to account for death. In contrast, in children with fewer injuries a pathologist will be searching for features to account for death and would be tempted to record the presence of gastric contents to reflect probable importance as a cause of death. It is potentially misleading to equate the presence of gastric contents in the airways at necropsy with appreciable hypoxia before death, without details of the quality of pathological examinations undertaken with respect to detailed neuropathology.

Small cell lung cancer

SIR,-In his editorial Mr Graham Crompton discusses the benefits of surgery in some patients with small cell lung cancer.' Our experience with resection of small cell carcinoma of the lung indicates that five year survival in patients after surgery is similar to that found by Prasad et al2 and slightly better than the five year survival figures published by Sorensen et al.3 Of 4749 patients who were diagnosed as having lung carcinoma in our TIMOTHY J D PIGOTT hospital over 10 years, 174 underwent resection of JAMES S LOWE small cell carcinoma with complete follow up of a University of Nottingham, minimum of five years. Twenty five patients died Queens Medical Centre, within one month of surgery. Of the remaining Nottingham NG7 2UH 149, 26 survived more than two years and 18 survived more than five years. Of those who 1 Sharples PM, Storey A, Aynsley-Green A, Eyre JA. Avoidable factors contributing to death of children with head injury. survived more than five years, 16 were treated by BrMedJ7 1990;300:87-91. (13 January.) surgery alone-that is, without adjuvant chemotherapy or radiotherapy. Of the 28 patients with stage I disease, 12 (43%) survived more than five years. AUTHOR'S REPLY,-My colleagues and I agree with We support the notion that surgery offers the Mr Timothy J D Pigott and Dr James S Lowe that prospect of long term survival, particularly for the existence of diffuse axonal injury cannot be patients with stage I and, possibly, stage II disease. excluded without detailed pathological examina- There is no doubt that surgery has a part to play in tion of the brain. It was the absence of such data in the management of small cell carcinoma of the many cases that precluded the use of neuropatho- lung, particularly when the tumour is small and logical criteria to judge the probability of survival situated peripherally, provided that a thorough in individual children, after the method of Rose check for metastases has been carried out including etal.' bone scans and computed tomography of the chest, The three children mentioned by Mr Pigott and abdomen, and brain. Abdominal ultrasonography Dr Lowe were classed by us as having an avoidable or isotope scans of the liver, or both, should be factor that probably contributed to death because performed if there is any doubt about liver involvethey had talked after the injury and subsequently ment on computed tomography. their condition deteriorated and they died, not It is now widely recognised that many small cell because of the findings at necropsy. If a patient carcinomas are fairly heterogeneous histopathowith head injury talks and later dies many authors logically and cytologically. Because of this heterohave stated that this suggests that the primary geneity it is not surprising that in a series of brain injury was not overwhelming and that death 850 patients. with pulmonary tumours who were resulted from secondary complications or asso- treated by resection 17% of the small cell carciated injuries.2 3 The findings at necropsy- cinomas were classified as being in the "grey namely, cerebral oedema with no other evidence of area."4 This is of considerable importance as this appreciable brain injury-were described for the study was carried out by experienced histopatholosake of completeness; other children with similar gists and resected material was assessed, which results at necropsy were not classed as having indicates that the grey area could have been even a potentially avoidable factor that probably or wider if small bronchoscopic biopsy specimens possibly contributed to death. or cytological preparations had been assessed. We also agree that there are major difficulties in Furthermore, the diagnosis is even more compliassessing the possible merits or otherwise of pre- cated by the fact that in a small number of cases hospital care retrospectively.4 In view of the large there is an overlap between small cell carcinoma numbers of children who died before admission to and carcinoid tumours that show atypical histohospital, however, we considered that it was logical features. These points should be borne in important to attempt to assess the incidence of mind when choosing certain therapeutic regimens potentially avoidable factors in this group. Our or analysing and comparing the results of different system of examining the possible effect of aspira- forms of treatment in different series. tion was identical with that used in a study by The recent extensive application of molecular Yates,5 which Jennett and Carlin cite as having biology and immunocytochemistry to pulmonary indicated that improved prehospital care would neuroendocrine tumours is likely to overcome not reduce mortality from head injury.6 Contrary some of the problems encountered in classifying results were found in our study despite the fact that and subtyping small cell lung cancer, which are we used a similar method. In view of the large currently largely based on morphological criteria.' number of children who die before arrival at A study of 40 patients with pulmonary neurohospital our data suggest that the possible benefits endocrine tumours that were investigated for of advanced prehospital care for patients with oncogene expression showed that there is some trauma in the United Kingdom should be deter- difference in the expression of oncogenes by these mined in prospective studies. tumours,6 and this may correlate with specific P M SHARPLES clinical and biological behaviour. Furthermore, Department of Child Health, investigation of oncogene expression may be used University of Newcastle upon Tyne, to identify the possible prognostically important Newcastle upon Tyne NE2 4HH subsets of such neoplasms that are not recognisable morphologically. 1 Rose J, Valtonen S, Jennett B. Avoidable factors contributing to death after head injury. BrMedJ 1977;ii:615-8. 2 Jeffreys RV, Jones JJ. Avoidable factors contributing to the death of head injury patients in general hospitals in Mersey region. Lancet 1981;ii:459-61. 3 Marshall LF, Toole BM, Bowers SA. The national traumatic coma data part 2: patients who talk and deteriorate: implications for treatment. 7 Neurosurg 1983;59:285-8. 4 Anderson ID, Woodford M, de Dombal FT, Irving M. Retrospective study of 1000 deaths from injury in England and Wales. Br MedJ 1988;2%:1305-8. 5 Yates D. Airway patency in fatal accidents. Br Med J 1977;ii: 1249-51. 6 Jennett B, Carlin C. Preventable mortality and morbidity after head injury. Injury 1978;10:31-9.

BMJ

VOLUME

300

24

FEBRUARY

1990

NASSIF B N IBRAHIM JAMES C BRIGGS C P FORRESTER-WOOD D AL-OKATI Departments of Histopathology and Thoracic Surgery, Frenchay Hospital, Bristol BS 16 ILE I Crompton G. Small cell lung cancer. Br Med _' 1990;300:210-1.

(27 January.)

2 Prasad US, Naylor AR, Walker WS, Lamb D, Cameron EWJ, Walbaum PR. Long term survival after pulmonary resection for small cell carcinoma of the lung. Thorax 1989;44:784-7.

3 Sorensen HR, Lund C, Alstrup P. Survival in small cell lung carcinoma after surgery. Thorax 1986;41:479-82. 4 Lamb D. Lung cancer and its classification. In: Anthony PP, MacSween RNM, eds. Recent advances in histopathology. No 13. Edinburgh: Churchill Livingstone, 1987:45-59. 5 Addis BJ, Hamid Q, Ibrahim NBN, Fahey M, Bloom SR, Polak JM. Immunohistochemical markers of small cell carcinoma and related neuroendocrine tumours of the lung. J Pathol 1987;153: 137-50. 6 Roncalli M, Springall DR, Varndell I, et al. Oncoprotein expression in endocrine tumours. J Pathol (in press).

SIR, -Though he correctly emphasises the role of surgery in patients with stage I or stage II small cell lung cancer, Mr Graham Crompton does not refer to the correct histological classification of small cell carcinoma.' Oncologists often claim that there is no problem in making this diagnosis, but this is often not true. Though the majority of small cell carcinomas have a characteristic appearance, there is a grey area in which it can be difficult to differentiate between small cell carcinoma and large cell undifferentiated carcinoma. In a review of 850 patients with resected tumours the diagnosis of large cell carcinoma was altered to small cell carcinoma in 13 cases and from small cell carcinoma to large cell carcinoma in eight cases-a grey area of about 17%.2 Thus an emphasis on the correct diagnosis of small cell carcinoma must be made in any article dealing with treatment. In the Edinburgh study 34 of the tumours were peripheral. Peripheral neuroendocrine carcinoma3 and peripheral carcinoid tumour have been misdiagnosed as small cell carcinoma. These tumours have a much better prognosis than small cell lung carcinoma: in a study of 25 patients who were followed up for two years or more after resection 21 had no evidence of recurrence; and of 15 patients followed up for five years or more, 10 had no evidence of metastasis.3 In summary, the correct diagnosis of small cell carcinoma is of paramount importance in any study dealing with treatment of this aggressive tumour. The problems inherent in making the correct diagnosis and the possibility of including other less aggressive tumours under the umbrella of small cell carcinoma must be taken into account. MARY N SHEPPARD National Heart and Lung Institute, London SW3 6LY 1 Crompton G. Small cell lung cancer. BrMedJ 1990;300:209-10. 2 Lamb D. Lung cancer and its classification. In: Anthony PP, MacSween RNM, eds. Recent advances in histopathology. Vol 13. Edinburgh: Churchill Livingstone, 1987:45-59. 3 Mark EJ, Ramireaz JF. Peripheral small cell carcinoma of the lung resembling carcinoid tumour. Arch Pathol Lab Med 1985;109:263-9. 4 Warren WH, Penfield Faber L, Gould VE. Neuroendocrine neoplasms of the lung. J Thorac Cardiovasc Surg 1989;98: 321-2.

Cognitive impairment and death in the elderly SIR,-Dr J M Eagles and colleagues report an association between cognitive impairment and mortality in elderly subjects living in the community.' They do not comment, however, on the baseline physical health of their cohort and were unable to distinguish between dementia and delirium. In our study of 119 patients admitted for acute geriatric care we found that mortality over' 10 weeks from admission was significantly higher in the demented (42%) than in the non-demented patients (15%; p

Small cell lung cancer.

to account for death. In contrast, in children with fewer injuries a pathologist will be searching for features to account for death and would be temp...
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