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


relationship of sputum cytology to the bronchoscopic findings, the anatomic stage, and the prognosis of these patients is of significant interest. The presence of adenocarcinoma cells in the sputum is a poor prognostic sign regardless of the bronchoscopic findings. Adenocarcinoma cells were in the sputum of 29 of the 114 patients (25 percent). A similar but slightly lower rate of 19 percent was reported during the prevalence screen of the early lung cancer detection study" Of these 29 patients, only 14 percent were categorized as either stage I (one patient) or stage II (three patients). Furthermore, three of the 29 patients (10 percent) were NO, five (17 percent) were Nl, and 17 (59 percent) were N2. Overall, 76 percent of the patients with adenocarcinoma in the sputum proved to have Nl or N2 nodal involvement. The size of the cancers was greater than 3 em in 86 percent of these patients. No patient with adenocarcinoma in the sputum survived five years. When both sputum cytology and the bronchoscopic examination were normal and yet adenocarcinoma was proven at resection, there was a much better prognosis. Fortunately, this was the most common presentation, occurring in 69 of the 114 patients (61 percent). The cancers were usually peripheral in location; 48 percent were stage I, and 12 percent were stage II. Nodal involvement was documented to be NO in 51 percent, while Nl and N2 nodes were involved in fewer than half of the patients (46 percent). Also, the lesions were less than or equal to 3 em in size in 46 percent of the patients and actually were less than 2 em in size in 16 percent of the patients, The five-year survival when the sputum cytology was normal and the bronchoscopic visual examination was unremarkable was 55 percent. An abnormal bronchoscopic examination is also a poor prognostic sign in adenocarcinoma regardless of the sputum cytology test result. Eighty-nine percent of these cancers were stage IlIA, IIIB, or I~ The poor survival of this group was similar to that of patients who presented with adencarcinoma cells in the sputum. For survival comparisons, Williams et al9 reported a five-year survival in stage I nonsmall cell carcinoma for all causes of death of 55 percent, and a five-year survival from lung cancer of 65 percent. Rossing and Bossing'? reported a five-year cancer survival for patients with adenocarcinoma of 48 percent; for unresectable adenocarcinoma, the five-year survival was 25 percent. With all of this in mind, it appears that the presence of cancer cells in cytology has different prognostic implications for squamous cell carcinoma and adenocarcinoma of the lung. For squamous cell carcinoma, the abnormal cytology may indicate the presence of a cancer that is resectable, has a low rate of nodal 1316

involvement, and has a good five-year survival rate. When adenocarcinoma cells are in the sputum, patients have a poor five-year survival due to a high rate of nodal involvement. Denis A. Cortese, M.D., F.C.C.R Rochester; Minnesota Thoracic Diseases and Internal Medicine, Mayo Clinic. Reprint requests: Dr. Cortese, Division of Thoracic Diseases, Mayo Clinic, Rochester; MN 55905

REFERENCES 1 Berlin NI, Buncher CR, Fontana RS, Frost JK, Melamed MR. The National Cancer Institute Cooperative Early Lung Cancer Detection Program. Am Rev Respir Dis 1984; 130:545-49 2 Frost JK, Ball WC Jr, Levin ML, Tockman MS, Baker RR, Carter D, et ale Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Johns Hopkins study. Am Rev Respir Dis 1984; 130:549-54 3 Flehinger BJ, Melamed MR, Zaman MB, Heelan RT, Perchick WB, Martini N. Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Memorial Sloan-Kettering study Am Rev Respir Dis 1984; 130: 555-60

4 Fontana RS, Sanderson DR, Taylor WF, Woolner LB, Miller WE, Muhm JR, et ale Early lung cancer detection: results of the initial (prevalence) radiologic and cytologic screening in the Mayo Clinic study. Am Rev Respir Dis 1984; 130:561-65 5 Fontana RS, Sanderson DR, Taylor WF, Woolner LB, Miller WE, Muhm JR, et al, Early lung cancer detection: summary and conclusions. Am Rev Respir Dis 1984; 130:565-70 6 Cortese DA, Pairolero PC, Bergstrahl EJ, Woolner LB, Uhlenhopp MA, Piehler JM, et ale Roentgenographically occult lung cancer: a ten-year experience. J Thorac Cardiovasc Surg 1983; 86:373-80 7 Woolner LB, Fontana RS, Sanderson DR, Miller WE, Muhm JR, Taylor WF, et al. Mayo Lung Project: evaluation of lung cancer screening through December 1979. Mayo Clin Proc 1981; 56:544-55 8 Melamed MR, Flehinger BJ~ Zaman MB, Heelan Kt Perchick WA, Martini N. Screening for early lung cancer: results of the Memorial Sloan-Kettering study in New York. Chest 1984; 86: 44-53 9 Williams DE, Pairolero PC, Davis CS, Bernatz PE, Payne WS, Taylor WF, et al. Survival of patients surgically treated for stage I lung cancer. J Thorac Cardiovasc Surg 1981; 82:70-6 10 Rossing TH, Rossing RG. Survival in cancer: an analysis of the effects of age, sex, resectability, and histopathologic type. Am Rev Respir Dis 1982; 126:771-77

Management of Acute Empyema pleural empyema is the accumulation of pus within the pleural space. Empyema may be acute or chronic and may be localized or diffuse. The development of empyema has been described as triphasic. 1.2 Empyema begins with an exudate as the pleura secretes protein-rich fluid in response to contamination. During this phase, the lung remains mobile within the fluid. The second phase, known as the fibrinopurulent phase, is characterized by the accumulation of large quantities of frank pus and fibrin. Fibrin deposition produces a thick pleural peel, which Editorials

The prognostic value of sputum cytology.

fluorescence technology can detect even radiographically and bronchoscopically occult early-stage cancers,6,7 use of this capability in combination wi...
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