who received IMA grafts and the patients who received SV grafts. Although their findings contrast with those of other studies.v? a number of differences in study design might explain the different findings. Light et al studied patients consecutively, which had not been done previously" They studied a larger, moderate-sized population, whereas previously only 25 patients had been evaluated. 7 These studies suggest that atelectasis is not related to the presence of pleural effusions, nor does the presence of a chest tube cause the development of pleural effusions or atelectasis. Finally, these studies found that the combination of atelectasis and pleural changes on a chest radiograph was the only radiographic finding that was associated with significant gas exchange abnormalities and decreases in lung volumes. Some factors were not addressed by these analyses, including whether blood loss and the amount of blood administered influenced the development of pleural changes or atelectasis. What is apparent is that performing a pleurotomy and using an IMA conduit on a patient does not significantly increase the incidence of postoperative pulmonary dysfunction or radiographic abnormalities compared with placement of a SV graft. Questions remain as to why pleural changes occur in both settings and why pulmonary dysfunction occurs in patients who have no chest radiograph abnormalities. Jeanine R Wiener-Kronish, M.D., F.C.C.R San Francisco Departments of Anesthesia and Medicine, Cardiovascular Research Institute, University of California, San Francisco. Reprint requests: Dr. Wwner-Kronish, Department of Anesthesia, Room C450, University of California San Francisco, San Francisco 94143-0648
REFERENCES 1 Peng MJ, Vargas FS, Cukier A, Terra-Filho M, Teixeira LR, Light R\\Z Postoperative pleural changes after coronary revascularization: comparison between saphenous vein and internal mammary artery grafting. Chest 1992; 101:327-30 2 Worth HC, Grundmann C, Goeckenjam G, Smidt U, Irlich G, Loogen F. Pre- and post-operative respiratory muscle fatigue in coronary artery revascularization surgery, Respiration 1984; 46:33-44 3 Begen R, Radoux ~ Cantin A, Menard IIA. Stiffness of the rib cage in a subset of rheumatoid patients. Lung 1988; 166:141-48 4 Greenwald L~ Baisden CE, Symbas PN. Rib fractures in coronary artery bypass patients: radionuclide detection. Radiology 1983; 148:553-54 5 Kenyon CM, Pedley TJ, Higenbottam TW Adaptive modeling of the human rib cage in median sternotomy. J Appl Physioll991; 70:2287-302 6 Hurlbut D, Myers ML, Lefcoe M, Goldbach M. Pleuropulmonary morbidity: internal thoracic artery versus saphenous vein graft. Ann Thorac Surg 1990; 50:959-64 7 Shapira N, Zabatino SM, Ahmed S, Murphy DMF, Sullivan D, Lemole G M. Determinants of pulmonary function in patients undergoing coronary bypass operations. Ann Thome Surg 1990; 50:268-73
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Photodynamic Therapy for Early Stage Lung Cancer Preferable to Resection? In this issue of Chest (see page 1319), Edell and Cortese-whose group at the Mayo Clinic has had much experience with photodynamic therapy (PDT) beginning with the early work of Lipson et al 1•2 _ present the interesting hypothesis that in certain patients with early-stage lung cancer (Tis), a conservative, localized form of treatment such as PDT may be preferred to resection. This is based on the attendant risks of surgery, the fact that surgery too is a localized form of treatment, the high risk of secondary cancers in these patients," and the desire to preserve lung function. As pointed out by the authors, PDT must prove to provide a benefit at least equivalent to that of surgical resection. The preliminary data in the article by Edell and Cortese point to this. Also, it appears that the risks of PDT are minimal in these patients.' However, as recently reported by Kato and Hayata' of the Tokyo Medical College, long-term control of early-stage lung cancer has been obtained with the use of PDT alone, even in a group of patients with non resectable disease. Survival times in these patients range to eight years," Interestingly, the results of Edell and Cortese for PDT in patients with resectable disease parallel those of the Tokyo group. As is well known, unfortunately, detection of lung cancer at this early stage is difficult. Although the American Cancer Society does not recommend largescale screening," the Mayo Clinic and the Tokyo Medical College are among the few institutions still carrying out early-detection programs, albeit in a somewhat different manner. While the Mayo Clinic screens high-risk patients who enter its facilities for a variety of medical reasons, the Tokyo Medical College is part of a national program and seeks high-risk patients through the media. The arguments against large-scale screening include the cost (estimated by Kato and Hayata' to be near $35,000 per case detected") and the unknown effect on survival. It is possible, however, that the cost of medical care for patients with undetected disease (surgery, radiation therapy, chemotherapy, and possible long-term terminal care) may offset the detection cost. If PDT (likely to be done on an outpatient basis for these patients and costing perhaps $3,000 or less) can, in fact, result in long-term control, in the final analysis, large-scale screening may be justified. In the meantime, it well may be worthwhile for individual institutions to follow the lead of the Mayo Clinic by screening high-risk patients who enter their facilities for other medical reasons. Furthermore, since current Editorials
fluorescence technology can detect even radiographically and bronchoscopically occult early-stage cancers,6,7 use of this capability in combination with a local treatment such as PDT could enhance both the detection rate and the "curability' of early-stage lung cancer. This, of course, requires the type of prospective trial suggested by Edell and Cortese.
Thomas J Dougherty, Ph.D. Buffalo
Department of Radiation Medicine, Roswell Park Cancer Institute.
REFERENCES 1 Lipson RL. The use of a derivative of hematoporphyrin in tumor detection. J Natl Cancer Inst 1961; 26:1-11 2 Lipson RL, Gray MJ, Baldes EJ. Hematoporphyrin derivative for detection and management of cancer. Proceedings of the IXth International Cancer Congress. 1966; 393 3 Woolner LB, Fontano RS, Cortese DA, Sanderson DR, Bernatz PE, Payne WS, et ale Roentgenographically occult lung cancer: pathologic findings and frequency of multicentricity during a 10 year period. Mayo Clinic Proc 1984; 59:453-66 4 Kato H, Kawate N, Kinosata K, Yamamoto H, Furakawa K, Hayata Y. Photodynamic therapy of early-stage lung cancer. Photosensitizing compounds: their chemistry, biology and clinical use. Ciba Found Symp 1989; 146:183-97 5 Guidelines for the cance ....related checkup: recommendations and rationale. CA 1980; 30:195-240 6 Balchum OJ, Profio AE, Razum NJ. Mapping bronchial carcinoma in situ lung cancer lesions by combined imaging fluorescence bronchoscopy and ratioing fluorescence probe. Laser interaction with tissue, SPIE. Ciba Foundation Symposium 146. Photosensitivity compounds: Their chemistry, biology and clinical use. New York: John Wiley, 1988; 908:103-06 7 Kato H, Cortese DA. Early detection of lung cancer by means of hematoporphyrin derivative fluorescence and laser photoradialion. Clin Chest Med 1985; 6:237-53
The Prognostic Value of Sputum Cytology sputum cytology test has contrasting prognostic T hesignificance for squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma presenting with cancer cells in sputum is often roentgenographically occult, early stage, and surgically resectable. Adenocarcinoma presenting with diagnostic sputum cytology tends to be larger and more advanced due to nodal involvement and, therefore, has a correspondingly poor prognosis. The role of sputum cytology in screening for lung cancer was evaluated during the Early Lung Cancer Cooperative Study from 1970 to 1980. The collaborating institutions included Johns Hopkins, Mayo Clinic, and Memorial Sloan-Kettering Cancer Center, and the University of Cincinnati was the statistical center. They worked under the auspices of the National Institutes of Health.!" During the prevalence screening phase of this study, 81 patients with squamous cell carcinoma were iden-
tified. Thirty-one of these patients (38 percent) presented with an abnormal chest roentgenogram and normal sputum cytology. Thirty-five patients (43 percent) presented with abnormal sputum cytology and a normal chest roentgenogram. The remaining 15 patients (19 percent) presented with both abnormal cytology and abnormal roentgenogram. Overall, 50 (62 percent) of the 81 patients with squamous cell carcinoma had cancer cells in the sputum. Importantly, of these 50 patients with abnormal sputum cytology, 35 (70 percent) had roentgenographically occult squamous cell carcinoma." A series of 54 patients with a total of 58 roentgenographically occult cancers who underwent complete resection has been reported. 6 Fifty-six of these cancers were squamous cell, while two had both squamous and large cell components. No adenocarcinomas were identified in these patients with roentgenographically occult lung cancer. Patients were staged by the TNM classification according to their most advanced cancer: 19 of the 54 patients (35 percent) had in situ carcinoma, Tis, NO, MO; 25 patients (46 percent) were TINOMO; five patients (9 percent) were Tl, Nl, MO; four patients (7 percent) were T2, Nl, MO; one patient (2 percent) was T3, NO, MO. In total, 45 of the 54 patients (83 percent) were free of nodal involvement. The five-year survival of the overall group was 90 percent. The fiveyear survival for the 44 patients who were Tis, NO or Tl, NO was 91 percent. Adenocarcinoma is a different disease. During the Early Lung Cancer Cooperative Study, 43 patients with adenocarcinoma were identified. Thirty-five patients (81 percent) had an abnormal chest roentgenogram and normal cytologic findings, while eight (19 percent) had both abnormal sputum cytology and an abnormal roentgenogram. No patient had abnormal sputum cytology as the only abnormal test; therefore, only 19 percent of the patients had a diagnostic sputum cytology test, and none was roentgenographically negative." In the Mayo patients, nine of 19 patients (47 percent) with adenocarcinoma were stage I. Only one of these patients had a positive sputum cytology test. Ten of 19 patients (53 percent) were stage III, but only two of these had positive sputum cytologic findings. 7 During the incidence screening portion of the study, the Memorial Sloan-Kettering group found 18 patients with roentgenographically occult lung cancer; five lesions were adenocarcinomas (28 percent), while 13 were squamous cell carcinomas," In this series, a total of 59 adenocarcinomas were identified, only five (8 percent) of which were roentgenographically occult. The article by Miura et al in this issue (see page 1328) is a detailed description of 114 patients with adenocarcinoma who had sputum cytology testing prior to bronchoscopy and surgical resection. The CHEST I 102 I 5 I NOVEMBER, 1992
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REFERENCES 1 Peng MJ, Vargas FS, Cukier A, Terra-Filho M, Teixeira LR, Light R\\Z Postoperative pleural changes after coronary revascularization: comparison between saphenous vein and internal mammary artery grafting. Chest 1992; 101:327-30 2 Worth HC, Grundmann C, Goeckenjam G, Smidt U, Irlich G, Loogen F. Pre- and post-operative respiratory muscle fatigue in coronary artery revascularization surgery, Respiration 1984; 46:33-44 3 Begen R, Radoux ~ Cantin A, Menard IIA. Stiffness of the rib cage in a subset of rheumatoid patients. Lung 1988; 166:141-48 4 Greenwald L~ Baisden CE, Symbas PN. Rib fractures in coronary artery bypass patients: radionuclide detection. Radiology 1983; 148:553-54 5 Kenyon CM, Pedley TJ, Higenbottam TW Adaptive modeling of the human rib cage in median sternotomy. J Appl Physioll991; 70:2287-302 6 Hurlbut D, Myers ML, Lefcoe M, Goldbach M. Pleuropulmonary morbidity: internal thoracic artery versus saphenous vein graft. Ann Thorac Surg 1990; 50:959-64 7 Shapira N, Zabatino SM, Ahmed S, Murphy DMF, Sullivan D, Lemole G M. Determinants of pulmonary function in patients undergoing coronary bypass operations. Ann Thome Surg 1990; 50:268-73
1314
Photodynamic Therapy for Early Stage Lung Cancer Preferable to Resection? In this issue of Chest (see page 1319), Edell and Cortese-whose group at the Mayo Clinic has had much experience with photodynamic therapy (PDT) beginning with the early work of Lipson et al 1•2 _ present the interesting hypothesis that in certain patients with early-stage lung cancer (Tis), a conservative, localized form of treatment such as PDT may be preferred to resection. This is based on the attendant risks of surgery, the fact that surgery too is a localized form of treatment, the high risk of secondary cancers in these patients," and the desire to preserve lung function. As pointed out by the authors, PDT must prove to provide a benefit at least equivalent to that of surgical resection. The preliminary data in the article by Edell and Cortese point to this. Also, it appears that the risks of PDT are minimal in these patients.' However, as recently reported by Kato and Hayata' of the Tokyo Medical College, long-term control of early-stage lung cancer has been obtained with the use of PDT alone, even in a group of patients with non resectable disease. Survival times in these patients range to eight years," Interestingly, the results of Edell and Cortese for PDT in patients with resectable disease parallel those of the Tokyo group. As is well known, unfortunately, detection of lung cancer at this early stage is difficult. Although the American Cancer Society does not recommend largescale screening," the Mayo Clinic and the Tokyo Medical College are among the few institutions still carrying out early-detection programs, albeit in a somewhat different manner. While the Mayo Clinic screens high-risk patients who enter its facilities for a variety of medical reasons, the Tokyo Medical College is part of a national program and seeks high-risk patients through the media. The arguments against large-scale screening include the cost (estimated by Kato and Hayata' to be near $35,000 per case detected") and the unknown effect on survival. It is possible, however, that the cost of medical care for patients with undetected disease (surgery, radiation therapy, chemotherapy, and possible long-term terminal care) may offset the detection cost. If PDT (likely to be done on an outpatient basis for these patients and costing perhaps $3,000 or less) can, in fact, result in long-term control, in the final analysis, large-scale screening may be justified. In the meantime, it well may be worthwhile for individual institutions to follow the lead of the Mayo Clinic by screening high-risk patients who enter their facilities for other medical reasons. Furthermore, since current Editorials
fluorescence technology can detect even radiographically and bronchoscopically occult early-stage cancers,6,7 use of this capability in combination with a local treatment such as PDT could enhance both the detection rate and the "curability' of early-stage lung cancer. This, of course, requires the type of prospective trial suggested by Edell and Cortese.
Thomas J Dougherty, Ph.D. Buffalo
Department of Radiation Medicine, Roswell Park Cancer Institute.
REFERENCES 1 Lipson RL. The use of a derivative of hematoporphyrin in tumor detection. J Natl Cancer Inst 1961; 26:1-11 2 Lipson RL, Gray MJ, Baldes EJ. Hematoporphyrin derivative for detection and management of cancer. Proceedings of the IXth International Cancer Congress. 1966; 393 3 Woolner LB, Fontano RS, Cortese DA, Sanderson DR, Bernatz PE, Payne WS, et ale Roentgenographically occult lung cancer: pathologic findings and frequency of multicentricity during a 10 year period. Mayo Clinic Proc 1984; 59:453-66 4 Kato H, Kawate N, Kinosata K, Yamamoto H, Furakawa K, Hayata Y. Photodynamic therapy of early-stage lung cancer. Photosensitizing compounds: their chemistry, biology and clinical use. Ciba Found Symp 1989; 146:183-97 5 Guidelines for the cance ....related checkup: recommendations and rationale. CA 1980; 30:195-240 6 Balchum OJ, Profio AE, Razum NJ. Mapping bronchial carcinoma in situ lung cancer lesions by combined imaging fluorescence bronchoscopy and ratioing fluorescence probe. Laser interaction with tissue, SPIE. Ciba Foundation Symposium 146. Photosensitivity compounds: Their chemistry, biology and clinical use. New York: John Wiley, 1988; 908:103-06 7 Kato H, Cortese DA. Early detection of lung cancer by means of hematoporphyrin derivative fluorescence and laser photoradialion. Clin Chest Med 1985; 6:237-53
The Prognostic Value of Sputum Cytology sputum cytology test has contrasting prognostic T hesignificance for squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma presenting with cancer cells in sputum is often roentgenographically occult, early stage, and surgically resectable. Adenocarcinoma presenting with diagnostic sputum cytology tends to be larger and more advanced due to nodal involvement and, therefore, has a correspondingly poor prognosis. The role of sputum cytology in screening for lung cancer was evaluated during the Early Lung Cancer Cooperative Study from 1970 to 1980. The collaborating institutions included Johns Hopkins, Mayo Clinic, and Memorial Sloan-Kettering Cancer Center, and the University of Cincinnati was the statistical center. They worked under the auspices of the National Institutes of Health.!" During the prevalence screening phase of this study, 81 patients with squamous cell carcinoma were iden-
tified. Thirty-one of these patients (38 percent) presented with an abnormal chest roentgenogram and normal sputum cytology. Thirty-five patients (43 percent) presented with abnormal sputum cytology and a normal chest roentgenogram. The remaining 15 patients (19 percent) presented with both abnormal cytology and abnormal roentgenogram. Overall, 50 (62 percent) of the 81 patients with squamous cell carcinoma had cancer cells in the sputum. Importantly, of these 50 patients with abnormal sputum cytology, 35 (70 percent) had roentgenographically occult squamous cell carcinoma." A series of 54 patients with a total of 58 roentgenographically occult cancers who underwent complete resection has been reported. 6 Fifty-six of these cancers were squamous cell, while two had both squamous and large cell components. No adenocarcinomas were identified in these patients with roentgenographically occult lung cancer. Patients were staged by the TNM classification according to their most advanced cancer: 19 of the 54 patients (35 percent) had in situ carcinoma, Tis, NO, MO; 25 patients (46 percent) were TINOMO; five patients (9 percent) were Tl, Nl, MO; four patients (7 percent) were T2, Nl, MO; one patient (2 percent) was T3, NO, MO. In total, 45 of the 54 patients (83 percent) were free of nodal involvement. The five-year survival of the overall group was 90 percent. The fiveyear survival for the 44 patients who were Tis, NO or Tl, NO was 91 percent. Adenocarcinoma is a different disease. During the Early Lung Cancer Cooperative Study, 43 patients with adenocarcinoma were identified. Thirty-five patients (81 percent) had an abnormal chest roentgenogram and normal cytologic findings, while eight (19 percent) had both abnormal sputum cytology and an abnormal roentgenogram. No patient had abnormal sputum cytology as the only abnormal test; therefore, only 19 percent of the patients had a diagnostic sputum cytology test, and none was roentgenographically negative." In the Mayo patients, nine of 19 patients (47 percent) with adenocarcinoma were stage I. Only one of these patients had a positive sputum cytology test. Ten of 19 patients (53 percent) were stage III, but only two of these had positive sputum cytologic findings. 7 During the incidence screening portion of the study, the Memorial Sloan-Kettering group found 18 patients with roentgenographically occult lung cancer; five lesions were adenocarcinomas (28 percent), while 13 were squamous cell carcinomas," In this series, a total of 59 adenocarcinomas were identified, only five (8 percent) of which were roentgenographically occult. The article by Miura et al in this issue (see page 1328) is a detailed description of 114 patients with adenocarcinoma who had sputum cytology testing prior to bronchoscopy and surgical resection. The CHEST I 102 I 5 I NOVEMBER, 1992
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