Recurrent bronchogenic pseudocyst 24 years after incomplete excision. Report of a case.

Bronchogenic cysts (BCs) are uncommon congenital anomalies. Due to the inherent complications, the mere presence of a BC should warrant surgical therapy. Partial excision of these structures leads to recurrence. Complete surgical excision using a thoracotomy or video-assisted thoracic surgery is the goal. We report a case of recurrent bronchogenic pseudocyst 24 years after initial excision. This case supports the argument for complete surgical excision of BCs at the time of diagnosis.

Rigid bronchoscopy. The forgotten art.

Rigid bronchoscopy is superior to flexible fiberoptic bronchoscopy in several clinical situations. General anesthesia is usually used with side port ventilation. In children, removal of foreign bodies is an important indication. Tracheal stricture dilatation and cryotherapy are indications in adults, but laser bronchoscopy has become the major indication for rigid bronchoscopy in adult medicine.

Liposarcoma of the pleura.

Pleural liposarcomas are extremely rare; only eight cases have been reported in the literature. Herein we describe a 38-year-old man who had dyspnea on exertion and chest pain. Computed tomography of the chest revealed a large mass in the right pleural cavity. Thoracotomy was performed, and the patient recovered with no complications. Postoperative adjuvant irradiation was successful. In addition to the current case, we review the previously reported cases of pleural liposarcomas and discuss the treatment outcomes.

Screening for lung cancer. A critique of the Mayo Lung Project.

The National Cancer Institute of the United States recently sponsored three large-scale, randomized controlled trials of screening for early lung cancer. The trials were conducted at the Johns Hopkins Medical Institutions, the Memorial Sloan-Kettering Cancer Center, and the Mayo Clinic. Participants were middle-aged and older men who were chronic heavy cigarette smokers and thus at high risk of developing lung cancer. Screening procedures were chest radiography and sputum cytology, the only screening tests of established value for detecting early stage, asymptomatic lung cancer. In the Hopkins and Memorial trials the study population was offered yearly chest radiography plus sputum cytology every 4 months. The control population was offered yearly chest radiography only. In these trials the addition of sputum cytology appeared to confer no lung cancer mortality rate advantage. The Mayo Clinic trial compared offering chest radiography and sputum cytology every 4 months to offering advice that the two tests be obtained once a year. This trial demonstrated significantly increased lung cancer detection, resectability, and survivorship in the group offered screening every 4 months compared with the control group. However, there was no significant difference in lung cancer mortality rate between the two groups. The statistical power of these trials was somewhat limited. Nevertheless, results do not justify recommending large-scale radiologic or cytologic screening for early lung cancer at this time.

Lung cancer: the American view.

Bronchogenic carcinoma is a major public health problem in the United States, and the leading cancer killer in both men and women. In the early 1970s, the National Cancer Institute (NCI) sponsored multicentre clinical trials to assess the effects of screening by sputum cytology testing and serial chest X-ray examinations on lung cancer mortality in high-risk male smokers. Although more lung cancers were detected, more early stage 1 cancers were resected, and 5 year survival rates were improved in the screened populations than in unscreened controls, there were nearly equal numbers of advanced cancers, and mortality rates were not significantly different. Thus, mass screening to detect early lung cancer has not been pursued as public policy in the United States. In the 1980s, emphasis has shifted to efforts at lung cancer prevention through educational programs aimed at smoking prevention and cessation. In 1984, the NCI adopted a national goal of reducing lung cancer mortality by 50% by the year 2000. Strategy to achieve this is an intensive behaviour modification program to encourage a social climate for smoking abstinence, prevent initiation of smoking among children and adolescents and supply educational materials and encouragement through health care workers and community-based programs.

Role of bronchoalveolar lavage in the assessment of opportunistic pulmonary infections: utility and complications.

We prospectively evaluated the diagnostic role of bronchoalveolar lavage in the assessment of opportunistic pulmonary infections and the incidence of associated complications in 100 immunocompromised patients during a 9-month period. Bronchoalveolar lavage was useful in detecting the presence of Pneumocystis carinii, viruses, fungi, bacteria, and mycobacteria in the lower respiratory tract. P. carinii was diagnosed by bronchoalveolar lavage in 17 patients and by open-lung biopsy in 1. Other organisms detected by lavage, lung biopsy, or both included viruses (eight patients), fungi (four patients), bacteria (six patients), and mycobacteria (three patients). Of the 100 patients studied, 33 had infectious agents detected in the lung; in 6 of these patients, more than one organism was present. Bronchoalveolar lavage detected the infectious organisms in 30 of the patients, in many of whom an open-lung biopsy was likely avoided because of the lavage studies. Although no major complications of bronchoalveolar lavage were noted in this critically ill population, five patients did require short-term mechanical ventilation after bronchoscopy. When correctly used, bronchoalveolar lavage is a safe and useful procedure for the assessment of immunocompromised subjects with suspected opportunistic pulmonary infections.

Lung cancer screening: the Mayo program.

The National Cancer Institute has sponsored three randomized controlled trials of screening for early lung cancer in large, high-risk populations to determine whether lung cancer detection can be improved by adding sputum cytological screening every 4 months to chest roentgenography done either yearly or every 4 months; and lung cancer mortality can be significantly reduced by this type of screening program, followed by appropriate treatment. Results of the three trials suggest that sputum cytology alone detects 15% to 20% of lung cancers, almost all of which are squamous cancers with a favorable prognosis; and chest roentgenography may be a more effective test for early-stage lung cancer than previous reports have suggested. Nevertheless, results of the randomized trial conducted at the Mayo Clinic showed that offering both procedures to high-risk outpatients every 4 months conferred no mortality advantage over standard medical practice that included recommended annual testing.

Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Mayo Clinic study.

The initial (prevalence) radiologic and cytologic screening for lung cancer in the Mayo Clinic study (Mayo Lung Project) involved 10,933 outpatients. All were men at high risk for lung cancer, but none were suspected of having it when they entered the Mayo Clinic. Screening identified 91 lung cancers (8.3 per 1,000 screened). Nearly two thirds of the prevalence lung cancers were detected by chest roentgenography alone. Half of these cancers were resected. Only a fifth of the cancers were detected by sputum cytologic examination alone; however, all but 1 of these were resected. Compared with a group of lung cancers encountered in contemporary clinical practice at the Mayo Clinic, the prevalence cancers were more than twice as likely to be (1) resectable, (2) postsurgical Stage I or II (AJCC), and (3) associated with survival 5 yr after treatment.

Roentgenographically occult lung cancer: pathologic findings and frequency of multicentricity during a 10-year period.

During the first 10 years of the Mayo Lung Project, 68 roentgenographically inapparent ("occult") lung cancers were localized and apparently completely resected. A pathologic classification was developed based on depth of tumor infiltration. The five categories were (1) in situ carcinoma confined to surface epithelium or ducts of mucous glands or acini (23 cancers), (2) intramucosal invasion not greater than 0.1 cm from mucosal surface (12 cancers), (3) invasion to bronchial cartilages (11 cancers), (4) invasion to full thickness of bronchial wall (10 cancers), and (5) extrabronchial invasion (12 cancers). Multicentricity of lung cancer was studied in 54 patients, none of whom had a history of cancer of the respiratory tract, and all of whom had had "complete" surgical resection of the initial occult lung cancer (or cancers). Neoplasms that were initially multicentric occurred in 4 patients, and a subsequent primary lung cancer developed in 11. The rate of detection of second primary lesions was 42 per 1,000 person-years of observation. A high incidence of unresectable cancers and a low survival rate were noted among patients who had a subsequent primary tumor. These findings were primarily attributable to invasiveness of the subsequent primary cancer or to respiratory insufficiency that resulted from obstructive lung disease or previous pulmonary resection. Because of the high risk of development of a second primary cancer after initial surgical resection, it is important to treat the initial occult cancer as conservatively as possible consistent with "cure."

Interstitial lung disease. Assessment by bronchoalveolar lavage.

Bronchoalveolar lavage is a new bronchoscopic technique that permits assessment of changes in the cellular traffic in the alveolar spaces. During a 16-month period, 120 patients underwent bronchoalveolar lavage at our institution. Control subjects (N = 11) had a predominance of alveolar macrophages (94 +/- 1%) with a few lymphocytes (4 +/- 1%), whereas 35 patients with idiopathic pulmonary fibrosis had a substantial increase in the number of polymorphonuclear leukocytes (17 +/- 2%), and 32 patients with sarcoidosis had an appreciable increase in the number of lymphocytes (27 +/- 2%). Further subtyping of these lymphocytes in 13 patients with sarcoidosis revealed the cells to be predominantly from the T-helper subclass (helper/suppressor ratio of 5.3/1.0; normal 1.8/1.0). In contrast, three other patients with a lymphocytic alveolitis (51 +/- 8% lymphocytes) had a pronounced predominance of T-suppressor lymphocytes (helper/suppressor ratio of 0.1/1.0) in the lavage fluid. Two of the three patients were thought to represent an unusual subset of patients with idiopathic pulmonary fibrosis, and the third patient had pulmonary involvement secondary to angioimmunoblastic lymphadenopathy. Thus, bronchoalveolar lavage may be a useful means by which to assess the influx of inflammatory or immune effector cells into the alveolar structures in patients with interstitial lung disease, and this procedure offers promise as a quantitative means by which to assess the disease activity and the response to therapeutic intervention in these patients.

Roentgenographically occult lung cancer. A ten-year experience.

During the past 10 years, 54 patients, all men, were found to have roentgenographically occult lung cancer. The mean age was 61 years (range 45 to 76 years). All patients had abnormal findings on sputum cytologic study (carcinoma in 41 patients and squamous cell atypia in 13). The cancer was localized by bronchoscopy in all patients (range one to five examinations, mean 1.5). Seventy-five percent of the tumors were localized within 169 days of the abnormal sputum cytologic examination. Pulmonary resection for cure was performed in all patients: lobectomy in 38, pneumonectomy in nine, and bilobectomy in seven. Operative mortality was 5.6% (three patients). Fifty-eight cancers were resected, all squamous cell carcinomas (two had a component of large cell cancer). Tumor TNM classification (AJC) was TIS N0 M0 in 19 patients, T1 N0 M0 in 25, T1 N1 M0 in five, T2 N1 M0 in four, and T3 N0 M0 in one. Overall 5 year actuarial survival rate (lung cancer deaths only) was 90%. Five-year survival rate for the 44 patients with TIS N0 M0 and T1 N0 M0 neoplasms was 91%. Currently, 21 patients have died, but only 10 of lung cancer. Subsequent additional lung cancer developed in 12 patients (22%). Eleven of these patients had a second primary squamous lung cancer, six of which again were occult. We conclude that patients with occult lung cancer have a strong likelihood of long-term survival if treated early. Close surveillance is indicated because of the high incidence of a second primary lung cancer.

Lung cancer detected during a screening program using four-month chest radiographs.

Ninety-two lung cancers were detected in the Mayo Lung Project in patients undergoing chest radiography every four months for screening. Fifty patients had a peripheral nodule, 16 had a perihilar nodule, 20 had hilar or mediastinal enlargement, and six had pneumonitis. The peripheral cancers grew slowly. Ninety per cent were visible in retrospect for months or even years. Despite this, 70% of the peripheral cancers were classified as postsurgical American Joint Committee (AJC) Stage 1. The central cancers grew rapidly, usually presenting as hilar or mediastinal enlargements after normal findings on the previous radiograph obtained four months earlier. Most were classified as AJC Stage 3 tumors.