRONCHOGENIC CARCINOMA males since 1930 The death rate in 1930 Smoking History in 100 Consecutive Patients from bronchogenic carcinoma was 7 per 100,000 'but by 1954 had reached 28 5 per 100 000” The corresponding figures for females was 28 in 1930 and 5 in 1954 During this same period other malignancies occurring in males, principally carcinoma of the stomach had shown a decline This indicates that the increase could only partially be explained by the increasing life expectancy due to better control and treatment of diseases of the earlier periods of life Doctor Breslow predicted that by 1960 carcinoma of the lung would be a major problem It was his opinion that we can normally expect a decline in Fig 1 cancer mortality except for those cancers and exposure to certain metals, especially caused by agents we introduce into our cobalt-all contribute to bronchial irrita environment such as cigarettes, smog and tion that may influence the formation of radiation fallout bronchial neoplasms "The suggestion that The cause of the rising incidence of previous pulmonary infections might be a bronchogenic carcinoma has been exten- factor in the formation of bronchial neosively investigated This investigation has plasms has been discarded However, re been in the form of statistical studies and cently there has been renewed interest Number of c 10F 30 Age of Patent ·THE TREATMENT OF BRONCHAL NEOPLASYS the incidence of bronchogenic carcinomas who has previously received an apparent arising in and adjacent to fibrotic areas sa cure following surgkcal resection of a preyi the lung (Fig 2) ously detected cancer of the lung (Fig 3) The careful postmortem studies of Auer The observation that there is an associa bachº have shown the changes in the tion between heavy cigarette smoking and epithelial lining of the bronchi from culated cancer of the lung unfortunately is not columnar to squamous metaplasta and then helpful in curbing the rising incidence of in local areas on to carcinoma in situ and this disease it is a human failing that finally to invasive malignancy His studies where pleasure is involved consequences are show that these changes occur consistently not heeded James Ewing the noted more often in men who have smoked ciga pathologist, over thirty years ago pointed rettes excessively as compared to men who out the relationship between smoking and have been either light or nonsmokers In cancer of the lung He said thar he did not individuals who have died from broncho believe dissemination of ihrs knowledge genic carcinomas there were a significantly would change smoking habits but that he greater number of areas of carcinoma in did think the public had the right to be situ than in ocher individuals dying of un informed The nuthors are in igreement related causes This observation explains with this attitude the rare occurence of a second primary The advent of surgical therapy was the bronchogenic caruinoma in in individual first ray of hope offered the victims of this Fig 24 The ksion sndistinctly seen in the film of the chest of a 44 year old 5338 was the source of small hemoptyses Fig 25 Planorraphy more distinctly outhnes tha nodule which has developed in a region uh ch is the site of bullous emphysema This combination is highly suggestne of a bronchial neoplasm aſsing in scar tissue The lesion was resected by lobectomy The prognosts for cure » good because d sturbance of lymphalıcs and vascular supply by the bullous cmphysema limits the opportunity of the no plasm to metastasize ·INTRODUCTION 5 8-31-45 11 7-51 6-5-56 Fig 3 Eleven years following right pneumonectomy for bronchogenic carcinoma this patient devel oped a secondary primary bronchogenic carcinoma in the left Iung which caused his death disease Before surgical therapy became cal therapy because of evidence of extension feasible there was little incentive to the of the neoplasm beyond the involved lung physician to diagnose bronchial neoplasms Some of these were seen by the authors on while still in a localized stage since no only one occasion These patients are in treatment was available The burden was cluded in the total series however in order now placed on the medical profession to to present as far as possible an unselected differentiate cancer of the lung from other group The inclusion of these patients pulmonary diseases and make surgical treat broadens the base of observation but lowers ment available to the patient In the first the percentages of operability resectability wave of enthusiasm many patients had their and total salvage A few of these patients chests explored and lungs resected who now had only a clinical diagnosis without tissue would be considered not suitable for surgery confirmation The course of the disease It took time and experience to determine over a period of time served to confirm the limitations of surgery in coping with the diagnosis Cases where the subsequent this disease course was not hnown or did not conform The authors are reporting their experience to the expected pattern of progression were with 1215 patients diagnosed as having excluded from the series bronchral neoplasms treated during the The attitude of the authors during the period from September 1945 to December (welve year experience being reported has 1957 One thousand one hundred eighty not remained static In our early experience of these tumors were bronchogenic carci we accepted the temporal theory of the nomas and 35 were adenomas of the bron evolution of a neoplasm We were impressed chi All of these patients were seen in also by the prevailing opinion that total private practice and were cared for per pneumonectomy was the operation of choice sonally by the authors Not included are a in the surgical removal of a cancer of the number of patients diagnosed as having fung Even during this early period how cancer of the lung treated by the staff in a ever encouraged by reports of Churchill city county hospital with which the authors and others we removed small peripheral ire associated in the capacity of consultants neoplasms by selective resection Our early Many patients included in the series were enthusiasm stimulated by a misguided urge found to be unsuitable candidates for surgi to help the patient out of his difficulty' ·6 INTRODUCTION to a high percentage of exploratory thoraco It has now been a quarter of a century tomies During this period there was also suce Graham performed the furst successful a tendency to try to resect the neoplasm pneumonectomy for bronchogenic carci once the chest was opened even though it noma in 1933 The bright promise of this was obvious that the lesion could not be brilliant achievement both for resectability completely resected It did not take long and satisfactory long term survival has not to find that this overaggressive application been realized in the majority of patien of surgical therapy was not increasing sur having this disease in the authors' serk vival time of patients to whom it was of 1180 patients, half of the patients ha applied Gradually, greater care was used lesions which were inoperable when fir. in selection of patients for surgery In seen, and another 15 per cent were foun pressed by the observation that patients to be nonresectable at the time explorator with selective resections were experiencing thoracotomy was done (Fig 5) One thir just as long and a better quality of survival of the patients had resectable lesions, and 1 lobectomy became the operation of choice only a small percentage of these were then (Fig 4) Conservation of pulmonary tissue carcinomas sufficiently well localized to per was practiced even to the extent of utilizing mt long term survival The increasta bronchoplastic procedures Since 1950 our frequency of bronchogenic carcinoma anı rationale of treatment as far as the applica the results of surgical treatment which maki tion of surgery is concerned has changed it evident that surgical removal for thi very little Realizing the limitations of sur ſesion has not measured up to the heavy gery we are presently employing both ir burdens placed upon it emphasize the neet radiation and chemotherapy to a greater for a re evaluation of the rationale of treat extent ment RELATIVE INCIDENCE OF TYPE OF RESECTION (420 Cases) 901 A- Pneumonectomy 700 PER CENT OF RESECTIONS 301 -Lobectomy 20 10F 1945 46 1947 1948 1949 7950 7951 1952 1953 7954 1955 1956 1957 YEARS Fig . Relative incidence of the type of resection for bronchogenic carcinoma plotted by years 1945-46 through 1957 ·INTRODUCTION 7 OPERABILITY AND RESECTABILITY RATES FOR BRONCHOGENIC CARCINOMA (1180 Cases) 104 60 INOPERABLE 50% 50 PER CENT RESECTION 35% 201 10 EXPLORATION INon resectable) 1946 1947 1948 1952 195278454 1955 1956 1937 1955 YEAR Fig 5 Operability and resectability rates for 1180 cases of bronchogenic carcinoma seen 1946 1957 The operability rate of 50 per cent and the resectability rate of about 35 per cent remain remarkably stationary REFERENCES 1 BRESLOW L HOAGLIN L. RASMUSSEN G and ABRAMS HK Occupations and cigarette smoking as factors in the etiology of cancer of the jung Am Pub Health 17 171 1954 2 AUERBACH O GERE) B PAWLOWSKI J M MUEHSAM MD SMOLIN HJ and STOUT AP Carcinoma in situ and catly invasive CarCINOMA Occurrsag in the tra cheobronchial trees in cases of bronchal carcinoma , Thoracic Surg 34 298 1957 ·The Rationale of Treatment THE HE RATIONALE OF THERAPY for bron curred in spite of evidence to the contrary chogenic neoplasms is necessarily inter- that it is often impossible to correlate better twined with the general knowledge of can end results with early treatment from the cer in any location Two antithetic theories standpoint of time alone In this concept exist at the present time to explain the the existing methods of diagnosis and treat spread of cancer and its prognosis The ment of cancer are considered adequate first of these, the classical temporal theory and responsibility for any delay in detection emphasizes the function of time and states is placed alike on the physician and the in that a cancer begins as a localized disease, dividual concerned The surgeon is often grows in a steady and irrevocable manner, absolved of the consequences of frilures of spreads to the regional lymph nodes in time, therapy on the basis that the patient ar and with the passage of more time dissemi rived too late to obtain a good result Thes nates throughout the body The second and is generally accepted in spite of the oppos more modern theory of biologic predetermi ing evidence that some of the long term nism states that the behavior of a neoplasm survivors are those with the longest histories in an individual host is an expression of a of their disease who arrived late for treatbiologic potential established in its induc- ment tive phase Its characteristics are estab Husfeldt has found in Denmark that the Iished in the preclinical phase and remain operability rate for bronchogenic carcinom? more or less constant throughout its life, is practically the same for those who como although it may undergo intermittent peri in early and those who arrive late for treat ods of growth and quiescence Cognizance ment He explains this apparent paradox of the respective merits of each theory forms to the doctrine of the temporal theory on the foundation for the rationale of treat the basis that the more rapidly growing ment of bronchogenic carcinoma carcinomas produce progressive symptoms in a shorter period of time but are frequent- Classical Temporal Theory ly inoperable On the other hand the more The classical temporal theory has been slowly growing tumors are accompanied by generally accepted by surgeons and forms less pronounced symptoms but may still be the logical basis for the traditional radical operable when the patient finally presents approach to carcinoma It has been widely himself for treatment promulgated, both within the profession Because it is reasonable to assume on and to the lay public, that the prognosis in the basis of circumstantial evidence that cancer can be altered by early and wide early detection and treatment may prolong excision of the neoplasm together with the survival time in some individual patients, it regional lymph bearing area This has oc is often disregarded that to diagnose a can 8 ·THE TREATMENT OP BRONCHIAL NEOPLASMS 9 cer earlier is to increase survival time by a ported by Crile' is a tenable concept which similar period even without treatment (Fig explains the course and prognosis of cancer 1) Rigler has shown in a retrospective on the basis of the biologic characteristics study of roentgenograms of the chests of involved The cell type location and the patients with bronchogenic carcinoma that resistance of the host largely determine the in over half of the hundred patients followed pattern of behavior and prognosis and the by this means their lesions were found to factor of time becomes less important as a antedate either symptoms or diagnosis by consequence only of the biologic traits of two years or more and as long as fourteen the particular neoplasm involved years The average survival time after in Application of the theory of biologic pre stitution of therapy was only nine months determinism to bronchogenic carcinoma ex whereas before this they had lived with plains the variegated pattern of behavior their cancers for years Earlier diagnosis and prognosis in this neoplasm and places would have resulted in a proportionately the rationale of treatment on a logical basis longer survival time after the diagnosis was The authors found in 1951" as a result of made regardless of treatment a study of 362 patients with bronchogenic carcinoma that in 25 per cent the initial Biologic Predeterminism complaint which prompted the patient to The theory of biologic predeterminism seek medical advice was one indicating in ennunciated by Tan MacDonald and sup operability such as headache due to cere it 4-2-51 4-24-57 fig 1 Roentgenograms of the chest sis yours apart of a woman found to havc proven inoperable carcinomi of the middly love with mediastinal nove insolement in 1957 The patient has seven years without treatment Farl er diagnos s v a resulted in survival for a si regardless of ·10 THE RATIONALE OP TREATMENT bral metastases, loss of voice due to in true (Fig 2) The fact that it may remain volvement of the recurrent laryngeal nerve, localized and symptomless for a long period pain due to involvement of the brachial of time, in some cases for years, is a direct plexus, venous distention due to involve- expression of its biologic character The ment of the mediastinum, painless pleural amount of time required for its eventual effusion, dysphagia due to involvement of growth peripherally or centrally to produce the esophagus, involvement of such distant symptoms depends on its cell type, the re organs as bone and peritoneum, or subcu taneous metastases due to generalized dis. Time is but a consequence of these factors sistance of the host, and its original location semination of cancer The occuit nature of The term early applies more to the degree the primary lesion, the insidious onset, the of localization rather than to its temporal paucity of symptoms, and the rapid growth aspects The phrase "detection in an early with early progression to metastasis in this phase' becomes preferable to "early derec group make the diagnosis and treatment im possible to attain during an early localized tion" with its chronologic connotation stage About 20 per cent of patients have The resistance of the host, the third an undifferentiated carcinoma, widely recfactor of importance in the theory of bio ognized for its rapid dissemination and con logic predeterminism, can be Ilustrated on sidered by many as a sign of inoperability the basis of circumstantial clinical evidence in itself If the 25 per cent of patients in Recent reports in the literature attest to whom the initial complaint indicated inop spontaneous cures of cancer. Evidence is erability are added to the 20 per cent who also available that malignant neoplasms have an undifferentiated carcinoma and al- may undergo alternating periods of growth lowance is made for overlapping of the two and quiescence of not actual regression groups, we estimate that roughly 35 per Recurrence from metastases after many cent of the patients having bronchogenic years of quescence without clinical evi carcinoma will have the type of tumor and dence of disease is not uncommon Some lack of resistance to predetermine inoper- individuals treated for cancer have attained ability biologically The function of time is unexpected and unpredictable long periods not important in this group in contrast, of survival (Figs 3 and 4) These vagartes low grade epidermoid carcinomas may re in the natural history of cancer infer a demain well localized for long periods of time, gree of natural resistance on the part of the produce less pronounced symptoms over host A sharper appreciation of this bio several years, and yield long periods of logic factor may enable a more logical uti survival after resection is finally done These lization of various surgical, radiotherapeutic lesions are late in point of view of time but or chemotherapeutic techniques to influ. favorable from the standpoint of biologic ence retardation of tumor growth with pro characteristics and localization Many of longation of useful and comfortable living the patients who survive for long terms fol Evidence of tissue resistance to the sprcad lowing resection are in this group with his. of cancer cells is found in the lymphatic tories extending over several years system Lymphocytic and round cell in A cancer may be early biologically but filtration found in experimental studies of late chronologically The observation that tumor transplants led Ewing to conclude a particular lesion, such as a pulmonary that 'the lymphocyte is an important agent nodule, is symptomless may give the impres- of defense against tumor growth" The sion that it is an early lesion in point of ranty of metastatic lesions in the spleen in of time but this may or may not be contrast to the liver suggests that cells ·JE MI) find it an unfavorable organ for growth relationship between the degree of sinus Black and Speer as a result of investi histiocytosis and prolonged survival in gating the relationship between the sur breast and gastric carcinomas The favor vival of cancer patients and various struc able prognostic significance of sinus histio tural features of their primary cancers cytosis was found to be independent of the and regional lymph nodes found a direct presence or absence or the amount of re 11-23-45 4-25-49 Fig 2 Bronchogenic carcinoma removed by lobectomy May 1949 after hemoptysis occurred Previous roentgenogram of the chest in November 1945 revealed a nodule in the left third interspace This cancer was early biolog cally but late chronolog cally The patient has survived ten years after lobec tomy and over twelve years after the earl est evidence of the lesion demonstrating its favorable biologic character 10) 1-30-50 9-14-50 11 8-55 Fig 3 Roentgenograms of the chest of a patient who has survived over eight cars following an exploratory thoracotomy in January 1950 which proved the lesion to be a nonresectable small undifferentiated hronchogenic carcinoma Irradiation therapy was given in September 1950 ·12 THE RATIONALE OF TREATMENT gional node metastases the grade of the reduced The authors are likewise im original tumor or the completeness of surgi pressed by the fact that in some patients cai eradication of the disease Since sinus having an extensive undifferentiated bron histiocytosis is an uncommon finding in the chogenic carcinoma the appearance of dis lymph nodes of cancer free humans and tant metastases may have been hastened by since it is a reactive change in the tissue of radical resection The explosive spread of a cancerous host associated with increased certain cancers after a period of slow pro survival it is believed to be an expression gression or even quiescence infers some of host resistance break down in the resistance of the host The possible role of the lymph nodes in This may be induced by unwise surgical preventing spread of cancer has received procedures with dissemination of the cancer iittle consideration by surgeons In general cells into blood vessels and lymphatics the lymph nodes are considered as passive through interference with the protective receptors of the actively growing neoplasm lymph barriers and wide dissection with removal in con junction with radical excision of the primary Carcinoma In Situ neoplasın is regarded as essential for ade Carcinoma in situ has been found often quate cancer surgery However the con in association with an epidermoid carci clusions of McWhirter and Haagensen and noma of the bronchus on the apsolateral or Stout suggest that there is a group of breast contralateral side Ryan and McDonald cancers in which harm is done by resecting reported the study of necropsy specimens of the involved lymph nodes and that by not the opposite or remaining lung after pneu dissecting the axilla the risk of dissemina monectomy for a squamous cell carcinoma tion of malignant cells to distant sites is on the primary side They found m sui $ rig 4 Roentgenograms of the chest of a pat ent who survived seven years follox ng iad alion apy for a proven nonresectable cp derno d catcinoma Death #35 due to cerebral artes osclerosis ·13 TIIE TREATMENT OF BRONCHIAL NEOPLASMS lesions of the squamous cell variety in five nineteen months after a lobectomy for the of 39 cases studied death having occurred first carcinoma on the contralateral side from a few days to three years after the The possibility of the later development of pneumonectomy Auerbach' has found in a second carcinoma from an in situ lesion Siu carcinoma in the bronchial tree bi favors the use of an adequate lobectomy laterally in a high percentage of autopsy where possible for the first lesion specimens studied the occurrence of in Carcinoma in situ presents a challenge situ carcinoma bilaterally with or without for early diagnosis Cytologic study of an associated carcinoma of the bronchus bronchial secretions may lead to the detecillustrates the futility of one sided complete tion of some of these lesions prior to or bronchial excision in an attempt to eradi shortly after their development into an incate all precancerous lesions Just as in vasive carcinoma It is in this regard that situ lesions of the cervix uteri have a long detection of bronchogenic carcinoma in an latent period and may never become in early phase may find its true application vasive in many patients So may in situ The following case reports illustrate the ac lesions of the bronchus Since these lesions complishment of this ideal are multicentric and undoubtedly have a long latent period, radical removal of all Case 1 LLH, a 59 year old man sites of involvement becomes both impossi with symptoms of a pneumonitis of the ble and unnecessary right lung of one week s duration Plain Long term survivors may run the risk of Toentgenograms revealcd an obstructive a second carcinoma developing from one pncumonitis in the anterior segment of the of these in situ lesions The authors have right upper lobe (Fig 7) Erimination of bronchial secretions and sputum reseen three such cases the second carcinom? vealed atypical cells suspicious of ma developing in the contralateral Jung nine lignancy (Papanicolaou Class IV) A teen months five years and eleven years right upper lobectomy was done for an respectively after resection of the first epidermoid carcinoma 4 mm squamous cell carcinoma (Figs 5 and 6) in the anterior segmental brochus of in one of these cases the second lesion was the right upper lobe (Fig 8) Sections resected by means of a segmental resection through the ncoplasm and bronchus re in size 8 31-45 11 7 51 65-56 Fig 5 Roentgenograns of the chest of a patient in August 31 1945 pror to a night pneumonec tomy for an epidermoid carcinoma November 7 1951 sit years later and June 5 1956 fourteen cars after the onset of symptoms due to the carcinoma in the right lung and 15 years after pneumonctony illustrating a second separate primary epidermoid carcinoma of the ·14 THE RATIONALE OF TREATMENT 2 2 56 9 20 57 Fig 6 Roentgenograms of the chest of a patient illustrating separate primary epidermoid carc nomas first in the right lung in February 1956 resected by lobectomy and nineteen months later a lesion in the left lung removed by a segmental resection Arew Fig7 Roentgenograms of the chest reveal ng an obstructive pneumonits in the anterior segment of the nght upper lobe

·1
Fig 8 (Upper) Photograph of the surgical specimen Case I following a right
upper lobectomy showing a small intralum nal carcinoma 4 mm in size in the
onfce of the anterior segmental bronchus
Fig 9 (Lower) Photomicrograph of the carcinoma Case 1 revealing epithelial
metaplasia carcinoma in $iu and invasive carcinom

·8 Den Fig 11 (Upper) Photograph of the surg cal specimen Case ? showing the intralum nal carcinoma in the orifice of the anter or segmental bronchus of the left upper lobe Fig 12 (Lower) Photom crograph of the carcinoma Case 2 reveal ng ep thel al metaplast changes and early invasive carcinoma ·THE TREATMENT OF BRONCHIAL NEOPLASYS 15 Fig 10 Case w Plain roentgenogram and plan gram of the chest sevealing a small hilar carcinoma in the anterior segmental bronchus of the left upper lobe producing hemoptysts vealed epithelial metaplasia carcinoma in radical approach to the surgery of cancer situ and early invasive carcinoma (Fig must be tempered in the case of broncho 9) genic carcinoma by practical considerations Case 2 MS a 50 year old man had of function Because bronchogenic carcı hemoptysis of ten days duration Plain nomas frequently occur in association with roentgenograms and planigrams revealed pulmonary emphysema and reduced func a nodular density in the anterior segment tron preservation of luog fissue is of the of the luft upper lobe (Fig 10) Bronchial utmost importance Survival rates alone are secretons were positive for malignant not the only measure of therapeutic effec cells Left upper lobectomy was done for tiveness The differences 15 mortaluy be an early epidermoid carcicoma 5 mm in size in the anterior segmental bronchus of fiveen radical and conservative approaches the left upper lobe (Fig 10) Sections and the quality of survival are equally im through the carcinoma ind bronchus re portant gauges of therapeutic efficiency vealed normal mucosa carcinoma in situ There is a great difference betkeen the pa and carly invasive carcinoma (Fig 12) tient who survives but is disabled and the one who lives for a similar period of time Operatise Approach but is able to continue with normal or near Application of the ideal of the traditional normal activity comfortably Furtherme ·16 THE RATIONALE OF TREATMENT the advantages thought to be gained in in to induce a period of slower grouth as sur creasing life expectancy by the radical ap- gested by Dunphy" may require further proach to bronchogenic carcinoma may be evaluation partially or completely offset by its injurious character Irradiation and Chemotherapy Operability and resectabılır) are not Since surgical resection is possible in on synonymous terms A neoplasm may be one third of the patients having broncho considered operable but be found to be non genic carcinoma, other modalities of treat resectable when an exploratory thoracotomy ment such as irradiation and chemotherapy has been done Similarly, a particular lesion are applicable to the remaining patients. may be rescctable by virtue of its size and These therapeutic methods are subject to location but be snoperable because of cell the same disadvantages as is surgery in that type, metastasis either distant or local, or the lesions chosen therapy frequently poor cardiac and pulmonary function Ex are biologically unfavorable or dissemi ploratory thoracotomy for a nonresectable nated Nevertheless, judicious application carcinoma is to be avoided where possible of irradiation or chemotherapy singly or since it carries a definite risk of surgical combined may induce quiescence in growth mortality without benefit to the patient er relief of distressing symptoms, and in a feu cept the confirmation that no surgical treat patients prolongation of life ment is feasible Sinularly, the tendency to The combination of irradiation therapy increase the scope of the operation or to or chemotherapeutic agents with surgical re perform palliative resections Inowingly section in the treatment of bronchogenic leaving behind carcinoma is likewise unde carcinoma warrants further exploration By sirable because of the attendant high mor means of various combinations of therapy tality and lack of benefit to survival time some patients may become suitable candi The ability to resect a particular bron dates for more definitive procedures chogenic carcinoma should not be the sole determining factor in the surgeons consid SUMMARY eration but rather what benefits are reason Whereas early detection and treatment able to expect on the one hand weighed may prolong survival time in some patients, against the possible harm that may accrue the temporal factor is of secondary imporon the debut side from resection The chal tance to the biologic factors in the rationale lenge is to learn enough about the biologic of treatment of bronchogenic carcmoma characteristics of the various types of bron Application of the theory of biologic predechogenic carcinoma so that it will be known terminism to bronchogenic carcinoma exwhich lesions are suitable for surgery, which plains the variegated pattern of behavior will be benefited by radical resections, and prognosis in this ncoplasm and places which may be treated by more conservative the rationale for treatment on a logical resections with a better quality of survival, basis The cell type location, and the reand which types will be harmed by resec sistance of the host fargely determine the tson through interference with the lymph pattern of behavior and prognosis The node barrier and dissemination of cancer factor of time becomes less important as a cells through the lymphatics and blood consequence only of the biologic traits of stream In some cases a penod of quies the particular neoplasm involved A carci cence may be induced by irradiation or nome may be carly brologically but late chemotherapy Pre-operative irradiation chronologically The term early applies therapy to block the lymphatics 23 well as more to the degree of localization rather ·TIIE TREATMENT OF BRONCHIAL NEOPLASMS 17 than to its temporal aspects cal resection on the basis of localization Application of the traditional radical ap The challenge is to learn enough about the proach to the surgery of cancer must be biologic characteristics of the various types empered in the case of bronchogenic carci of bronchogenic carcinoma so that it will oma by practical considerations of the vital be known which lesions are suitable for inctions of the lung and the biologic fac surgery, which will be benefited by radical rs involved The differences in mortality resections which may be treated by more tween radical and conservative ap conservative resections with a better quality vaches and the quality of survival are im of survival and which types will be harmed tant gauges of therapeutic efficiency by injudicious application of surgical tech The biologic characteristics of a particu niques being better treated by means of neoplasm determine suitability for surgi irradiation or chemotherapeutic methods REFERENCES AUERBACH O GERE) B FORMAN JB 8 HUSTELDT E Carcinoma of the lung Johan PETRICK TGSVOLIN HJ MUENSAM Holst Memorial Volume University of GE KASSOUNY D Y and STOUT A Oslo Norway 1955 p 119 P Changes in the bronchial cpithel um in 9 MacDONALD LAN The individual basis of bio relation to smoking and cancer of the lung logic variability in cancer Surg Gynec New England 1 Med 256 104 1957 & Obst 106 227 1958 2 BLACK MM and SPCER FD Sinus MACDONALD IAN Biologic predeterminism histiocytosis of lymph nodes in cancer in human cancer Surg Gynec & Obst Surs Gynec & Obst 106 163 1958 99 443 1951 3 COLE WH and EVERSON T C Spontane 10 MCWHERTER R Discussion The treatment ous regression of cancer Preliminary re of cancer of the breast Proc Roy Soc port Ann Surg 144 366 1956 Med Lond 41 122 1948 + CRILE GJR Factors influencing the spread 11 PAULSON D L and SHAW R R Early deof cancer Surs Gynec of Obst 103 342 tection of bronchogenic carcinoma 1956 ΤΑ ΜΙΑ 146 S25 1951 S DUNPHY JE Some observations on the 12 RIGLER LC Duration of carcinoma of natural behavior of cancer in man New lung Dis Chest 23 50 1953 Cnsland / Med 342 167 1950 13 RYAN RF and McDONALD JR Bron (Ewig J Neoplastc D seases Philadelphia chogen c carcinoma with in situ carcinoma Saunders 1940 in the opposite lung Proc Staff Meet 7 HAAGENSEN CD and STOUT AP Carct Mayo Cl 31 478 1956 noma of breast Results of treatment 1935 1917 Ann Surg 134 15 151 ·Selection of Patients for Surgery BECAUSE ECAUSE OF THE BIOLOGIC characteristics therapy, must be kept in mind These other of bronchogenic carcinoma, any improve modalities of treatment may allow longer ment in survival rates following resection prolongation of life in comfort for patients can be achieved mainly through a better having a localized lesion in whom other selection of the biologically early lesions for considerations make surgical ercision in surgical therapy The fact that certain pa adı sable, if the carcinoma is biologically tients may have localized lesions that can unfavorable, or if it has extended beyond be cured by surgical excision does not mean the limits of surgical excision that surgical therapy will be applicable to all patients having bronchogenic carcinoma BIOLOGIC FACTORS It is not prudent to submit a patient to a Owing to the biologic characteristics of surgical procedure which is destined to bronchogenic carcinoma half of the pa prove frutless and perhaps harmful Even trents have lessons which are inoperably an exploratory thoracotomay for a nonre when first seen and another 15 per cent arc sectable lesion is attended by a significant found to be nonresectable at the time of mortality, will inevitably add to morbidity, exploratory thoractomy One third of the and will very likely reduce the period of patients have resectable lesions and in only Survival a small percentage of these are the carcin It is the responsibility of the surgeon to omas favorable for long term survival The appraise carefully the patient who has a biologic factors of cell type location and bronchogenuc carcinoma from the stand resistance of the hose largely determine the point of biologic characteristics and for any pattern of behavior and prognosis Ap evidence of extension of the disease bezond preciation of the importance of this concept the limits of possible surgical excision before will lead to a better selection of patients for reaching the decision that surgery is ad surgery and improved survival rates 125able Other factors not directly con From the standpoint of evaluation of the nected with the disease being treated (age, individual patient having a bronchogenic general physical condition, pulmonary and carcinoma the cell type the location the cardiac function, and other diseases carrying progression of the lesion, and the a grave prognosis) should be carefully evalu length of brstory of symptoms are all im ated to determine the ability of the patient portant consideracions Twenty percent of to tolerate the proposed surgery, and the patients have a small cell undifferenti whether or not as a result of the surgery ated carcinoma widely recognized for its the patient's prospect of survival in comfort rapid dissemination and considered by many can be improved In Heighing these factors as a sign of inoperability in itself Frequently other methods of treatment carrying less patients with carcinomas of this type man! fisk, such as irradiation therapy and chemo fest signs of rapid progression such as rate of 18 ·19 THE TREATMENT OF BRONCHITAL NEOPLASMS roentgenographic evidence or early deterior are so well aware of this fact that in patients ation and have a paucity of symptoms or a presenting symptoms of a brain tumor short history They may present themselves routie x rays of the chest are made in because of symptoms due to a metastasis order to rule out the presence of a primary In contrast the patient having a biologically bronchogeni carcinoma (Figs la and lb) favorable low grade cpidermoid carcinoma Although it may be true that in approxi frequently has a longer hsstory of specific mately one third of patients having a meta symptoms definitely localized to the lung stasss to the brain from a bronchogenic and evinces slow progression of the lesion carcinoma the metastasis will be a single Dependable biopsies of the neoplasm ob one combined attacks upon the cerebral tained by bronchoscopic examination may metastasis and the primary lesion by surgery well be decisive in arriving at a wise deci have not been rewarded by a significant sion regarding the advisability of surgery increase in survival time Any palliation Location of the shadow on the roentgeno that has been afforded has usually been due gram as nodular hilar or extremely peri to the removal of the cerebral lesion and not pheral is also an important consideration due to pulmonary resection removing the in the cvaluation of the individual patient primary tumor Irradiation therapy over Bronchogenic carcinoma presenting as a the cerebral lesion may provide some pallia pulmonary nodule is resectable in a high tion of symptoms with less risk of causing percentage of cases and yields high survival additional neurologic defects or operative rates particularly in the absence of symp mortality coms even though there may be evidence Spinal Metastases The spine is also a that it has been present a long time in common site for blood borne metastases contrast the hilar lesson particularly in the from bronchogenic carcinomas The oc left lung may be disappoinung due to ex currence of a localized lancinaring pain tension along the hilum to the mediastinum usually in the low thoracic or high lumbar not readily visualized asthin the arch of the region radiating along enoun nerve path jorta Laminography is often of assistance ways is the usual symptom caused by such an evaluating possible mediastinal extension metastases The severe unrelenting charac or metastases Extreme peripheral lesions ter of the pain will usually differentiate 18 even though they involve chest wall may be from the pain caused by a prolapsed disc resectable There is usually little roentgenographuc evi dence of the metastases as shown by erosion ABSOLUTE SIGNS of the vertebrae The intervertebral disc or IvorERABILITI may be involved The occurrence of a pain There are certain evidences of extension of this type in a patient knoạn to have a of a bronchogenic carcinoma that should primary bronchogenic carcinoma and es he recognized as absolute signs of inoper pecially if it is of short duration is sufficient bility in contrast to those that are only to contraindicate pulmonary resection Al suggestive though patriation can be effected by irradia Distant Metastases tion therapy over spinal metastases the The presence of distant metastases as a period of improvement is usually quite general rulc males surgical excision of the short The pain as a rule recurs and often primary lesson inadvisable complete paraplegia will occur before death Cerebral Metastases Brain tumors Jue Abilominal Metastases. Metastases to to blood bome metastases are common in the abdominal organs chsely the Iner and bronchogenic carcinonta Neurosurgeons adicnals and occasionally the kidney's a ·20 SELECTION OF PATIENTS FOR SURGERY i Fig la This roentgenogram of the chest of a 45 year old man was taken as a routine study because of symptoms suggest ve of a brain tumor Fg Ib Stratograph of the chest which s ves better del neat on of the pulmonary nodule presumed to be a primary bronchogen c carcinoma Before advis ng that this asymptomat c nodule be resected It should first be established whether or not the brain tumor is a metastat c les on peritoneum often occur but may be diffi nal metastases and the difficulty in diagnos cult to detect clinically Involvement of the ing them is one factor in the disappointing retroperitoneal nodes also is common in short survival of many patients following disseminated carcinoma At the time of pulmonary resection for bronchogenic carcı post mortem examination it is often amazing noma how much neoplasm is discovered in a pa Metastases to Bones Bronchogenic carci tient who exhibits no more than mild lassi nomas commonly metastasize to bones tude The ability to palpate an enlarged These metastases are usually to the flat nodular liver in the absence of other forms bones such as the ribs and skull but oc of hepatic disease is highly suggestive of casionally they involve the long bones metastases to the liver and should be con Metastases to ribs on the involved side or sidered a sign of inoperability Bronzing of contralateral side may occur Their pres the skin and lassitude out of proportion to ence may be detected because of a patho obvious disease should make one suspect logic fracture that might be confused with adrenal metastases An exploratory laparo a cough fracture Metastatic lesions to tomy is seldom advisable to establish the bones from malignancies of the lung are of presence of metastases within abdominal an osteolytic type It may be necessary to organs Radiographic techniques are of perform a biopsy of the bone tumor to little help in determining the presence of establish its true nature before deciding abdominal metastases except in the rare that the presence of the bony lesion contra situation where there may be large retro indicates resection of the tumor in the lung peritoneal masses The incidence of abdomi Pulmonary Metastases. Involvement of - ·21 THE TREATMENT OF BRONCHAL NEOPLASMS 9-29-51 2-2-56 1-11-57 Fig 2a b, c This bronchiolar carcinoma arising in the right louer lobe remained a localized leston for several years When dissemination occurred the left tung became involved rendering the patient inoperable This case illustrates the importance of advising resection for pulmonary nodules of unknown etiology the contralateral lung in bronchogenic carci. as soon as it goes beyond the peribronchial noma is common as a late development in nodes On the left side, the spread from the the type of malignancy being designated as neoplasm in the upper lobe will follow the alveolar or bronchiolar carcinoma Meta- nodes under the arch of the aorta and then stases may occur rarely in other types of along the paratracheal nodes to reach the bronchogenic carcinoma Extension through supraclavicular nodes in the fat pad overthe subcorynal nodes to involve the op. lying the anterior scalcnc musclc A carcin posite bronchus occurs occasionally Con- oma in the left louer lobe may spread along tralateral pulmonary metastases represent one or both of two lymphatic routes The an absolute sign of inoperabihty (Fig 2a, first would be to the nodes below the inb, c) ferior vein which communicate with the Lvidences of Dissemination General nodes in the abdomen in the retroperitoneal dissemination of a bronchogenic carcinoma space The second route would go to the may be obvious by the occurrence of meta nodes in the cory nal region and thence static nodules in the skin and scalp In the would follow the paratracheal nodes 01 course of a physical examination of a pa. either side to reach the supraclavicular trent the scalp should be carefully palpated nodes on either or both sides of the neck for any evidence of nodules that might Carcinomas in the upper and middle have recently occurred and escaped detec- lobes on the right metastasize along the tion by the patient If there is doubt as to nodes between the trachea and the vena cava e iniute of the module, biopsy should be 10 reach the right supraclavicular nodes in carried out to establish whether or not a the scalene fat pad rollowing involvement metastasis is present it is obvious that any of the node immediately above the 3zygos such sign of generalization of the disease fein the extension may be toward the left contraindicates pulmonary resection for the to the nodes lying just above the arch of the primary lesion aorta from which group they could extend upward along the left side of the trachea LYMPH VTIC ENTENSION following the same path as extension from The spread of a bronchogenic carcinoma the left upper lobe Neoplasms in the in the lymphatic system becomes complet loucr and middle lobe typically m ·22 THE RATIONALE OF TREATMENT to the corynal mass of nodes from which From the foregoing paragraphs it be they can follow a lymphatic path on either comes obvious that the presence of lymph side of the trachea The complex lymphatic nodes in the supraclavicular fossa known system of the chest (Fig 3) affording ample to be involved by neoplasm represents a opportunity for spread of the carcinoma sign of incurability Palpable nodes should along many diverse routes, explains why be removed for pathologic study to estabradical resection of the lungs with an fish this fact When one is presented with attempt to excise involved lymphatics has a patient having bronchogenic carcinoma been so unrewarding in the treatment of in whom bronchoscopic examination might bronchogenic carcinoma be diagnostic, but there are also palpabi- Paratracheal Tytoph nodes Paratracheal ymph nodes Connection to thoracie duct To shoulder breset and arm Supraclavicular Jymph nodes Right Sup Tracheobronch al ivmph nodes lett sup tracheobronchial 1ymph node Left recurrent nerve Bronchopulmonary ymph node Bronchopulmonary 1 ymph nodes Ira he tronch a Tih noses Sutpericardia1 lymph node Mediastinal by ph nodes Tig 3 This drawing shows the complex inter communicating lymphatic channels draining the tracheobronchial tree Tumor cells may spread early to the hilar and to the contralateral lymph nodes through the rather liberal crossed lymphatic drainage of the bronchi particularly through the subcorznal region from the left side ·23 THE TREATMENT OF BRONCHIAL NEOPLASMS nodes in the supraclavicular fossa, examina examination was done in the absence of tion of the involved lymph nodes should palpable nodes Because of the complex be carried out first If these nodes are in lymphatic system of the chest, if this pracvolved by neoplasm, both the diagnosis tice is to be followed, bilateral scalene node and the evidence of incurability have been biopsies would have to be done It is doubt. established and it is unnecessary to subject ful whether it is advisable to subject every the patient to the additional procedure of patient suspected of having a bronchogenic bronchoscopy carcinoma to scalene sode biopsies When the physician senses, however, that the pa SCALENE NODE BIOPSY tient being considered represents a poor Routine scalene node biopsies have been candidate for excisional surgery, or there is practiced in some clinics Cuykendall' re- roentgenological evidence of mediastinal ports finding metastases to prescalene lymph nodc involvement (Fig 4), examination of nodes in 20 per cent of cases in which this the nodes in the scalene fat pad, even though Tepe Tig 4 The sadering of the mediastinum on the right is sufficient en dunce of ponresectability in the case of this 67 year old man Even though bronchoscopy and cervical nove biopsy did not result in pathologic confirmation of bronchogenic carcinoma exploration of the chest was not advised Exploratory thoracotoms in this type of case is of little value to the patient and may result in loss of survival time Irradiation therary was advised A cerebral melastsus become evident within one month of the taking of this film

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·THE TREATMENT OF BRONCHIAL NEOPLASMS 25 is not accompanied by fever Examination which seems to accomplish approximately of fluid aspirated from the chest in such a the same result now makes pleurectomy a case will usually reveal neoplastic cells The less useful operation fluid may or may not be bloody in appeal Pleural effusion may also be present as ance but usually red blood cells will be an indication of complete obstruction of a numerous when examined microscopically major pulmonary vein due to a tumor Surgical resection is inadvisable in the pres thrombus or occlusion of the vein by infil ence of fluid positive for carcinoma cells tration of the tumor around it In addition Pleurectomy has been advised as a palliative to the pleural effusion the lobe or lung procedure in order better to control the beyond the obstructed veins will be edemat pleural effusion The availabilty of radio ous causing it to cast a solid shadow in the Isotopes and nitrogen mustard the use of roentgen film of the chest without evidence TS The complete orac ty of the right hemithoras suggests a massise pulmonin ve ns by the neoplasm and cates inoperabit) ·26 SELECTION OF PATIENTS FOR SURGERY of a concomitant loss of volume (Fig 5) bracheocutaneous nerve to the inner surface The pleural fluid will be high in fibrin con of the arm does not preclude a successfu tent and there may be fibrinous deposits of en bloc resection of the involved lobe o the chicken fat clot type within the pleural the lung with a portion of the chest wall cavity Aspiration of the pleural cavity in We are at present testing the combination this situation will yield a much smaller of irradiation therapy followed in sur ti quantity of fluid than one expects to get as eight wcehs by resection in this type o judged by the physical findings and the fesion (Fig 6a and b) The morbidity 1 roentgen appearance of the chest Neo so severe and so often prolonged in th plastic cells usually cannot be recovered case of the superior sulcus tumor that pal from fluid secondary to venous occlusion The occurrence of fluid in the presence of the face of causing neurologic defects r nation of pain alone is justifiable even an engorged lobe or lung is a sign of in the hand and arm on the involved side operability Pleural fluid may also accompany atelec BRONCHOSCOPIC OBSERVATIONS tasis secondary to bronchial obstruction by Observations made at the time of bror neoplasm in a major bronchus When there choscopy may reveal evidence of extensio is bronchoscopic or bronchographic evi of the neoplasm sufficient to rule out th dence of an obstruction of a major bronchus possibility of a successful resection Th and evidence of suppuration beyond the presence of visible neoplastic tissue at th blocked bronchus as shown by fever and level of the carina or trachea representin toxicity the presence of fluid does not a direct extension from neoplasm original represent a contraindication to resection ing in a bronchus is a sign of inoperability Typically neoplastic cells are not found in If the visible neoplastic fissue can be see fluid occurring secondary to atelectasis and within 2 cm of the carina a carini suppuration of the lung distal to a bronchial biopsy should be done even though th neoplasın mucosa at this point appears normal sinc In summary the question of whether or neoplastic cells may be demonstrated in th not the presence of pleural flud complicat submucosal plane or in the lymphatic' ing a bronchogenic carcinoma indicates a Gross fixation of a major bronchus wit sign of inoperability depends upon the de gross widening or distortion of the carin tection of neoplastic cells in the fluid and is an indication of mediastinal involvemer the determination of whether or not the to a degree that would prohibit a successfu fluid is secondary to occlusion of a major resection As the surgeon gains experienc pulmonary vein with bronchoscopic examination more patients will be rejected for surgica BRACHIAL PLEXUS INVOLVEMENT therapy on the basis of bronchoscopic find Gross invasion of the brachial plexus ings alone accompanied by swelling in the supraclavi QUESTIONABLE SIGNS OF çular fossa Horner s syndrome and radio INOPERABILITY logic evidence of osteolytic destruction of Signs of Extension Beyond Lung the posterior portion of the upper ribs close to the spine presents an impossible technica) Local invasion of neighboring tissues by problem to one attempting to cradıcate such direct extension may not represent an abso a lesion Invasion by a peripheral broncho lute sign of inoperability unless some vital genic carcinoma causing pain along the structure has been involved Paralysis of ulnar distribution to the hand and the the diaphragm on the involved side, indica man ·27 THE TREATMENT OF BRONCHIAL NEOPLASMS 52-57 9-11-57 Fig 6a The lesion seen within the circle of the first rıb on the right caused severe pain in the shoulder and arm of a 52 year old man Fig 6b Four months later the lesion was seen to have enlarged Seven weeks following completion of irradiation therapy (3000 R) the lesion was surgically removed by an en bloc resection which included the apical segment and portions of the 1st 2nd 3rd and 4th ribs with intervening intercostal muscle bundles The neoplasm was found to have been converted into a fibrous mass by the irradiation therapy - making identification of cell type difficult ing invasion of the phrenic nerve, is a is not a sign of inoperability if there is no questionable sign of inoperability, but since gross invasion of the spine A localized It is feasible to remove the pericardium area of invasion of the chest wall even when along with the nerve and its accompanying ostcolytic destruction of ribs is evident does vessels resection still might offer a chance of not necessarily preclude the possibility of cure Direct invasion of the diaphragm may an en-bloc resection of a portion of the not preclude a successful resection The chest wall along with the involved lobe size of the tumor in such situations would (Fig 7) play a large part in the decision as to wheth er or not surgery should be advised Poor Pulmonary Function Pulmonary emphysema and brochogenic Invasion of Chest Wall carcinoma are two commonly associated Involvement of the chest wall by direct diseases Severe degrees of pulmonary em. extension from a peripheral pulmonary neo physema, which have already caused the plasm becomes an absolute sign of inoper- patient to become a pulmonary cripple, may ability only when the involvement is of large represent an absolute sign of inoperability dimensions or in such a position as to in In evaluating a patient from this standpoint, volve structures which cannot be ercised one will have to consider the overall pulsurgically re, aorta, brachial plexus, monary status in view of the extent of the bodies of the vertebrae, etc Involvement resection that may be required Total pneuof the first and second intercostal nerves monectomy may be absolutely ·28 SELECTION OF PATIENTS FOR SURGERY Fig 7a The scapular shadow partially obscures the shadow cast by thus neoplasm which has iny the chest wall of a 58 year old man Pain radiating along the third and fourth intercostal nt to the anterior portion of the right chest was the presenting symptom Fig Tb A roentgen film taken to show bony detail shows clearly the osteolytic destruction of tions of the 3rd and 4th ribs An en bloc resection including the right upper lobe and portion the involved 2nd 3rd 4th and 5th ribs adequately removed the lesion The muscles of the shou girdle protect the defect in the thoracic wall The patient is well and free of pain more than a following surgery cated, but lobectomy and even segmental lobectomy and occasionally even total pri lobectomy might be tolerated with very monectomy Physiologically, many patiei little diminution of pulmonary function having a bronchogenic carcinoma appear (Fig 8) be much older than their chronologic ag This may be an inherited characterist Age and Coronary Artery Disease There is evidence, however, that excessi' Age often has to be considered in de cigarette smoking may hasten the agtr termining whether or not surgery should process, so that in addition to being a be advised in the treatment of bronchogenic inciting cause for the bronchogenic carc carcinoma Although the chronologic age noma, there has been a general deterioratio may not be as important as physiologic age, of the tissues of the body aside from th ut very often has to be considered since it respiratory tract This is usually evidence may be directly associated with the patient's by a sallow, unhealthy appearance, a la philosophy of living Many patients ad- skin, premature graying of the hair, anc vanced in age chronologically with clear general loss of vigor Very often the phy * mental insight into the realities of life prefer sician s first impression of the patient being mot to be subjected to a major surgical considered for surgery is that this man will Tre for the treatment of a malig not tolerate major surgery well This im nancy On the other hand, many individuals pression accompanied by other manifesta beyond the age of 70 are well able to tolerate tions of the degenerative processes such as ·29 TITE TREATMENT OF BRONCHIAL NEOI LASMS P Fig 8 Poor pulmonary reserve due to en physema contra nd cated total ght pneun onectomy ih s 70 year old mn However r ght upper lobectomy vas well tolerated One year follow ng surgery he scom fortable and w thout s gn of recurrence of the squamous call cute noma coron iry artery disease and cerebal arteri standpoint of time of survival may be poorer osclerosis may well be sufficient to warrant than that of the pulmonary neoplast the decision that surgery is inadvisable Many patients with a limited cardiac re SUVVARS seric tolerate surgery well and make uncom The surgeon must select carefully for plicated recoveries However the presence surgical therapy patients having neoplasms of dyspnca any part of which can be suitable for resection ascribed 10 a failing heart would certainly The salvace rate from the surgical treat contraindicate w pulmonary resection of the ment of bronchogenic carcinoma in the ma magnitude of a total pneumonectomy jority of patients is so lou that little will Chronic cardiac decompensation unrelieved be gained and much harm can result from by medical measures would make the ad in over aggressive surgical polov in selec visablity of pulmonary resection for bron fion of patients for surgery Survival rates chogenic carcinoma very questionable since following surgery for bronchogenic carui the prognosis of the cardiac discasc from the noma must take into consideration an ·30 SELECTION OF PATIENTS FOR SURGERY creased mortality and morbidity and an into the equation his knowledge of the dis actual shortening of lives in the final results ease and its possible ramifications of the The authors agree with Maier' who states ability of the patient being considered to * The little that might be gained by a very tolerate the proposed surgery, of the limita radical approach is more than offset by the tions of surgery and of the effectiveness of high mortality and morbidity that most other therapeutic modalities Only then surgical cancer reports are lacking in a can he arrive at the wise solution for th broad viewpoint in that due consideration problem presented by the individual patient is not given to the debit side of the surgical Through an appreciation of the biolook balance sheet, namely, the lives of patients characteristics of the various types of bron in reasonable comfort that have been short chogenic carcinoma it is possible to arrive ened by high operative mortahty resulting at a more critical selection of patients for from ultraradıcal surgical procedures' It surgery, a better choice of operative pro 15 the responsibility of the surgeon to place cedure, and improvement in survival rates REFERENCES 1 CUYKENDALL J H Use of prescalene sectability rate in operations for lung lymph node biopsy in absence of palpable carcinoma 17 orar 12 79 1957 supraclavicular nodes AMA 155 741 3 MAIER HC Pulmonary Carcinoma New 1954 York New York Univ Press 1956 2 SMITH AR The results of raising the re 337 ) ·Selection of Operation BASED ON THE RATIONALE of treatment et Pulmonary tissue is vital tissue and should is believed that lobectomy is the operation be conserved as carefully as possible in a of choice in the surgical treatment of a pa patient of any age Conservation of pul tient having a bronchogenic carcinoma monary tissue becomes increasingly impor Total removal of a visceral organ which is tant in patients in the age groups susceptible the site of a primary neoplasm traditionally to primary neoplasms of the lung is the ideal surgical procedure This should Bugher in a paper entitled Some Prob include removal of the regional lymph nodes lems of Interpreting Statistics on Cancer in an en bloc resection To state however Diagnosis and Treatment concludes It that total pneumonectomy with dissectron of seems clear on reflection that survival time the regional lymph nodes is the ideal opera is not an adequate index of therapeutic ef tion for bronchogenic carcinoma does not ficiency There needs to be some measure mean that it is the operation of choice for of the quality of survival There is a great the patient having a neoplasm of the lung difference between the patient who manages Telah Suvert arthrt s involving the ankles was the symptom that led to the detection of th s Lirgc neoplastic mass in the left upper lobe The les on was removed by I ft upper lohectomy wh ch should permit a stiperior quality of survival without sacrificing i me of surnal The arthritis com pletely disappeared in two weeks following surgery 31 ·32 SELFCTION OF OPERATION to survive as a suffering incapacitated and in this country, in which there is undoubted bedridden individual and one who although ly some selection of patients in that those living for the same period of time is able hopelessly ill when first diagnosed may not to continue with normal or near normal be referred for surgical evaluation show activity for most or all of the period There only a slightly better salvage rate from is the implication in existing data that the surgery The uniformity of these reports therapeutic measures used may themselves indicate that total pneumonectomy can be of such injurious character that the in- achieve little more than lobectomy in com creasing life expectancy from eradication of pletely eradicating the neoplasm and has the neoplasm may be partly or completely the disadvantage of a significantly higher offset " To no other visceral organ of the mortality and a poorer quality of surma! body does this principle apply as clearly as There is no indication in the terature that it does to the lungs (Fig 1) the surgical skill of the individual surgeons Review of the recent literature on the reporting affects the survival rates once the surgical treatment of bronchogenic carci patient has recovered from the operation noma reveals that Brock ' Ochsner,' and The variations in surgical mortality rates Gibbons' among others advocate the neces are probably due to factors m selection of sity of performing a total pneumonectomy patients for surgical therapy and in post Evaluation of their survival rates does not operative management seem to bear out the prediction made by The objection to lobectomy in the treat Graham in 1948 that the routine per ment of bronchogenic carcinoma is that it forming of total pneumonectomy for can does not allow an adequate mediastinal dis cer of the lung should yield a significantly section This objection infers that pneu higher five year survival rate as compared monectomy offers a better chance of com with survival rates in series of prtients plete cure by being able to remove all can where selective resection is used when ccrous tissue Certainly in any operation feasible Advocates of pneumoncctomy, in for cancer the regional lymph nodes should advising a more radical surgical approach, be excised Johan Holst' in discussing the are not able to achieve a higher rate of re- problem of gastric resection for malignancy sectability as compared with those using asked the question "Just where do the re selective resection The operative mortality gional lymph nodes end and the nodes of following pneumonectomy ranges from 9 to the general lymphatic system begin?' Dc 23 per cent according to various reports cause of the complex lymphatic drainage Surgeons limiting the extent of the resection of the lungs within the mediastinum and the when feasible generally have an over all vital structures with which the nodes are is surgical mortality under 10 per cent direct continuity (Fig 3, Chap III), for Husfeldt' (an advocate of total pncu- practical purposes the regional lymph nodes monectomy), working in Denmark where as far as the lungs are concerned are the there are accurate vital statistics in a country peribronchial and hilar nodes These can with a uniform population and medical sys- be as easily remosed with Jobectomy as tem, has shown that the over all five year with pneumonectomy Likewise the corynal salvage achieved by surgery is 5 per cent and peritracheal mass of nodes can be dis In the 1954 report' of 'Organized Clinical sected and ercised in performing lobectomy nvestigation of Cancer' by the University although the chance of affecting surnal of Michigan, 5 2 per cent of patients having time if they are grossly involved with neocancer of the lung who were eligible sur plasm is not great There is a great possi vied five years Reports from other clinics bility in disecting within the mediasti ·THE TREATMENT OF BRONCHAL NFOPLASMS 33 num, grossly involved with lymphatic spread Graham," when he performed the first of neoplasm, that barriers of resistance will successful total pneumonectomy for bronbe disturbed so as to lead to a more rapid chogenic carcinoma started the operation and widespread dissemination of the cancer with the plan of limiting the resection to the The position of the neoplasm in respect left upper lobe It was only when the poto the point of section of the bronchus is sition of the lesion with respect to the major the chief factor in determining the extent of bronchus was determined that the cour resection The point of division of the bron. agcous decision was made to remore the chus should be at least 15 cm (Clagett total lung it was fortunate that this historic et al') from visible or palpable evidence of operation was done on a patient having neoplasm This factor is not a problem in adequate pulmonary reserve permitting long emoving peripheral neoplasms by lobec survival with no apparent physical limitaomy When the lesion has originated in a trons This brilliant result unfortunately ajor bronchus of necessity a total pneu cannot be duplicated in a large body of panectomy must be done unless lobe or tients having bronchogenic carcinoma be. s can be preserved by performing a cause of their limited pulmonary reserve choplasty Lobectomy will be feasible In many of these patients a more Irmited "er in one-half of the patients suitable resection is well tolerated Graham, rgical resection though he was generally in favor of total land has reported 2 cases of re pneumonectomy in the surgical treatment of re of carcinoma in the bronchial bronchogenic carcinoma stated "There are Nunip in a series of 21 patients following cases in which it is worthwhile to take a ſobectomy for carcinoma He concludes chance on a lobectomy because of the horri from this that total pneumonectomy should ble situation in which a patient may be he the operation of choice for patients hiv left of total pneumonectomy is perfomed ing bronchogenic carcinoma and that a Churchill" in 1937, in entering into the lobectomy should only be done as a com argument of lobectomy versus pneumonectpromise for consideration of pulmonary omy compared the lymphatic system of the function He ignores the fact that there is mediastinum to a 'swamp or a morass' and at least a 6 to 10 per cent difference in the stated that under certain circumstances he trgical mortality of lobectomy versus pneu elected to perform lobectomy for cancer In onectomy so that at least 2 of the 21 pa 1950 reporting the twenty year experience tients treated with lobectomy would not at the Massachusetts General Hospital with hale survived to have a recurrence if they the surgical management of carcinoma of had been subjected to total pneumonectomy the lung he stated that he elected to per. rinally the 19 palients remaining are im form ſobectomy (1) When there was lou measurably more comfortable with lobec- pulmonary or cardiac rescrie (2) when the tomy than they would have been if they had diagnosis was in doubt (3) for small perte been deprived of the use of a total lung pheral lesions without evidence of lymph The concept that fess than total pncu- pode estension and (4) as a palliative pro monectomy may be an adequate operation cedure for bronchogenic carcinoina is not nes al Neuhoff and Aufses" in 1948 concluded though opinions expressed in the literature that "Lobectomy is a properly concensed on this subject have not stressed that lobec. operation that may be curative for circumfony in the interest of conservation of pul- scribed and peripherally invasive carcinoma monary function makes it the operation of of the lung They had no survivals for choice more than a year in patients discos ..

·34 SELECTION OF OPERATION have extensive regional node involvement however, are leading active lives with only as shown by examination of the resected minor restrictions specimen In patients in whom the resected specimen revealed no lymph node in SEGMENTAL RESECTION volvement, a common factor causing death was blood borne metastases, a factor which lung by removing less than a lobc rarely 15 Resection of a primary neoplasm of the is not affected by the type of operation Robinson, Jones and Meyer" in 1956 segmental resection may be an adequate justified In certain patients, however : reported the result of a survey they had procedure Very small pulmonary nodules made concerning the practice of thoracic due to a primary neoplasm located in th surgeons in respect to selective resection in periphery of a segment in which there is the treatment of bronchogenic carcinoma Seventy seven per cent of the surgeons no evidence of glandular involvement may queried stated that they perform lodectomy mental resection Our longest survivor fol at times be adequately removed by seg as an operation of choice ander circumstances of their own choosing 40 per cent of age who 12 years ago had resection of lowing resection is a woman now 76 years use it only as a compromise when there is some contraindication to pneumonectomy, an anterior segment of the left upper lobe and only six surgeons (2 per cent) stated that they consider lobectomy the operation of choice whenever it is anatomically fcası ble A frequent comment by surgeons an swering the questionnaire dealt with the poor over all experience in attempting to cure pulmonary carcinoma This comment indicated that they were finding surgical therapy helpful to a limited group of pas trents and were searching for a method of improving results from surgery Experience indicates that this can be accomplished not by extending the limits of surgical excision by more radical procedures but by a careful selection for surgery of patients who can be benefited by resection Insufficient pulmonary and cardiac re serve accounted for eleven of the seventeen surgical deaths following pneumonectomy and three of six deaths following lobectomy forced a stream or blood in the mucus she cleared Fig 2 for three weeks this 64 year old woman in our patients The high mortality from from her throat cach morning X ray rescaled this cause in patients that have been care an abnormal shadow in the left upper lung ficlJ fully evaluated from the standpoint of their A small primary bronchogenic carcinoma was ability to tolerate the proposed resection removed by resccting the anterior segment of the further emphasizes the necessity of preseryupper lohe The patient is alive and well tuche ing pulmonary tissue whenever possible A years later six years before this x ray was talen an early carcinoma of the cervis was detected ew of the patients who survived pneumo and cured by radium therapy Thus an intelligent nectomy are now completely incapacitated patient atded by her afert physician has survived by their low pulmonary reserve The others, two separate primary carcinomas ·35 THE TREATMENT OF BRONCHIAL NEOPLASMS w Fig 3a & b This small bronchiolar carcinoma was removed by segmental resection from the right lung of a 61 yeir old woman The two v rays taken four years apart were made as part of preemployment examinations for a small primary epidermoid carcinoma too widely from the traditional concept of (Fig 2) Small bronchiolar carcinomas the surgical treatment of neoplasm but inmay be adequately excised by segmental re dividualization is important in the overall section (Figs 3a and b) Patients having approach to this problem Segmental repoor respiratory function due to severe pul section may be the operation of choice or monary emphysema who would otherwise the only procedure feasible in certain pa be considered inoperable may tolerate re trents suffering from primary cancer of the moval of a segment of lung Patients who lung have previously had resections now oc casionally present themselves for the prob. INDICATIONS FOR lem of resection of an newly acquired lesion PNEUMOYECTOMY (Fig 41 and b) In such patients segmental Pneumonectomy becomes necessary in resection may be feasible and may oc- approumately one half of patients having Custonally be an adequate operation Peri surgery for bronchogenic carcinoma due to pheral neoplasms (rig sa and b) which the frequent location of the neoplasm in the in addition require reinoval of a portion of major branch bronchi This is the most the chest wall because of parietal invasion common site for the low grade epidermoid may be adequately excised in some instances carcinomas Although the primary site may by resecting less than the entire lobe The be relatively close to the lymph nodes at Crux of the probiem in these instinces usual the hulum of the lung many of these lesions Iy lies at the periphery of the lung and in due to their biologic nature are locally ! the chest wall and not in the hilum It is vasive and slow to disseminate The recognized that it is undesirable to depart scem to spread less commonly + R

·36
SELECTION OF OPERATION
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·THE TREATMENT OF BRONCHILAL NEOPLASVS Fig 43 (Puge oppusile-upper) A right upper lobeciomy was done to remove the pulmonary nodule casting the shadow in the ray of the chest of a 70 year olu man The lesion was a primary broncho genic carcinoma-Squamous cell type Fig 4b (l'uge oppoutempper) Mineteen months later a new nodule was seen to have developed 4 in the fingular portion of the lett upper lobe Thi, fesich was removed by resecting the lingula and * # subsegment of the anterior segment Pathologic study revealed this second lesion to be a new primary by neoplasm The use of lobectomy in treating the original carcimoma permitted successful resection of the second lesion leaving the patient with an adequare breathing capacsty for comfortable living 3 Fig Sa (Page oppositeloner) Peripheral squamous cell carcinoma (Pancoust tumor) invohong chest wall and invading brachial plexus causing severe pain in upper chest shoulder and along the ufnar d stru bution to the right at The neoplasm was removed by excising the apicoposterior segment of the upper lobe with an en bloc resection of portions of the involved rsbs and bodies of the vertebrae ng 5b Appearance of chest one year following resection The patient is well wrthout pain freen months following operation 1 ·38 SFLFCTION OF OPERATION blood stream Thus although due to their moving a lobe when there is evidence that location in the bronchial tree, preservation the neoplasm has extended along the of a portion of the lung is out of the ques lymphatic channels to lymph nodes beyond tion they may by being localized represent the involved lobe A radical pneumonec good lesions for surgical eradication An tomy with excision of all accessible nodes epidermoid carcinoma even when small is the operation of choice in this situation (Fig 6a), by blocking a major bronchus However, if pulmonary function must a may cause wheezing severe cough, and considered a more limited resection may fever due to pneumonitis so that the pa be preferable This may be followed by trent seeks medical attention early Al irradiation therapy over regions of known though the temporal factor is of secondary involvement (Fig 7a b and c) importance to the biologic factors con cerned, time is nevertheless of great impor BRONCIIOPLASTIC PROCEDURES tance in this type of bronchogenic carci Bronchoplastic procedures may be useful noma so that resection may be applied while in selected patients in conserving pulmonan the lesion is still localized to the primary tissue in the treatment of bronchogenn site carcinoma The use of this technique scems The finding of metastatic nodes in the to find its greatest usefulness when used hilum of the lung or in the mediastinum deliberately as an elective procedure con makes pneumonectomy the operation of cerved as an adequate cancer operation for choice This is true even though the pri the particular case being treated Thus, 1! mary tumor may be peripheral within the should not be reserved for patients in whom lobe There is little to be gained by re total pneumonectomy is out of the question Fig 62 This 74 year old man had cough and fever at the time this yras was taken Pensculi ? therapy brought partial relief of symptoms but ray shadow persisted He was still active seven years after left total pneumonectomy Fig 66 Small bronchogenic carcinoma squamous cell is pe causing fibroid pneumonius of left upper lobe ·ngayon THE TREATMENT OF BRONCHIAL NEOPLASMS 5-28.56 5-28-56 e + Tig 7a and b This squamous cell carcinoma ansing in the periphery of the middle lobe was found at surgery to have metastasized to the hilar and subcarinal nodes Poor pulmonary function contraindicated total pneumonectomy 39 ·40 SELFCTION OF OPERATION 10-10-57 Fig 7c Appearance of chest fourteen months following resection of the middle lobe and involved nodes combined with irradiation therapy over mediastinum The patient is well and working almost two years following ſobectomy because of poor pulmonary function where the right upper lobe bronchus or its first this procedure has been used in an attempt order branches, even when the tumor is to extend the limits of surgery in performing visible by bronchoscopy, may be adequately a total pneumonectomy with resection of removed by upper lobe lobectomy includ the lower trachea and coryna with anasto ing removal of the right main bronchus and mosis of the remaining bronchus to the a portion of the intermediate bronchus as trachea results have been disappointing as a sleeve resection The remaining portion far as significant survival times are con of the intermediate bronchus can then be cerned Such an operation may, however anastomosed to the trachea at the region of provide palliation when no other treatment the coryna In the patient who has survived would be available longest (over five years) following a bron The right upper lobe bronchus and the choplastic type of resection for broncho superior segmental bronchus of the left genic carcinoma in this location a wedge lower lobe are two locations for neoplasms resection was employed without completely that customarily require a total pneumonec- transecting the right bronchus (Fig 9) A tomy because of the proximity of the lesion bronchial leak occurred at the point of to the main bronchus It is in these tuo bronchial repair causing a complicating locations where bronchoplastic procedures empyema which was drained by the are of particular value section The patient subsequently made 3 A neoplasm (Fig 82, b and c) arising in good recovery although pooling of secre ·TIIF TREATMENT OF BRONCHIAL NEOPLASMS 41 6-2-55 2-4-57 2 REGION OF CARCINOMA Resection right upper lobe Anastomosis of intermedi and right main bronchus ary bronchus to stump of right main bronchus Tug 8a b and c A 48 year old man with obstructive pneumonts due to localized epidermod carci nom of right upper lobe bronchus Resect on of right upper lobe and ight man bronchus pre Surv ng night m dule and lower lobes Alve and well after two and one half years tions in the linked bronchus has been an served by sectioning the left upper lobe noying Although this case represents a bronchus just proximal to its bifurcation and satisfactory survival complete transection sectioning the left main bronchus at ap of the bronchus with cnd to end anasto proximately its mid point The remaining mosis appears to give a better result with portion of the left upper lobe bronchus less morbidity We have used this type of can then be anastomosed to the stump of unastomosis preserving the lower and mid the left main bronchus following the re dle lobes in seyun patients moval of the left lower lobe (Fig 10) We A kell localized neoplasm arising in thy have employed this type of bronchoplastic superior branch bronchus of the left lower procedure in four patients lobe because of its proximity to the left Preservation of the right upper lobe was main bronchus would usually necessitate a possible in three patients having cpidermoid left total pneumonectomy In certain of carcinomas extending into the intermediat these cases the left upper loh can be pre bronchus In the patients a V plasty ·1? SELFCTION OF OPERATION A B CARCINOMA Right upper lobe and portion of main bronchus removed Closure approximates walls of right main bronchus Fig 9 used to preserve the airway to the upper found in the lungs are grossly indistinguish lobe (Fig 11) In the third patient the able from neoplasms Granulomas due to upper lobe bronchus was anastomosed to tuberculosis fungus infections, and lipoid the side of the trachea after severing it from pneumonitis may be particularly hard to the right main bronchus which was com differentiate from carcinoma by palpation pletely resected the left lower lobe was and gross inspection Even the pathologist preserved in two patients by performing a with the limitation of frozen section tech wedge resection and transverse closure of nique may be capable of error in diagnosing the bronchus after removing the left upper lesions sent to him at the time of surgery lobe Peripheral lesions of unknown enology Bronchoplastic procedures were donc on should first be resected as tumor biopsies or two patients who had right total pneumo by segmental resection and sent to the path nectomies in a deliberate extension of the logic laboratory for diagnosis If a diag usual limits of resectability In both the air nosis of neoplasm is established a more er way to the left lung was preserved by an tensive resection may be indicated Bron end to end anastomosis of the left bronchus chiolar carcinomas when small may be ade to the trachea following resection of the quately removed by segmental resection right lung along with the coryna and lower Neoplasms of other types generally require trachea (Fig 12). One patient died on the lobectomy unless involved hilar nodes are twelfth postoperative day due to insufficient present indicating total pneumonectomy pulmonary function The other lived in The surgeon must consider not only the na reasonable comfort for one year before ture of the lesion but the patients total dying of carcinoma economy in deciding the extent of resection desirable RESECTION FOR LESIONS OT Hilar lesions obstructing major bronchi UNPROVEN ETIOLOGY and accompanied by distal suppuration may be very difficult to identify histologically treatment of bronchial neoplasms is capable Incising into the lesion to obtain adequate of the greatest harm to the patient in the tissue for identification is often technically resection of a pulmonary lesion of unproven difficult and may involve injury to major etiology Many benign lesions commonly structures committing the surgeon to 3 more ) The radical surgical approach to the ·TIF TREATMENT OF BRONCHIAL NFOPLASMS 43 A (B -CARCINOMA Lede Iowar tobo and portion of main bronchus removed Laft upper lobe bronchus gutured to teft man bronchus Fog 10 A 17 year old nian with history of recent pneumonitis which cleared with antimicrobial therapy Bronchoscopy and bronchography revealed tunor and notching of lower lobe bronchus. Resect on with bronchoplistic procedure for a small localizeu undifferentiated carcinoma Surviteu four years extensive resection than desirable Bron and lipoid granulomas all may simulate a chotomy at a point prorimal to the obstruct hilar carcinoma Bronchial adenomas also ing lesion often is helpful in establishing the should be differentiated from bronchogenic diagnosis without commttung the surgeon carcinoma since they generally can be re to an extensive resection Broncholiths mosed by partial resections of the distal primer mucoid impactions impacted forcign bodies pulmonary tissue has not been irrepar ·SELECTION OF OPERATION B CARCINOMA Resection fight middle and lower lobes with portion of right main bronchus Anastomosis of right upper lobe bronchus to stump of right main bronchus Fig 11 A В CARCINOMA RS Resection right lung, lower trachea and carina End-to-end anastomosis of left main bronchus to trachea Fig 12 damaged The importance of conservation resection for the purpose of affording pallia of pulmonary tissue cannot be overempha- tion of unpleasant symptoms in patients sized When dealing with neoplasm radical having bronchogenic carcinoma In apply surgery often is mandatory and the risks are ing the principle of palhanive surgery, how justified These same radical measures and ever, the surgeon should keep in mind that risks, however, should not be imposed upon one cannot palliate a patient who has no patients having lesions of unproven etiology symptoms or only vague symptoms It is that may represent little or no threat to the not possible to predict accurately the symppatient's life or health It is just as repre toms that will be expenenced in the future hensible to remove an entire lung for å by a patient having a bronchogenic carci benign lesion causing no symptoms because noftia The loss of pulmonary function due of a mistaken idea that it is a neoplasm as to the resection ay cause far more dis to remove an arm or a leg because of the tressing and disabling symptoms than would presence of A benign tumor have been etperienced by the patiens of the disease had been allowed to run its normal PALLIATIVE RESECTION course without interference by surgery There is a definite place for pulmonary Similarly, imprudent palliative attempts ·THE THEATMENT OF BRONCHIAL NEDI LASMS 45 may actually shorten survival time by overly tion over the obstructing neoplasm com aggressive interference with the lymph node bined with antimicrobial therapy Attempts barrier and dissemination of the carcinoma to effect palliation by the total removal of Palliation can seldom be afforded by re a lung when the point of bronchial section section of the primary carcinoma when des traverses neoplasm will frequently lead to tant metastases are already evident The a bronchial stump leak and a complicating metastases may cause the more aggravating empyema This complication frequently symptoms and be the determining factor in makes the patient more uncomfortable and the survival time Pulmonary resection as may lead to a shorter survival period than 2 palliative procedure must be justified by if the lung had not been removed Although an attempt to control distressing symptoms in general the results of palliative resections already in evidence The most common are usually disappointing the rapid al symptoms that can be relieved by surgery though temporary improvement following are hemoptyses toxicity from suppuration resection of a destroyed suppurating lobe or cough and pain lung distal to a bronchial neoplasm may be most gratifying Hemoptysis Hemoptyses due to bron chogenic carcinoma are rarely severe Typi Cough Severe cough due to a bronchial cally the neoplasm ulcerates within the neoplasm that cannot be relieved by irradia bronchial lumen causing small amounts of tion therapy and by the use of opiates oc blood to be mixed with the expectorated casionally becomes an indication for a bronchial secretion If however the neo pallative resection A persisting unrelent plasm crodes into a major pulmonary vessel ing cough especially when it appears in a quickly fatal hemorrhage can result exhausting paroxysms may greatly weaken Hemoptyses due to bronchial adenomas are the patient and make it impossible for him frequently severe and may cause death by to get adequate rest Pulmonary resection flooding of the tracheobronchial tree even though it is known that it cannot bw Usually the indication for pulmonary resec curative may be justified in such a situation tion specifically to control coughing up of It has been observed that if at the time of blood occurs in the peripheral type of carci the attempted resection it is found that the nonia that has undergone central necrosis procedure will be unduly hazardous due to resulting in abscess formation The patient the involvement of major pulmonary vessels having such a lesion is plagued by a per or major bronchi that severing branches of sistent cough productive of foul bloody the vagus nerve below the recurrent laryn sputum At times the amount of blood geal nerve will often afford palliation of coughed up may be alarming In such a this symptom situation resection may be of great value in Pain Relief of pain by excising a neo el minating the cough and the hemoptysis plasm which has invaded parietal structures cven though the rescction is not curative may be an indication for a palliative resec Suppuration Suppuration beyond a tion Peripheral cancers of the lung may bronchial neoplasm that has caused absces attach themselves to the chest wall invading ses and irreparable damage to the involved the pleura and eventually infiltrating inter luns is an indication for pulmonary resec costal nerses This will cause a severe un lion even though cure may not be possible relenting type of pain which radiates along It must be borne in mind that the obstruc the nene pathways Even though there may ton and suppuration of recent origin at be preoperative evidence of spread of the times can be more easily relieved by irradia diseasu beyond the limits of resection* ·46 SELECTION OF OPERATION lobectomy or segmental lobectomy along thoracotomy they should be kept in mind with resection of the chest wall involved and applied in suitable cases when thoracomay give prolonged relief from pain tomy has been done to determine the possi Neoplasms involving the superior sulcus bility of successful resection or to establish of the chest which invade the first and sec- diagnosis ond intercostal nerves producing pain along Evaluation of Palliative Surgery. Palli the distribution of the ulnar and brachio ative resections in alleviating symptoms cutaneous nerves can be removed surgically caused by bronchial neoplasms are difficult without producing structural disability Re to evaluate from the standpoint of increas section of a lesion which has more exten ing survival time They cannot be judge' sively invaded the neural roots of the in retrospect unless the surgeon has state brachial plexus may be of temporary value in the record at the time of surgery that the as a palliative procedure, although there resection was done for palliation and not will be permanent neurologic defects in the for cure The concept of palliative resec arm and hand on the involved side Char tions must not be used to justify the per dack and MacCallum" have reported a five formance of a resection in situations where year survival without evidence of recurrence It cannot conceivably prolong life and of carcinoma following a combination of alleviate suffering merely because it is tc surgical excision and v ray therapy in such nically feasible Smith" recently (195 a lesion reported on the results of raising the reset Occasionally a peripheral lesion in the ability rate in operations for cancer of th lower lobes will involve the diaphragm lung Alarmed by the high mortality o causing pain in the shoulder Excision of exploratory thoracotomy in nonresectable the lobe along with a portion of the dia cases of cancer of the lunghe determined to phragm is a feasible surgical procedure that carry out a palliative resection in every may give relief of prin even though cure case in which surgery was undertalen He cannot be effected achieved a resectability rate of 972 per cent in 147 cases Forty eight of thes PALLIATIVE SURGERY resections were deemed to be palliative u OTIIER TIIAN RESECTION that known neoplasm was left behind in the Palliation of symptoms may be possible course of the resection The survival of in situations where exploratory thoracot- these 48 patients was carefully evaluated omy and resection of the ncoplasm is not from the standpoint of time and relief of feasible or is inadvisable Lesions that have symptoms The operative mortality in this invaded the phrenic nerve or diaphragm group was 21 per cent of the remaining may cause severe pain in the shoulder In 38 patients 19 patients survived eigh terruption of the nerve above the neoplasm months and 14 survived one year Bignal!" will relieve this pain Intercostal neurec in analyzing the survival rate of 255 un tomy may be of great help in relieving pain treated patients found that one half of these due to a peripheral neoplasm that has in patients survived nine months In discussin vaded the chest wall so extensively that re pallation Smith pointed out that pneumon section is not feasible Pleurectomy is use ectomized patients usually have a short ful in preventing the accumulation of terminal illness a doubtful dividend of pleural fluid when the pleural surfaces are surgical pallation Smith states that 'the tudded with neoplastic implants While results in the later period were very muc! none of the above procedures might offer worse than those of the first half of the enough palliation to in themselves justify series and this may be explained by the ·THE TREATMENT OF BRONCHIAL NEOPLASMS - 47 inclusion, not deliberately, of a number of be expected from irradiation therapy are cases in the later period which would have probably more than offset by the harm done been excluded earlier This tendency to by the erploration both in respect to morincrease the scope of operation beyond the bidity and mortality accepted indication seems in all respects Exploratory thoracotomy for diagnosis undesirable " Smith found palliative resec in patients having lesions that are obviously tons most useful in relieving hemoptysis, not resectable should not be advised until cough, and the effects of suppuration but every other diagnostic procedure that might less useful in relieving pain provide suitable tissue for eramination has Exploratory Thoracotomy. Exploratory been carried out 10, bronchoscopy, cervi. cal mediastinal node biopsy, needle biopsy, thoracotomy for the purpose of establishing the diagnosis of neoplasm in situations examination of sputum and availablc pleural where the clinical evidence indicates non fluid for neoplastic cells Exploratory resectability is justifted under certain cirthoracotomy in patients in shom patho cumstances It should be recognized, how. logic proof of bronchial neoplasm has been ever, that such a thoracotomy carries a obtained and who have lesions obviously definite mortality, inevitably adds to the nonresectable has only the dubious value of morbidity, and may shorten survival time proving that surgical resection is impos Boyd" reports an 86 per cent hospital sible mortality for exploratory thoracotomy in nonresectable cases of carcinoma in SUMIYLARY Ochsner's series" the mortality was 18 per 1 Lobectomy when feasible is the opera cent Taylor" (1954) found that 31 per tion of choice in treating the patient having cent of patients died in three months follow. bronchogenic carcinoma ing erploration for carcinoma when resec- 2 Pneumoncctomy will be necessary i tion was not feasible The appreciation of the harmful effects of exploration seems approximately one-half of patients havin a malignant bronchial neoplasm because o greater among lay people than by the medi the location of the lesion and the presence cal profession The fear is often expressed of lymph node metastases by patients that surgery will "spread the cancer" This fear is not wholly ungrounded 3 Bronchoplastic procedures in the interand it is the responsibility of surgeons to est of preservation of pulmonary tissuc find eliminate as much as possible explorations a useful place in the surgical treatment of carcinoma of the bronchus that are of doubtful value to the patient 4 Palliative resection is justified to re- There is an understandable reluctance lieve unpleasant symptoms Hemoptyses, imong radiologists to treat a lesion not cough, effects of suppuration, and pain may tistologically proven to be neoplasm In all be palliated by surgery e interest of accurate reporting of results 5 Exploratory thoracotomy in the in therapy such confirmation of diagnosis is ghly desirable However, the harm resultcurable patient is accompanied by an incuit able morbidity and a significant mortality to the patient with nonresectabic bron It is justifiable, however in borderline cases genic carcinoma, especially if media. to establish the fact of nonresectability a utal involvement has caused tracheal or al times to obtain histologic proof of Tena caval obstruction, should prohibit erdiagnosis when this information can ploration The beneficial results that might obtained by a lesser procedure ·48 SELECTION OF OPERATION REFERENCES 1 BUCHCR, JC Some problems of interpret- 11 GRAHAM, EA, and SINGER ) I Successful ing statistics on cancer diagnosis and treat removal of an entue lung lor carcinoma of ment M Bull Univ Michigan, 22 488- the bronchus VAMA, 101 1371, 1933 496, Nov 1996 12 GRAHAM E. A Discussion of paper by 2 BROCK, R, and WHYTEHEAD LC Radical Gtbbon et al Cancer of the Sung Ann pneumonectomy for bronchial carcinoma Surg. 138 489, 1953 Brut Surg 43 8, 1955 13 CHURCHILL ED Discussion of Symposium 3 OCHSNER, A, RAY, C), and ACREC, P W on Surgery of Lung and Mediastinum Cancer of the lung? Louisiana Stale Thoracic Surs. 6 335, 1937 Med Soc 106 263, 1954 14 CHURCHILL, ED, SWEET, R }, SOUTTAR 4 GIBBON, JH JR ALBRITTON, F F 3x, L and SCANNELL, J G: Surgical manage TEMPLETON, 3 Y IIS, and NEALON TF ment of carcinoma of the lung / Thor JR Cancer of the fung-Analysis of 532 Ocic Surg , 20 349, 1950 consecutive cases Ann Surg 138 489 15 NEUHOF, H, and AUFES AH Cancer of 1953 the lung Thoracic Surg, 17 297, 1918 5 GRATIAM EA Discussion of paper on 16 ROBINSON IL, JOVES, C, and MEYER, Neuhof, H and Aufses, A HJ Thoracic B W Indications for lobectomy in the Surg 17 297, 1948 Cancer of the Lung treatment of carcinoma of the lung 6 HUSFELDT, E Carcinoma of the lung in Thorucic Surg, 32 500 1956 Memorial Volume to Johan Holst Oslo 17 CHARDACK W M. and MACCALLUM,J D Norway, Uny Oslo, 1955 p 119 Pancoast tumor / Thoracic Surs, % 535, 7 LATOURETTE, H B LAMPE I, and Hopes 1956 F3 Organized clinical investigation of 18 SMITH, AR The results of raising the cancer M1 Bull Uni Michigan 27 283, rescctability rate in operations for lune Nov 1954 cancer Thorax, 72 79, 1957 8 Holst, I Discussion of Paper by Allison, P 19 BIGNALL S R Natural duration of bronchial Meeting British Thoracic Society, Oslo, carcinoma Lancet 2 210, 1955 Norway, Sept 1949 20 BOD DP, SMEDAL, ALI, KIRTLAND 9 HOBEIN HC JR MCDONALD JR, and HB, KELLEY, G E, and TRUMP, J G CLAOGETT O T Recurrent carcinoma in Carcinoma of the lung ) Thoracic Surg the bronchial stump Thoracic Surg 28 392, 1994 31 703, 1956 31 OCHNER A, RAY C 3, and ACREE, P W 10 HOLLAND RH Carcmoma of the fung Cancer of the jung Louisiana Sex treated by lobectomy, The problems of Soc 106 263, 1954 local recurrence Thoracic Surg, 32 TANLOR A B United Birnningham Hos 35 274, 1958 pitals Amal Cancer Rep. : 36, 1954 ·Irradiation Therapy I RRADIATION RRADIATION THERAPY occupies a major technical details of the actual application role in the treatment of bronchogenic carcin of urradiation therapy Likewise no com oma Only one third of the patients with parison will be made of the effectiveness of ihss d scase have surgically resectable lesions irradiation therapy given by the standard and less than 10 per cent can be cured by therapy units as opposed to the cobalt 60 surgery due to the biologic characteristics and supervoltage units Choice of the of the neoplasm and the difficulty of de method by which the patient is treated rests tecuing it when still in a localized state properly in the hands of the radiologist who Many of the remaining patients become understands the technical advantages of one cand dntes for irridiation therapy This unit over the other in the management of modality of treatment is capable of modify the particular patient to be treated Con ing the natural history of the neoplasm to sideration of total dosage and fractioniza bring about relief of distressing symptoms tion of the dose into individual treatments in many patients and an apparent cure in is also the prerogative of the radiologist an occasional case Studies of survival The physician or surgcon responsible for curves comparing untreated patients with the care of the patient should have a know1 those receiving irradiation therapy indicate edge of the value and also the limitations that in the majority of patients receivino of irradiation therapy so that he will refer therapy survival time is not increased (Fig to his radiolonic consultant patients present 11) In the series receiving therapy how ing patholooic aspects of the disease in ever there will be a small percentage of which irradiation therapy may be helpful patients surviving beyond the fifth year Irradiation therapy involves the use of a whle in untreated patients rarely will a physical agentsery real though unseen patient Ire more than three years following that is capable of destroying living cells onset of symptoms The value of irradia In its use side effects that may bc un on therapy is chiefly in its role of pallation pleasant must be accepted Although the so that this therapy must be kept in mind total dosage used will vary according to the in the management of patients having bron aim of therapy and the character of the normal tissues that may be alfected an The role of irradiation therapy in the aggressive attitude should be the rule of frentment of bronchogenic carcinoma is bencfit is to be expected It is incongruous te ng presented by the authors from the for a surgeon who accepts a patient for fick point of the thoracic surgeon und physi surgery with little thought of the ordeal of cian responsible for the d rect care of the surgery incisional pain and weeks of mor pallent rather than from that of the radi bidity 10 withhold irradiation th ul hande no altempt will be made to present becauc asant sed, cliccts, chogenic carcinoma 49 ·50 IRRADIATION THERAPY should a surgeon who removes an entire oma was being treated the results were lung with equanimity be disturbed by ir disappointing and irradiation therapy was radiation fibrosis? An over radical attitude judged to be of little value it is fair to which may reach a point of diminishing pose the question as to whether irradiation returns and increasing harm, whether it be therapy would be as effective as surgical surgical therapy or usradiation therapy is to excision in patients having localized bron be avoided Once chosen hoxever the chial neoplasms This question will probmodality of irradiation therapy should be ably never be answered since no one may employed with a vigor consistent with the have the courage deliberately to withhold ultimate welfare of the patient surgical excision from patients with favori Irradiation therapy has been reserved in ble lesions An occasional patient with such general for patients having bronchial neo a lesion who refuses surgery (Fig la b c plasms not suitable for surgical excision d) or whose pulmonary function contraind: Before 1933 when pulmonary resection was cates surgery (Fig ba and b) becomes demonstrated as feasible in the treatment for available for irradiation therapy Results bronchogenic carcinoma patients had been of irradiation therapy in this group sugoest Creared exclusively by means of irradiation that this modality may be curattle to a therapy Diagnostic measures during that greater extent than most physicians realize period were not sufficiently developed to The major obstacle to determining the effec allow frequent detection of a localized bron tiveness of cancericidal doses given to local chial neoplasm Since disseminated carcin ized peripheral bronchial neoplasms is the $ 4-27-56 1-10-58 Fig la X ray of a 60 year old man who was found bronchoscopy to have 1 small spidermod Cascinoni obstructing the bronchus to the superior segment of the night lower lobe He refused to have surgers Irradiation therapy was gisen over the obstructing neoplasm Fig 16 Twenty one months later x ray of chest shows minimal scanag at sle of previous pneumonitis and pulmonary abscess Patient is well and without symptoms ·THE TREATMENT OF BRONCHIAL NEOPLASMS 51 3-19-56 1-10-58 Få lc Rght lateral project on showing abscess in superior segment of lower lobe beyond obstruct ing carcinoma Fig id Tuenty two months later only min mal scarring remans difficulty of obtaining histologic proof of patient however may be influenced less by such lesions without surgical exploration the cell type of the neoplasm than by its de and biopsy Due to this factor surgery will gree of localization The patient having a probably remain the treatment of choice for highly undifferentiated bronchogenic carcı localized neoplasm originating in the lung noma of the small round cell type almost while irradiation therapy will be used for always has a widely disseminated ncoplasm inoperable and non resectable lesions re by the time the diagnosis is established AL Currences following surgery and metastases though irradiation therapy may be useful in temporary control of symptoris due to the IRRADI VTIO TU1 RAPI primary lesion or metastases that retrogress REI ITION TO CFI L TYTF quickly follosting therapy the patient rarely The response of a neoplasm to irradia Survises for more than a few months tion is governed largely by its cell type In spite of its greater resistance to the Highly undifferentiated tumors are very re effects of irradiation the well differentiated sponse to irradiation therapy Well dif squamous cell carcinoma hy virtue of its lerenuated epidermoid carcinomas fall in tendency to remain localited for a longer the median scale of responsiveness to period of time is the most favorable losion cordone radiation Adenocarcinomis including the for irradiation therapy The info brunchrolar type and the cylındroniatous biologic characteristics of thc 19 of hronchil tenoit respond very tains just as surely to the Title to this type of cars tion therapy as it does i The value of irradition therapy 10 thc surgery

·52
IRRADIATION THERAPY
KA
Fig 2a
Squamous cell carcinoma which at
was found to be nonresectable because of my
vertebrae
INDICATIONS FOR IRRADIATION ized
THERAPY IN INOPERABLE AND
by th
NONRESECTABLE PATIENTS
radiati
Inoperable and nonresectable patients of thi
having malignant bronchial neoplasms not plasm
suitable for surgical excision make up the lesio
largest group for whom irradiation therapy surv
ss indicated The usual contraindication to the
resection is evidence of extension of the
eoplasm beyond the site of origin This to
ay be manifest by direct extension to a
tha
structure that it is not feasible to resect pan
along with the neoplasmi, ie, aorta, esopha gra
gus, trachea, spine, etc (Fig 2a, b) In may
this event the neoplasm may be well local. Even

·TIF TREATMENT OF BRONCHIAL NEOPLASMS 53 F8 26 Appearance of chest 3 months follow ng rrad at on therapy There has been complete d sappearance of the severe pa n that was the present ng sympton Th s 46 year old man feels well and is work ng one year following therapy the ncoplasm these studies along with the mediastinal extension Histologic proof may chnical picture presented by the patient be obtained from bronchoscopic cxamina often permit an accurate diagnosis of bron tion or from a carvical or high mediastinal chogenic carcinonia These patients should lymph node obtained by means of cervico be treated with irradiation therapy without mediastinal exploration Even though histo being subjected to exploratory thoracotomy logic proof is not easily avatlable irradia The risk of exploratory thoracotomy for a tion therapy in combination with chemononresectable bronchogenic carcinoma out therapy should be used Patients having weighs the benefits derived from it gross swelling of the neck and arms and those dyspncic due to trachcal compression Mediastinal Invasion should be treated initially by means of Invasion of the mediastinum by direct chemotherapy This type of therapy pro extension or by metastases to lymph nodes duces shrinkage of the neoplasm without is a common sign of inoperability Sons the initial swelling th it may follou the first of superior cna caval obstruction tracheal treatments with irradiation therapy It may compression and insolvement of the re be safe to proceed cautiously with irradia current laryngeal nerves are indications of tron two to three days followin the i ·52 IRRADIATION TIERAI Y 3 Fg Squamous cell carc npm3 wh ch at exploratory thoracotomy was found to be nonresect ble because of nvas on of the bod es of the vertebrae INDICATIONS FOR IRRADIATIO ized so that it can be totally enc THERAPI IN INOPERABLE AND by the therapeut c field of irrad MONRESECTAELE PATIENTS radiation therapy over an inoper to Inoperable and nonresectable patsents of this type may result in cure of having malignant bronchial neoplasms not plasm as evidenced by regress or suitable for surgical excision make up the lesion as shown by x ray and I largest group for whom irradiation therapy survival without evidence of su is indicated The usual contraindication to the local site or metastases (Figs resection is evidence of extension of the Exploratory thoracotomy may be neoplasm beyond the site of origin This to establish the diagnosis and to may be manifest by direct extension to a that the lesion is non resectabi structure that it is not feasible to resect patients such diagnostic measure along with the neoplasm re porta esopha grams bronchograms and be gus trachea spine etc (Fig 2a b) In may reveal evidence of ponre this event the neoplasm may be well local Even in the absence of histolo ·TIF TREATIENT OF BRONCHIAL NEOPLASMS 55 Fig 4a Exploration of the left chest of this patient revealed a pulmonary neoplasmi was nonresect able because of invasion of the aorta and esophagus Fig 4h Six months later the neoplasnı had greatly enlarged Irradiation therapy was gen A tumor dose of approximately 4000 roentgens was given through four 15/15 cm parts in a period of 20 days Using 220 V equipment Tig 4c X ray of chest six years later Patient is well working and without sign of recurrence of the neoplasm almost erght years following irradiation therapy Tig AJ Biopsy revealed an anaplastic carcinoma contaming large picomorphic tumor cells Hematory fin and cosin 1700 Loon of chemotherapy As a rule patients transient but we have observed one pasient with mediastinal involvement respond well who lived over two years following irradia 10 irradiation therapy and obtain welcome tion over a prorcn bronchogenic carcinoma relict from distressing symptoms (Fig ) causing severe vena caval obstruction This It is true that the period of reliet may be patient was free of symptoms and worked ·IRRADIATION TI{FRAPY < + Fig 3a X ray 1 15-46 This 54 year old man whose chief complaint was pain in right shoulder was found at cxploratory thoracotomy to be nonresectablc beciuse of a ncoplasm arising in the right upper lobe bronchus which hnd invaded the phrenic nerve and lower trichea Biopsy revealed squamous cell carcinoma Fig 36 X ray 4 1-46 Two and one half months following x ray therapy hilar niass almost completely disappeared This man survived seven years without sign of recurrence and died of an unrelated A tumor dose of approximately 3000 roentgens was given through four ports over a period of 20 days using 400 kV equipment cause Fig 3c Photomicrogram of neoplasm showing pleonorphic spinul shared and giant tumor cells in epidermoid carcinoma Hematorylın and eosin X700 ·THE TREATMENT OF BRONCHIAL NEOPLASVIS 55 Fig ta Exploration of the left chest of this patent revealed a pulmonary neoplasm was nonresect able because of invasion of the aorta and esophagus Fig 4b Sur months later the neoplasm had greatly enlarged Irradiation therapy was gen A tumor dose of approximately 4000 roentgens was given through four 15 15 cm parts in a period of 'days us ng 220 IV equ pment Fiz bu ray of chest six years later Patient is well working and without sign of recurrence of the neoplasm almost eight years following irradiation therapy Fig 41 Bopsy rezcaled an anaplastic carcinoma contuin ng large pleomorphi tumor cells Hematorylin and cosin X700 ten of chemotherapy As a rule patients transtent but uc have observed one patient Rich mediastinal involvement respond well who lived over two years following strada to irradiation therapy and obtain welcome tion over a prosea bronchogenic carcinoma rehef from distressing symptoms (Fig 5). causing severe vena caral obstruction This It is true that the period of reliet may be patient was free of symptoms and worked ·54 IRRADIATION THFRAPY Fig 3a X ray 1 15 46 This 54 year old man whose chief complaint was pain in right shoulder was found at exploratory thoracotomy to be nonresectable because of a neoplasm arising in the night upper lobe bronchus which had invaded the phrenic nerve and lower trachea Biopsy revealed squamous cell carcinoma Fig 3b X ray 4 1-46 Two and one half months following x ray therapy hilar mass almost completely disappeared This man survived seven years without sign of recurrence and ded of an unselated cause A tumor dose of approximately 3000 roentgens was given through four ports over a period of 20 days using 400 V cquipment 1 Fig 3c Photomicrogram of neoplasm showing pleomosphc spindle shaped and grant tumor cells in epidermoid carcinoma Hematoy bn and eosin X700 ·to irradiation therapy and obtain welcome relief from distressing symptoms (Fig 5) It is true that the period of relief may THE TREATMENT OF BRONCHIAL NEOPLASMS 55 Fie 4a Exploration of the left chest of this patient revealed a pulmonary neoplasm was nonresect able because of invasion of the aorta and esophagus Fig 4h Six months later the neoplasm had greatly enlarged Irradiation therapy was given A tumor vose of approximately 4000 roentgens was given through four 15/15 cm parts in a period of 20 days using 220 kV equipment Fig 4c X ray of chest six years later Patient is well working and without sign of recurrence of the neoplasm almost eight years following radiation therapy Fig 4d Biopsy revealed an anaplastic carcinoma containing large picomorphic fumor cells Hematovyhn and cosin 7700 tion of chemotherapy As a rule patients transient but we have With mediastinal involvement respond well who lived over two ye fion over a proven causing severe was it ·56 IRRADIATION THERAPY * 12-15-57 3-17-58 Fig 51 This 69 year old man had gross swelling of the neck shoulders and arms due to vena caval compression and wheezing respirations due to tracheal narrowing caused by mediast nat invas on of a bronchogenic carcinoma arising in the right upper lobe Fig 56 Four months following irradiation therapy using 2 MEV cquipment delivering 3500 poent gens to the tumor area The patient is completely free of symptoms The swelling of the neck and arms is no longer present actively during eighteen months of this the involved hilum Pleural effusion due to period extensive neoplastic implants on the entire visceral and parietal surfaces presents a Pleural Effusion problem of too great an area of involvement The presence of pleural effusion compli to be treated eastly with irradiation therapy cating a bronchogenic carcinoma may alone The instillation of radioisotopes or contraindicate the use of surgical therapy nitrogen mustard compounds into the An absolute contraindication exists if neo pleural cavity in such cases is helpful in plastic cells are demonstrated in the fluid delaying the formation of the pleural fluu Irradiation therapy may be helpful how and in some cases causes obliterative picur ever, in the management of a patient having itis sufficient to prevent further accumulu this sign of extension of the neoplasm tion of fluid Irradiation therapy may be Roentgenograms of the chest following combined effectively with chemotherapy in aspiration of the fluid may reveal a shadow many patients having malignant pleural effu producing localized mass within the in sions secondary to bronchogenic carcinoma volved lung In this situation the neoplasm has probably broken through the pleural Distant Metastases marrier and is shedding neoplastic cells into Patients wlio are inoperable because of pleural space to cause the effusion the obvious presence of distant metastases Irradiation therapy given over such a neo may receive benefit from combinations of plasm may induce regression or quiescence irradiation and chemotherapy Srradiation in growth and bring about clearing of the like surgical therapy can be effective si pleural effusion Effusions secondary to prolonging survival time only when it is venous obstruction due to neoplasm may applied to a localized lesion it may quite also clear temporarily following therapy over effectively control the primary lesion treated ·TITE TREATMENT OF BRONCHIAL NEOPLASMS 57 20 a patient who finally succumbs to wide or cardiac disease may prohibit resection spread metastases Irradiation over hilar and even exploration in patients whose chest masses may relieve cough or hemorrhage roentgenograms reveal obvious broncho and open obstructed air passages Pain genic carcinomas (Fig 6) Irradiation due to invasjon of parietal structures is often therapy should not be withheld from these relesed following irradiation therapy patients merely because of the lack of histo Chemotherapy may be used later or con logic proof Inclusion of these patients with comutantly in an attempt to control the unproven diagnosis in a reported scries distant meastases The fact that such met treated with irradiation therapy for carcin cases are present should not deter one from oma would undoubtedly be challenged In use of irradiation for palliation of symp the interest of accurate reporting the results is unless it is felt that life expectancy is of therapy in these patients may be reported te short separately from the results in proven cases NADEQUATE PULMONARI AND TOLLOWING RESECTION CARDIAC FUNCTION Irradiation therapy nay be indicated fol Severe diminution of respiratory function lowing resection of the primary lesion of res 9.4.56 Fig 6a This 66 year old male patient was severely crippled by poor pulmonary funct on due to b lateral pulmonary emphysema Even lobec tomy for removal of the bronchogenic carcinoma in the right upper lobe was constdered inadvisable ·18 IRRADIATION TIFRAPY 9-11-57 Tg (h One year follo ving irrad at on therapy there s 1 ttlu reman ng cv doncc of the neopl sm The pit cnt is still ni ve tenty n onths follow ng therapy gross ncoplastic tissue is knowingly left (Tug 7) Judgment is required at the i nie behind or if there is the probibility of an of surgery in borderline cascs of resecta incomplete resection in the proximity of the bility as to whether resection should be at neoplasm Irradiation therapy over the tempted since often irradiation alone will region of known or suspected involvement bu niuch more effesinic thin resection fol may be lclpful in retarding the extension of lowed by irridution over remnants of neothe neoplasmi Silver clips applied nt sur plasmi gery to outline the area of Inoun involve IRRIDIATIOIOR I OCAL ment will be helpful to the radiologist in RF CURRENCE ROL I OWING accurntely applying therapy However the RISICTION results of irridntion therapy for this type Evidence of its Juil malignancy mal of indication is particularly discouraging latcr de clop follow in, resection Tliere is presumptiue cuidence that dissec majority of patients this will occur within tion in masses of neoplastic nodes or disturb ? period of those ir Reoperation csen for ince of the lymph channels beneath the a kell localized tocurrence ranly is feas ble pleura my break down barriers of resist Irradition ther ins loucher may he bene ance and encourage ripid dissemination facial of the area of the recurrence is of such in the ·# 6-20-52 7-2-57 Fig 7a The presence of the pulmonary nodule in the right upper lobe of this 72 year old wonian was thought to represent no threat to her health Ftg 7b Over 5 years later the nodule has greatly enlarged but still caused no symptoms At opera tion an epidermoid carcinoma was found that was attached to the parietal pleura Right upper lobectomy was carried out along with resection of the involved pleura 8-30-57 12-16-57 Fig 7c Two months following resection the chest appears clear Fig 7d Five months following resection there was evidence of rapid growth of the neoplasm in chest wall The patient had severe pain in the right shoulder and arm Dissection in the extr plane involved with neoplasm accelerated the growth of the lesion probably brought on symptoms and hastened death Irradiation therapy following surgery gaye benefit surgery it might b pat value ·IRRADIATION THERAPY 60 7-8-57 Fig 8a The chest of this man appears clear a year and one half follow ing right upper lobectomy for a peripheral squamous cell carcinoma Fig 8b (Page opposite --- Itpper) Almost two years following resection there is evidence of recurrence of the neoplasm in the hilum of the right lung The patient had developed a harrassing cough and complained of pain Positive confirmation of recurrent neoplasm was obtained from examination of a node removed from the right cervical fossa Fig8c (Page opposite ---- lower) Four months following irradiation therapy the ncoplasm has regressed Pain and cough were completely relieved size as to be easily encompassed by a rela localized accurately enough to permit " tively small field so that a cancericidal dose radiation therapy unless it can be detected can be delivered to the neoplasm This bronchoscopically in the trachea or bron opportunity for temporary control of re chial stump Irradiation therapy over locally sidual neoplasm occurs most often when the resection has been limited to a lobectomy bloody expectoration pain and vena caval recurrent neoplasm may alleviate cough since the presence of air containing pul obstruction thus permitting a more comfort monary tissue within the hemithorax allows able quality of survival Its availability as radiographic detection of the recurrence therapy does much to encourage the patient (Figs 8 9 and 10) Following total pneu in spite of the knowledge that the dreaded monectomy recurrence within the hemı cancer has returned thorax may be suspected but cannot be ·12-2-57 ·IRRADIATION THERAPY 62 11-2-55 2-4-58 Fig 9a There was evidence of recurrence of neoplasm in the right hilum of this 70 year old man one year following resection of the right lower and middle lobes for a squamous cell carcinom Fig 96 Over two years later following irradiation therapy over the right hilum there was eviden of radiation fibrosis but the patient was well and free of symptoms IRRADIATION TIIERAPY tient died two years later due to metastases PRELIVIINARY TO RESECTION Fifty patients thought to have neoplasms The value of irradiation therapy as a localized to the primary site were given preliminary treatment to resection has not irradiation therapy and at a later date 24 of been fully explored Irradiation over neo these had total pneumonectomies Twelve of plasms that have invaded main bronchi in the 50 patients were deemed inoperable close proximity to the carina may cause the because of bronchoscopic findings Five of tumor to recede so that a patient at first the 12 subsequently had total pneumonectoconsidered inoperable becomes a suitable mies One died later from a recurrence in candidate for resection later Cleland in the stump but the other four were doing well 1949 began studying preoperative irradia at the time of the report Cleland found the tion therapy combined with resection This operative difficulties no greater in thes study was prompted by an experience in patients than in untreated cases Lindsko which a patient under his care deemed in has recently reported 2 patients who who operable because of the bronchoscopic find first evaluated for surgery were deem ings of carcinoma close to the carina and inoperable because of the bronchosco subcarinal widening became resectable four findings of neoplasm within a centime months following a radical course of irradia of the carina Following irradiation ther tion Examination of the night lung follow the airway opened and atelectasis was to ing resection failed to reveal macroscopic lieved Subsequent bronchoscopic examina or microscopic evidence of tunior The pa tion revealed a normal bronchus with no ·63 THE TREATMENT OF BRONCHIAL NEOPLASMS 5-30-56 Fg 10a X ray of chest showing sat sfactory condt ons x months follow ng resect on of the r ght lower and m ddle lobes for a squamous cell carc noma n the bronchus to the super or segment of the lower lobe visible carcinoma Both then were sub the endothoracic fascia and microscopically jected to left pneumonectomy One patient the extension may be far more extensive is alive and well four years following resec than indicated by macroscopic evidence tion and the other has survived over a year This explains the rapidly distressing painfu without sign of recurrence Obviously this recurrence of carcinoma in cases where the combination of therapy is of value only dissection in the extrapleural plane break when there is no evidence of extension of across these involved lymphatics during re the disease beyond the area encompassed by section of a lobe or lung (Fig 7) Unles the irradiation therapy and in the presence a wide en bloc resection of the chest wal of a favorable cell type and involved lung is employed the result Irradiation therapy preliminary to resec of surgery in this group of patients is un tion may be even more useful when used rewarding These cells in the subpleura over peripheral carcinomas that have in lymphatics are exposed and vulnerable to vaded the chest wall Lesions in this loca Irradiation therapy so that if it is used ove tion often remain localized to the site of an area sufficiently large to include a gene origin for a long period of time they do ous field around the visible mass the e however invade the lymphatic channels in of the des on may be narrowed down ·IRRADIATION THERAPY 64 7-24-57 Fig 106 Ten months later planogram demonstrates a recurrent neoplasm which has invaded the wall of the trachea encroaching on the lumen The patient complained of wheezing and cough with expectora tion of bloody sputum resection offers a better chance of cure verse process, and a portion of the bodi The authors have treated two patients of the vertabrae en bloc (Fig 5, Chap IV with peripheral bronchogenic carcinomas A second patient treated deliberately w invading the chest wall with a combination this combination which included an alm of preliminary irradiation followed by re identical resection is well and free of 1 section Both patients had lesions in the over six months following surgery (Fif extreme right apex of the chest causing the Chap III) Examination of the rest typical syndrome associated with superior lesion showed that the irradiation thi sulcus or the so called Pancoast, tumors had reduced it to an amorphous mi Resection was carried out in the first patient fibrous tissue in which it was diffic one month following the conclusion of ir- identify the cell type of the origins radiation therapy which was given because plasm the lesion was deemed nonresectable He is The objection may be raised that trear still alive, well, and free of pain a year and ment of these peripheral lesions by this a half following resection of the involved regimen involves giving irradiation therapy segment, ribs, intercostal structures, transto a lesion of unknown etiology The validity ·65 THE TREATMENT OP BRONCHIAL NEOPLASMS 3-5-58 Fig 10c Seven months following irrad atson therapy over the recurrent neoplasm the tracheal lumen was clear Wheezing cough and expectora tion had disappeared There was evidence of tradiation i brosis of this objection cannot be denied However course of irradiation therapy prior to resec the errors of diagnosis in the clinical syn tion The hardship to the patient and the drome caused by radiographically visible hazard of disseminating the neoplasm by peripheral pulmonary lesions of this type exploratory thoracotomy and biopsy out would be few With osteolytic destruction weigh consideration of the possible infre of involved ribs and the presence of quent error in diagnosis Horners syndrome there is even less chance of a diagnostic error Tuberculous granulo TREATTIEVT OT VETASTASES mas and occasionally a dense fibrosing Pain and disabilities due to blood pneumonitis may simulate a peripheral metastases to distant parts of the bronchogenic carcinoma Hoth of these be temporarily reheved by lesions are indications for resection and no apy Severe headache and ne harm would result due to a preliminary > due to metastases to the

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·THE TREATMENT OF BRONCHIAL NEOPLASMS 67 equipment This factor alone justifies the RESULTS OF IRRADIATION choice of this type of therapy over conven THERAPY tional types in sttuations where it is applic The results of irradiation therapy for able since the undesirable effects of bronchogenic carcinoma can be evaluated irradiation in an already debilitated patient only in regard to the aim of therapy in the may nullify the therapeutic usefulness of individual patient Since this modality is the treatment used chiefly as a means of palliation in Damage to the skin and underlying tis patients having lesions not sufficiently local sues is a factor that limits total exposure to ized to permit resection and frequently to irradiation Irradiation therapy using high relieve symptoms produced by metastases doses given by conventional techniques for it should not be judged solely by its effects treatment of bronchogenic carcinoma often on survival time The value of irradiation produces severe painful burns of the skin therapy should be judged primarily on the Final healing of the burn leaves a deeply basis of its effectiveness in palliation of the tanned area in which there is telangiectasia symptoms for which its use was indicated Once final healing occurs however other A total of 259 of the 1180 patients who than the disfiguration there are nown have been under our care are known to pleasant effects Super voltage techniques have received irradiation therapy Forty are capable of delivering to the region of four (40 per cent of the 133 patients seen) the neoplasm therapeutic and at times can were treated during the past year so that it cericidal doses without causing more than is too early to evaluate the effect of therapy a slight increase in pigmentation of the ex upon their survival time Thirty five pa posed skin tients treated previously have been lost to Esophagitis has been the most annoying follow up There remain 180 patients who complication accompanying the use of super were treated more than a year ago and voltage irradiation for bronchial neoplasms whose fate is known The symptoms of this complication are A comparison of survival time of the dysphagia and a burning sensation deep in 180 patients in this series who received the chest The dysphagia seems to result radiation therapy with that of untreated from the atonia in the muscle of the affected patients studied by Bignall showed little segment due to itradration damage to the variation in the two survival curves (Fig musculature A true esophagitis or ulcera 11) Bignall analyzed the survival of 255 tion of the mucosa in the region exposed to patients having bronchogenic carcinoma the irradiation probably is responsible for who received no treatment that would affect the burning sensation The symptoms of time of survival These patients were seen this complication usually become manifestat an institution where there is an active during the latter part of the course of surgical program so they represented pa therapy The burning sensation may be tients who were either unsuitable for surgi somewhat alleviated by a bland diet and cal therapy or refused surgery Thirty nine the use of coating agents usually employed per cent of these patients survived one year in the treatment of esophagitis or gastritis and 14 per cent two years Bignall used The dysphagia may persist for many weeks the date of onset of symptoms as a startins following treatment It gradually becomes point in determining survival time less annoying with time probably due to an the patients in the authors seri unconscious re education in the act of swal radiation therapy experienced lowing six months from onset ·68 IRRADIATION THERAPY JOU 90 NORMAL EXPECTANCY 90% 80- 70 PATIENTS TREATED WITH IRRADIATION THERAPY 60H PER CENT SURVIVAL 50 40- 30- 20 UNTREATED PATIENTS 10 5 % 6 mo 1 2 3 YEARS * Shaw Paulson and Kee Fig 11 Bronchogenic carcinoma Survival of 180 patients treated with tradition therapy* compared with survival of untreated patients (Bignali) to beginning of therapy the survival curve well eight and twelve years respectively is adjusted to start six months later than following therapy for small cell undifferenti that of Bignalls patients It is granted that ated carcinomas (Figs 3 and 4) Fifty tuo comparison of survival of patients compar (20 per cent) survived one year, 16 (10 ing figures of two different groups of ob per cent) tivo years, 7 (5 per cent) threc servers is not entirely valid It is surprising years, 5 (5 per cent) four years, and 3 (5 however, how closely the curves coincide per cent) five years (Percentages listed are during the first two years of observation determined from the patients alive of the The only significant difference in survival number eligible to survive ) in these groups is the few patients who are Many patients who did not survive ino alive and well five years following irradia- years following therapy received relief from tion therapy Bignall observed no untreated the distressing symptoms for which the treat patients surviving five years although 2 ment was prescribed Judged on the basis were still alive forty and forty one months of palliation the therapy in these patients following the onset of symptoms Three was worthwhile Shrinkage of neoplasms patients in our series of 180 patients, all blocking major bronchi relieved cough and with histologic proof of carcinoma, treated atelectasis which brought welcome respite by means of irradiation following explora- from dyspnea The most dramatic pallia, tion survived more than five years One tion came in patients having mediastinal died of a cerebral hemorrhage seven years involvement causing tracheal and vena caval after irradiation of an epidermoid carcin compression Many of these patients er oma and the other two are still alive and perienced relief of symptoms and enjoyed ·THE TREATMENT OF BRONCHIYAL NEOPLASMS months of trouble free productive life fol passed by the therapeutic field It is not lowing irradiation and chemotherapy Con curative when used in disseminated carci- 170) of pain by radaron over metastases noma, but it may be useful when applied to allowed others to be comfortable during localized lesions to relieve symptoms ir their remaining months of life before return radiation is of proven value when used over of pain again necessitated the use of nar. local nonresectable lesions and occasionally cotics The ability of irradiation therapy will seemingly eradicate the neoplasm Irto modify the course of bronchogenic carcin- radiation as a preliminary treatment to reoma indicates its use whenever localized sectional surgery should be considered in tumor is causing disturbing symptoms patients having hilar lesions that invade the major bronchi close to the carina and peri- SUMMARY pheral neoplasms that involve the chest wall Irradiation therapy occupies a major role The results of irradiation therapy should be in the treatment of bronchogenic carcinoma judged by its ability to relieve symptoms It suffers from the same general limitations rather than its effect on prolongation of life of surgery based on the biologic factors in In a few patients, however, this modality of volved in that it must be used over a lesion treatment is followed by an apparent cure that is sufficiently localized to be encom of the disease -- REFERENCES CLELAND WP Discussion of paper by 3 MARTIN CL Role of radiation therapy in Meade RH, and Rasmussen RA The the treatment of inoperable lung cancer management of the patient with inoperable Dallas MI 43 284 1957 cancer of the chest ) Thoracic Surg 4 BIGNALL JR Natural duration of bron- 22 501, 1951 chial carcinoma Lancet, 2 210 1955 2 LINDSKOG Personal communication, 1958 ·Chemotherapy EVERY VERY PATIENT with a malignant bron relieve temporarily pain or control cough chial neoplasm is potentially a candidate Control of a disseminated neoplasm can for chemotherapy The biologic nature of only be accomplished by some agent that bronchogenic carcinoma predetermines ap can pass through the blood stream to every proximately 4 out of 10 patients suffering part of the body This agent must be se from this disease to be unsuitable for surgi lectively injurious to the malignant cellt in cal therapy Two out of every 10 patients doses that can be tolerated by the normal will have an undifferentiated carcinoma of tissue cells the round cell or oat cell type widely recog nized for its rapid dissemination Four out AVAILABLE CHEMOTHERAPEUTIC of 10 patients will have endence of dissemi AGENTS nated neoplasm at the time they first seek Cancer tissues and normal tissues have medical advice Often the patient's chief similar biochemical components, but en complaint is due to symptoms caused by a zymatic function is less in neoplastic tissue secondary lesion rather than the primary Low metabolite activities in malignant cells tumor In addition to these patients is the make them vulnerable to appropriate antag group of individuals who have had surgical onistic chemotherapeutic agents of the anti resection that are subsequently discovered metabolite group Shapiro has demon to have disseminated neoplasm who may strated that as the enzyme concentration in become candidates for chemotherapy If a tissue becomes tower, the degree of la chemotherapeutic agents can destroy neo- hibition by the antagonist of the enzyme plastic cells free in the blood stream it may becomes greater This investigator also be useful when given at the time of or im found some chemical agents used alone to mediately following resection of localized be capable of producing only carcinostasis neoplasms to prevent dissemination Thus, Kligerman and Shapiro' have published chemotherapy alone or combined with sur evidence of the efficacy of chemical agents gery or irradiation therapy, plays a role in in sensitizing the tumor cells to irradiation preventing dissemination delaying the therapy in carcinoma of the breast in ex growth of the neoplasm, increasing survival perimental animals zime, and in allaying distressing symptoms As in the case of radiotherapy tumor What do we have to offer patients with doses of chemicals must be compromised disseminated neoplasm? Irradiation thera- because of injury to norma} (issues by py which is considered in another chapter carcinocidal doses Repeated or prolonged will be of great benefit to many of these administration of excessive doses of chemo patients But irradiation therapy like sur therapeutic agents alone or combined with gery must be able to narrow its effect 10 a irradiation therapy may result in cumulative local region Like Surgery it can offer little toxic effects to the normal cell as well 25 of value in disseminated cancer except to the neoplasm The risk of depression of 70 ·71 THE TREATMENT OF BRONCHIAL NFOPLASVS the hematopoietic system (bone marrow) dose seemed to be well tolerated although is particularly great, resulting in severe pri transient nausea and vomiting and phlebo mary anemia, leucopenia, and thrombocy. thrombosis of the vein in the arm used for topenia This risk must be calculated and the injection occurred in almost every pashould be explained to the individual pa- tient Our present plan of administration tient and his family prior to the institution is to give a total dose of 0 5 mg per kilo. of such therapy gram of body weight in four divided doses on consecutive days The treatment is given MECIILORETIIAMINE following the evening meal so that the pa HYDROCIILORIDE AND tient has the night to recover from the RELATED DRUGS nausea and vomiting that almost uniformly Mechlorethamine hydrochloride is the follows the injection The injection is only nitrogen mustard compound that has given by starting an intravenous drip of been released for general use by the medi 1000 cc of 5 per cent glucose in distilled cal profession The authors' experience has water to which 50 mg of chlorpromazine been largely limited to the use of this drug has been added to counteract the nausea Triethylene melamin (TEM) which is a When it is certain that the needle is in the compound that can be administered orally lumen of the vein, the tubing is clamped has been released for experimental use Our close to the adapter The nitrogen mustard experience with this drug has been more compound dissolved in 10 cc of distilled limited but in general it seems to produce water is then injected into the tube taking about the same response as nitrogen musabout ien seconds to make the injection tard given intravenously Our observations The Clamp is then released from the tube on the effectiveness of triethylene thuophos. and the intravenous drp allowed to conphoramide (Thiotepa) have been too limit- tinue ed to warrant a comparison with nitrogen TEM which is administered orally is supmustard It seems to be less toxic and to phed in five milligram tablets The usual give fewer unpleasant symptoms during ad course of treatment we have employed is ministration The difficulty in evaluating a total dose of 25 mg giving one tablet on response to these drugs because of the va. each of five successive mornings on an guries of the disease being treated and the empty stomach one hour before breakfast lack of controls make it almost impossible This therapy can be taken by the patient to compare their therapeutic effectiveness in the home He should, however, be under close observation by his physician due to DOSAGE AND METIIOD the danger of the toxicity of the drug to the OT ADMINISTRATION bone marrow Repeated courses of therapy In our use of the nitrogen mustard com have been given at six to twelve week interpounds we have varied the dosage and the vals The risk of depression of the bone method of administration from time to time marrow mahes imperative blood counts be Early, impressed by the toxicity of the drug fore and at weekly intervals after the ad the usual adult pattent was given eight to ministration of any of the nitrogen mustard ten milligrams in four divided doses in as drugs many days Later, influenced by the reports of other workers, we became bolder OBJECTIVE EVIDENCE OF VALUE and gave in a single dose 0 5 mg per kilo Since chemotherapy is not capable of gram of body weight, making the total dose curing neoplasms of the bronchi, wha for the average patient 35 to 40 mg This lective evidence is there that it is ·72 CHEMOTHERAI Y 9-27-57 Fig la This 50 year old woman was found on examinat on of a cervical node to have a small round cell und fferentiated carcinoma that had crused cough dyspnea and substernal pa n She was treated with irra diation therapy and experienced temporary rel of of symptoms therapeutically? Karnofsky et al' reported patients having undifferentiated neoplasm a most careful detailed study of the thera The favorable response was at times bru peutic effects of nitrogen mustard therapy in duration but they felt the therapy ha in 25 patients with proven bronchogenic definite value in the inoperablc patient carcinoma found to be inoperable Seventy Several observations can be set fort! four per cent of these patients improved testifying that the benefit is real and no symptomatically and 49 per cent had ob imaginary Patients having sesere head jective evidence of improvement Skinner aches due to brain metastases may experi Carr and Denman reported palliation of ence gratifying relief for a period of time iymptoms with nitrogen mustard therapy following nitrogen mustard therapy The out found no evidence that life was pro severe lancinating pain caused by spinal onged Lynch et al' treated 60 inoperable metastases often is greatly relieved so that patients with nitrogen mustard as the only life becomes more tolerabic Svelling of the herapy They found that more than half neck shoulder, and arms due to sena caval howed objective evidence of improvement compression by mediastinal nodes wall fre vith the greatest percentage being in the quently dramatically disappear following a

·TIIE TREATMENT OF BRONCHIAL NEOPLASMS
73
VES
why
1-17-58
Fig 1b Less than four months later the atelectasts of the lower and
middle lobes had cleared She was admitted to the hosp tal because of
extreme fatigue and left hemianopsta Her liver was found to be enlarged
and nodular Sixty mult grams of nitrogen mustard was given intra
venously in six d vided doses over a period of two wecks
course of chemotherapy Palpable cervical
COMBINED WITII IRRADIATION
nodes can be observed to reduce in size fol Biochemical means either to sensitize the
lowing this therapy Frequently a patient tumor cell to or augment the effect of irradı
incapacitated by severe lassitude when given ation therapy by a cancerostatic effect is de
a course of therapy will experience a feeling sirable and should be explored further chini
or well being and again renew pursuits in
cally It is true that with combined therapy
which he had lost interest (Fig 1) It is
it is difficult to assess results of treatment
true that these benefits are quite transitory
However in dealing with a fatal disease all
being carcinostatic rather than carcinocidal modalities of therapy that may be of value
but they are real and are appreciated by should be utilized Irradiation can only be
the patient and the fanily The availability used effectively when focused on a limited
of this therapy should not be overlooked so region of involvement such as the primar
that the patient in discouragement seeks tumor mediastinal masses and
help outside of the medical profession from and spinal metastases If evidence
dissemination of the carcinoma
cancer quacks

·72 CHEMOTHERAPY 9-27-57 Tig la This 50 year old woman was found on examination of a cervical node to have a small round cell undifferentiated carcinoma that had caused cough dyspnea and substernal pain She was treated with Irra diation therapy and experienced temporary relief of symptoms therapeutically? Karnofsky et al' reported patients having undifferentiated neoplasms a most careful detailed study of the thera The favorable response was at times brief peutic effects of nitrogen mustard therapy in duration but they felt the therapy had in 25 patients with proven bronchogenic definite value in the inoperable patient carcinoma found to be inoperable Seventy Several observations can be set forth four per cent of these patients improved testifying that the benefit is real and not symptomatically, and 49 per cent had ob imaginary Patients having severe head jective evidence of improvement Skinner, aches due to brain metastases may experi Carr, and Denman reported palliation of ence gratifying relief for a period of time symptoms with nitrogen mustard therapy following nitrogen mustard therapy The but found no evidence that life was pro severe lancinating pain caused by spinal longed Lynch et al treated 60 inoperable metastases often patients with nitrogen mustard as the only life becomes more tolerabic Swelling of the therapy They found that more than half neck, shoulder, and arms due to vena caval showed objective evidence of improvement compression by mediastinal nodes still fre with the greatest percentage being in the quently dramatically disappear following a greatly reitesed so that ·الم on the but they are real and are apprecited by should be used Issad ation can only be modalities of Ierapy that may pc of value the patient and the family The ay tilability used cftultivul when focused on a limited region of in uement such as t e primary fumor mudinal mass arc cerebral and spinal melastasesidence points dissemination of the carturma THE TREATMENT OF BRONCHIAL NEOPLASMS 7 1-17-58 Fig 1b Less than four months later the atelectasis of the lower and middle lobes had cleared She was admitted to the hosptal because of estremu fatigue and left hem ps. Hier liver was found to be enlarged and nodular Sixty mlligra f nitrogen mustard was given intra Venously six divided Over a period of tuo weeks course of chemotherapy Palpable cervic COMBINED WITSI IRRADIATION nodes can be observed to reduce in size foi Barchemical means either to sensitue the lowing this therapy Frequently a patient Un call to or augment the effect of irradı incapacitated by severe lassitude when given a course of therapy will experience a feeling of well being and again renew pursuits in which he had lost interest (Fig 1) It is true that these benefits are quite tr insitory However nu ling with a fata disease all being carcinostatic rather than carcinocidal of this therapy should not be overlooked so that the patient in discourauenent Sueks help outside of the medical profession from cancer quacks ·74 CHEMOTHERAPY } 3-4-58 Fig 1c Eight weeks following in tiat on of chemotherapy the chest ap peared normal palpable nodes in the neck had disappeared vision was normal and the patient had returned to work completely svmptom frec can be used to control the more obvious or been able to demonstrate neoplastic cells symptom producing lesions and chemo in the blood aspirated from vens draining therapy be given for the disseminated neoplasms of the colon stomach and kid lesions Where irradiation has been used neys at the time of surgical resection of as initial therapy and cannot be repeated these lesions in 54 per cent of cases Fisher chemotherapy may be used later when there and Turnbull' found tumor cells in the is evidence of relapse or dissemination venous blond in 32 per cent of 25 specimen COMBINED WITII SURGERY of colorectal carcinoma examined by them The value of the use of chemotherapy Moore Sandberg and Schuberg' identified given at the time of or immediately follow neoplastic cells in the venous blood in 93 ing pulmonary resection for bronchogenic out of 179 cases (52 per cent) of visceral carcinoma is not yet proven From both carcinoma studied by them They recov clinical and animal research there is evi ered tumor cells in the blood in 60 out of dence that it should aid in the control of 109 (55 per cent) patients at the time of dissemination of the neoplasm Engel' has surgery This indicated to them that sur ·THE TRFATMENT OF BRONCHIAL NEOPLASMS 75 gery might be an important factor in dis- favorably influence a longer survival time semination of carcinoma cells These find- by preventing the implantation of cells set ings have been confirmed by Cole and his free in the blood stream by the trauma of co workers *** Cole further demonstrated surgery and retarding the development of that in experimental animals nitrogen mus metastatic lesions already present Followtard injected into the blood stream has pre ing thoracotomy the patient must necessarivented implantation of neoplastic cells in- ly be hospitalized for a period of time This troduced by intravenous injection of a free time can well be spent in the giving of a suspension of these cells If this is also true course of chemotherapy The addition of in the human patient, nitrogen mustard chemotherapy during the period when nargiven intravenously at the time of surgery cotics for relief of pain and intravenous could prevent survival and implantation of fluids are being used adds little to the dis malignant cells that might be freed into the comfort of the postoperative course of the blood stream by handling of the lesion at patient In addition to the actual therapeuthe time of surgery That dissemination of tic benefit there is the value of the increased the disease at the time of surgery is a hazard morale of the patient and the family in should be recognized by every surgeon Re knowing that something is being done to cent reports in the literature emphasize the combat the disease However, the increased importance of blood vessel invasion by the risk of bone marrow depression in combined neoplasm as a major factor in the prognosis therapeutic and irradiation programs must for long term survival (Collier et al") be considered Chemotherapy may be helpful in modifying the hazard of this pathologic aspect of the CIIEMOTHERAPY FOR MALIGNANT disease PLEURAL EFFUSION It would seem reasonable to give nitrogen Pleural effusion due to extension of the mustard in an intravenous drip at the time of neoplasm to the pleural surfaces is a fresurgery or in the immediate postoperative quent complication of bronchogenic carcı period in every patient having a resection noma It is typically painless but usually or exploratory thoracotomy for broncho it causes dyspnea For a time the dyspnea genic carcinoma The authors have recently can be controlled by frequent thoracenteses used chemotherapy as an adjunct to surgery These repeated aspirations of the pleural in a few patients The series of patients thus fluid are disturbing to the patient and any treated is too small and the time elapsed therapy that can stop the formation of the since surgery too short to allow evaluation fluid is helpful in the management of the of this combined therapy The risk of bone case marrow depression in the postoperative pa- Solutions of radioactive gold and phos tient may outweigh the benefits, however phorus have both been used intrapleurally to help control pleural effusion due to neo CILEMOTUIERAPY FOLLOWING plasm Although both of these agents have E\PLORATORY THORACOTOMY been of proven value the cost of production The surgical mortality and poor survival the short half life (making transportation time following exploratory thoracotomy for and arranging for administration difficult) bronchogenic carcinoma when the lesson is and the technical precautions that must found to be non resectable has already been be observed in the handling of these agents discussed in previous chapters Chemo- makes their general application impractical therapy probably could not modify the Nitrogen mustard or Thiotepa given intra surgical mortality but conceivably it could pleurally seemingly have about the same ·76 CHEMOTHERAPY beneficial effects as the radioactive sub primary anemia may result This compli stances and have the advantage of being less cation usually becomes apparent two weekexpensive, easier to handle, and more readı following therapy It follows both the use ly available When used intrapleurally ap of nitrogen mustard intravenously and TEM proximately the same dose can be used as is orally It is more likely to occur following given with a course of intravenous therapy, repetition of therapy 04 mg per kilogram of body weight The The blood of the patient who has re same precautions should be used in watch- ceived chemotherapy should be studied once ing for damage to the bone marrow follow a week following therapy This study should ing the use of chemotherapy intrapleurally include a platelet count as well as a count as intravenously Intrapleural injection of of the cells The most serious aspect of nitrogen mustard can be repeated at shorter depression of the bone marrow is damage to intervals (two to four weeks) if the pleural the megakaryocytes leading to thrombocy fluid is still forming and no anemia has topenia The finding of a low platelet count resulted from the initial injection can be checked with a study of the sternal bone marrow The reason that thrombo- COMPLICATIONS OF CHEMOTHERAPY cytopenia is so serious is that as yet there is no effective treatment for it The use of The immediate complications of nitrogen transfusions of fresh blood and steroid mustard therapy when given intravenously therapy may be of help but there is no are nausea and vomiting and phlebothrom assurance that the condition can be con bosis of the vein used for the injection The trolled Death may occur quickly due to nausea and vomiting can be minimized by generalized capillary bleeding giving the therapy following the evening The patient can usually be supported dur meal so that the patient has a long period ing a period of agranulocytosis by blood of induced sedation before the next meal transfusions and penicillin therapy Folic Fifty milligrams of chlorpromazine can be acid in adequate dosage may also be of given in the intravenous drip that follows value while the white count is low the injection of the nitrogen mustard com The primary anemia is usually less pound This can be supplemented by 25 concern since citrated blood can be given mg doses of chlorpromazine by mouth or in adequate amounts as replacement therapy intramuscularly at intervals as indicated by until the period of bone marrow depression the individual reaction of the patient has passed The complicating phlebothrombosis al Two patients that we have treated with though annoying is not a serious problem nitrogen mustard therapy have died due to Usually no therapy is required other than uncontrolled thrombocytopenic purpura In assurance to the patient and family that the both instances therapy had been repeated condition will clear with time Elevation of after an initial favorable response in trejt t heat may ing disseminated carcinoma Admittedly Although the risk of nitrogen mustard therapy is res! in several and death may result but in treating such patients in none was it a serious factor in a serious condition as disseminated carci the management of the overall problem noma risks must be accepted Surgeons are The most serious complication of nitro prone to make little of the risks of surgical gen mustard therapy is due to its depressing therapy and shrink from the risks of medt effect on the hematopoietic system A pro cations Internists in contradistinction em found thrombocytopenia, leucopenia, and phasize s but are complacent ·TUF TREATMENT OF BRONCHIAL NEOPLASMS 77 about severe complications of drug therapy CONCLUSION Both groups must realize that to take an Chemotherapy now available constitutes aggressive attitude toward the treatment of an important means of treatment of the ma malignancies implies the calculating and jority of patients suffering from broncho incurrence of risk of complications genic carcinoma At the present time chemotherapeutic agents appear to be cap REPETITION OF CHIESIOTHERAPI able of producing carcinostasis only through Chemotherapy can be repeated The deinhibition of enzymatic function of neo cision as to whether it should be repeated plastic tissue The beneficial results can best be evaluated in the relief of distressing would depend upon (1) a favorable re sponse to the initial course (2) the absence symptoms and the causing of a sense of well of evidence of depressed hematopoiesis and being rather than in a lenghemng of the (3) an appraisal of the general condition of survival time If a patient can be kept rea the patient Usually at least six to twelve sonably comfortable and maintain an in weeks should elapse between courses of terest in life during the greater part of the therapy to allow time for observation of a terminal illness something useful has been favorable response and to check damage to accomplished It is in this realm that the hematopoietic system It would be un chemotherapy is of value The ultimate wise to repeat nitrogen mustard therapy in hope of cancer research is that in time a substance will be found that will be carci a patient rapidly approaching a terminal state The dosage employed in subsequent nocidal either by selectively destroying the courses is generally the same as that used cancer cell or by depriving it of some chemi cal substance necessary for its survival In in the initial treatment Oral TEM adminis the meantime induction of quiescence by tration may be employed as a subsequent means of chemotherapeutic agents alone or course of therapy following the initial in in combination with irradiation therapy travenous nitrogen mustard treatment warrants further exploration REFERENCES 7 1 SHAPIRO DM Quantitative biochemical differences as a basis of cancer chemo therapy Radiology 69 188 1957 2 KLIGERMAN MM and SHAPIRO DM Augmentation of radio therapeutic effect by cancer chemotherapy Radiology 69 194 1957 ) KARNOFSAY DA ABELMAN H CARVER LF and BURCHE RAL JH The use of the nitrogen mustards and the palliative treatment of carcinoma Cancer 1 63 1948 4 SKINNER EF CARR D and DENAAY W E The treatment of inoperable bron chogenic carcinoma with Methyl Bis 3 Thoracic Surg 17 418-438 1948 LYNCH I PWARE PT and GAENSLER Γ Α Ntrogen mustard in the treatment of inoperable bronchogenic carcinoma Surgery 27 368 1950 6 ENGEL HC Cancer cells in the circulat ing hood Acla chuir scand Suppl 20 1955 FISHER DR and TURNBULL RR JR The cytologic demonstration and signifi cance of tumor cells in the mesenteric venous blood in patients with colorectal carcinoma Surg Gynec & Obst 100 102 1955 8 MOORE GE SANDBERG A and SCHUBERG BS Clinical and ctperimental observa tions of the occurrence and fate of tumor cells in the blood stream Ann Surg 146 550 1957 9 CRUZ EP MCDONALD GO on COLE WH Prophylactic treatment of cancer Surgery 10 291 296 1956

·78
CHEMOTHERAPY
10 MORALES F, BELL M, MCDONALD GO,
and COLE WH The prophylactic treat
ment of cancer at the time of operation
Ann Surg 146 588, 1957
11 COLLIER, FC, BLAKEMORE W S, KLINE
RH, ENTERLINE H T, KIRDY (
and JOHNSTON J Carcinoma of the
Factors which influence five year su
with special reference to blood vess
vasion Ann Surg 46 417, 1957

·Terminal Care CARE OF THE PATIENT having a bron- statistically and objectively Nevertheless, chogenic carcinoma who cannot be cured this function is the major one confronting by surgery is undoubtedly the most im the physician caring for a patient having portant, yet at the same time, the most diffi a disease that cannot be cured cult and neglected phase of the management The majority of people accept the fact of of this disease Less than one third of the ultimate death although if one is living a patients may have surgical excision of the satisfactory life and is in full command of neoplasm, and only a small percentage of his mental and physical faculties, the desire these can be regarded as cured Another to stay alive as long as possible is ever presone percent may receive an apparent cure ent It is a severe shock to the average pafrom irradiation and chemotherapy The re tient to come face to face with the realizamainder unless death results from some tion that he is suffering from an incurabic other cause eventually succumb to the ef disease Many do not want to know or if fects of the cancer of the lung For some informed of the diagnosis, and its implica the course of the disease may be rapid with tions are explained to them, in a natural death ensuing within a few weeks of the human reaction to escape harsh reality, detection of the disease Many of the in rarely completely realize what is happen. curable patients will live more than a year ing to them Even if one accepts the fatal from the time of diagnosis and a few will implications of the condition from which survive for several years It is the responsi he suffers he can maintain good morale probility of the physicians caring for these pa vided hope is not destroyed, the date of tients to make this period of survival as death is uncertain, and distressing symptoms comfortable and as productive as possible can be somewhat alleviated A patient As a profession in our evaluation of the should never be told there is nothing more resuits of the treatment of any particular that can be done for him and a date for disease there is a tendency to place too death prophesied The result too often is much emphasis on "cure' and the "saving complete dissolution of morale, destruction of lives In the last analysis we do not of hope, and paniched search for benefits Save Ines We merely prolong lives if a from quasi therapeutists of cancer It is fair patient under treatment experiences months to give the patient some insight as to the und even years of reasonably comfortable problem he faces but the physician must happy productive living, no credit is given re-enforce hope through assurance that he to the medical management His death is will stay with him and do all in his power listed in vital statistics as due to a certain in the coming struggle for survival disease and the treatment is considered as WHAT SIIALL TIIE PATIENT having failed Prolongation of life and re BE TOLD: lief of suffering are difficult to evaluate the problem arises "w ·80 TERMINAL CARF the patient be told?' There is no easy an in loss of confidence in the physician since swer to this question There are too many the patients spouse will inform him At variables involved The physician must con the request of the family, or if confronted! sider the probable extent of the neoplasm with a direct question that permits no exa It is usually best to talk to the patient re sion, the true diagnosis and the outlook ferring to the lesson as a tumor If this for survival should be disclosed to the satisfies the patient and the lesion is one patient This disclosure need not be abrupt that surgery may cure, no other term need and should be made with all compassion and be used If, however, when confronted with hope The blow to the patient's morale can a patient whose lesion is probably curable, be softened by intimating that treatment is one senses that surgical recommendation available to delay the malignant process will not be readily accepted, it may be neces and to alleviate the more unpleasant sary bluntly to inform the patient that he symptoms has a cancer Otherwise, the patient has no true basis of fact other than his confi TIIE FAMILY'S ROLE dence in his doctors on which to base such The major task in the care of the patient an important decision as to whether or not will usually fall upon the family It is he should accept surgery Unless patho necessary, therefore, that they be fully in logic proof of the nature of the lesion has formed concerning certain aspects of the been obtained, the physician or surgeon is disease some of which the physician may not justified in talking positively of the not wish to disclose to the patient Thev lesion as being a cancer or a malignant one must be instructed to encourage the patient Errors in clinical diagnosis are possible in to maintain activity in any pursuits he even what appears to be a clear-cut situa enjoys that are within his physical capacity tion Such an error may cause irreparable As long as the patient is ambulatory and damage to the morale of the patient even reasonably comfortable work visits to refa though he is assured later that he did not tives, fishing trips and even tours abroad have a malignant lesion As a corollary of should be encouraged All such activities such an erroneous clinical diagnosis are the if genuinely desired and enjoyed by the medico legal implications and at least the patient will not only fill his remaining days unfavorable reflection on the physician's with interest, but will probably actually ability prolong his life There is no point in urgino The more difficult problem arises when such activities of the patient's condition has the diagnosis of cancer of the lung has been deteriorated to the point that the capacity proven or is clinically obvious in a patient to enjoy life has vanished whose lesion is incurable by surgery JE Preservation of morale may depend a possible, the diagnosis and the position in great deal upon the patients appraisal of which it places the patient should be dis his usefulness to his family Return to work cussed with the patient's family, especially after initial treatment is desirable even if the husband or wife The physician should the estimated time of survival may be short generally be guided by the wishes of the Housewives and mothers should be encour spouse as to what the patient should be told aged to take up their usual responsibilities Many married couples have a pact that they in the home, even will not deceive each other about such im- imposed by their disease may make it neces, portant matters and their wishes should sary for others to share in the houschold be respected Evading the question of the duties Every effort should be made to true diagnosis in such a situation results present invalidism being imposed by over ough the limitations ·81 THE TREATMENT OF BRONCHIAL NEOPLASMS Cine solicitous relatives or being prematurely to discuss the diagnosis and prognosis with accepted by the patient because he has lost the patient and family even though in the hope patient's interest he may not tell the entire truth Working with the referring physician, TIIE ROLE OF THE he should arrange for irradiation therapy TANIILY PAYSICIAN af such seems indicated He must make The family physician often bears the recommendations for and at times carry brunt of the professional care The care of Out himself indicated chemotherapy The the incurable patient is seldom pleasant and referring physician must be fully informed sorely tests the faculty of the art of medi. as to the diagnosis, prognosis, and general Numerous and repetitious questions plan of future care Likewise, he must be must be patiently answered, always keeping told what information has been given to the in mind "how will he interpret this answer?' patient and the family so that he will not Often drugs must be prescribed with full inadvertently divulge facts that may have realization that they cannot possibly cor- been withheld rect the condition or completely relieve the Unless distance is a barrier, the consymptoms for which they are prescribed sulting surgeon should see the patient peri- Details concerning diet, rest at night, and odically for checkup examinations These habits must be discussed Problems troub examinations can mean much to the support ling the patient no matter how trivial must of the family and referring physician in be resolved to the best of the doctors their care of the patient even though theraability The physician and the religious peutically little seems to be accomplished counsellor will share in the support of the It means much to the patient to be exmorale of the family as well as that of the amined Every finding should be presented patient in its most favorable light Drug schedules may have to be rearranged, some discarded TIIE ROLE OT TIIE if they seem ineffective, and new ones pre- CONSULTING SURGEON scribed Any new development in the field The role of the consulting surgeon may of cancer therapy of which the patient has de brief in point of time and few in the become aware should be discussed with the number of contacts with the patient but patient The new therapy, if ethical, should nonetheless is very important by virtue of be tried in applicable situations, or the his experience As far as the patient is fact that the treatment is not suitable should concerned the consulting surgeon is the be explained to the patient's satisfaction court of last appeal He is the one who has "The patient should gain the impression that interpreted the roentgenograms, seen the everything possible is being done to combat tumor through the bronchoscope, or opened his disease when making the appointment and explored his chest He has determined for the next visit, a definite time should be the course of treatment to be followed It is set in the future so that the patient gains only natural that the patient should look the impression that the consulting surgeon to the consulting surgeon for counsel and confidently expects him to be able to return later in his care should refer major prob at that future date fenis back to him for solution Even though the surgeon cannot cure the patient by TREATMENT OF SYNIPTOVS resection of the neoplasm, his responsibility Specific measures in the treatment of the to the patient remains incurable patient are related to the reli It is the duty of the consulting surgeon of cough dyspnea, pain, hemorrhage ·82 TERMINAL CARE general debility Vena caval and tracheal it is seemingly due to bronchitis the im obstruction cause most unpleasant symp- portance of eliminating bronchial irritation toms The treatment for relief of these two by refraining from smoking should be er complications of bronchogenic carcinoma plained to the patient are discussed in the chapters dealing with The administration of antitussive agents irradiation and chemotherapy and narcotics eventually becomes the mam COUGHI measure required to control the severe cough Codeine and hycodan may be used Cough is a frequent symptom that may initially in effective doses The doses may represent the major problem disturbing the have to be increased as time passes When comfort of the patient Although some cough may have been present for years as these drugs are finally ineffective, dilaudid should be used It is the most effective a "smoker's cough," the increasing persis- available narcotic for the control of cough tence of the cough and the severe paroxysms It can be added to any vehicle in strength of it may become intolerable The physical so that each dose will give 1/64 gr At exertion demanded in coughing and the this level of dosage, given three to four disturbance of rest may be a major factor times daily, even a severe cough can be in the deterioration of the patient's physical almost eliminated condition Cough may be caused by the obstruction DISPNEA of the bronchi or trachea by neoplasm, Dyspnea may be due to loss of the airway pressure on the trachea or bronchi, or by to a lobe or an entire lung by the obstruct an associated bronchitis Irradiation therapy ing neoplasm or compression of the lung by and chemotherapy may give temporary relief pleural fluid More often dyspnea of the cough by causing regression of the to an associated generalized pulmonary neoplasm Bronchoscopy with manual re emphysema resulting from chronic obstruc moval of neoplastic tissue may open the air- tive bronchitis A failing heart due to the way for a period of time Repeated broncho mounting pressure in the pulmonary arter scopies for this purpose are rarely justified may contribute to dyspnea in the terrain In selected patients palliative resections may state be justified for the sole purpose of eliminat Relief of the bronchial obstruction tei ing the causes of harassing coughs Vago porarily may result from manual removal tomy below the branching of the recurrent bits of neoplastic tissue túrougit the han laryngeal nerve has been advocated as a choscope Irradiation therapy over the o useful measure to relieve cough in patients structing neoplasm may cause absorpc found to be non resectable at the time of of the tumor and allow the bronchus 1 exploration Daily administration of low reopen resulting in dramatic relief of dy doses of antibiotic drugs combined with pnea cough and pain expectorant cough medicines will be of Accumulations of pleural fluid should t value especially when the cough is due to removed by thoracenteses as often as re bronchitis Attempts to control a cough quired to relieve the patient s dyspne: due principally to bronchitis will be futile if Nitrogen mustard derivatives and radioisc the patient persists in smoking cigarettes topes introduced into the pleural cavity ma excessively As a general principle it is not delay and even stop the formation of ſurd kind to quarrel about a lifelong habit with Irradiation therapy has a definite role in thi a patient whose life expectancy is short If treatment of pleural fluid formation due to cough is a major distressing symptom and neoplastic invasion of the pleura As the is due ·TIF TREATMENT OF BRONCHIAL NEOI LASMS neoplastic infiltration of the pleura pro Bronchogenic carcinoma commonly meta zresses the time is reached when no more stasizes to the spine invading the vertebrae luid can be aspirated and the resultant loss and at times the neural canal The involve of pulmonary function leaves the patient ment of the nerve roots either due to with dyspnca which cannot be relieved At direct invasion or impingement at the inter this point sedation and narcotics should not neural canal results in severe pain of the be withheld even though in general they are radicular type Invasion of the sympathetic contraindicated in the severely dyspneic chain causes an intense poorly localized patient burning type of pain within the chest Dyspnea due to an associated pulmonary Palliative resections may be very useful emphysema can often be partially relieved to control pain when a peripheral neoplasm by a vigorous attack on the generalized the lung has invaded the chest wall bronchitis Expectorant cough mixtures and Irradiation therapy is usually not successful bronchodılating drugs should be prescribed relieving pain due to direct extension of for daily use Often an element of infection a neoplasm into the parietes of the chest is present that can be partially eliminated It does however yield gratifying relief when by the use of antimicrobial drugs using a used to control pain due to spinal and bony low daily dose Positive pressure breathing metastases Headaches due to cerebral techniques using wetting agents may help metastases are frequently temporarily re improve ventilation This therapy can be lieved by irradiation therapy over the site instituted in the hospital and if the prog of the secondary lesion Chemotherapy nosis from the standpoint of time makes it often gives gratifying results in helping to advisable the equipment can be obtained by relieve pain due to both the primary and the patient and used in his home secondary lesions Nerve blocks in certain Tracheostomy is useful in the relief of instances of localized parietal pain have dyspnea in the emphysematous patient it been effective finds its greatest usefulness immediately Neurosurgical procedures for the relief following resection in the patient with bor of pain have a definite place in the treat derline pulmonary function Its use in the ment of these patients Cordotomy and incurable patient suffering from severe dys intercostal neurectomy may relieve the pain due to lesions below the mid thoracic level pnca as a measure of prolonging life for a short period does not seem justified They will be of no help to the patient with brachial plexus involvement Intramedul lary spinothalamic tractotomy has been ob Pin served to give complete relief of pain in this Pain is always a difficult symptom to type of neural involvement and should be control Bronchogenic carcinoma in the considered of v. is felt that the plans periphery of the lung may invade the pleura estimated survival time is at least six months causing a severe localized pain at the site This surgical procedure has the disadvan of the leston Further extension into the tage of carrying considerable risk and of ribs and intercostal nerves will result in being a technique which has been mastered sciere unrelenting radiating pain along the by few neurosurgeons Return of severe nere distribution The most severe pain pain following intramedullary tractotomy is is caused by the invasion of the nerve routes usually due to further extension of the neo making up the brachial plexus by a peri plasm to nerve pathways beyond the funits pheral carcinoma in the superior sulcus of rendered insensible by the procedure the chest the so called Pancoast tumor D Errcomhas described the ·tite TERMINAL CARE limitations complications and technique of complaint if there has been destruction of this neurosurgical procedure the adrenal glands by metastases In this HENOPTYSIS situation the use of steroids as replacement The coughing up of blood is alarming therapy may be of temporary value Hink to a patient The typical bleeding from an potency vitamin and protein preparations obstructing carcinoma in the bronchus is seem to be of value in some of these patients. an oozing of blood which is expectorated 300 mg daily have a stimulating effect and Marsilid and Isoniazid given in doses of mixed with mucus Irradiation therapy may be successful in eliminating this distressing may for a period help to increase the appe Sign In selected cases where the bleeding The tranquilizing drugs also have is severe, palliative resection is useful Drugs by counteracting some of the mental depres their place in the treatment of these patient generally used to improve the clotting sion that inevitably accompanies the realiza. mechanism or to reduce capillary fragility tion that he is afflicted with an incurable are of little practical value in coping with disease bleeding from bronchial neoplasms At times their use is justified for psychologku THE REWARDS OF TERWINAL CARE reasons to help the patient realize that everything is being done for him in the Some of the closest human relationships face of severe life threatening hemorrhages between a physician and his patient develop from the bronchi in the incurable patient during the care of the incurable patient heavy sedation and the liberal use of nar The patient and the family are eternally cotics is not only justified but mandatory to grateful for the attention and consideration allay the patient s apprehension even though shown them by the physician during this their use may hasten death trying period Words of cheer and consola tion patient attention to the patients com GENERAL DEBILITY plaints readiness to make available any Weakness or general debility may be the drugs that may be required and a firm main complaint and at times the only com handshake at the end of a period of con plaint of the patient suffering from a dis sultation can all do much to lighten misery seminated carcinoma This is the usual during the days of terminal illness REFERENCES D ERRICO A Intramedullary spraothalamic tractotomy Neurosurg 7 294 1950 ·Results EVALUATION AVALUATION OF RESULTS of therapy for tologically proven Thus ignores a sigofi cancer of the lung is a complex problem cant group of patients in whom an accurate To demonstrate that therapy has had a clinical diagnosis can be made but it is beneficial effect on the time of survival it either not teasible or unwise to obtain his must be shown that the survival curve tologic proof Patients having cerebral departs from the survival curve of untreated metastases gross mediastinal involvement patients having the same type of disease and with vena caval or tracheal compression approaches the survival curve of people of spinal metastases superior sulcus tumors the same age and sex who do not have paralyzed vocal cords fluid due to pul cancer of the lung Although the survival monary venous occlusion severe pulmonary curve of healthy people is well established emphysema and advanced age a}} may fall the curve of untreated patients having bron in this group It is true that an occasional chogenic carcinoma is often impossible to error may be made in making a clinical establish because of the difficulty in estab diagnosis of primary cancer of the lung fishing the time of onset of the disease To not supported by histologic confirmation diagnose a cancer earlier in its course is to but in any large series of patsents followed increase survival time by a similar period for a significant period of time it- percent cven without treatment The abtity accu age of error would be small Unless these rately to assess the quality of survival is even clinically diagnosed patients are included in more confusing in order to arrive at a the total evaluation the rate of approxi reasonable prognosis in the case of a par mately one third of patients having cancer nicular parent being considered it is neces of the lung will be ignored and the 12 Nary to know the clinical course of tistics wl be weighted in la or of the neoplasms of a similar type This means surgical cases Reports from various clinics that in addiuion to the determination of the reporting on total etpenience rescat thar overall survival rates of patients it is neces histologic proof s obtained in approu sary to determine survival rates according mately 70 per cent of the pruents have to the special categories in the broad picture cancer of the lung Thuis percentage retnam of bronchogenic carcinoma remarkably stationary but may van a Reports in the literature dealing with the attitude of the phyians as to survival and cure following surgical cuci tengths are justified to chain tissut sion of bronchogenic carcinoma are con 373301031 fusing due to the variety of methods of reporting used by vanous authors Per OPERABILIT) AND ELSECTAMM centages are stated but there is a great Operable patients are those w variation in what is considered the base line karns that can be remove Some authors include only carcinomas his may benefit os 83 ·86 RESULTS section At the time thoracotomy is per- would be easier to compile if a uniform formed, a certain percentage of operable method of reporting becamic standard The patients will be found to have lesions that most logical method would seem to be one can be removed and are then designated as in which 100 per cent included as a base being resectable Conversely, a particular line all patients seen with cancer of the lesion may be resectable but inoperable lung, including both clinically diagnosed because of distant metastases or cell type and histologically proven cases The oper Thus, resectability is not synonymous with ability rate would then be the percentage of operability Operability and resectability this total group thought to be suitable for rates will reflect the attitude of the surgeon's surgical therapy Likewise, the resectability aggressiveness in applying surgical therapy rate would refer to that proportion of the An excessively high operability rate in rela total group in whom resection was per tion to the resectability rate indicates an formed It is of benefit to divide this group unjustified tendency to perform exploratory into resections thought to be curative and thoracotomy for all lesions regardless of the those considered palliative provided the possibilities of resection and the inherent classification is made at the time of surgery mortality rate for thoracotomy for the non The surgical mortality should include all resectable carcinoma A policy which is too patients dying within a month of surger) aggressive as far as resection is concerned whether or not they died in the hospaz? will be reflected in a high operative mor It should also include later deaths due to tality and in a smaller percentage of patients complications directly relating to the sur Surviving the first year following operation gery Survival rates are pertinent for the The percentage of operable and resectable separate groups receiving surgical therapy cases will appear high if only histologically irradiation, and chemotherapy as well as proven cases are used as the base line of the salvage rate of the entire group Such 100 per cent excluding the cases diagnosed uniform reporting would place the evalua by clinical means alone Ideally, in order von of therapy in proper perspective and to limit induced surgical morbidity and mor should lead to an improved rationale of tality as much as possible, the operability therapy rate should not be excessively greater than REPORTS OF OTIIER AUTORS that of resectability Every effort should be made to establish the resectability of a Husfeldt' has reported the total experi lesion before thoracotomy is performed ence with suczucal tresment of broncho This does not preclude the necessity of genic carcinoma in Denmarh in the year 1949 50, 450 cases of cancer of the lung exploration in doubtful cases in order to establish the correct diagnosis were detected Ninety three patients (21 per cent) underwent total pneumonectomy REPORTING OF RESULTS Seventy nine patients survived the operation and of these, 24 were alive and well fisc Reporting of survival following resec years later This represents a 5 per cent tion also varies with authors Some report salvage of the entire group These results percentage of survival of all cases resected are significant since they are reported from while others report survival of those re a country with a uniform population cared covering from the resection This latter for by a well organized medical system with method is not objectionable as long as the care available to all The total cases re total number of resections and the operative ported probably represent as all inclusive a mortality are clearly stated base from which to evaluate the results as Composite results of surgical therapy it is possible to obtain ·TUF TREATMENT OF BRONCHIAL NFOPLASMS 87 Latourette, Lampe, and Hodges' reported bronchogenic carcinoma up to date Bethe total experience of the University Hos tween 1950 and 1957, 604 additional pa pital at the University of Michigan with tients with histologically proven carcinomas survival in bronchogenic carcinoma Up to have been seen Since in the previous re- 1954 1,207 patients had been seen Five port cases histologically proven represented und two tenths per cent of the 591 patients 60 per cent of total cases, if there has been eligible had surviveu five years This report no change in aggressiveness in obtaining is from the Organized Medical Investiga histologic proof, this means that they saw tion of Cancer" being carried out at this approximately 1000 patients during this institution and thus represents an unselected period in the 604 proven cases the opergroup of patients Seventy-two per cent or ability rate was 55 per cent and the re 867 patients of the total series had positive sectability rate 35 per cent During the histologic proof of primary carcinoma of period 1948 1955 there were 93 Jobec. the lung fonses and 127 pneumonectomies - a ratio Churchill et al in 1950, reported the of three to four The hospital mortality experience at the Massachusetts General during this latter period was 6 4 per cent Hospital with 1,130 patients in which a for lobectomies and 10 per cent for pneuclmical diagnosis of carcinoma of the lung monectomies The five year cumulative surhad been made Sixty per cent (681) of vival during this latter period was 33 per these had histologic proof of diagnosis Out cent for lobectomies and 24 per cent for of this entire group 26 per cent (294) pneumonectomies These excellent results were subjected to thoracotomy and 15 per from surgical therapy seem to be due to cent (171) were resected Of the resected careful selection of patients suitable for group 114 underwent pneumonectomy and resection This conclusion seems justified 57 lobectomy, and 137 patients survived when one considers that approximately 22 resection The operative mortaluy for pneu per cent of the total patients including both monectomy was 228 per cent and for chnically and histologically proven cases lobectomy 14 per cem The mortahy for were found suitable for resection The total patients operated upon during the last two salvage in terms of five year survival of al} years covered by the report was 3 7 per cent patients thus appears to be between 6 and 7 for pneumonectomy and 38 per cent for per cent lobectomy - a truly praiseu orthy record Boyd et al ' in 1954, reported the expert Of the 48 patients who had pneumonec ence of the Lahey Chinc with 403 patients tomies more than five years before report with carcinoma of the lung seen during the ing 6 112 per cent) were alive Similarly, previous 15 years Excluding diagnosis by of the 21 Jobectomy patients 4 (19 per cytology alone 30) of their cases or 75 per cent) survived five years Percentage sur cent were histologically proven With the vival of the total group eligible to surube addition of 27 cases diagnosed by cyrology, five ycars was not reported From the avail 328 (80 per cent) had positie diagnoses able statistics reported it appears that less Fifteen patients lived five years or more than a 5 per cent salvage was achieved It This is 94 per cent of the total cases They mas noteworthy in this report that the sur- reported one patient who had survived frve vival curve for patients treated for pneu years following ray therapy alone Thirtymionectomy practically coincided with the eight per cent of the patients who had been curve of the lobectomy group given what was thought to be a curatic Churchill et al' in recent repact have sesection survived five years or longer Of brought their study of the treatment of 104 reserta 32 of 307 per cent ·88 RESULTS tions lobectomies The total resection mortality than 6 per cent survived one year Two was a very creditable 76 per cent The patients, however, survived more than four operability (538 per cent) was high as years The price of total pneumonectomy compared to the resectability (258 per was reflected in the high operative mortality cent) indicating an aggressive surgical (19 per cent) with three out of four deaths policy The price of this aggressive policy being due to cardiorespiratory complica is shown by an 8 6 per cent mortality fol Only 31 per cent of the patients lowing exploratory thoracotomy It can be survived one year following pneumonectoms seen from this and subsequent reports that and 15 per cent survived five years -- statistics from clinics and surgeons engaged 66 per cent salvage of the entire group in private practice may reflect a high sal Brock in 1955 reported his experience vage rate in the treatment of bronchogenic since 1947 with radical pneumonectomy carcinoma This is probably due to some as a routine surgical procedure in the surg selection of patients more favorable for cal treatment of bronchogenic carcinoma surgical therapy who are sent to these The operative procedure advocated by groups and individuals by referring physi- Brock results in a true en-bloc resection of cians the total lung, mediastinal pleura, lymph Taylor and Waterhouse,* 1950, reported nodes, phrenic nerve with its accompanying the combined experience of several surgeons vessels, and a pericardial cuff The pul in Great Britain in the surgical treatment of monary arteries and veins are secured intra bronchogenic carcinoma of 1,147 patients pericardially as suggested by Allison' in subjected to pneumonectomy, 527 per cent 1946 This procedure was carried out in survived one year -- 137 per cent five 145 patients Sixteen patients (11 per cent) years Assuming a resectability rate of 35 died as a result of the operation Seventy per cent, this would indicate a 5 per cent two of the 129 patients who survived opera salvage of all patients diagnosed tion were still alive at the time of the report Ochsner' in 1954 reported his experience of these 35 had survived over two years with 1,365 patients having bronchogenic and the remaining 37 had survived varying carcinoma Forty-five per cent (619) were lengths of time up to two years It was considered inoperable when first seen of interesting to note that of the 29 patients the remaining 746 patients 680 or 50 per surviving more than three years only 2 were cent of the total group underwent surgery found to have lymph nodes involved with (66 refused surgery), 442 or 32 4 per cent neoplasm upon examination of the resected of the total group had pulmonary resections, specimens Brock compared this series with and 84 or 19 per cent of these patients died 49 simple pneumonectomies done by the following resection It is interesting to note same group of surgeons during the sanie that of the 238 patients who had exploratory period of time In this group there was an thoracotomy without resection 42 died in 18 per cent operative mortality and only 18 the hospital, a mortality of 18 per cent In per cent of the patients were still alive summary, 50 per cent of the patients had no Since the basis of selection of patients on surgery, 50 per cent had surgery, 33 per whom these pneumonectomies were done is cent were resected and 17 per cent had not stated it is difficult to state whether the thoracotomy without resection These fig. comparison of results is valid However ures are practically identical to those being the natural surgical inclination to apply the reported by the authors Ochsner con procedure of simple pneumonectomy to the sidered 74 per cent of his resections to be poorer risk patients reserving radical pneu. palliative of the untreated patients, less monectomy for the better risk patients with ·89 THE TREATMENT OF BRONCINAL NEOPLASMS more favorable lesions (only 2 of 29 pu 38 per cent had resections Seventy four tients surviving more than three years had per cent of the resections were total pneu involved lymph nodes) might explain the monectomies of the conservative type as difference in results compared to a radical pneumonectomy of Watson'ın 1956 reported the experience the type described by Brock Lobectomy at Memorial Hospital with the surgical was done in 26 per cent The surgical treatment of bronchogenic carcinoma during mortality was 7 per cent Twenty five pa the period from 1926 1955 A total of trents or 25 per cent of those resected sus 2967 patients was seen during that time vived a five year period The overall 2631 of them being seen since 1938 when salvage rate for the entire group was 87 the first total pneunionectomy was done at per cent Collier emphasized the importance that institution The patients treated from of finding blood vessel invasion by the neo 1949 55 were analyzed Exploratory sho plasm as seen microscopically in the surgi racotomy for nonresectable lesions was cal specimen Only 6 per cent of the found to have a mortality of 74 per cent patients found to have blood vessel invasion (35 deaths in 470 cases). The resections survived five years as compared to 75 per were divided into radical pneumonectomy cent who survived a similar period who did (125 cases with 136 per cent mortality) not have this finding Neuhof' had pre simple pneumonectomy (52 cases with 173 viously pointed out the importance of distant per cent mortality) and fobectomy and metastases due to blood vessel invasion in segmental lobectomy (50 cases with 8 per support of his contention that selective re ccnt mortaly) The five year survival rate section may be the operation of choice of those cuses eligible (1949 51) was 27 where possible in the treatment of broncho per cent for radical pneumonectomy 22 per genic carcinoma cent for simple pneumonectomy and 25 Gibbon et al 'n a recent paper reported per cent for selective resection Since the results of treatment of 353 patients with Watson states the radical pneumonectomies histologically proven primary carcinoma of were done for parents judged to be good the lung treated during the period 1946 51 risks and simple pneumonectomy was done Thuriy per cent (107) were considered in for bad risk patients requiring chest wall operable 29 per cent or 101 patients under pericardial and diaphragmatic resections went thoracotomy without resection and 41 the groups are not comparable In view of per cent or 145 patients had resections this selection of patients and a 5 per cent Seventy per cent operability and 41 per cent better mortality rate for lobectomy the resectabilny rates are higher than reported Survival rates do not support a contention by most workers and are undoubtedly due thai radical pneumonectomy accomplished to coasideration of only histologically substantially more than routine resection proien cases A total pneumonectomy was preserving pulmonary tissue whenever done in all but 9 cases This radical surg fcasible cal policy is reflected in the 23 per cent Collier et al reported the etperience at surgical mortality Thirty patients having the hospital of the University of Pennsy! resections susisved five years (21 per cent vanuia with 600 patients having carcinoma of the resected group) The lobectomics of the suns seen during a siticen year Here not done by design but because of a period ending D.cembur 31 1955 Torty mistalen impression that the lesson being 10 per cent (256) were deemed to be removed was boniga tuo of 9 patics opcrable Fifty eight per cent (344) had thus treated survived five years esploration of the chest and of these 226 or felt that cutension of the lesson ·90 RESULTS lung was the single most important factor vide a background for the reporting of the influencing survival Cell type seemed less own results important No patients having resection of a portion of involved chest wall survived AUTHORS' SERIES more than 18 months Four patients considered to be inoperable had survived five of 1180 patients seen by us who were dia We have analyzed the results of treatme: years 2 after exploration followed by X-ray nosed as having bronchogenic carcinon therapy The over all five year survival of during the period from 1945 1957 In 7 34 out of 353 patients (96 per cent) is per cent of these patients we obtained histe considerably higher than reported by most logic proof of the diagnosis while in the n workers and reflects the selection of material in favor of the surgical cases maining 30 per cent clinical evidence su ported by observation of the patients cours Burford" has reported the survival rates seemed sufficient to warant a diagnosis following treatment of 1008 patients all malignant bronchial neoplasm One ha' with histologically proven bronchogenic (505 per cent) of the patients were foun carcinoma that were seen by him and his to be not suitable for surgical therapy Th associates at the Barnes Hospital between other half (49 5 per cent) had surgery January 1, 1948 and December 31, 1955 Thirty-five per cent of the total group ha Forty per cent (405) of the patients were resections and 15 per cent underwent ex considered inoperable or refused surgery ploratory thoracotomy without resection Sixty per cent or 356 of the 603 patients (Table I) The operative mortality for re considered operable had resections a re sections was 6 per cent with the mortality sectability rate of 35 per cent Pneumonec for pneumonectomy 9 per cent and that ol tomy was the preferred operation although lobectomy 3 per cent The 420 resections 20 per cent of patients had lodectomies were almost equally divided between pneu because of considerations of pulmonary monectomies (214) and lobectomies function and cell type (bronchiolar carci- (206) Exploratory thoracotomy for non noma) The mortality following exploratory resectable lesions in our hands carried a thoracotomy without resection was 9 per mortality of 28 per cent (5 deaths in 177 The pneumonectomy mortality was patients) Thirty eight patients of those 13 per cent and that of lobectomy 12 per eligible survived a five year period a salvage Of the 461 patients followed who rate of 65 per cent if only histologically were eligible 40 (22 per cent) survived five proven tases and cornered as a bise line years There were no 5 year survivals in for determining the salvage rate the figure inoperable or nonresectable patients The would be 92 per cent Although there is overall salvage rate was 9 per cent It is interesting to note the similarity of these percentage figures to those of Gibbon" who OPERATIYE MORTALITY FOR BRONCHOGENIC also reported only histologically proven cent cent TABLET CARCINOMA 1945 1937 cases Deaths Nun ber per cent Type of Operation Number The summaries of reports made by vari ous workers of results of treatment of bronchogenic carcinoma given above is not in tended as a comprehensive review of the literature on this subject These reviews have been included by the authors to pro Resections Pacumonectomy 214 19 90 Lobectomy 206 7 JO Total 490 26 60 Exploratory Thoracotomy 177 5 2.8 Total patients seen 1180 resectabusty rate 35 per cerca ctplorat on rate 15 per cent.

·91 THE TREATMENT OF BRONCHIAL NEOPLASMS indication that by better application of pres- asymptomatic prior to surgery Fifteen had ently available modalities of treatment this had symptoms less than sir months and 15 overall salvage rate may be improved, be more than six months In the latter group cause of the biologic nature of broncho 6 had had symptoms more than a year and venic carcinoma, the percentage improve 4 more than two years ment will be small The survival of patients whose length of symptoms indicated the presence of the neo- TIVE YEAR SURVIVORS plasm for many months prior to resection Seventeen patients survived five years indicates that the time factor is only of following pneumonectomy. 18 following relative importance in the surgical treatment obectomy, and 3 following exploration and of bronchogenic carcinoma and that the absequent irradiation therapy of these 5 biologic nature of the neoplasm plays a rvived more than ten years and 16 more greater role in determining the chance of more than eight years without evidence of survival recurrence of disease One patient who sur- Twenty-nine of the 38 patients surviving Of vived more than ten years following right five years had epidermoid carcinoma pneumonectomy developed a new primary the remaining, 6 patients had adenocarcıbronchogenic carcinoma in the left lung 10 nomas and I a bronchiolar carcinoma Two which he succumbed One patient who sur patients having small cell undifferentiated vived five years following pneumonectomy carcinomas survived five years following died of metastatic carcinoma from the ongi irradiation therapy given after exploratory nal neoplasm Three additional patients thoracotomy These results merely reflect among the five year survival group have that in general the chance of survival is best died of unrelated causes fyre, seven, and with the differentiated neoplasms and that seven years respectively following resection since the greater number of bronchogenic One of these patients was 75 and another carcinomas are differentiated squamous ce 83 years of age at the time of death carcinomas the majority of long term sur Ten of the patients surviving five years yhors will have had this type of lesion It is following pneumonectomy and two follow significant, however, that there were no five ing lobectomy (one with bronchoplastic re year survivors follow ing resection in patients construction of the airway) had hilar lesions having undifferentiated neoplasms that were bronchoscopically visible prior to resection The prevalent opinion that pa- QUALITY OF SURVIVAL tients having hular carcinomas are incurable Quality of survival is equally as imporis therefore not justified Metastatic carci tant as length of survival but is less subject noma was found in the bilar and mediastinal to statistical analysis However, of the 17 nodes in seven patients that had pneumonec patients who survive fue years following tomies and in to that had lobectomics total pneumonectomy 6 are dyspneic to the There was invasion by neoplasm of the pers. degree that they are almost completely disbronchial nodes in many of the other sur abled by their poor pulmonary function viving patients Admittedly lymph node in The remaining 12 patients lead reasonably usion is a finding indicating a poorer prog. active inves One of the 18 patients who nosis for long survival but with adequate suryayed five years following lobectomy resection of the involved regional nodes cure a 75 year old man succumbed to respo is still possible ratory inadequacy but he was dyspness Only 8 of the 38 patients who have sur the time of surgery and would not ned fne years following resection were tolerated.12941 pm enectomy T 3 ·92 RESULTS ditional patients in the lobectomy group ventional techniques (See Chapter on who were somewhat dyspneic before sur radiation Therapy) gery are now forced to live restricted lives It is interesting that the survival con because of poor pulmonary function The (Fig 1) of patients deemed to be remaining 15 patients have no important operable and those found to be nonresec physical restrictions and lead active pro- able at the time of operation are practical ductive lives Such comparisons with small identical This is true even when the fie groups of patients are somewhat meaning year of survival is broken down into qu? less There is no doubt, however, that total ters (Fig 2) pneumonectomy is a crippling operation Taylor reports that 31 per cent of A and that the quality of survival following tients having exploratory thoracotomies d lobectomy from the standpoint of pulmo within three months following surgery an nary function is superior to that following concludes that this poor survival time is die pneumonectomy to injury caused by surgery If one grant that as a group patients chosen for surgic SURVIVAL RATES IN therapy and found to be nonresectad! INOPERABLE PATIENTS should have a longer survival because dis We were able to obtain accurate follow-up semination is not obvious as it is in man Information on 319 of the 400 patients who patients considered to be inoperable ou during the period from 1945 55 were either data would tend to support this conclusion considered inoperable or did not return for The conclusion is justified, at least, tha treatment of these 87 per cent (279) sur- thoracotomy for the nonresectable lesson vived less than one year (Fig 1) Of the carries a definite mortality (3 per cent 13 per cent who survived one year only 6 the authors' series) with no benefit and or 2 per cent were alive at the end of two possible shortening of survival when com years Two patients have survived four pared to snoperable lesions The only su years although one has since died It may vantage that can be claimed is pathologic be significant that both of these patients re- proof in the diagnosis of the indeterminate ceived irradiation therapy lesion Other methods of obtaining this proof, such as bronchoscopic examination SURVIVAL TOLLOWING cervica mediastinal exploration and needle EXPLORATORY THORACOTONY biopsy may be preferable The authors One hundred forty three patients during strive to maintain a rate of 10 per cent of the period from 1945-57 had exploratory less of all patients for exploratory thoracothoracotomies and were found to have non tomy without resection resectable lesions 'The fate of 124 of these patients is known One hundred three or 84 SURVIVAL TOLLOWING RESECTION per cent did not survive one year of the 21 who survived one year only 5 (4 per Four hundred twenty of the 1180 patients cent) were alive at the end of two years seen during the period from 1945 57 have Three (3 per cent) survived five years or had surgical resection of their neoplasms. more and 2 are still living --- one twelve Two hundred fourteen patients had pneu years and the other eight following explora- monectomies and 206 lobeciomies Three tion in which tissue removed gave patho hundred seventy five of these resections logic proof of a malignant bronchial neo were done more than a year ago of these plasm All three patients who survived five 193 were pneumonectomies and 179 lobxe years received irradiation therapy by con tomies The fate of all of these patients ·100 901 NORMAL EXPECTANCY 80 70 90 % 60 PER CENT SURVIVAL 405- EXPLORATION 30- 20 10 INOPERABLE 0 3% Fig 1 2 3 YEARS (Shaw Paulson and kee 1945 57) Survival of 319 inoperable patients and 124 patients having erploratory thoracotomy for bronchogenic carcinoma 100 90 804 101 EXPLORATORY THORACOTOMY PER CENT SURVIVAL 40! INOPERABLE a 30! 20 10 17 0 3 6 9 12 MONTHS Shaw, Poutson, and kee) Tag : Survival during first year of 319 inoperablc patients and 124 patients etpforatory thoracotomy for bro carcinoma 1124 ·94 RESULTS 100 902 80, SURVIVAL CURVES FOR 375 RESECTIONS FOR BRONCHOGENIC CARCINOMA 1945 - 1956 OPERATIVE MORTALITY Lobectomy Pneumonectomy 9% ANI Resections 6% 70 60 PER CENT SURVIVAL 50F PER a 304 hobectomy 20 ALL RESECT ON to- Pneumonectomy 0 4 5 3 YEARS Fig 3 the is known Fifty four per cent of all patients tomies is superior to that of the patients who having resection survived one year 35 per have lost an entire lung The fact that in cent survived two years and 19 per cent both groups approximately one half five years Sixty one per cent of the patients patients did not survive one year indicates having lobectomies survived one year as that this poor survival was due 10 factors contrasted to only 46 per cent of the pa not related to the type of reseciion but tients having total pneumonectomy The rather to the biologic nature of the disease corresponding figures for two years were 46 The survival curves for patients having per cent and 27 per cent At the end of five resections for bronchogenic carcinoma fot years 23 per cent of the lobectomy patients low the same pattern as curves of survival and 15 per cent of the pneumonectomy following surgery for neoplasm elsewhere is patients were still alive Combining the two the body The percentage chance of suf groups 19 per cent of patients having re vival after two years becomes increasingly section survived five years without sign of good and approximates the survival curve of recurrence of neoplasm The survival curves the general population of the same age (Fig 3) indicate that the prognosis fol group The pneumonectomy patient who lowing lobectomy is soniewhat better than survives three years appears to be in a more that following pneumonectomy This is un favorable position from the standpoint of doubtedly due to the inclusion in the lobec survival than the patient treated by lobec tomy group of many of the more favorable tomy This is probably due to the selecie lesions No one would seriously challenge factor of the increased mortaluy operating the fact that as a group the quality of in the first three year period since at the survival of the patients having only lobec end of five years only i5 per cent of the ·95 THE TREATMENT OF BRONCHIAL NEOPLASMS pneumonectomy group were alive as com long period of time Contrariwise in an alpared to 23 per cent of the lobectomy most asymptomatic patient it may be depatients tected as a widespread bilateral infiltration wholly unsuitable for surgical therapy FACTORS AFFECTING SURVTVAL Small cell undifferentiated carcinomas were FOLLOWING RESECTION resectable in only 24 per cent of cases Fif- Influence of Pathologic Type on Type of Surgery and Survival teen per cent had pneumonectomies and 9 per cent lobectomies in the majority of in- If one disregards general factors such as stances in this type of lesion the resection age, sex and certain morbid conditions, the was carried out before the pathologic type pathologic type of tumor is the single most could be determined The small cell un important factor influencing survival time differentiated carcinoma is usually unsuit- This factor is first reflected in the influence able for surgery because of rapid dissemiit has on the type of surgery (Table II) nation Sixty per cent of the patients having a neoplasm of the differentiated squamous cell The survival rates for five years of those patients treated by resection were 17 per ype were resectable Thirty-three per cent cent for the squamous cell carcinoma, 22 f patients with this cell type had pneu. per cent for the adenocarcinoma, and none onectomics and 27 per cent lobectomies for the small cell undifferentiated carcinoma le preponderance of pneumonectomies is (Fig 4) of the entire group, including e to the tendency of this type of lesion the inoperable and nonresectable lesions, quently to have its origin in major bronchi 94 per cent of those patients having a and to infiltrate locally The resectability squamous cell carcinoma, 100 per cent of TABLE II the group with adenocarcinoma, and 3 3 per RESECTABILITY RATES TOR 736 PROVEN CASES OF cent of those with a small cell undiffer- BRONCHOGENIC CARCINOWA TOTAL CASES 1055 1945 1956 entiated carcinoma survived five years There were three patients whose lesions ability Type of Resection Percent Lobec were operable but not resectable proven Cell Tipe pathologically, who lived seven to twelve Squamous cell years after irradiation therapy Two of Adenocarcinoma these patients had small cell undifferentiated Small cell undifferentiated carcinomas and one had a squamous cell Iarge cell carcinoma (See Chapter on Irradiation undifferentiated 24 28 Bronchiolar Therapy ) Resec! age Pneumonectomy 60-6 45 romy 336 14 27 31 24 15 9 $2 45 Total 0 36 45 23 Chest Wall Invasion ute was 45 per cent for adenocarcinomas We do not share the generally expressed With this cell type lobectomics were more pessimism in regard to survival following frequent 11 per cent as compared to 14 per resection of peripheral ncoplasms that have Lent for pneumonectomy This reflects the invaded the chest wall (Fig 5a and b) tendency of adenocarcinomas to develop in Forty five patients having pulmonary rethe peripheral portions of the lung Bron sections also had resection of a portion of cholar carcinomas could be resected by the involved chest wall in an en-bloc relohectomies or even segmental resections in section Bronchial neoplasms that invade 45 per cent or not at all this type of pul- the chest wall more often can be adequate] monary neoplasm may remain as a localized crcised with a selectnc pulmonary resec tumor is the periphery of the fung for a OF 45 patients only 11 re { ·96 RESULTS 100 SURVIVAL RATES AFTER RESECTION ACCORDING TO CELL TYPES 1945-1951 Squamous Cell 120 Cases 75 Per cent Survival 50! 25 0 100 Adenocarcinoma 24 Cases Undifferentiate 20 Cases Per cent Survival 3 4 50 3 2 Years 2 Years Fig 4 total pneumonectomy In 12 patients a seg- nation was thought to represent a new mental resection was done The remaining mary neoplasm The survival curve ( 22 patients had lobectomies There was no 6) of these patients scems to depart surgical mortality in this group little from that of all patients treated Twenty one of 38 eligible survived eight- surgical resection of a bronchogenic ci een months or more Gibbon' reported noma that they had no patients surviving more than eighteen months in whom it was neces- BRONCHOPLASTIC PROCEDURE sary to resect a portion of the involved chest The use of bronchoplastıc procedure: wall It may be significant that only 2 of the surgical treatment of bronchogenic i the 11 patients surviving had total pneu cinoma in the interest of preservation monectomies the remainder having lobec. lung tissue is an innovation and for! tomies or segmental resections reason the results following this type tients or 20 per cent have survived three section will be recorded in more detail years and of these 6 are still living, one use of this technique may be mandat over six years following a right lower lobec- when applying surgical resection in a pali tomy One patient died four and one half who could not tolerate total pneumon years following resection of the apicopos tomy because of poor respiratory funct Jterior segment of the left upper lobe along the deliberate use of this technique as with a portion of the dome of the involved adequate cancer operation is justified in chest wall Death was due to carcinoma in attempt to improve the qualty of survival the right lung that on post mortem examı patients with adequate pulmonary functa of Seven pa- ·Tis Sa Thus squamous cell carcinoma invaded the chest wall destroying a port on of the third rib It caused severe pain along the distribut on of the third intercostal nerve The patient is alive and well five years fol lowing nghe upper lobectomy includ ag en bloc resection of a port on of the chest wall ·Fig 56 Right upper lobe with resected portion of chest wall showing invasion of the third rib and intercostal nerve by the peoplasm ·pulmonary function but the other survived in only one of these patients the one who THE TREATMENT OF BRONCHIAL NEOPLAS VS 100. 900 97 SURVIVAL CURVE FOR 40 RESECTIONS FOR BRONCHOGENIC CARCINOMA INVADING THE CHEST WALL 1945 - 1956 (Compared with Curve for All Resections) 80L PER CENT SURVIVAL 50+ 304 201 RESECT ONS FOR CA NVAO NO CHEST WALL 10! AL REJECT ONS YEARS Fig 6 patients had bronchoplastic pro found in all three at the time of resection suures in an extension of the usual limits The four remaining patients are alive and of resectability for reasons of palliation in relatively comfortable considering their se both the left bronchus was anastomosed to duced respiratory function fifteen months the trachca following resection of the right three years three and one half ycars and lung along with the carina One died on the five years following surgery Lymph node kelfth postoperative day due to insufficient metastases were found at the time of surgery sened year in reasonable comfort has survived five years Sixteen patients have had bronchoplastic In the other nine patients bronchoplasty ocedures to avoid removing the total fung was performed delsberately as an adequate tere was no mortality Two patients de cancer operation There was recurrence of poned empyemas postoperatively which neoplasm at the site of the anastomosis in led with rib resection drainage In the one of these patients whose right lower and patients twenty three lobes were pre middle lobes were preserved following upper lobectomy This patient died three years The procedure was indicated in seven following surgery Three additional patients patients because of poor pulmonary func in this group have died two and one half lion Tuo patients died at four and six months due to recurrence of carcinoma at three and four years respectively following surgery None of these deaths could be the site of anastomosis and one succumbed ascribed to the type of technique employed to spinal metastases nineteen months follow The remaining fne patients are alue a ing surgery Lymph node metastases were normally active without evidence of ·98 RESULTS rence eight months, ito and one-half years, for one year and 35 per cent for two years three years and three and one-half years All patients with the exception of those following surgery dyspnesc prior to surgery have adequate It is difficult to draw sound conclasions respiratory capacity for active living (Fig from the fate of 16 patients All had hilar 7) lesions Included in the group are several Recurrence at the site of anastomosis w2 patients having small cpidermoid carci more frequent (3 out of 7) in patients 18 nomas that had blocked major segmenta] whom the right lower and middle lobes were bronchi which gave rise to symptoms lead preserved by anastomosing the intermediale ing to their detection while in a localized bronchus to the right bronchial stump close state Six patrents, however, had positite to the trachea The bronchwal section in evidence of invasion of hilar lymph nodes these cases was as high as could be obtained resected at the time of surgery The in in doing a nght total pneumonectomy Ade clusion of the patients with poor pulmonary quate resection of a carcinoma which is function (one of whom had previously had involving the bronchial wall in the region a seven rib thoracoplasty on the opposite side of the right upper lobe orifice is difficult by for treatment of pulmonary tuberculosis) any technique because of the short right probably makes this group faily representa main bronchus Recurrence at the anastotive of hilar lesions in general in considera- motic site occurred in 1 patient who had tion of these facts it is gratifying that 14 of anastomosis of the left upper lobe bronchus the 16 patients (88 per cent) survived one to the left main bronchus performed as 1 year, and 11 of 14 (80 per cent) patients compromise with poor pulmonary funcion eligible survived two years The correspond- but did not occur in 3 other parents in ing percentages of survival of all our pa- whom the same procedure was used in re tents having resections were 54 per cent moving smaller neoplasms 12-13-54 1-25-57 Fig 7 An adequate resection of this large squamous cell carcinoma was accomplished by utilizing a bronchoplastic procedure to preserve the lower and medul lobes The piticht is working daily Without disability three years folloning surgery ·THE TREATMENT OF BRONCHIAL NDOPLASMS 99 This experience with bronchoplastic pro mediastinal involvement of the 81 patients cedures to preserve pulmonary tissue in se- who had resections 10 had total pneumoneclected patients is encouraging and seems to tomies, 62 lobectomies, and 9 segmental deserve a continuing trial lobectomies There was I death, a surgical mortality of 12 per cent This was due to PULMONARY NODULES cardiac arrest occurring following com The most favorable morphologic type of pletion of a right upper lobectomy The bronchogenic carcinoma for resectional TABLE III therapy is the one that presents as a pul SURGICAL STATUS OF 102 PLLMONARY NODULES DUET nonary nodule Unfortunately only 10 per BRONCHOGENIC CARCINOMA ent of all patients seen fall in this group hese lesions not only can usually be re Status Mo Cases oved by a sclective resection but also Inoperable Distant metastases present the most favorable lesion from the Poor pulmonary funct on wundpoint of survival Refused surgery Operable-With evidence of node involvement One hundred two patients had broncho Lobectomy genic carcinomas that presented as pulmon Pneumonectomy Exploration ary nodules Twenty of these patients were Operable Without evidence of node involve inoperable cither because of the presence Segmental lobectomy of distant metastases or because of poor Pneumonectomy pulmonary function Eighty two patients Total were operable and in only one of these was resection not advisable because of gross One death following lobectomy due to cardiac arrest (12) Shaw Paulson and Ace 1945 57 IS 20 21 14 6 ment 1 Lobectomy 9 61 100 102 904 80 NORMAL EXPECTANCY ---- 90% 70- 60 ALL PAT ENTS WIN NOQULTS PER CENT SURVIVAL ماه مد۴ ما NVOLVED NODES (47) 40 30 48 % 20 42% WTH NODES INVOLVED 33% (16) 10- ALL RESETT ONS 0 19% - 5 YEARS Show Poulson, and kr 1945 58) Tag & Survival following 65 resections for bronchogenic carcinoma in patients hinta pulmonary nodules 4 ·100 RESULTS were no major surgical complications patients having asymptomatic nodules re (Table III) sected less than two years ago are still Sixty five patients had resections more living and 70 per cent of those resected than a year ago and the fate of these pa more than two years survive (Table V) tients is known Survival percentages using In summary a patient who has an asymp the life table method were for one year, 73 tomatic nodule due to bronchogenic carci per cent, two years 63 per cent, three years, noma who at the time of surgery is found 52 per cent, and for four and five years, to have no lymph node involvement can 42 per cent (Fig 8) have the neoplasm resected by lobectomy Eighteen patients were found to have with minimal risk and with a two out of lymph node metastases at the time of re three chance of surviving five years without section This finding seriously prejudiced evidence of recurrence (Fig 9a and b) the chances of survival since only 55 per cent survived one year and 33 per cent two SUMMARY years Those eligible to survive beyond two Evaluation of results of treatment of years, however, are still alive -- 3 for three bronchogenic carcinoma considering all years 2 for four years, and 1 for five years types found in a series as a single unit leads following resection (Fig 8) to misleading conclusions and may foster The survival rate of the 47 patients in an attitude of therapeutic nihilism that is whom no nodal metastases were found was not justified One cannot compare the re much better Eighty one per cent survived sults of treatment in unlike cases using solely one year Again using the life table method the criterion of time of survival The life the rates were for two years, 73 per cent, history of a small cell undifferentiated carci three years 58 per cent four and five years, noma cannot be compared to that of a 48 per cent (Fig 8) bronchiolar or well differentiated epider The presence or absence of symptoms moid carcinoma because both are neo that could be attributed to the nodule was plasms any more than the life span of a field of prognostic significance Forty five pa mouse can be compared to that of an ele tients had nodules resected which caused phant though both are mammals The bron symptoms Sixty six per cent of those re chial adenoma meets all of Virchows tenets sected less than two years ago were still for neoplasm but was removed from the alive but only 30 per cent of those resected general classification of bronchogenic carci more than two years ago still survived noma because of this factor of difference (Table IV) In contrast 80 per cent of the in life history TABLE IV SURVIVAL FOLLOWING RESECTION OF 45 SYMPTOMATIC PULMONARY NODULES DUE TO BRONCHOGENIC CARCINOMA TABLE V SURVIVAL FOLLOWING RESECTION OF 36 ASYMPTOMATIC PULMONARY NODULES DUE TO BRONCHOGENIC CARCINOMO Period Since Resechon Number of Resections Nimber Alive Per cent Surviving Period Snce Resecnon Number of Number Resect ons Per fear Sun, ing Alne Less than 1 year Less than 1 year 7 8 6 6 80 66 1 year 9 7 1 year years 8 11 2 3 3 years 4 6 3 8 70 4 2 3 6 2 years 3 years 4 years 5 years or more Total 30 7 years years or more Total 36 21 20 Two deaths were due to causes other than bronchogenic carcinoma Shaw Paulson and Kee 1945 57 Three deaths were due to causes other than carcinoma. ShaPaulson, and Lee 1945 57 ·Fig 9a Th s large asymptomat c pulmonary nodule was d scovered by a rout ne x ray of the chest n the night upper lobe of a 52 year old woman The patent is al ve and well two years follow ng lobec tomy She now has pract cally a normal I fe cxpectancy for her age and ser Tig 9b Resected right upper lobe contar ng a typ cal squam cell carc noma present ng as a large pulmonary nodule

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·THE TREATMENT OF BRONCHIAL NFOPLASMS 101 Surgery can be usefully employed for the played by the biologic nature of bron_ho semoval of biologically early neoplasms genic carcinoma in the overall prognosis of The surgery should be carried out with treatment of this disease Approximately maximum preservation of pulmonary func one half of patients are inoperably when ton Radical pneumonectomies may of first diagnosed and only one third have necessity be required to encompass large lesions that can be resected Studies of locally infiltrating neoplasms but in the series of patients incorporating a broad base usual case simple pneumonectomy or lobec with inclusion of clinically diagnosed cases tomy with dissection of mediastinal and with those histologically proven indi itu hilar lymph nodes are adequate cancer op that a salvage of approximately six per cent erations The survival of patients suitable of all patients as evidenced by five year for surgical therapy should not be compared survival is being accomplished by present with that of inoperable patients inferring methods of treatment If only histologically that surgical therapy was responsible for proven cases are considered the salvage rate the increased time of survival They are is approximately 9 per cent Increasing tht totally unlike series of cases The only scope of surgery by radical resections has justification for comparing survival in such not improved this survival rate This is unlike series is to place in proper perspective due not only to the biologic nature of the the prognosis of a patient in respect to the disease but the fact that factors resulung Toup within which he falls Bronchogenic due to radical resections tend to lessen the carcinomas that have extended to the gen period of survival On the other hand a eral lymphatics are no more a surgical entity patient having an asymptomatic neoplasmı than Hodgkins disease and once they have presenting as a peripheral pulmonary nodule invaded the blood stream as evidenced by with no evidence of nodal metastases has a distant metastases are no more curable by 70 per cent chance of five year survival surgical therapy than leukemia The sur following resection Unfortunately less than geon should be vigilant in his search for 10 per cent of a total series of bronchial lesions suitable for surgical therapy but neoplasmis will fall within this favorable judicious in the decision to apply surgery classification The finding of more patients so as to avoid harming patients who cannot with biologically early neoplasms should in be benefited by this modality of treatment crease the survival rate but this increase The uniformity of the results reported by will be limited by the very nature of the Sarious authors emphasizes the major role disease REFERENCES 1 ILSETOT E. Carçınoma of the Jung in Memorial Holante to Jolan Holst Univ Oslo Norway, 1955 p 119 2. LATOURETTE KB LABIPE 1 and HODGES Fi Organized clinical investigation of cancer M Bull Unit Afichigan 21 283 Nov 1954 3 CHELRCIAL E D SWEET RH, SOUTTER Land SCANNELL JG The surgical ftianagement of carcinoma of the lung TIeracic Surg 20 349 Sept 1950 #CHURCHILL EDSWEET R H SCANNEIL 16 and WILKINS E Turther studies S.M.S. MEDICA RIGIN" in the surgical management of carcinoma of the lung 1 Thoracic Surg in press 5 Bord D P SVEDAL MI KIRKLAND I B hELLY GE and TRUMP JG Carcinoma of the lung Thoracic Surg 98 392 1954 6 TAYLOR AB and WATT RIIOLSE JAH Progress for bronchial carcinoma Thurat 5 257, 1930 7 OCHSNER A RAY C J and ACRIE P Cancer of the lung Lensana State 11 Soc 106 263 1954 8 BROCK R WHYTITEAD LC Radica

·102
RESULTS
pneumonectomy for bronchial carcinoma with special reference to blood vessel ma
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салсег
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results Cancer 9 1167, 1956
14 CENTER S, and BURFORD TH Results 13
COLLIER FC BLAKEMORE W S, KLEIN
the treatment of bronchogenic carcinoma
RH, ENTERLINE HT KIRBY CK
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Factors which influence five year survival

·Bronchial Adenoma By JOHN LESTER Kec, JR MD INTRODUCTION AND HISTORY will be considered individually in the dis- THE ADENONA OF THE BRONCHUS is one cussion of the clinical or pathological aspects in which they differ This termiof the most interesting of the primary bion. nology is not used because it is necessarily chial neoplasms and for many years has best but because it is the most generally been the subject of a great deal of discus accepted The term “adenoma" was first sion and controversy The first report of used by Mueller' and has been the one most one of these tumors was made by Mueller widely used by most authors for the entire in 1882. This was a case of u benign group of tumors although some have used pedunculated adenoma with partial calci- this term for the carcinoid type alone There fication found post mortem in the left main is a real objection to calling these tumors bronchus of a woman aged 22 who had "adenomas' since this term inplies a beniga suffered eight years from profuse expectora. nity which is not always characteristic of tion of blood and foul sputum At autopsy these neoplasms Other names which have there were marked bronchicctatic changes been used are polypod adenoma, basal cell in the bronchus distal to the site of the carcinoma adenomatous polyp benign adenoma Following this report there were glandular bronchogenic tumor. vascular occasional reports of adenomas found adenoma, mixed tuinor, grade 1 adenocarci cither at autopsy or by bronchoscopic es noma, and malignant adenoma The term amination but it was not until 1932 that cylindroma' was first applied by Billroth these tumors were established as a recog in 1859 to a tumor of the paranasal sinus nizable clinical entity by Wessler and invading the orbit' The similarity betucen Rabın' Since that time many cases have these tumors arising in the accessory nasal been reported and much has been learned sinuses and those in the bronchial tree was about the natural history and behavior of recognized and the same term used for this tumor these tumors It was thought that they There have been threc main areas of occurred wherever major or minor salwary Unsagreement in regard to the adenoma glands or simple mucous glands were These disputes have centered around the found' In recent ycars as more data have proper terminology, the cellular ongin and been collected concerning the carcinoid and the degree of malignancy in this discussion cylindromatous adenomas it has been in we have used the term "adenoma" 10 apply creasingly apparent that there is a definite to the whole group of tumors The term difference between thesc tumors in rega "bronchial adenoma" is used to include the to their location, degree of malignanc carcinoid and cylindromataus types which response to treatment In spite 103 1 ·104 BRONCHIAL ADENOMA differences, however, these two tumors are in the mucous glands and their ducts in the closely related and cause similar clinical bronchial walls manifestations Because of differences in natural history and prognosis, it is of im- MALIGNANCY portance that these tumors be recognized and a sharp distinction made between them For many years there was considerable and bronchogenic carcinoma disagreement over the malignancy of the adenomas Some writers believed them THEORIES OI ORIGIN entirely benign, some considered them benign but capable of undergoing a malig There have been many theories suggested nant change, and still others considered to explain the origin of adenomas and the them to be malignant tumors which grow variations seen in the cellular pattern Heck" very slowly and metastasıze late in their (1916) advocated origin from embryonic course There is now ample evidence that buds or non developed foci of lung anlages these tumors do grow slowly, are locally Wessler and Rabinº believed that the aden invasive and also may metastasize to lymph omas origmated in the duct epithelum of nodes, mediastinum, vertebrae, and Inter mucous glands because (1) the tumors are Numerous authors have reported cases of covered by intact epithelium and lie on an metastatic adenomas and have shown that uninterrupted basement membrane, and (2) the adenomas of the cylindromatous type ther cellular elements do not resemble ele- are much more likely to metastasize tha ments of mucous glands and no apparent the carcinoid adenonas McBurney, kisk transition from normal mucous glands could lin, and Woolner" reported 87 instances be seen Hamperl and Stout' believed that of bronchial adenoma with metastases stat the adenomas arose from the peculiar cells ing that ten per cent of all adenomas known as oncocytes' or 'pyknocytes' metastasized They believe that the histowhich are found in mucous and serous pathologic picture may indicate that a given glands and their ducts Crafoord and Lind adenoma may have metastasızıng qualities gren placed the bronchial adenomas with None of the adenomas in the Mayo Clinic the mucous and salivary sland tumors rec series that had perfectly regular carcinoid ognizing their characteristic slow growth as pattern and little or no pleomorphism of well as a tendency toward "local malignan mitotics figures metastasized distantly in cy, ie, local invasion of surrounding two cases such adenomas did metastasize to structures Because of a certain resemblance lymph nodes in those rumors that mela of some of the adenomas to fetal lung tissue stasized distantly the carcinoid pattern was Womack and Graham suggested that they not orderly Pleomorphism mitouc figures were associated with failure of the embry and irregular cell pattern were more fre onic buds to develop into normal structures quent Adenomas of the cylindromatous and termed these tumors “mixed tumors” of type were three times as likely to mely the lung They believed that they were stasize as those of the carcinoid type In formed of both entodermal and mesodermal our series of 35 cases 4 showed evidence of clements and regarded them as potentially local invasion and 3 had distant mess malignant They considered them similar stases of the 3 patients who had distant n behavior and origin to the mixed tumors metastases, ie, metastases to cervical nodes of the parotid gland After years of con diaphragm, or contralateral Jung, 2 patients troversy it is now generally acknowledged had tumors which were histologically of the that bronchial adenomas have their origin cylindromatous type ·TIIE TREATMENT OF BRONCAL NEOPLUMS 105 Negro in this group The youngest patient was 14 years old while the oldest was 65 LOCATION Adenomas are most frequently found arising from the bronchial wall of one of the LOCATION OF ADENOMAS 135 Cases Х INCIDENCE Adenomas are said by various authors to comprise between 6 and 10 per cent of all primary lung tumors Only 3 per cent of our 1215 primary bronchial tumors were adenomas Adenomas are found more fre quently in women than in men in contrast to bronchogenic carcinoma In our series, adenomas were found almost twice as frequently in women as in men (23 females 12 men) The average age of our patients when seen for treatment was 42 years with the majority of the patients in the 30-39 year age group (Table 1) The greatest number of these patients noticed the onset of symptoms between the ages of 20-30 years and had had symptoms for an average of six years at the time they were first seen These figures do not differ greatly from larger collected series of adenomas but arc strikingly different from the figures for bronchogenic carcinoma There were 33 white patients, 1 American Indian and 1 • = Carcinoid type X = Cylindromatous type FR 1 Location of adenomas in the tracheobron chial trec AGE OF PATIENTS WITH BRONCHIAL ADENOMA 15 Age at onset of symptoms Age when seen (Average duration of symptoms 6 yrs) NUMBER OF CASES w <20 20-29 30-39 40-49 50-59 50+ YEARS TABIET Age of patients at onset of symptoms and age when seen The average duration of symptoms was $15 tars ·106 BRONCHIAL ADENOMA major bronchi For this reason a very high carcinoid adenoma rarely if ever involve per cent are visible by bronchoscopic ex the trachea amination and accessible for biopsy In our series 80 per cent were located in the major GROSS PATHOLOGICAL AND BRONCHOSCOPIC APPEARANCE bronchi where they could be seen by means of bronchoscopy (Fig 1) Since the gland- Grossly the adenoma is usually found as ular elements from which the adenomas polypoid or sessile, lobulated mass protrud arise are found as far out into the bronchial ing from or through the bronchial wall The intrabronchial portion frequently constitutes tree as the cartilage extends, je, to a di- only a small part of the tumor mass with ameter of 1 mm," theoretically tumors the arısıng in these glands may be found quite regionAt the time of operation the tumor major portion being in the peribronchial far out in the periphery of the lung Maier may be felt as a soft to moderately firm found 10 per cen to be located peripher- peribronchial mass which can be separated ally " However, these tumors are most fre without great difficulty from the surround quently seen in the major bronchi probably ing lung and mediastinum but with a very because the glands are more numerous in firm bronchial attachment Through the the larger bronchi In our series only two bronchoscope the adenoma may be seen as tumors were seen on roentgenograms as a pinkish or reddish lobulated intrabronchial pulmonary nodules, 1e, a peripheral nodule structure covered by intact bronchial mu surrounded by lung parenchyma The cyl- cosa Because of the great vascularity of indromatous type is more likely to occur these tumors, serious bleeding may result near the coryna or in the trachea while the from biopsy and even exsanguination has Fig 2 Photomicrograph of a typical carcinoid duena 150) ·THE TRFATMENT OF BRONCHIAL NEOPLASMS 107 been reported following biopsy" For this oval deeply staining and usually centrally reason, many surgeons prefer not to biopsy placed There is little pleomorphism and any tumor that has the typical broncho mitoses are absent in the well-differentiated scopic appearance of an adenoma The cyl carcinoid pattern These tumors resemble indromatous adenomas seen in the trachea the carcinoid tumors of the small intestine may show more evidence of ulceration and but argentaffın granules have rarely been be more diffusely situated over the tracheal demonstrated 1 wall There may be marked bronchiectatic The cylindromatous type of adenoma is changes and destruction of lung tissue due composed of small cells with darkly stained to the presence of chronic infection distal round or oval nuclei (Fig 4) There is a to partial or complete obstruction of the moderate amount of clear cytoplasm present bronchus The cells are arranged in branching masses forming tubules or in groups forming ar- MICROSCOPIC APPEARANCE regular spaces which are filled with mucoid The carcinoid pattern is found micro secretion Mitoses are rarely seen cxccpt scopically in 90 per cent of the adenomas in actively infiltrating areas This tumor is These tumors are composed of small uni much more likely than the carcinoid type form cuboidal cells which contain a moder to invade locally as well as to have distant ale amount of very finely granular eosino metastascs The only late deaths in our series philic cytoplasm and are arranged in were in two patients who had the cylindro strands sheets or in acinous formation matous pattern in a series of cases re- (Figs 2 and 3) The nuclei are round or ported by Enterline and Schoenberg lg 3 Bigher magnification of the 1 adenoma (100) ·10G BRONCHIAL ADENOMA major bronchi For this reason a very high carcinoid adenoma rare! per cent are visible by bronchoscopic ex the trachea amination and accessible for biopsy In our series 80 per cent were located in the major GROSS PATIO BRONCHIOSCOPIO bronchi where they could be seen by means Grossly the adenoir of bronchoscopy (Fig 1) Since the glandular elements from which the adenomas polypoid or sessile ] ing from or through arise are found as far out into the bronchial intrabronchia? porti tree as the cartilage extends, ie, to a di only a small part ameter of I mm," theoretically tumors the major portion arising in these glands may be found quite region. At the ti far out in the periphery of the lung Maler may be felt as found 10 per cent to be located perspher peribronchial 11 ally " However, these tumors are most fre- without great d quently seen in the major bronchi probably ing lung and i because the glands are more numerous in firm bronchi the larger bronchi in our series only two bronchoscop tumors were seen on roentgenograms as a pinkish or pulmonary nodules, re, a peripheral nodule structure ce surrounded by lung parenchymi The cyl- cosa BLC indromatous type is more likely to occur these tuni near the coryna or in the trachea while the from br W ·THIE TREATBIENT OF BRONCHIAL NEOPLASMS 109 uncommon As the obstruction becomes seen by means of bronchoscopic examinamore complete and drainage to the affected tion in a high per cent of cases (80 per cent lung is impaired chronic infection develops of our series) and a biopsy taken The distal to the tumor site and the clinical hazards associated with bleeding following pature becomes that of chronic suppurative biopsy have already been mentioned The disease of the lung with productive cough, surgeon should also be aware of the diffi fever, and chest pain This was the most culty in making an accurate diagnosis patho frequent symptom complex in one half of logically on a small biopsy specimen There the patients in our series Although the is not only considerable difference between bronchial adenoma may be present as a the microscopic appearance of different silent lesion in only 2 of the 35 patients tumors but also in the appearance of dif was this the case The tumors in these ferent areas of the same tumor For this pattents were found as asymptomatic pul- reason a pathologic diagnosis made on a monary nodules on chest roentgenograms biopsy specimen should be accepted by the The diagnosis of bronchial adenoma is surgeon only if it is consistent with the usually not difficult The long duration of clinical history and findings Papanicolaou symptoms suggestive of bronchial obstruc smears of bronchial washings are usually tion associated with hemoptysis or chronic negative for tumor cells The adenomas are localized suppurative discase of the lung covered in most instances by intact mucosa may lead the clinician to suspect the pres so that tumor cells are not found in the ence of an adenoma The tumor may be bronchial washings 1 lg 5 Chest roentgenograms of a 3? year old woman showing a typical rounded hilar shadow caused ho un ad noma The patient was asymptomatic The tumor was discovered on a routine suney film Patient wine and well four years after a night midjic lobectomy ·110 BRONCHIAL ADENOMA ROENTGEN APPEARANCE TREATIENT The adenoma may present one of two Proper treatment of the bronchial aden roentgenographic patterns It may be seen oma must be based on an accurate diagnosis on roentgenograms of the chest as a rounded as well as a thorough knowledge of the long smooth mass usually at or near the hilum in natural course of the tumor its tendency to a patient without symptoms (Fig 5) This recur locally after inadequate removal and was the appearance in 2 of the 35 cases in its malignant potentialnies Surgical te this series More commonly however one moval of the tumor is the accepted treat finds the roentgen appearance associated ment of choice Endoscopic removal was with obstruction of a bronchus to a lung advocated for many years by some but non lobe or segment with loss of volume or ob has been abandoned except in certain structive pneumonitis of the involved portion special situations There are several objec of lung depending on the degree and me tions to bronchoscopic removal as a method chanics of the obstruction Bronchograms of treatment of bronchial adenomas it has and stratograms may be of great value in been shown that the portion of the tumor demonstrating the nature and site of the available for removal by bronchoscopy con bronchial obstruction (Fig 6) Out of 35 stitutes only a small part of the tumor 1 patients in our series 26 had demonstrable most cases thus explaining the high rate lesions by one or more roentgenographic of local recurrence after endoscopic re techniques moval Scrous and even fatal bleeding Fig. 6a & b Bronchograms of a 16 year old white grl who had had 3 cough and whecz ng respira tions for eighteen months A preoperative bronchogram (A) shoved an obstruct in caused by an adenoma in the left upper lobe A left upper lobectomy oth a plast c repus of the bronchus ... * performed Post-operative bronchogram (B) with the remain ng loser lobe crpand d to ??? the the left chest (See Fig 7 bottom sketch for d agram of the bronchoplast c rerar) ·Re TUF TREATMENT OF BRONCHIAL NEOPLASMS 111 Tollowing endoscopic removal is not infre tumor and yet preserve all lung uninvolved quent in the majority of cases the symp by tumor or chronic infection have their toms caused by the adenoma are those due greatest usefulness in the treatment of this to chronic suppurative disease associated tumor Five of the 35 patients in thi: with the bronchial obstruction in many series had such procedures with excellen instances these symptoms can be alleviated results (Fig 7) In most of our case: only by removal of the chronically infected however lobectomy or pneumonectomy wi lung distal to the obstructing adenoma necessary Lobectomy was performed Endoscopic removal may still be indicated eleven cases bilobectomy in nine and pre however in severely debilitated elderly indi monectomy in five cases Juals who would not tolerate operation It such patients constitute a very small IRRADIATIO THIERAPI ercent of patients with adenomas eated checks for recurrence are necessary Irradiation therapy may be of value in the I thc adenoma is removed by broncho cylındromatous adenomas when surgical te scopy because local recurrence can occur moval is not possible We have used in and has been reported as long as ten years radiation therapy in two cases of recurrent after endoscop c removal Because of the cylindromas of the bronchus and in one slow growth and tendency to metastasize extensive cylindroma of the trachea with late in its course a limited resection is often perhaps some beneficial results There is adequate for complete removal of these very little evidence from reports in the litera tumors Bronchoplastic procedures which ture that irradiation therapy has any effect accomplish the complete removal of the on the carcinoid adenoma TREATMENT OF 35 CASES OF BRONCHIAL ADENOMA 2014 LOBECTOMY OR BILOBECTOMY 20 Operative Deaths 3 cases including 1 tracheal resection NUMBER OF PATIENTS PNEUMO NO NECTOMY OPERATION ENDOSCOPIC REMOVAL OR EXPLORATION BRONCHOTOMY 5 ONLY 2 1 surg cal rat ents TABI 11 Treatment of 15 cases of bronch al adonda OX cicon of the tum r 21 3rt ·110 BRONCHIAL ADENOVA ROENTGEN APPEARANCE TREATMENT The adenoma may present one of two Proper treatment of the bronchial aden roentgenographic patterns It may be seen oma must be based on an accurate diagnosis on roentgenograms of the chest as a rounded as well as a thorough knowledge of the long smooth mass usually at or near the hilum in natural course of the tumor, its tendency to a patient without symptoms (Fig 5) This recur locally after inadequate removal, and was the appearance in 2 of the 35 cases in its malignant potentialities Surgical re this series More commonly, however, one moval of the tumor is the accepted treat finds the roentgen appearance associated ment of choice Endoscopic removal was with obstruction of a bronchus to a lung, advocated for many years by some but nos lobe, or segment with loss of yolume or ob has been abandoned except in certain structive pneumonitis of the involved portion special situations There are several objec of lung depending on the degree and me. tions to bronchoscopic removal as a method chanics of the obstruction Bronchograms of treatment of bronchial adenomas It has and stratograms may be of great value in been shown that the portion of the tumor demonstrating the nature and site of the available for removal by bronchoscopy con bronchial obstruction (Fig 6) Out of 35 stitutes only a small part of the tumor in patients in our series 26 had demonstrable most cases," thus explaining the high ratu lesions by one or more roentgenographic of local recurrence after endoscopic re techniques moval Serious and even fatal bleeding ANTES Fig 6a & b Bronchogranis of a 16 year old white girl who had had a cough and wheczing respeto troas for eighteen months A preoperative bronchogram (A) showed an obstruction caused by an adenoma in the left upper lobe A left upper lobectomy with a plastic repass of the bronchus ** performed Post operative bronchogram (B) with the remaining lower lobe expanded to fill the the left chest (Sec Fig 1 bottom sketch for diagram of the bronchoplastic repair) ·- THE TREATMENT OF BRONCHIAL NEOPLASMS following endoscopic removal is not infre tumor and yet preserve all lung uninvolved quent in the majority of cases the symp by tumor or chronic infection have their toms caused by the adenoma are those due greatest usefulness in the treatment of this to chronic suppurative disease associated tumor Five of the 35 patients in this with the bronchial obstruction In many senes had such procedures with excellent unstances these symptoms can be alleviated results (Fig ?) In most of our cases, only by removal of she chronically infected however, lobectomy or pneumonectomy was lung distal to the obstructing adenoma necessary Lobectomy was performed i Endoscopic removal may still be indicated cleven cases bilobectomy in nine and pneu kowever, in severely debilitated elderly indi monectomy in five cases viduals who would not tolerate operation but such patients constitute a very small RABATION TERAPY percent of patients with adenomas Re peated checks for recurrence are necessary Irradiation therapy may be of value in the if the adenoma is removed by broncho cylindromatous adenomas when surgical re scopy because local recurrence can occur moval is not possible" We have used ir and has been reported as long as ten years radiation therapy in two cases of recurrent after endoscopic removal. Because of the cylindromas of the bronchus and in one slow growth and tendency to metastasize extensive cylindroma of the trachea with late in its course a limited resection is often perhaps some beneficial results There is adequate for complete removal of these very htile evidence from reports in the litera tumors Bronchoplastic procedures which ture that irradiation therapy has any effect accomplish the complete removal of the on the carcinoid adenoma TREATMENT OF 35 CASES OF BRONCHIAL ADENOMA 201 LOBECTOMY OR BILOBECTOMY 20 Operative Deaths 3 cases including I tracheal resection NUMBER OF PATIENTS PNEUMO- NO NECTOMY OPERATION ENDOSCOPIC REMOVAL OR EXPLORATION 5 BRONCHOTOMY 3 2 ONLY TABLER Treatment of 35 cases of bronchial au nom Or the 25 stients who had surg etmon of their tunur 21 (** per centi are known to the living and well ?, are dead and have been lost to follos up ·112 BRONCHIAL ADENOMA RESULTS of the lung One of these patients died six The results of the surgical treatment of years after exploration with metastases to the adenomas and particularly of the carci the abdomen The other patient is still liv noid type have been very gratifying (Table ing three years after operation but with IV) Out of a group of 20 patients who had roentgen evidence of a large mediastinal either a lobectomy or bilobectomy 18 or mass 90 percent are known to be living and well No operation was performed in threc as long as seventeen years after operation cases One patient refused operation after a We have been unable to locate one patient bronchoscopic biopsy and is still living with and one died nineteen years after her origi out symptoms sixteen years later Another nal operation This patient had a left lower patient who refused to accept surgical treat lobectomy for a cylındroma which recurred ment died eight years later with metastases twelve years later in the bronchial stump A to the mediastinum and scalene nodes A second operation was performed but resecthird patient was not operated upon because tion was not possible because of the extenof metastases to the spinal canal This pa sive spread of the tumor to pericardium, tient was a 65 year old paraplegic with se diaphragm, and mediastinum This patient vere heart disease who for thirty years had lived for seven years after her second operahad complete opacity of the left lung field tion Five patients had a pneumonectomy on roentgen examination This was caused performed and of this group three are living by obstruction of the bronchus by an ade and well as long as seven years after operanoma which could be seen at the time of tion One of the patients who had a pneubronchoscopy monectomy has been lost to follow up and One patient in this series had a broncho another died eight years after her original scopic removal of a small polypaid adenoma operation This patient was a 39 year old This patient is alive and free of evidence of woman who had a cylindroma of the left years after removal main bronchus removed by left pneumo- Another patient had a very limited resection nectomy Seven years after operation she of an adenoma and a plastic repair of the was found to have a cylindromatous adedefect without removal of any lung tusslic noma in the right upper lobe which was re- (Fig 7) This patient is alive and free of moved by segmental resection This patient recurrence eight years after operation died several months after her second opera Bronchoplastic procedures have been tion It is interesting that the only two late performed in five patients (Fig 7) All of deaths in the resection cases have been in these cases have done well and have shown patients who had cylindromas no evidence of recurrence in the period In three patients exploration only was since operation which in one case has been done At the time of operation the tumor as long as ten years Limited resection has was found to be too extensive for resection been used wherever possible in order to One was in a 34 year old woman who had preserve all lung tissue not involved by had repeated illnesses due to lung abscess tumor or chronic infection " Goldman" has and empyema requiring drainage on sev recommended consideration of local exc! al occasions Pneumonectomy was atsion in every case where the following con tempted but was impossible because of erditions can be met tensive involvement of pericardium and pul- The tumor monary vessels The patient died a week (1) is established to be benign, semi later of complications of suppurative disease benign or only potentially malignant, recurrence seven ·MONTE THE TREATMENT OF BRONCHIAL NEOPLASMS 113 HONCHIAL UNA ADCWOMA Lett lawer lobe and pertson of mon bronchus removed to upper tobe branchus sutur.4 to left main bronchu Astrenght middle and lower tobus w portion at tght main bronchus Plastic repair of right upper Jobe bronthus Loft ower love removed DAWCHAL ADENOMA For e roma o 99 m. branch w Iet upp Area of 1410 ac plast nprofroht man bronchu. and corne ico PENSULATED MAURON A ADENOMA Last upp. lo removed Þessereya of teft me Brannus Obserusted upper lodo Fig? Brunchorlastic procedures donc in 3 cases These parents are all alive and well from one to ten scars following operation with no evidence of recurrence (2) has not undergone malignant de performed in one patient who had a cylingeneration metastasized or widely intil. droma involving most of his thoracic trachea traied the bronchus, and extending downward to involve both (?) is located in the trachea or an easily the night and left main bronchi This pa accessiblc bronchus tient was threatened with suffocation from (4) is localized has no criensic extra complete tracheal obstruction Irradiation bronchial growth and has not caused presa therapy had been tried but the obstruction surc necrosis, became nors so this form of therapy was (5) has a stall like or small area of abandoned Approumately 12 cm of the sessile itachment, trachea and blurcation were tesected and (6) his caused no recuersibis pulmon replacců with a prosthesis fashioncu 3) damage in the long distal to its location dermis over 3 coil of tec) H11 Completc etion of the trachea has died {uo days following operatio This ·114 BRONCHIAL ADENOMA respiratory obstruction due to kinking of the due to damage to the blood supply at the major bronchi at the site of the anastomoses time of operation This cleared without In two similar cases with one survival re treatment ported by Belsey resection of the entire tracheal circumference was not necessary SUMMARY Both of these cases had cylindromas re The bronchial adenoma is a tumor which sected and the tracheal defect repaired with arises from the mucous glands and their a prosthesis made of fascia from the patients ducts in the bronchial wall It is character thigh and number 32 gauge stainless steel istically a slow growing tumor which may wire be locally invasive or in a small percent of cases have distant metastases The clinical OPERATIVE DEATHS AND signs are those due erther to the vascularity COVPLICATIONS of the tumor with associated hemoptysis or There were 3 operative deaths One oc to bronchial obstruction and chronic sup curred following exploration mentioned purative disease of the affected lung above The second occurred in a 32 year The diagnosis is usually not difficult old woman who expired on the operating The long history of hemoptysis or localized table due to inadequate ventilation It was suppurative disease of the lung associated discovered too late that the endotracheal with bronchial obstruction may lead the tube had slipped down into the right main clinician to suspect the presence of an aden bronchus The third death occurred follow oma The tumor may be seen by means of ing resection of the trachea for a cylin bronchoscopic examination in the majority droma already referred to above of patients Specialized roentgen technics Postoperative complications occurred in such as stratograms or bronchograms may 7 patients Two patients had postoperative be of value in demonstrating the site and hemorrhage necessitating re opening of the nature of a bronchial obstruction chest to control the bleeding One patient Surgical excision of the adenoma is the developed a superficial hematoma of the treatment of choice Endoscopic removal wound which caused a disruption requiring is not recommended because of the likeli secondary closure Two patients developed hood of recurrence the hazards of uncon an empyema following a small bronchial trolled hemorrhage and the failure of this leak These cases were successfully treated method of treatment to relieve the symptoms by closed thoracotomy and tube drainage due to chronic suppurative disease in the One patient had a collection of serosangui lung distal to the adenoma The results in nous fluid in the chest requiring aspiration terms of complete removal of the tumor and In one case there was roentgen evidence of relief of symptoms are excellent in patients infarction of the right lower lobe presumably in whom surgical excision is possible REFERENCES 1 MUELLER H Zur Entstehungsgeschichte der 3 BILLROTH T Beobachtungen uber Gesch Bronchialerweiterungen Inaug Dissert #ulste der Speicheldrusen Virchows Arch Halle 1882 Vol 15 path Anat 17 357 375, 1859 Quoted by PATTERSON E I Benign bron Quoted by ENTERLINE N T and SCHOEN chial neoplasms Arch Otolar) ng 12 739 BERG HW (Sec Ref No 4) 1930 ENTERLINE HT and SCHOENBERG H 2 WESSLER Hand RABIN CB Benign Carcinoma (cylindromstous type) of the tumors of the bronchus Am J A SC trachea and bronch, and bronchial ade 183 164 1932 noma Cancer 7 663 1954 ·THE TREATMENT OF BRONCHIAL NEOPLASMS 115 3 Hrck, W, Veber primäres polyposes Bros 13 HOLLEY, S W Bronchial adenomas Mil chsalkarzinom Inaug Dissert, Bonn, Surg. 99 528, 1946 1916 Foor, NC Pathology in Surgery. Phila- Quoted by Engelbreth Holm, J Benign delphia, Lippincott, 1945, pp 187.188. bronchial aednomas Acta chir scandina, Quoted by RAMSEY, H and REIMANN, D 90 383, 1944 L Bronchial adenomas arising in mu- HAMPERL, H Veber gutartige Bronchialtucous glands Am ) Path 29 339, 1953 moren (Cylindrome und Carcinoide) IS BRUNN H. and GOLDMAN, A Bronchial Virch Arch, 300 46, 1937 adenoma Am J Surg, 54 179-192, 1941 Quoted by Engelbreth Holm See reference 5 16 MOERSCH HJ and MCDONALD, IR 7 STOUT, AP, Cellular origin of bronchial Bronchial adenoma JAMA, 142 299 adenoma Arch Path 35 803, 1943 304 1950 8 CRAFOORD C, and LINDGREN AGH 17 VIETA JO, and MAIER HC The treat- Mucous and salivary gland tumors in the ment of adenoid cystic carcinoma (cylinbronchi and trachea Acta chur scandinav droma) the respiratory tract by surgery 92 481 506 1945 and radiation therapy Dir Chest, 31.493. 9 WOMACK NA and GRAHAM EA Mixed $11, 1957 tumors of the lung so-called bronchial or 18 GOLDMAN A Transpleural bronchotomy pulmonary adenoma Arch Path 26 165, Thoracic Surg 23 237, 1952 1938 19 BELSEY, RONALD Resection and reconstruc- 10 MCBURNEY RP, KIRKLIN JW and tion of the intrathoracic trachea Brity WOOLNER LB Metastasızıng bronchial Surg 38 200 1950 adenomas Surg Gynec & Obst 96 482 20 PAULSON D L and SHAWRR Preser- 1953 vation of lung tissue by means of broncho 11 LAPPHS Benign tumors of the bronchi plastic procedures Am Surg 89 347. Arch Otolaryng 31 148, 1940 355 1955 12 MAIER HC and FISCHER W W Ade 21 WATERMAN DH Discussion of papers of nomas arising from small bronch: not Drs Goldman, Rabin and Neuhof om visible bronchoscopically J Thoracic bronchial adenomas 1 Thoracic Sury Surg 16 392. 1947 78 158, 1949 ·Conclusion minism 1 THE AUTHORS in presenting their philoso doing an increasing percentage of selective phy of treatment evolved from a combined resections due to practical considerations of experience of 1215 patients having bron- pulmonary function and cell type chial neoplasms hope to contribute to an The classical temporal theory of the improvement in the results of both the spread a ncoplasm and its prognosis is surgical and nonsurgical treatment of this now being challenged by an antithetic disease They feel that this improvement theory designated as biologic predeter can be made mainly by a better selection The temporal theory emphasizes of patients for surgical excision and to a the function of time in the spread of cancer betterment in the quality of survival through and states that a malignant neoplasm begins application of selective resections of the as a localized disease, grows in a steady and lung in patients with suitable lesions It is irrevocable manner, spreads 10 the regional realized that this attitude may represent a lymph nodes in time and with the passage departure from the ideal of the traditional of more time disseminates throughout the radical approach to the surgery of cancer body The classical temporal theory has of an internal organ It is believed, hon ever, been generally accepted and forms the 10g) that the traditional concept must be tem cal basis for the traditional radical approach pered in the case of bronchogenic carcin to carcinoma it implies that the majority omna by of bronchogenic carcinomas can be drag and the nosed at a time when early and wide surgical Churchi eradication is possible provided patients and cancer of the lung started with the very physicians alike are sufficiently aware of the radical approach and swung back toward early symptoms of the disease and present a middle ground, whereas the surgery of diagnostic techniques are fully utilized in every other organ started with a limited this concept, the existing methods of dial and often inadequate resection and pro nosis and treatment are considered adequate gressed toward a reasonable middle ground and responsibility for any delay in detection I think the answer to this is largely the during a localized phase is placed alike on stage of surgery at which resection for the physician and the individual concerned cancer of the lung began, and also simply This theory in its practical application puts from the technical fact that it is simpler a severe burden upon both the patient and and quicker to do a total pneumonectomy the physician and leads to feelings of re than it is to do a lobectomy with adequate crimination on the part of the patient and Temoval of the regional lymph nodes " Re his fannly and contributes to a feeling of gardless of philosophy of treatment even gult upon the part of the physician when a those who advocate a radical resection for diagnosis of bronchogenic carcinoma ! bronchogenic carcinoma find themselves made at a stage where surgical removal of 116 -nt one of fint on ·THE TREATMENT OF BRONCHIAL NEOPLASMS 117 the lesion is impossible explains the variegated pattern of behavior The theory of biologic predeterminishi and prognosis in this neoplasm and places 15 a tenable concept which explains the the rationale of treatment on a logical basis course and prognosis of cancer on the basis It explains why approximately tuo out of of the biologic characteristics involved The three patients are not suitable for surgical cell type the location, and the resistance of therapy It dispels attitudes of therapeutic the host largely predetermine the pattern nihilism by fitting the treatment to the of behavior and prognosis, and the factor particular characteristics of the neoplasm of time becomes less important as a conse inolved it does not absolve the physician quence only of the biologic traits of the and the surgeon of the responsibility for particular neoplasm involved The charac- diagnosis of the localized bronchogenic teristics of an individual neoplasm are estab carcinomas that are suitable for resection lished in the preclinical phase and remam and emphasizes the necessity of differentiat. more or less constant throughout its life, ing from this group the ncoplasms which by although it may undergo intermittent periods their very nature are more suitable for of growth and quiescence (induced or spon- other methods of therapy Nonsurgical taneous) Certain bronchul neoplasms, therapeutic measures such as irradiation and namely adeno, bronchiolat, and squamous chemotherapy, in this rationale of treatment, cell carcinomas, may have a long natural are not regarded as modalies to be used for history and may remain as localized tumors surgical failures alone but rather for specific for even a period of years before extending indications in that group of neoplasms for beyond the site of origin Such lesions may which surgery enther is not indicated or us be early biologically but late chronologically contraindicated Other forms of therapy are and ideal for surgical therapy Even within considered preferable to surgery under these thesc cell types, however, certain neoplasms circumstances may be very orderly as far as their cell The selection of patients for surgery paltern is concerned but may be widely based on this rationale of treatment condisseminated carly with the production of stitutes the most important single factor in only minimal symptoms because of an un. the improvement of results of surgical favorable location or lack of resistance on therapy The fact that certain bronchial the host "The small cell un neoplasms may be detected while still in differentiated and to a lesser extent the large an carly phase and thus are suitable for cell undifferentiated neoplasms as a group sesection does not imply that all patients have a much shorter life history and usually having bronchogenic carcinoma should be cannot he diagnosed at A stage shen they subjected to thoracotomy because it is the dre amenabic to surgical therapy creept for only chance of cure" Neoplasms that hasc thosc located peripherally Biologic pre reached the general lymphatics or have bedeterminism recognizes that the sale of come generalized as evidenced hy distant grouth of a ncoplasm is an inherent charac blood stream mctastases are no more amenteristic depending on the biologic traits of able to surgical therapy ihan Jodgkin's the particular neoplasi insolved, which disease os leulema This allude does not may vary within the life history of the ind. preclude frankly palliati\c resections for dual lesion and is affected by factors of relief of specific distressing symptoms in an cell type location and the resistance of the attempt to improve the quality of survival host tissues to us inipiantation and growth It does, however, deny the value to the Application of the theory of biologic patient of coploraton thoracotomy in fredeterminam o bronchogenic carcinoma stances where nonresectability 15 the part ·118 CONCLUSION and of meddlesome resections of lungs leay have peripheral neoplasms some of which ing behind gross neoplasm thus exposing the will have invaded the chest wall necessitat patient to rapid progression of the disease ing an en bloc resection of a portion of the by breaking down natural barriers of re chest wall Total pneumonectomy is indi sistance in the overall evaluation of results cated for peripheral neoplasms which have the harm that may have been done by ill metastasized to hilar and mediastinal nodes advised surgery must be added to the nega unless considerations of pulmonary func tive column This harm is evidenced by the tion make a lesser resection mandatory surgical mortality of exploratory thoraco Pneumonectomy is more often indicated tomy for nonresectable lesions and the post because of the site of origin of many epi operauve morbidity and shortening of dermoid carcinomas in the lobar and main survival time in this group of patients The bronchi The necessity of making the bron fact that one half of patients die within the chial section at least 1 5 cm from the point first year following resection emphasizes the of visible neoplasm indicates total pneu difficulty of properly selecting patients for monectomy for these tumors unless lobes surgical therapy It is unrealistic to suggest can be preserved by bronchoplastic prothat surgery has been of benefit to patients cedures Conservation of pulmonary tissue that survive for so short a period Para becomes increasingly important in patients doxical as it may seem reduction by careful in the age groups susceptible to primary screening of the number of patients deemed neoplasms of the lung in the interest of operable represents the best opportunity to the quality of survival surgical therapy must improve the results of surgical treatment for be applied so that patients may obtain bronchogenic carcinoma The surgeon be maximum benefit without introduction of fore advising surgery must carefully con irreversible factors that may make it im sider the nature and the degree of possible for them to live comfortable and localization of the neoplasm whether or not productive lives the patient can tolerate the proposed resec Irradiation therapy which is capable of tion and live comfortably following it and modifying the natural history of the nedbe aware of other modalities of treatment plasm may bring about relief of distressing that may be more suitably applied either symptoms in many patients and occasionally alone or in combination in an attempt to results in an apparent cure The most fre control the neoplasm Only in this manner quent application of irradiation therapy will can the surgeon arrive at a rational solution be for the neoplasm not suitable for surgical to the problem of the patient having a therapy because of extension into structures malignant bronchial neoplasm that cannot be safely resected or into the Based on this rationale of treatment it is lymphatic system to an extent that precludes believed that selective resection is the opera a successful resection Recurrent peoplası lion of choice in the surgical treatment of a following resection may often be held under patient having a bronchogenic carcinoma control by irradiation therapy for several This should include removal of the hılar months giving gratifying relief of symptoms and mediastinal lymph nodes Experience Irradiation therapy is useful in the control has shown that a selective resection will be of pain due to cerebral and bony meta feasible in approximately one half of pa stases Used preoperatively over hilar le fients having bronchogenic carcinoma suit sions that have infiltrated the bronchus close able for surgical therapy The majority of 10 the coryna and over neoplasms that base these patients having selective resection will invaded the chest wall radiacion therapy ·THE TREATMENT OF BRONCHIAI NEOPLASMS 119 of the lung may cause a regression that will allow suc- weit being rather than in a lengthening of cessful resection resulting in some cases in survival time The ultimate hope of cancer an apparent cure Bronchiolar and adeno- research is that a substance will be found carcinomas respond poorly to irradiation that taken internally will be cancerocidal or therapy "The small cell undifferentiated cancerostatic either by selectively destroy. carcinoma responds quickly to uradiation ing the cancer cell or by depriving n of therapy but because of the tendency of this some metabolic substance necessary for its neoplasm to be widely disseminated the survival palient rarely survives for a long period of The terminal care of a patient having a time Low grade epidermoid carcinomas bronchogenic carcinoma is the most im. fall midway in the scale of responsiveness to portant and yet the most easily neglected irradiation therapy but because of their phase of the management of this disease tendency to be more localized may repre The relief of suffering and the maintenance sent the best indications for irradiation of morale is as much a responsibility of the therapy frradiation therapy, like surgical physician as to cure Close cooperation therapy, suffers from the disadvantage of between the specialist in the field of cancer not being able to deal with disseminated therapy, the physician responsible for the disease its use, however, in selected pa intimate daily care of the patient, and the tients may be of great benefit in the overall family can do much to relieve the distress management of patients having carcinoma of the terminal illness Every use should be made of all available measures to control Chemotherapy, using the nitrogen mustard unpleasant symptoms Above all the pacompounds, is the only presently available tient should never be allowed to gain the therapy of a specific nature that can modify impression that he is being abandoned by the course of disseminated neoplasm Ail the physician because nothing more in a patients with a malignant bronchial neo curati e sense can be done for him Some plasm are potentially candidates for chemo of the closest human relationships between therapy At the present time it is used alone a physician and his patient develop during in repeated courses in the treatment of pathe care of the incurable paticni The pa (ichts having widely disseminated neoplasms tient and the family are eternally grateful It may be combined usefully with irradia for the attention and consideration shown tion therapy using the latter modality over by the physician during this trying period the primary neoplasm in the hope that The results of iherapy in the treatment chemotherapy will induce a remission of the of bronchial neoplasms are subject to stagrowth of the more distant metastases tistical analysis. insofar as numbers of sur- (hemotherapy used in conjunction with Vilors ate concerned, but certain features surgical resection at the time of operation is such 35 quality of survival and length of 101 y of proven valuc, but certainly de survival time defy accurate analysis Pa. crves a thorough clinical trial since there is tients may survive long periods of time sound cyperimental evidence that it is capa. before treatment is instituted or without any hic of presenting to some degree the im treatment A study of the avibors series plantation of neoplastic cells that have along with those of other physicians treating latvaded the blood stream The bencficial this discuse indicates that if a broad base of tasults of chemotherapy can more often b: obcenation is maintained including hustoobsence in the relief of distressing symp logically proven as well as thoxe clinicalls toms and in the production of a sense of diagnosed that approximately one ·120 CONCLUSION patients will be deemed suitable for surgical without symptoms and without evidence of therapy One third of all patients wall be nodal metastases have a 70 per cent chance found to be resectable although at the time of surviving five years with a good qualis of operation many of the resections may be of survival since most of these lesions can considered palliative rather than curatile be removed by lobectomy It is difficult to Less than one fourth of patients having re show that irradiation and chemotherapy af sections of their bronchial neoplasms will fect survival time due to the lack of ade survie fre years Thus, the total salvage quate controls with similar untreated cases of the entire group in the terms of five year The observed ability of these modalities to survival will be in the neighborhood of 7 improve the quality of survival however should not be overlooked The survival There is danger in overgeneralization in curves of patients having irradiation therapy quoting results of therapy Patients should as compared with those untreated are quite be evaluated from the standpoint of prog similar except that in the case of irradia nosis in relation to the group in which they toon therapy there will be a small percentame fall at the time of recognition of the neo of patients alive at the end of five years plasm Patients with small cell undifferenti who are apparently cured The gicat varta ated carcinomas hare hette chance of iron in the life history of neoplasms and the surviving a year following diagnosis On impossibility of determining the time of the the other hand patients with neoplasms origin of the neoplasm in a sense renders presenting as peripheral pulmonary nodules studies of survival time somewhat meaning per cent SURVIVAL CURVES IN BRONCHOGENIC CARCINOMA 100 NORMAL EXPECTANCY 90 904 804 70 NODULES WITHOUT INVOLVED NODES 60 48% PER CENT SURVIVAL 505 40 ALL RESECT ONS 304 19 20 UNTREATED PAT ENTS IRRAD AT ON TREATMENT 10% 1 YEARS Shay Paulson and Nee) TABLE I ·THE TREATMENT OF BRONCHIAL NEOPLASMS 121 less The determination of onset of the ment of bronchial neoplasms and to allow disease by the first occurrence of symptoms a more realistic determination of prognosis is highly inaccurate due to the tendency of in the individual patient by evaluating his certain ncoplasms to remain symptomless outlook from the standpoint of the group for several years and to the difficulty of within which he falls determining that the symptom leading to The challenge today is to learn more investigation actually was caused by the about the biologic characteristics of the ncoplasm Presentation of survival curves various types of bronchial neoplasms so should not suggest that the efficacy of the that we will know which lesions are suitable various methods of treatment are being com for surgical resection and which are treated pared (Table 1) The patients comprising better by other means, which will be bene ihc groups both untreated and treated by fited by radical resections, and which may various modalities are totally dissimilar and be treated by more conservative resections not subject to comparison Survival curves without sacrifice of survival time but with are useful, however, in givin a more ac the attendant advantages of a lower morcurate picture of the overall results of treat tality rate and a better quality of survival REFERENCES 1 CITURCHILL E D Personal Communication 1958 ·Index A Abelman, WH, 72, 77 Abrams, HK, 7 Acree, PW, 48, 101 Adenocarcinoma characteristics of. 117 grade one, Ser Bronchial adenoma lobectomy for, 95 Pneumonectomy for, 95 resectability of, 95 responsiveness to irradiation therapy, si survival rates, 95, 96 Adenoma definition of termi, 103 first use of term, 103 other terms used, 103 Adenomatous polyp. See Bronchial adenoma Adrenal metastases of bronchogenic carcinoma inoperability of, 20 symptoms of, 20 Agranulocytosis as complication of chemotherapy, 76 treatment of, 76 Albritton. F F F 48 Allison, PR, 88, 102 Anemia, Primary as complication of chemotherapy, 76 treatment of, 76 Antithetic theories of cancer brologic predeterminism, 8 classical temporal, & Atelectasis and pleural fluid in major bronchus neoplasm, 26 resectability of neoplasm and, 26 symptoms of, 26 Auerbach, 0, 4, 7, 13, 17 Aufses, A H, 33, 48, 102 Benign glandular bronchogenic tumor, See Bronchial adenoma, 111 Bignall, 3. R, 46, 48, 67, 68, 69 Billroth, T, 103, 114 Bilobectomy, Use of as treatment for bronchal adenoma, 111 Biologic predeterminism theory application of theory, 9, 16, 116, 117 definition of term "early", 10,16-17 factors for growth and production of symptoms, 10 inoperability following initial symptoms of bronchogenic carcinoma, 9-10 term defined, 8, 9 X-rays illustrating, 11 Bropsy of lymph nodes, 23 of neoplasm prior to surgery, 19 of scalese node, 23-24, See also Scalene node biopsy Black, M M., 11, 17 Blakemore, W S, 75, 78, 89, 102 Bone metastases to biopsy for diagnosis of, 20 location of, 20 palhological fracture as symptom of, 20 relief of pain of with irradiation therapy, 66 type of metastatic lesion, 20 Boyd, D P, 47, 48, 87, 101 Brachial plerus involvement Pain in, 26 prognosis of, 26 symptoms of, 26 treatment of, 26 irradiation therapy, 26 resection, 26 Brain relief of symptoms of metastases to with irradiation therapy, 65 66 Breslow, 1, 3, 7 Brock, R. 32, 48, 88, 89, 101 Bronchia) adenoma, 103-123 areas of disagreement regarding, 103 B Basal cell carcinoma, See Bronchial adenoma ell, M, 78 Belsey, Ronald, 114, 115 122 ·INDEX 123 cellular origin 103 degree of mal gnancy 103 Proper terminology 103 bronchogenic carcinoma differential diagnosis 43-44 characteristics of 114 chest roentgenograms of 109 110 clocal signs symptoms and diagnosis of 108 109 114 cause of 108 d agnosis of 109 hemoptysis as predominant symptom 108 symptoms due to obstruction 108 109 table of predominant symptoms 108 table of signs and symptoms 108 Variation of symptoms with location of tumor 108 109 conduions necessary for excision of 112 113 definition of term 103 dagnosis of 109 114 duration of symptoms 109 use of biopsy 109 use of bronchoscopic examination 109 use of Papanicolaou smears 109 Jiagram of treatment of 111 Cxcision of trachea in 113 114 gross pathological and bronchoscop c appear ance 106-107 appearance at surgery 106 appearance through bronchoscope 106 complication of bleeding from biopsy 106 107 h story of 103 first reported case 103 Incidence of 105 according to age 105 accord ng to race 105 accord ng to sex 105 age at onset 105 dagram of age at onsct 105 time prior to diagnosit 105 irradiation therapy 111 cffect on carcino d adenoma 111 cffect on cylindroma adenoma 11 use when surf cal removal not feasible 111 location of 105 106 diagram of in tracheobronch al tree 105 use of rocntgenograms for local ng 106 vis hilty by bronchoscopy 100 mal gnancy or 10+ ab 1st to metastasize 104 cases of reported 10% MITCp c afrearance 107 108 of carcinoid pattern 107 of cylindromatous type 107 108 operative deaths and compl cations 114 cause of death 114 postoperative complications 114 origin of 104 results of treatment of 112 114 conditions necessary for crcrsion of tumor 112 113 etcision of trachea 113 114 follow up of cases 112 roentgen appearance 110 Illustration of 109 110 patterns on 110 use in diagnosis of bronchial adenoma 110 use of bronchograms 110 use of strafograms 110 theories of origin 101 treatment of 110-111 114 basis for 110 bronchoplastic procedures 111 bronchoscopic removal 110.111 endoscopic removal 110-111 necd for repeated checks following 111 surgical removal 110 use of bilobectomy 111 use of lobectomy 111 use of pneumonectomy 111 types Included 103 carcino 103 cylindromatous 103 Bronchogenic carcinoma advent of surg cal therapy for 45 broncht tissue changes in smokers and non smokers 4 bronchial adenoma d fferential diagnosis 3 44 bronchoplastic procedures See Bronchoplastic procedures bronchoscopic observat ons 26 See also Bronschoscopy challenge of treatment in future 121 changes found in postmortem studes 4 characteristics of 117 chart of smoking history in patients with 3 chemotherapy 70-71 Sce also Chenotherapy chest wall invasion 95 96 resectabity 95 96 survival curve 96 sursival rates following resectablty 96 comparison of patients treated with irradation therapy and non treated cars, K8 concluvons of author 116-121 ·124 THE TREATMENT OF BRONCHIAL NEOPLASMS danger of overgeneralization of results of therapy, 120 determination of onset, 121 early diagnosis versus survival time, 8-9 evaluation of results, 85 difficulty in use of statistics, 85 difficulty of proof of diagnosis, 85 use of survival curves, 85 evaluation of treatment, 118, 119-120 evidences of dissemination in 2! biopsy for diagnosis, 21 diagnosis of, 21 symptoms of, 21 evolution of treatment used, 56 factors affecting survival following resection, 95-96 chest wall invasion, 95 96 influence of pathologic type on type surgery and survival, 95 factors contributing to rising incidence of, 3 exposure to metals, 3 inhalation of fumes, 3 inhalation of tobacco smoke, 3 five year survivors, 91 diagnosis of, 91 symptoms prior to surgery, 91 treatment given, 91 illustrations of, 34, 38 cases treated with irradiation therapy, 57, 58 cases treated with resection and irradiation, 60, 61, 62, 63, 64, 65 of neoplasm invading chest wall, 28 of obstructive pneumonitis due to, 41 of Pancoast tumor, 36-37 of prior to resection, 27 of removed by segmental resection, 35 of right upper lobectomy, 36-37 of with vena caval compression, 56 incidence of, 3 death rate, 3 increase in females, 3 increase in males, 3 indications for pneumonectomy, See Pneumonectomy inhalation of fumes as factor in, 3 inoperability following onset of initial symptoms of, 9-10 investigation of rising incidence, 3 by observation of patients, 3 by statistical studies, 3 involvement of brachial plexus, See Brachial plexus involvement of esophagus, See Esophagus Irradiation therapy, 49-69, See also Irradiation therapy jeston as shown on X-ray, 4 lesion found following arthritis of ankles, 31 lymphatic extension, 21-23 biopsy of lymph nodes, 23 diagram of lymphatic channels of tracheobronchial tree, 22 presence of lymph nodes as sign of inopera bilaty, 22 routes of metastases, 21-22 metastases, 19-21, See also Metastases abdominal, 19-20 bone, 20 cerebral, 19 dissemination, 21 distant, 19 pulmonary, 20 21 spinal, 19 operability defined, 85-86 rates of, 7, 8, 86 operative approach to, 15-16 considerations prior to radical surgery, 15 16 operability of neoplasm, 16 resectability of neoplasm, 16 operative mortality for ten year period, 90 palliative resection, See Palhative resection palliative surgery other than resectron, see Palliative surgery, other peripheral squamous cell carcinoma, 36-37, 39-40 pleural effusions associated with bronchit ned plasms, 24-26, See also Pleural effusion quality of survival, 91-92 difficulty of statistical analysis of, 91 following treatment of, 31-32 physical restrictions of patients, 91 92 recurrence following surgical resection 4 relationship to fibrotic arcas in lung 3-4 reports of various authors, 86 90 Allison, 88 Boyd, 87-88 Brock, 88-89 Burford, 90 Churchill, 87 Collier, 89 Gibbon 89 90 Hodges, 87 Husfeldt, 86 Lampe, 87 Lalouette, 87 Neuhof. 89 Ochsner, 88 ·INDEX 125 Taylor, 88 Waterhouse 88 Watson 89 reporting of results of treatment 86 need for uniform methods 86 reporting surgical mortalities 86 use of survival rates 86 variation with authors 86 resectability of agressiveness of surgeon in 86 defined 86 of extreme peripheral lesion 19 of hlar lesion 19 of pulmonary nodule 19 rates for 7 86 resection for lesions of unproved ctiology 42 44 bopsy of peripheral lesions 42 diagnosis of hilar lesions 42-44 difficulty of diagnosis 42 harm of radical surgery for 42 results of research by authors 90-91 results of treatment 118 salvage rate from surgical treatment 29 scatene node biopsy 23 24 See also Scalene nosc biopsy segmental resection 34 35 See also Segmental Tesection selection of operation in treatment of 31-17 selection of patients for surgery 117 specimen of intraluminal carcinoma 14a Sa squamous cell type illustration of 38 summary of results of treatment for 100-101 surgical status of ratsent with pulmonary nolules due to 99 survival curve following resection for pul monary nodulas 99 survival curve in 120 121 survival following exploratory thoracotomy 92 dagram of survival curves 93 justifcation of thoracotomy 92 methods of proof of draenesis 92 survival curve 92 survival following resect on 92 95 survival rates in tnorerable patients 92 SUTVIS 1 1 fol ning pulmonary resection for 20 term nal care 79 84 119 See also Terminat carc Tolacco smoke inhalat on as (actor in 3 treatment of 117 use of chem therapy for f use of irrad atx niv 6 UVC of factomy for 95 96 use of pneumonectomy for 6 vena caval obstruction See Vena Caval obstruction vocal cord paralysts See Vocal cord paralysis x says illustrating cpidermaid carcinoma 13 14 x rays illustrating inoperable carcinoma of middle lobe 9 x rays illustrating secondary primary 5 x rays illustrating treatment by lobectomy 11 x rays of following irradiation therapy 11 12 X rays of nonresectable case 23 x rays revealing hilar carcinoma 15 X rays showing 5 Bronchogenic neoplasm therapy for based on antithetic theories 8 Bronchoplastic procedures diagram of techniques 113 for resection of left upper lobe 41 for preserving night upper lobe 4142 illustration of localized undifferentiated carsi noma removed by 43 Indication for 97 procedure used for removal of neoplasm 40 Tecurrence of bronchogenic carcinoma fos lowing 98 results of use 97 98 statistics regarding use 97 technique of 96 use 35 operation of choice 38 40 use for neoplasm in certain locations 40 use in conserving pulmonary tissue 38 uses of 96 97 99 use to extend resectabilty I mits 42 Bronchoscopy for biopsy prior to surgery 19 for relief of cough in terminal care 82 ohservations from 26 use in decision regarding resectability 26 use prior to carinal biopsy 26 Brunn 11115 Bugher SC 31 48 Rullous cmphysema tays illustrating noulule in ste of 4 Burcheral I 1 72 77 Burford TH 90 102 0 Cancer ant thehc theoncs, 8 biosc predeterminism & classical temporal R Carcinoid gucnoma See Bronchial aucooma $ ·124 THE TREATMENT OF BRONCHIAL NEOPLASMS danger of overgeneralization of results of therapy, 120 determination of onset, 121 early diagnosis versus survival time, 8 9 evaluation of results, 85 difficulty in use of statistics, 85 difficulty of proof of diagnosis, 85 use of survival curves, 85 evaluation of treatment, 118, 119-120 evidences of dissentination in, 21 biopsy for diagnosis, 21 diagnosis of, 21 symptoms of, 21 evolution of treatment used, 56 factors affecting survival following resection, 95-96 chest wall wy2sion, 95-96 influence of pathologic type on type surgery and survival, 95 factors contributing to rising incidence of, 3 exposure to metais, 3 inhalation of fumes, 3 Inhalation of tobacco smoke, 3 five year survivors, 91 diagnosis of, 91 symptoms prior to surgery, 91 treatment given, 91 illustrations of, 34, 38 cases treated with irradiation therapy, 57, 58 cases treated with resection and irradiation, 60, 61, 62, 63, 64, 65 of neoplasm invading chest wall, 28 of obstructive pneumonttis due to, 41 of Pancoast tumor, 36-37 of prior to resection, 27 of removed by segmental resection, 35 of right upper lobectomy, 36-37 of with vena caval compression, 56 incidencc of, 3 death rate, 3 increase in females, 3 increase in males, 3 indications for pneumonectomy, See Pneumonectomy inhalation of fumes as factor in, 3 inoperability following onset of initial symp toms of, 9-10 Investigation of tising incidence, 3 by observation of patients, 3 by statistical studies, 3 involvement of brachiul plexus, See Brachtal plerus involvement of esophagus, See Esophagus Irradiation therapy, 49 69, See also Irradiation therapy leston as shown on X-ray, 4 lesion found following arthritis of ankles, 31 lymphatic extension, 21-23 biopsy of lymph nodes, 23 diagram of lymphatic channels of tracheobronchial tree, 22 presence of lymph nodes as sign of inopera bility, 22 routes of metastases, 21-22 metastases, 19 21, See also Metastases abdominal, 19-20 bone, 20 cerebral, 19 dissemination, 21 distant, 19 pulmonary, 20-21 spinal, 19 operability defined, 85-86 rates of, 7, 8, 86 operative approach to, 15-16 considerations prior to radical surgery, 15-16 operability of neoplasm, 16 resectability of neoplasm, 16 operative mortality for ten year period, 90 palliative resection, See Palliative resection palliative surgery other than resection, Sce Palliative surgery, other peripheral squamous cell carcinoma, 36-37, 39-40 pleural effusions associated with bronchial neoplasms, 24-26, See also Pleural effusion quality of survival, 91-92 difficulty of statistical analysis of, 91 following treatment of, 31-32 physical restrictions of patients, 91 92 recurrence following surgical resection 4 relationship to fibrotic areas in lung, 3-4 reports of various authors, 86-90 Allison, 88 Boyd, 87-88 Brock, 88-89 Burford 90 Churchill, 87 Collier, 89 Gibbon 89 90 Hodges, 87 Husfeldt, 86 Lampe, 87 Latourette, 87 Neuhof, B9 Ochsner, 88 ·INDEX 125 Taylor 88 Waterhouse 88 Watson 89 reporting of results of treatment 86 necd for uniform methods 86 reporting surgical mortalities 86 use of survival rates 86 variation with authors 86 resectability of aggressiveness of surgeon in 86 defined 86 of extreme peripheral lesion 19 of hilar lesion 19 of pulmonary nodule 19 rates for 7 86 resection for lesions of Unproved etiology 42 45 biopsy of peripheral lessons 42 diagnosis of hlar lesions 42-44 d If culty of diagnosis 42 harm of radical surgery for 43 results of research by authors 90-91 results of treatment 118 salvage rate from surgical treatment 29 scalenc noue biopsy 23 24 See also Scalene noxic biopsy segmental resection 34 35 See also Segmental resection selection of operat on in treatment of 31-7 selection of patients for surgery 117 specimen of intraluminal carcinoma 14a 15a squamous cell type illustration of 38 summary of results of treatment for 100-101 surg cal status of patient with pulmonary no lules due to 99 survival curve following resection for pul monary noulules 99 Survival curve in 120 11 survival following exploratory thoracotomy 92 dagram of survival curves 93 justification of thoracotomy 92 methods of proof of d agnost 92 survival cutres 9? suronal following resect on 92 95 survival rates in inoperable pat ents 9! survival t mc following pulmonary resection for 20 term nal care 79 84 119 See also Terminal care tohacco smoke inhalation as façior 19 3 treatment of 117 use of chemotherapy for use of ittad ation for 6 use of inhectomy fx 95 96 use of pneumonectomy for 6 vena caval obstruction Sec Vena Caval obstruction vocal card paralysis See Vocal cord paralysis #rays illustrating epidermoid carcinoma 13, 14 x rays illustrating inoperable carcinoma of middle lobe 9 x rays illustrating secondary primary 5 xrays illustrating treatment by lobectomy 11 rays of following irradiation therapy, 11, 12 rays of nonresectable case 23 xrays revealing hilar carcinoma 15 X rays showing 5 Bronchogenic neoplasmn therapy for based on Antithetic theories 8 Bronchoplastic procedures diagram of techniques 113 for resection of left upper lohe 41 for preserving right upper lobe 41-42 illustration of localized undifferentiated cara noma removed by 43 indication for 97 procedure used for removal of neoplasm 40 recurrence of bronchogenc carcinoma ich lowing 98 results of use 97 98 statistics regard ng use 97 technique of 96 use as operation of choice 38 40 use for neoplasm in certain location an use in constrving pulmonary Issue 3 uses of 96 97 99 use to extenu resectabilty 1 - 11 : Bronchoscopy for biopsy prior to surgery 1, for relef of cough in tersir observations from 36 use in decision regarding me', ute prior to carnal biory : Nrunn 11 115 Bugher JC 31 48 Bullous cmphysema rays 2 1 site of 4 Burcheral 1 H 72 77 Burford T 90 102 C Cancer ant thela theones, & halos w for determ class Carcine :

·126 THE TREATMENT OF BRONCHIAL NEOPLASMS Carcinoma factors necessary for growth and for producing Toentgenogram of chest illustrating, 20 treatment of primary lesion, 19 symptoms, 10 Chardack, W. M. 46, 48 celt type, 10 Chemotherapeutic agents used in treated of original location, 10 resistance of host, 10 bronchogenic carcinoma. 70-71 mechlorethamine hydrochloride, 71 mortakty rates trethylene melamin, 71 decline in when due to disease, 3 triethylene throphosphoramide, 71 increase in when doe 10 environmental chemotherapy, 70-77 agents, 3 avariabit chernotherapeutic agents, 70-71, Sec Telanonship between degree of sinus histiocylo also Chemotherapeutic agents sis and prolonged survival in breast and combined with irradiation, 73-74 gastric, 11 combined with surgery, 74-75 resistance of host 10 complications of, 75 growth and regression of malignant neo dissemination of carcinoma cells by surgery, plasms, 10 74-75 need for appreciation of, 10 experiments in animals, 75 recurrence from metastases without clinical use of nitrogen mustard during surgery, 75 evidence, 10 complications of, 71, 76-77 spontaneous cures of cancer, 10 agranulocytosis, 76, See also Agranulocytosis tissue resistance to, 10-12 depression on hematopoietic system, role of lymphatic system, 10 minimization of, 76 sinus histiocytosis, 11-12 phlebothrombosis, 76 Carcmoma, bronchogenic, sce Bronchogenic thrombocytopenia, 76, See also Thrombocarcinoma cytopenia Carcinoma, epidermoid, characteristics of, 19 use of chlorpromazine, 76 Carcinoma, epidermord, low grade dosage and method of administration, 71 characteristics of, 10 following exploratory thoracotony, 75 survival time following resection, 10 complications of, 75 Carcinoma in situ to increase morale of patient and family, 75 association with epidermoid carcinoma of to influence longer survival time. 75 bronchus, 12 for malignant pleural effusion, 75-76 findings in bronchial tree bilaterally, 13 purpose of, 75 findings of following unilateral pneumonec use of strogent mustard or thotepa, 75-76 tomy, 12-13 use of radioactive gold and phosphorus, 75 latent period of, 13 for relief of cough in terminal care, 82 need for early diagnosis, 13 for vena caval obstruction, 24 risk of second carcinoma from, 13 matuman of bronshageal carcinoma, 6 Carcinoma, stomach limits of 70-71 decrease in incidence in males, 3 objective evidence of value, 71-73 Carcinoma, undifferentiated benefit to patient and family, 73 inoperability of, 10, 18 relief of symptoms, 72-73 rapid progression of, 18-19 study of effects of nitrogen mustard therapy. Cardiac function 7172 inadequacy of as contraindication to resec decision regarding, 77 tron, 57 use of irradiation therapy in presence of, 37 Cardinal biopsy, prior to resection, 26 Carr, D, 72, 77 theory of chemotherapy, 70 Carver, LF, 72, 77 use for sellel of pain in terminal carc, 83 Use in mediastinal unvasion, $3 Center, S, 102 erebral metastases of bronchogenic carcinoma use of in treatment of bronchogenic car uradiation therapy to, 19 lengthening survival time, 19 repetition of, 77 dosage employed in, 77 timing of, 77 Lsse of, 16, 70 oma, 119 ·INDEX 127 radioisotopes 82 thoracenteses, 82 tracheostomy 83 use of drugs for bronchitis 83 use to control distant metastases 57 use with irradiation therapy for treatment of pleural cffusion 56 use with chemotherapy 71, 76 Church:tt E. D, S 33 48 87 101 116 121 Cigarette smoking See Smoking cigaretic Claggett O T, 33 48 Classical temporal theory 8 116 defined 8 carly diagnosis and survival timc discussed 8 9 importance of early diagnosis in 8 Cleland, WP 62 69 Codeine use for relief of cough in terminal care 82 Cole W H 17 76 77 78 Collier F C 75 78 89 102 Confucius 24 Cordotomy for relief of pain in terminal care 83 Corynal node mass removal during surgery 32 Cough 82 as major factor in deterioration of physical cond tion 82 cause of 82 el mination of smoking 82 treatment of 82 use of drugs 82 Crafoord C 104 115 Chle G Ir 9 17 Cruz, E. P 77 uykendall I 23 30 Cylindroma See also Bronchial adenoma differences to bronchial adenoma 103 104 location of 103 metastases of 104 similarity to bronchial adenoma 103 Cytologic study of bronchial secretions case illustrations 13 15 in diagnosis of carcinoma in Str 13 E Engel HC 74 77 Engelbreth Holm I lis Enterlinc HT 75 78 89 102, 107 114 Epidermoid carcinoma illustration of case treated with irradiation therapy following resection 59 irradiation therapy following resection 38 location most common 35 pneumonectomy for 38 presenting symptoms 38 primary site 35 surgical eradication of 38 uiming of resection 38 Esophagitis as complication of irradiation therapy 67 relief of symptoms 67 symptoms of 67 Esophagus involvement of in bronchogenic carcinoma 34 symptoms of 24 use of irradiation therapy 24 Everson TC17 Ewing James 4 10 17 Exploratory laparotomy to establish presence of abdominal metastases, 20 Exploratory thoracotomy findings by 6 in nonresectable cases 47 Selection of patients for 18 survival curves following 93 survival following 92 to establish nontesectabilty of lesion 52 53 use of 16 use of chemotherapy following 75 complications of 75 purposes of 75 use of in past 5-6 Denman WE 72 77 D Errico A 83 84 Differentiated epidermoid carcinoma responsive ness to irradiation 51 D lauded for relief of cough in termina) care 82 stant metastases or bronchogenic carcinoma 19 Dunphy 1 E 16 17 Dyspnea 82 83 cause of in terminal stage of bronchogenic carcinoma 82 83 treatment of 82 83 irtad ation therapy 82 Ditrogen mustard 82 fimiline pressure freathing technique 83 fischer R$ 115 Fisher DR 74 77 Fool NC 115 Forman ) B 17 f Gaensler EA 7: 77 General del ty as complikation in term nal cart 84 ·128 THE TREATDIENT OF BRONCHIAL NEOPLASMS cause of, 84 treatment of Isoniazid, 84 Marsilid, 84 tranquilizers, 84 vitamin and proteins for, 84 Gere, J B, 7, 17 Gibbon, J H, Jr, 32, 48, 89, 90, 96, 102 Goldman, A, 112, 115 Gold, radioactive limitations of use, 75 use in treatment of malignant pleural effusion, 75 Graham, EA, 6, 32, 33, 48, 104, 115 II Haagensen, CD, 12, 17 Hamperl, H, 104, 115 Heck, w, 104, 115 Hemoptysis complication of terminal care, 84 treatment of, 84 drugs, 84 Irradiation therapy, 84 palliative resection, 84 Har leston of unknown etiology bronchotomy for diagnosis, 43 difficulty of diagnosis, 42-43 resectability of, 19 Hilar lymph nodes, removal during surgery, 32 Histology changes in tissue of bronchi, 4 photomicrograph of cylindroma of trachea, 108 photomicrograph of intraluminal carcinoma 14a, 15a photomicrograph of typical carcinoid adenoma 106, 107 Hoaglin, L, 7 Hobein, HC, Jr, 33, 48 Hodges, FJ, 48, 87, 101 Hodgkin, 101 Holland, RH, 33, 48 Holley, Sw, 115 Holst, J 32, 48 Horner, 26, 65 Husfeldt, E, 8, 17, 32, 48, 86, 101 Hycodan, for relief of cough in terminat care, 82 Intercostal neurectomy, for relief of pain in terminal care, 83 Intraluminal carcinoma, surgical specimen, 143, 15a Intramedullary spinothalamic tractotomy, for relief of pain in terminal care, 83 Irradiation sickness minimization of, 66 use of super voltage equipment to avoid 66 67 use of tranquilizing drugs in, 66 Irradiation therapy, 49-69 applied to primary lesion in metastases, 56-57 attitude of physician regarding use of, 49 50 combined with chemotherapy, 73-74 comparison of patients treated with and nontreated cases, 68 comparison of treated and untreated cases of bronchogenic carcinoma, 49 complications of, 66 67 damage to skin and underlying tsue, 67 esophagitis, 67, See also Esophagitis irradiation schness, 66, See also Irradiation sickness contraindications, 66 economic drain on family resources, 66 massive involvement of hver, 66 neoplasms with central necrosis, 66 presence of bronchoesophageal fostula, 66 presence of paraplegia and hemiplegia, 66 short hfe expectancy, 66 unconscious patients, 66 following resection of accessible nodes. 38 following resection of primary lesson, 57 for involvement of esophagus, 24 for local recurrence following resection, 58 60 use following lobectomy, 60 use following total pneumonectomy, 60 use to relieve symptoms, 60 for pleural effusion complicating bronchogenic carcinoma, 56 results of, 56 for relief of cough in terminal care, 82 for rehef of dyspnea ia terminal care, 82 for relief of pain due to parietal structure in vasion, 57 for relief of pain in terminal care, 83 for spinal and bony metastases, 83 10 selseve headaches, 83 for treatment of metastases to ribs and long bones, 66 for vena cava obstruction, 24 illustration of case receiving irradiation rather than surgical ercision, 50, 31 sllustration of cases treated with, 54, 55, 60, 61, I Intercostal nerves, invasion of as questionabic sign of operability, 27 ·INDEX 129 Isoniazid use for general debility in terminal cate 84 Johnston ), 75 78 89 102 Jones J C 34 48 к harnofsky DA 72 77 hassouny D Y 17 hee John Lester 103 helly G E 48 87 101 Kirby CA 75 78 89 102 Kirklin I w 104 105 hirland HB 87 101 Klein R H 89 103 Algerman M M 70 77 Kline RH 75 78 L (? (3 64 65 72 73 74 Mostration of case with poor pulmonary fune tjon treated with 57 58 illustration of treatment of vena caval compres son with 56 illustration where used following resection 59 indicat on for in inoperable and nonresectable patients 52 57 distant metastases S6 S7 See also Melas tascs distant mediastinal invasion 53 56 See also Medi astinal invasion pleural effusion 56 See also Pleural effusion in relation to cell type 51 in treatment of bronchogenic carcinoma 6 irrad alion to local zed ncoplasms 52 judicious use of 66 knowledge of needed by physician 49 obstacle to determining effectiveness of can cercidal doses of 50-51 over har masses 10 relieve symptoms 57 prel minary to Tescction 62 65 results or ? stat stics yllustrating 62 UNC in inoperable cases latcr found to be operahıc 62 use over penipheral carcinomas 63 relucf of pain of spinal metastases with 6 rcice or symptoms relaid to metastases to hrain 65 66 role of pallation 49 results of 67 69 evaluation accord ng to aim of therapy 67 medication of course of bronchogenic carci noma 69 relief of symptoms 68-69 *105 cs of survival t me following irracia on therapy 67-68 survival of frealed chics 49 to retard erlension of neoplam 58 treatment of a stunt metastases with 56 treatment of metastases with (56f U for freement of hemoptysis in terminal care 87 wie (or widespread pulmonan metastases foto use in borderline cares of resectability SA UVC in place of surgical ctcision so Use in the past 50 use in treument of bronchial adenomy 111 in of 16 4 ) 118 119 unc of in mountinol invason f 11 wing chema theraps sts un of preoperatchi 16 use of silver cips during surpety 10 help in SX Laff HI 115 Laminography use in evaluating metastases 19 Lampe L 48 87 101 Latourelle H B 48 87 101 Lindgren AGH1104 115 Lindskog 662 69 Liver metastases of bronchogenic carcinoma 20 inoperability of 20 symptoms of 20 Lobectomy as treatment for bronchogenic carcinoma 6 comparison with pneumonectomy in treatmeni of bronchogenic carcinoma 32 33 factors determining use of 33 in treatment of bronchogenic carcinoma 31 objections to in treatment of bronchogenic carcinoma 3? prognoris following 94 recurrence of carcinoma in bronchial stump following 33 survival rates following 95 use of as treatment of bronchial adenona 111 use of by thoracic Surgeons 34 use of ny years 6 use of for bronchogenic cateinoma 95 Iymph nodes etcision of duting surgery 3? mela3f755 18 prescalere ? reginal lymph nodes der neu 32 femoval of corynal mass during lotectomy 32 removal of pctitracheal may during surgery Inulis of removal of 1 role in prevent ng spread of cancer 1:

·130 THE TREATMENT OF BRONCHIAL NEOPLASMS Lymphatic system extension of in bronchogenic carcinoma, 21-23 evidences of dissemination in biopsy of lymph nodes, 23 biopsy for diagnosis, 21 diagram of lymphatic channels of tracheo. diagnosis of, 21 bronchial tree, 22 symptoms of, 21 pulmonary, 20-21 presence as sign of inoperability, 22 routes of metastases, 21 22 extension of, 21 role in preventing spread of cancer, 12 inoperability of, 21 role in tissue resistance to spread of cancer involvement of contralateral lung in, 21 spinal, 19 cells, 10 characteristics of pain of, 19 Lynch, J P, 72, 77 contraindication for pulmonary resection, 19 localized lancinating pain as symptom of, 19 M paraplegia as result of, 19 MacCallum, JD, 46, 48 use of roentgenography in diagnosis of, 19 MacDonald, Ian, 9, 17 to bones, 20 Maler, HC, 30, 106, 115 biopsy for diagnosis of, 20 Malignant adenoma. See Bronchial adenoma location of, 20 Marsılıd, use for general debility in terminal care, pathological fracture as symptom of, 20 84 type of metastatic lesion, 20 Martin, CL, 66, 69 treatment of with irradiation therapy, 65 66 McBurney, RP, 104, 115 Meyer, BW, 34, 48 Mixed tumor, See Bronchial adenoma McDonald, G 0, 77, 78 McDonald JR, 12, 17, 33, 48, 115 Moersch, HJ, 115 Moore, GE, 74, 77 McWhirter, R, 12, 17 Morales, F, 78 Mechlorethamine hydrochloride, 71 Muchsam, G E., 17 Mediastinal invasion Muehsam, MD, 7 as common sign of inoperability, 53 Mueller, H, 103, 114 indications for mediastinal extension, 53 use of irradiation therapy with chemotherapy, N S3 Nealon, TF, Ir, 48, 9, 102 Mediastinal nodes Nerve blocks, for relef of pain in terminal care, biopsy by laryngoscope, 24 83 use of biopsy of, 24 Neuhof, H, 33, 48, 89, 102 Metastases of bronchogenic carcinoma Neurosurgical procedures abdominal, 19-20 for relief of pain in terminal care, 83 adrenal metastases, symptoms of 20 cordotomy, 83 enlarged nodular liver in, 20 intercostal neurectomy, 83 Inadvisability of exploratory laparotomy in intramedullary spinothalamic tractotomy, 83 20 Nitrogen mustard compound therapy involvement of retroperitoneal nodes 20 complications of large doses of, 71 survival time following pulmonary resection depressing effect on hematopoietic system 76 20 mechlorethamine hydrochloride, 71 Use of radiographic techniques for diagnosis objective evidence of value of, 75-72 of, 20 plan of administration now used 71 blood borne as cause of death, 34 risk involved in use of, 76-77 cerebral, 19 technique of administration, 71 irradiation therapy to, 19 timing of treatment, 71 lengthening survival time, 19 use for relief of pleural fluid, 82 roentgenogram of chest illustrating. 20 use for treatment of pleural effusion, 25 treatment of primary lesion, 19 use in treatment of malignant pleural effusion 75-76 distant 19 treatment with radiation and chemotherapy, advantages of use, 75-76 56-57 dosage used, 76 ·131 INDEX precautions in use of 76 use of salrapleurally 76 use in treatment of pleural cffusion 56 use of chlorpromazıne 71 use of TEN following. 77 0 Ochsner A12 47 48 88 101 P Pain cause of in terminal care 83 control of in terminal care 83 treatment of 83 chemotherapy 83 dration therapy 83 ve hlocks 83 urosurgical procedures 83 alhative resection 83 Aive resection I cough as indication for resection 45 severance of vagus nerve branches 45 Cor hemoptysis 45 cough in 45 Indicat on for resection 45 rhynology of 45 for pain 45-46 at and cation for reseciton 45-16 excus on of lobe causing shoulder pain 46 resection of ncoplasm's producing 46 survival following arcision and x ray therapy of lesson 46 suppuration 45 ipl cation following removal of lung 55 scat on for resechon 45 c of tradation and ant microb al therapy use of radiatson therapy in place of 47 Palliative surgery other than resection 46 use in lesions invading diaphragm 46 use in lesions invading phrenic nerve 46 use of intercostal neutectomy 46 use of pleurectomy 46 Pancoast tumor illustration of 36-37 pain in terminal care of 83 Papanicolaou smear uselessness in diagnosis of bronchial adenoma 109 Paratracheal nodes biopsy by laryngoscope 24 use of biopsy of 24 Patterson EJ Paulson DL 17 U15 Pawlowski | M 7 Penbronchial lymph nodes removal during sur Sery 32 Peripheral carcinoma case examples of treatment with Iridration therapy chances of diagnostic errors 65 invasion of lymphatic channels 63 objections to erradiation therapy to 64-65 results of sradiation therapy to 63-64 USC of irradiation therapy pre moary to fc Section 63 use of wide on-bloc resection 63 Peripheral lesion extreme resectability of 19 T'eripheral lesions of unknown ctrology removal by segmental resection 42 resection for Joagnosis 42 Peritracheal node mass removal during surg. 32 Perick TG 17 Phlchothrombosis as complication of chemotherapy 76 treatment of 76 Phosphorus use in realment of malignant plural clfunon 75 fim tations of use 73 Phrenic nens invasion of as questionable sign of operahitty 26-27 Pleural el(usions as contraind calin of surgical therapy in bronchogenic carcinoma sto au ndication of mayer pulmonary on ohutus hy 25 26 aspiraton of furu 21 incetat Ins of 6 pleural fund in 26 sympoms of 26 aptoms relesed by 45-46 cough 45 hemoptius 45 pain 5-6 surruratino 45 une ( 44-3 alhaltig uurgery aluation of 16-7 sesults of 43 stud ss mock 41-7 cuplorators thoracunomy 47 arrreciation of hamrul effects of 17 ft wing her Juggmestic faxrJures 47 tosclts of in nonrexactable cases 47 statistics from 47 ·132 THE TREATMENT OF BRONCHIAL NEOPLASMS associated with bronchial neoplasms, 24-26 atelectasis secondary to neoplasm in bronchus, illustration of, 29 26 use of Jobectomy in presence of, 27-28 resectability of, 26 Pulmonary function symptoms of, 26 inadequacy of as contraindication to reseccomplications caused by, 24-25 tion, $7 detection of neoplastic cells in, 26 use of irradiation therapy in presence of, 57 examination of fluid aspirated, 25 Pulmonary metastases, 20-21 ertension of, 21 Irradiation therapy for, 56 treatment of inoperability of, 21 involvement of contralateral lung in. 21 by pleurectomy, 25 use of nitrogen mustard, 25 use of irradiation therapy is, 66 Pulmonary nodules, 99-100 use of radioisotopes, 25 ullustration of cases with asymptomatic, 100a use of nitrogen mustard compounds in, 56 prognosis following resectablity, 99 use of radioisotopes in, 56 resectability of, 19, 99 use of roentgenograms in diagnosis of, 56 Pleural effusion, malgnant significance of symptoms to progrosts, 100 surgical status of due to bronchogenic carctuse of chemotherapy for, 75-76 noma, 99 limitations of use of thoracenfeses, 75 survival curve following resection for, 99 treatment of dyspnea, 75 survival of patients with lymph node metasuse of radioactive gold and phosphorus 75 tases, 100 use of Thiotepa or nitrogen mustard, 75-76 survival rates following resection of asympto- Pleurectomy, for pleural effusion, 25 matic, 100 Pneumonectomy survival rates following resection of symptoas operation of choice for metastatic nodes in matic, 100 Jung, 38 survival rates without nodal metastases, 100 as treatment for bronchogenic carcinoma, 6 Pulmonary resection, for vena caval obstruction comparison of total and selective resechon, 32 24 comparison with lobectomy in treatment of Pulmonary vein obstruction bronchogenie carcinoma, 32, 33 aspiration of fluid, 26 evaluation of survival rates, 32 moperabilty of, 26 high mortality rates following, 34 meining of pleural effusion to, 25 26 indications for, 35-38 pleural fluid in, 26 in treatment of bronchogenic carcinoma, 31 symptoms of, 25 26 operative mortality rates, 32 R original use of, 33 prognosis following, 94.95 Rabin, CB, 103, 104, 114 salvage rates, 32 Radiography, for diagnosis of abdominal met35- survival rates followidg, 95 tases, 20 use by thoracic surgeons, 34 Radiossotopes use for localized neoplasms in bronchus of use for relef of pleural fluid, 82 lower lobe, 41 use for treatment of pleural effusion, 25 use for major bronchus lesion, 33 use in treatment of pleural effusion, 56 use of, 101 Ramsey, 3 3, 115 use of as treatment of branchial adenoma, 111 Rasmussen, G, 7 use of by years, 6 Ray, C3, 48, 101 use of for bronchogenic carcinoms, 95 Reimann, D, 135 Pneumonitis, obstructive Resectability of bronchogenic carcinoma illustration of due to bronchogenic carcinoma, contraindication in presence of inadequate puf 41 X-rays illustraling. 14 contraindications to resection, 32 Polypoid adenoma, See bronchial adenoma diagnostic measures to establish nonresectabil Imonary emphysema Jassociated with bronchogenic carcinoma, 27 monary and cardiac function 57 ity, 52 53 bronchograms, 52 ·133 INDFX bronchoscopy 52 esophagrams 52 in presence of fluid in blocked bronchus 26 of cutreme peripheral lesions 19 of hlar lesion 19 of pulmonary nodule 19 Resection of neoplasm See also Surgery as palliative treatment for relief of cough in terminal care 82 as palliative procedure for rchef of pain in terminal care 83 determ nation of extent of 33 determining factors for 16 determ ning suitability of neoplasms for 17 factors affecting survival following 95 96 chest wall invasion 95 96 influence of pathologic type on tyre surgery and survival 95 mulmonary survival time following 20 d cal removal of lymph nodes during 12 scctability defined 16 urvival curves following 93 94 survival following 92 93 survival rates accord ng to cell types following 96 survival rates following 95 use as palliative procedure for hemoptysis in terminal care 84 use of 16 Ros rel of of pain of metastases with irradation therapy 66 Rigler LC9 17 Robinson J L 34 48 Roentgenogram extreme peripheral 19 1 xation of shadow on 19 hilar 19 nodular 19 Use in evaluation of patient 19 Ryan RT 12 17 poor respiratory function 35 small neoplasms 34 35 Shapiro DM70 77 Shay RR 17 115 Singer 48 Sinus histiocytOSIS as expression of host resistance 12 relationship between degree of and prolonged survival in carcinoma 11 Shinner EF 72 77 Smedel MI 48 87 101 Smith AR 24 30 46 47 48 Smoking cigarette attitude of smokers toward bronchogenic carcı nom3 4 el mination of for relief of couch in terminal care 8? relationship to aging process 28 evidence of aging 28 tissue changes in bronchi in smokers and non smokers 4 Smoiin HJ 7 17 Soutter L 48 87 101 Speer F D 11 17 Spinal metastases of bronchogenic carcinoma characteristics of pain of 19 contraindication for pulmonary resect on 19 paraplegia as result of 19 relief of pain of with irradiation therapy (o symptoms of 19 use of roentgenography in d agnosis of 19 Squamous cell carcinoma characteristics of 117 illustration of 36-37 39-40 960 960 Hlustration of case treated with resection and irradiation 60 61 62 63 64 (5 Hlustration of nonresectable 52 53 illustration of treated with irradiation therapy 54 illustration of urse of bronchoplastic procedure for 98 resectability of 95 survival rates 95 96 use of lohectomies for 95 use of pneumonectom os fr 95 Stout AP 7 12 17 104 115 Surgery See also lohectomy Pneumonect my and Resection of neoplasm apsisat on of radxal approach 17 bro! gis factors dcterm ang selection of pa tients for 38 cell tire 18 met length of history of simptomt 18 neoplasm 18 S Sandberg A 74 77 Salonc node bory 23 24 as diagnatic procedure 23 24 Klection of patents for 2394 Use of laryngoscope 24 Wannel! J G 48 87 101 Scheenberg H 107 314 Schuberg BS 74 77 Segmental resection Klect on of patients for 34 15 newly acquireu les ens 35 per pheral neoplasmi i ·134 THIE TREATMENT OF BRONCHIAL NEOPLASMS rate of progression of lesion, 18 resistance of host, 18 T combined with chemotherapy, 74-75 Taylor, A B, 37, 48, 88, 92, 101 complications of, 75 Telangiectasia, as result of irradiation therapy, 67 dissemination of carcinoma cells by surgery, TEM 74-75 complications of, 71 experiments in animals, 75 course of therapy, 71 use of nitrogen mustard during surgery, 75 depressing effect on hematopoidlic system. 76 considerations prior to for bronchogenic carcia method of administration, 71 soma, 29 30 use following nitrogen mustard treatment, 77 development of as treatment for bronchogenic use in treatment of bronchogenic carcinoma, 71 carcinoma, 45 Templeton, J Y, III, 48, 89, 102 diagnostic measures to establish nontesectabil Terminal care ity, 52-53 cough, 82, See also Cough diagram of resections, 44 dyspnea, 82 83, See also Dyspnea evalution of other methods of treatment, 18 family's role, 80-81 exciston of regional lymph nodes during, 32 activities of patient, 80 factors determining advisability of, 18 encouraging patient, 8D factors in surgical mortality rates, 32 prevention of invalidism, 80 81 goal of, 118 Usefulness of patient. 80 inoperability of neoplasm, 19-21 general debility, 84, See also General debility abdominal metastases, 19-20 hemoptysis, 84, See also Hemoptysis cerebral metastases, 19 informing family of diagnosis and prognosis, 80 distant metastases, 19 informing patient of diagnosis, 79-80 evidence of dissemination, 21 informing patient of prognosis, 80 metastases to bone, 20 pain, 83-84. See also Pain pulmonary metastases, 20-21 physician's goal, 79 spinal metastases, 19 reaction of patient to prognosis, 79 inoperability of small cell und fferentiated car responsibility of physician, 79 Cinoma, 18 lobectomy, See Lobectomy rewards of, 84 operability defined, 16 role of consulting surgeon, 81 operability of neoplasm, 16 attempting new therapy, 81 pneumonectomy, See Pneumonectomy cooperation with family physician, 81 direction of medical care, 81 questionable signs of inoperability, 26 29 discussion of diagnosis and prognosis with age and coronary artery disease, 28-29 chronic cardiac decompensation, 29 patient and family, 81 invasion of chest wall, 27 maintaining patient's morale, 81 periodic eramination of patient, 81 invasion of first and second intercostal role of family physician, 81 nerves, 27 invasion of phrenic nerve, 26-27 treatment of symploms, 81-82 relief of complications, 82 poor pulmonary function 27 28 relief of symptoms, 81 presence of dyspnea, 29 pulmonary emphysema, 27 Thiotepa, 71, 75-76 signs of extension beyond lung, 26 27 use in treatment of malignant pleural elusion, 75-76 use of lobectomy in presence of pulmonary emphysema, 27-28 advantages of use, 75-76 resectability defined, 16 dosage used, 76 resectability of neoplasm, 16 precautions in use, 76 salvage rate from, 29 Use of intrapleurally, 76 selection of patients for, 18.30, 117, 118 Thoracentescs, for removal of pleural fluid for selection of procedure to be used, 118 relief of dyspnes, 82 Use of bropsies, 19 Thoracotomy, exploratory See Exploratory thoracotomy. Sweet, RH, 48, 87, 101 ·135 INDEX Thrombocytopenia as complication to chemotherapy, 76 confirmation by sternal bone marrow, 76 death due to 76 khousness of, 76 treatment of, 76 use of blood studies to avoid, 76 Tracheobronchial tree, drawing of lymphatic channels draining. 22 Tracheostomy, for rehel of dyspnea in terminal care, 83 Triethylene melamin, 71, See also TEM Triethylene throphosphoramide, 71 Trump 3 G, 48, 87, 101 Turnbull, RB, Ir, 74, 77 Vena caval obstruction as sign of inoperabilty, 24 chemotherapy for, 24 irradiation therapy for, 24 meaning of, 24 results of pulmonary resection, 24 signs of, 24 signs of inoperability, 24 use of pulmonary resection, 24 Vieta, 10, 115 Virchow, 100 Vocal cord paralysis, 24 as contraindication to resection, 24 cause of, 24 pathology of, 24 use of resection, 24 U Undifferentiated bronchogenic carcinoma resectability of, 95 responsiveness to irradiation therapy, 51 survival rates, 95, 96 use of irradiation therapy for temporary control of symptoms, 51 use of lobectomy, 95 Ware, PF, 72, 77 Waterhouse, J AH, 88, 101 Waterman, DH, 115 Watson, WL, 89, 102 Wessler, H, 103, 104, 114 Whytehead, L C, 48, 101 Wilkins, E, 87, 101 Womack, NA, 104, 115 Woolner, LB, 104, 115 V Vagolomy, for relief of cough in terminal care, 82 Vascular adenoma See Bronchial adenoma

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