Lung Cancer: Early Diagnosis and Management (American Cancer Society, 1969)

[Graph indicating Deaths from Various Cancers – U.S.A.] [Narrator:] Soon after 1930, the deaths from lung cancer turned sharply upwards. By 1980, if the present rate continues, there will be 90,000 deaths per year. Or will there? Today, physicians are increasingly the doing the things that can reduce this mortality and make a different story possible. [X-ray films of a person’s lungs are placed on a viewer.] [G. Hugh Lawrence, M.D., Surgeon:] By pre-operative selection of potentially favorable lesions, we have experienced a fourfold increase in the overall survival from bronchogenic carcinoma. [Oscar Auerbach, M.D., Pathologist:] There is no question in my mind that precancerous lesions from smoking are reversible. [Thomas Carlile, M.D., Radiologist:] Today it is increasingly important for all physicians to have an aggressive attitude about this disease because the cure rates can be further improved. [Dr. Lawrence:] Early thoracotomy is indicated in all new lesions which defy the usual methods of diagnosis. These small asymptomatic tumors have the best prognosis. [Dr. Auerbach:] Here is the photograph of a normal lung in a non-smoker. And here is the photograph of a lung cancer in a man who had smoked most of his adult life. [Side-by-side photos show a healthy lung labeled Non-Smoker and a cancerous one labeled Cancer in Heavy Smoker.] After a study of some 1,972 autopsies at our hospital, we are able to determine when the man has smoked heavily over a long period of time. We are also able to determine when a heavy cigarette smoker has given up the habit for a considerable period of time prior to his death. [Image of bronchial epithelium is shown with arrows pointing to different elements.] Normal bronchial epithelium consists of a layer of ciliated columnar cells. Beneath it is a layer of one or two basal cells of uniform size with small evenly staining nuclei. The basal cells lie on a basement membrane. Early changes toward malignancy can be recognized where there is a conspicuous and abnormal increase in the number of basal cells with numerous atypical nuclei. Carcinoma in-situ is characterized by the fact that there’s an easily identified increase of the basal cells, resulting in a thickening of the epithelium of five or more rows, and the absence of cilium. There is as yet no invasion of the basement membrane. All of the cells are atypical with prominent hyperchromatic nuclei. With an early invasive bronchogenic carcinoma, there is an extensive cellular atypism and extension beyond the basement membrane. Even at this late stage of development, the lesion is not large enough to be seen in the x-ray nor is it large enough to produce any clinical symptoms. Now let us see how the process reverses itself when the individual has given up smoking. [Image of lung cells.] Here’s an example of an individual who had smoked two packs of cigarettes a day for twenty years and had given up the habit for five. [Graph titled “% of Tissue Slides with Atypical Nuclei”] In a recent study, we found that cells with atypical nuclei were present in only 1.2 percent of the slides from those who had never smoked regularly, compared with 93 percent among slides from those who were smokers up to the time of their last illness. Among those who had smoked for at least ten years but not within five years prior to death, there were only six percent of the slides with cells with atypical nuclei. Perhaps the greatest motivation for patients to give up the habit of smoking lies in the fact that the process is reversible. [Dr. Carlile:] Certainly, it is the responsibility of physicians to discourage their patients from smoking. However, the more immediate problem is the management of patients who have lung cancer or are in the high-risk group. Periodic chest x-ray is the most widely available and simplest method for the detection of lung cancer. [A man is shown getting an x-ray, then medical staff are seen standing in front of shelves and charts and films.] Routine films on asymptomatic patients, particularly on smokers, besides disclosing unsuspected lesions, serve as a valuable purpose for future baseline of comparisons. [The doctor places x-ray films on the viewer and flips on the light.] Is the early diagnosis of lung cancer really worthwhile when the national average is less than ten percent in overall survival? The answer very definitely is yes. I would like to illustrate several points that are very important in the management of lung cancer with some chest x-rays. This first patient represents an early diagnosis and represents the value of the baseline film. This film of several years ago was normal. We then have a film that was taken about two years later, and this was also called normal. [The doctor describes what he seeing on various x-ray films.] However, because this was a heavy smoker, and because of suspicion of pulmonary pathology, an additional film was taken six months later, and at that time, for the first time, a small density, less than one cm in diameter, was found hidden in part by this rib. [X-ray film is shown with arrow pointing at lesion.] As we looked back at the film of six months ago, we could see the genesis of this lesion. This patient had a conventional diagnostic workup, and following that a right upper lobectomy, and we see here the rib resection and the result of lobectomy and the expansion of the remaining lung to fill up the space of the lobe that was removed. This patient lived more than five years. I would like to be able to say that early diagnosis of this nature is the complete answer to lung cancer. It does improve curability, but there are some lesions that are so biologically unfavorable that in spite of everything we do, we still cannot obtain survival for the patient. This next series of films, for example, illustrates that point. [The doctor places a new set of films on the viewer.] First we have a chest x-ray with a rather subtle lesion above the right hilar root and again, in part, behind the rib. However, this was recognized, and thought to be suspicious enough to warrant further investigation. A bronchogram was done, demonstrating obstruction of the bronchial going to the particular area in suspicion. Then finally the lesion was found to be inoperable, and the patient was dead of his disease within a matter of three or four months, in spite of the fact that this was a very small lesion. While we have been stressing the importance of lesions of small size, this case illustrates another point, and that is the location of the tumor. [Animated image of lungs.] When they are placed centrally and close to the mediastinum, they rapidly metastasize to the mediastinal nodes and become inoperable. Thus, the patient is prevented an opportunity of a cure even when the lesion is small. This again illustrates the inherent biological potential of certain types of lung cancer, which make it such an unfavorable disease in contrast to other forms of cancer. [Graph indicating Deaths from Various Cancers–U.S.A.] It also emphasizes the necessity of prevention. There is another type of situation for which we must be alert. This is the time when pneumonia masks a lung cancer and may prevent its diagnosis. [The doctor places x-ray films on the viewer.] This lady had recurrent attacks of bronchitis over a period of years, and they responded to antibiotics and customary therapy. However, on one occasion, a lesion appeared in the region of the lingula of her left upper lobe, and this persisted more than two weeks. Under antibiotic therapy, it not only didn’t go away, but its margins became more distinct and sharper, and this led to the suspicion that it might be a carcinoma. Further studies were made, as is our custom, and finally the patient was submitted to exploratory thoracotomy and lobectomy. This proved to be an alveolar cell carcinoma of relatively small size without lymph node metastasis, and she is alive and well many years later. In addition to the problem of pneumonia, there are other diseases that may cover lung cancer and obscure it. [A new set of x-ray films is mounted on the viewer.] This particular patient had a cavity in his right upper lobe. It doesn’t look particularly like tuberculosis, yet this must be considered in the differential diagnosis. However, the right hilar root is rather heavy, and there is some lower lobe pulmonary fibrosis. This patient was explored and proved to have an inoperable lung cancer. Any lung shadow that persists more than two weeks warrants suspicion of cancer, and further diagnostic procedures should be undertaken at once. Among other x-ray diagnostic tools is fluoroscopy, which allows one to observe the pulmonary dynamics. [A man is shown in a medical office receiving a fluoroscopy, then sitting down while the doctor examines him.] Bronchography may outline a small obstruction. Tomography, that is body section roentgenography, may reveal additional details. [A man is shown lying down with a tomography machine operating above him.] [Dr. Lawrence:] Early exploratory thoracotomy is indicated whenever the diagnosis is in question, or when endoscopic evaluation indicates that a curative resection is feasible. Before a thoracotomy, each patient should be carefully evaluated in order to delineate the nature of the lesion and its extent as well as the patient’s cardiopulmonary reserve. Sputum cytology is an integral part of this diagnostic evaluation. In the poor-risk patient, it may be the only means of safely establishing the diagnosis. [A nurse places an oxygen mask on patient, then removes it, at which time he coughs into a cup.] When positive, it not only reinforces the diagnostic suspicion and the indication for exploration, it allows the surgeon to proceed with the definitive resection [A sample is examined through a microscope.] at the time of thoracotomy without risking spread of the lesion by operative biopsy. Bronchoscopy is another important diagnostic procedure. [A patient lying down and swathed in surgical gowns undergoes a bronchoscopy, in which a long, thin surgical instrument is inserted into the throat.] It may visualize a centrally-located lesion. A right-angle telescope increases the extent of this observation. [A view of tissue through a telescope is shown.] Bronchoscopy may provide diagnostic tissue or cytologic washings. Findings of bronchoscopy help define resectability. We have almost routinely performed scalene lymph node biopsy at the time of bronchoscopy. It has yielded positive nodes in one quarter of our patients. [Tissue is removed with a scalpel and smeared on a sterile cloth.] These are, in our opinion, criteria of inoperability. Mediastinoscopy, an extension of node sampling to within the mediastinum may be helpful in establishing a diagnosis and in determining operability. The scope is passed into the mediastinum through a cervical incision, [The procedure is demonstrated.] and nodes along the trachea, carina, and main stem bronchi are visualized and biopsied as indicated. Involvement of the laryngeal nerve, superior vena cava, [Animated diagram points out these parts of the body.] or distant metastases are other criteria which usually indicate inoperability. However, superior sulcus tumors, invading the apex of the thorax, have on occasion responded favorably to combined resection and radiation therapy. Exploratory thoracotomy is performed in the absence of the above-mentioned criteria of inoperability, [Surgeons are gathered around a patient on the operating table.] and resection is offered to all patients without mediastinal spread or significant chest wall invasion. It is unquestionably the surest way of arriving at a definitive diagnosis and hopefully effecting cure by proceeding with the definitive resection. Lobectomy is the operation of choice in bronchogenic carcinoma when the tumor is confined to the lobe. [Animated diagram of the lungs shows a lesion on the right lung.] Pneumenectomy is performed when the tumor crosses the fissure or when the associated interlobe bar or hilar lymph nodes are involved. Pneumenectomy is usually performed intrapericardially in order to obtain a wider vascular margin with an end block resection of involved lymph nodes. Extended resection of mediastinal nodes, chest wall, and contiguous vascular structures is reserved for the younger patients who are better able to tolerate the increased morbidity of the procedure. The factor which has the greatest influence upon survival is the size of the lesion. [The lung lobe is removed from the patient on the operating table and the tumor examined.] Our experience indicates the favorable nature of lesions of three centimeters or less confined to one lobe. [Dr. Carlile:] What can we offer to the patient whose lung cancer is inoperable or in whom surgery cannot remove all of the disease? Radiation therapy is a valuable adjunct in the management of lung cancer. [A man lying on a gurney is positioned under a machine that will irradiate his lung tumor.] In fact, a cure can be effected in a small but definite number of patients. There are some situations where its intelligent and judicious use can control certain symptoms such as hemorrhage, infection behind obstruction, and particularly of pain. There are some special situations, such as superior sulcus tumors, superior vena caval syndrome, and pleural effusions where effective control can be obtained by radiation. Pre-operative irradiation is being evaluated today in a number of institutions, and the final answer on it is not yet in. Chemotherapy plays a limited role in the management of lung cancer in contrast to other forms of disseminated cancer. However, there are some special situations where it may be of value. The surgical curability of lung cancer was demonstrated more than thirty years ago. Since that time, we have learned much about its prevention and also about its diagnosis and treatment. The fate of the individual patient frequently depends upon the prompt and full application of this knowledge. [Screen goes dark]

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