The

BRITISH JOURNAL
OF RADIOLOGY F O U N D E D 1896

NEW SERIES, VOL. X MARCH 1937 No. I l l

THE DIAGNOSIS AND TREATMENT OF PRIMARY CANCER

OF THE LUNG
By ARTHUR C. CHRISTIE, M.D., Washington, D.C.
(The Nineteenth Silvanus Thompson Memorial Lecture, delivered at the Annual
Congress of Radiology, December 3, 1936)

PRELIMINARY REMARKS

M Y first duty, and at the same time a great pleasure, is to express my

grateful thanks to the British Institute of Radiology for the honour
conferred upon me by the invitation to deliver the Silvanus Thompson Memorial
Lecture. My feeling of satisfaction, however, is tinctured with one of trepidation
when I recall the names of those who have delivered this lecture in previous
years. I think it is no accident that the lecture has been delivered not only
by specialists in radiology but by leaders in physics and biology on the one
hand and by eminent clinicians and surgeons on the other. Such a distribution
is in harmony with the evident policy of this Institute to maintain close
connection with the basic sciences upon which radiology is founded and with
clinical medicine which it serves.
I have a personal debt to acknowledge at this time, in that the preparation
of this lecture has stimulated me to become better acquainted with the man
for whom it was founded. The delightful biography written by his wife and
daughter reveals Silvanus Thompson as a great and charming personality.
His many-sided interests and activities, scientific, cultural and humanitarian,
gave him not only a national but an international influence which extended
over a period of many years. In the United States he was known to several
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142 A. C. Christie
generations of students through his Elementary Lessons in Electricity and
Magnetism, and to a wide reading public through his Life of Faraday, Light
Visible and Invisible, and his Biography of Lord Kelvin.
The wideness of Professor Thompson's sympathies and interests is well
illustrated by his election in 1897 as the first president of the British Rontgen
Society, which was composed largely of medical men and organised to further
the interests of medical radiology. The following statement in his presidential
address is as true to-day as when it was uttered nearly forty years ago. He
said: "We are confronted with a marvellous record of progress. Excepting
only the introduction into surgery by Lord Lister of antiseptics, and the
discovery of anaesthetics, no discovery in the present century has done so
much for operative surgery as this of the Rontgen rays."
Although Silvanus Thompson was not himself a physician, his wide
humanitarian interests were such that it is not out of place for a lecture
dedicated to his memory to deal with an important disease which is of par-
ticular interest to the radiologist in both the diagnostic and therapeutic fields.

INTRODUCTION

The subject which I have chosen, "The Diagnosis and Treatment of

Primary Cancer of the Lung," is one that has aroused much interest during
the past twenty-five years. The disease was quite unknown until the latter
part of the eighteenth century. In spite of its accurate description by great
clinicians of the nineteenth century, notably Laennec, Graves and Stokes, and
study of its pathological aspects by Rokitansky and Virchow, it was looked
upon as a rare and hopeless disease until Adler in 1912 published his classical
monograph. 2 In that work the author not only gives a brief summary of each
of 374 cases of malignant lung tumour, all that he could collect from the
world's literature, but he gives a concise and accurate description of the
pathological and clinical aspects of the disease, a description that has been
scarcely improved upon to the present day. From the time of the publication
of that wrork down to the present moment, the interest in carcinoma of the
lung has steadily increased. Interest has been stimulated by several circum-
stances. The first is the apparent increase in incidence of the disease. Whether
this is rightly explained on the grounds of more accurate diagnosis and greater
care at autopsy to search for its presence or upon a real increase in relation
to cancer elsewhere in the body, the fact is established that cancer of the lung
now accounts for from 5 to 10 per cent, of all carcinomas found at autopsy.
The order of frequency is well shown by the following table taken from
an article by Rosedale and McKay.69 Among 466 malignant neoplasms of
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The Diagnosis and Treatment of Primary Cancer of the Lung 143

all types the table shows the number of cases for the twelve most frequently
found malignancies.

Stomach .. 71 Bram tumours .. 24

Uterus .. 33 Colon .. 22
Lung .. 33 Breast .. 19
Rectum .. 30 Bladder .. 17
Oesophagus .. 30 Pancreas .. 16
Prostate .. 24 Tongue .. 15
The relative frequency varies somewhat in different statistical reports,
but in all it is shown that primary lung cancer is not a rare disease but a
very common one. It is about on the order of frequency of cancer of the
rectum.
The second reason for increased interest in the disease is the improvement
in diagnostic methods which has taken place during the past twenty-five years.
The perfection of X-ray examination with the addition of bronchography
and the development of bronchoscopy have greatly improved our ability to
make an early diagnosis.
Within the past few years an added incentive to study the disease has
grown out of the possibility of its successful treatment. We are just now
in the midst of developments in thoracic surgery and in radiology, which offer
the prospect of saving at least some of these hitherto hopeless cases.
It is now the rather generally held opinion that cancer of the lung is
increasing not only in total number of cases but out of proportion to cancer
in general This opinion is based upon the fact that in European countries
and the United States the number of cases of lung cancer, clinically diagnosed
and disclosed at autopsy, has showrn a gradual but steady increase for the
past twenty-five years. It is impossible within the limits of this lecture to
give an idea of the vast amount of investigation which has been carried on
in many countries on this single aspect of the study of lung cancer, namely,
its increase in frequency in recent years. In spite of the fact that both the
investigative work and general clinical experience point very strongly to an
actual and relative increase, there are still many who believe that the increased
number of cases reported is due, at least in large part, to more accurate methods
of diagnosis and to more careful search for the disease at autopsy.
Whatever the true explanation, there is no doubt of the fact that we are
dealing with a disease of a high order of frequency, and one that the physician
must always have in mind as a possibility when a patient presents himself
with chest symptoms.
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144 A. C. Christie
PATHOLOGY
The pathology of lung cancer must be considered briefly before we
proceed to its clinical aspects. There have been many elaborate classifications
based upon histogenesis. It is now well established that primary cancers of
the lung are all bronchiogenic in origin. That is, they arise from the primitive
generative epithelium of the basal layer of the bronchial mucosa. Whether,
therefore, they originate from the lining cells of a bronchus, or from those
lining the mucous glands of a bronchus, or from the cells of the pulmonary
alveoli which are a continuation in modified form of the lining cells of the
bronchioles, they can all be classified as bronchiogenic carcinoma.
The histologic classification which is now quite generally accepted,
divides bronchiogenic carcinoma into: (1) Adenocarcinoma; (2) Squamous csll
carcinoma; (3) Undifferentiated cell carcinoma. This suggests the question
of grading. Bronchiogenic carcinoma runs the entire gamut from the almost
completely undifferentiated mass of indifferent basal cells to the highly
differentiated adenocarcinoma or squamous cell carcinoma. It must be
recognised, too, that this variation may occur within the same tumour and
that histologic examination may be completely misleading if the tissue examined
includes only a small part of the tumour.
From a practical standpoint the location of the tumour may be of more
importance than its structure. Tuttle and Womack76 offer convincing evidence
that tumours arising in the peripheral portions of the lungs are more likely
to involve the mediastinal glands and to metastasise to distant parts at an
early stage of the disease than are cancers arising in the main bronchial trunks.
They also offer statistical evidence to show that peripheral tumours run a
more rapid course than those located in a major bronchus. In their series
the average duration of life for the patients with a peripherally located tumour
was 7-3 months compared with 26-3 months for those with the tumour located
in a main bronchus. The prognosis is also affected by the location of the
tumour with relation to the wall of the bronchus. If it is located within the
bronchus and spreads along the bronchial mucosa it is much less malignant
than the type that originates deep in the bronchial wall and is invasive in
character. The latter, instead of producing a tumour which can be seen within
the bronchus, early invades the deeper structures, extends out into the lung
parenchyma and may involve the mediastinal structures and the pleura before
a diagnosis is made.
METASTASIS
An important aspect of bronchiogenic carcinoma is its high rate of
metastasis. Many cases are reported in the literature in which the finding
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The Diagnosis and Treatment of Primary Cancer of the Lung 145

of a metastatic lesion preceded the discovery of the primary lesion in the
lung. The latter, in fact, often was not found until autopsy. One of the most
striking characteristics of the disease is the frequency of metastasis to the
brain. Many cases have been reported in which the patient was operated
upon for primary brain tumour when in fact the brain lesion was secondary
to carcinoma of the lung. The metastatic tumours are also frequently found in
the bones, both long bones and flat bones being involved. Aside from the
central nervous system and the bones, bronchiogenic carcinoma is noted for
its widespread metastasis to many organs. The most frequent is the liver
but it has been reported in the adrenals, kidneys, pancreas, spleen, ovary,
intestines, skin, and in many other localities.

SYMPTOMS
It is of special importance to emphasise the symptoms of bronchiogenic
carcinoma, because if headway is to be made in treatment a diagnosis must
be made much earlier than has been the rule in the past. Most observers
agree that cough is the most common early symptom. There is nothing charac-
teristic about it, but when cough arises in a person at or beyond middle age
and is persistent, its serious possibilities should be kept in mind. Pain in the
chest which may or may not be accompanied by cough is the next most
important early symptom. It may be only a sense of heaviness or a dull ache
which the patient refers to some particular locality, or it may be sharp and
lancinating. The third symptom is dyspnoea, which may amount to shortness
of breath or only to a feeling of inability to fill the lungs with air. The fourth
important symptom is hemoptysis. Sometimes this is the very first indication
that the patient has anything the matter with him. It may be only a slight
blood-tinged sputum or a haemorrhage of considerable amount. To summarise
the symptoms, a persistent cough with the raising of a small amount of sputum
which is sometimes blood-tinged and accompanied by moderate dyspnoea
and pain in the chest, especially if they occur in a patient forty years of age
or older, should immediately raise suspicion of carcinoma of a bronchus.
There are cases in which the first symptom is fever due to localised pneumonitis
in the area of lung distal to the tumour and in which there is incomplete
aeration due to obstruction by the tumour. In one of our patients the attacks
of fever were always preceded by a violent chill. Other cases of rapidly growing
peripheral tumours first report to a physician because of pain due to pleurisy
or pleural effusion. Later in the disease the symptoms are those of complica-
tions such as suppurative processes or of pressure effects in the mediastinum
such as hoarseness due to paralysis of a vocal cord. Emphasis is placed upon
 MARCH 1937

146 A. C. Christie
the early symptoms, because if the presence of bronchiogenic carcinoma is
once suspected we now have means for its definite diagnosis in the majority
of cases.
Physical signs are of little value. The}' are simply those of varying degrees
of bronchial obstruction or of complicating conditions such as bronchiectasis,
abscess or pleural effusion. Vinson78 emphasises the importance of finding
evidence of bronchial obstruction upon physical examination as evidenced by
distant breath sounds without corresponding impairment of the percussion
note.
The final diagnosis of bronchiogenic carcinoma in the majority of cases
must rest upon a careful correlation of information obtained by several
different methods of investigation. The first in order is the rontgenological
examination.
RONTGENOLOGICAL FINDINGS
Many writers have attempted to classify the rontgenological signs of
lung cancer, but elaborate classifications have added little to our ability to
make a correct diagnosis. The complications present in nearly every case
produce pictures of such diversity that the individual case can rarely be placed
in any definite class except one that is very broad and general. A fact that
has emerged from the experience of the past few years is that there are two
fairly distinct types of bronchiogenic carcinoma. Kirklin and Paterson43
recognised this in their terms "bronchial" and "parenchymal" types. Tuttle
and Womack76 offer evidence to show that the centrally located and the
peripherally located cancers differ markedly in their cytology, clinical course
and rate of metastasis. They classify them as "tumour in major bronchus"
and "tumour in periphery of lung." The\^ place all tumours distal to the first
bifurcation of the major bronchus in the "peripheral" class. Such a division
corresponds very well to the rontgenological findings. At the present time
it seems helpful, therefore, to recognise two types which I shall name the
"hilar type" and the "parenchymal type." It seems better to substitute
"hilar" for "bronchial" in Kirklin and Paterson's classification, since the
latter term, applied to the main trunk tumours, implies that the peripheral
tumours are not bronchial in origin.
A third class may be usefully added to the first two, namely the "apicaJ
type." These tumours deserve separate classification because they constitute
a distinct type both clinically and rontgenologically, and because it is rarely
certain in an individual case whether the apical tumour has originated in a
main bronchial trunk or in the periphery of the lung. Reference is made to
this type of tumour later under differential diagnosis.
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The Diagnosis and Treatment of Primary Cancer of the Lung 147

The well-circumscribed and relatively small areas of increased density
observed in early cases are often fairly characteristic or at least will point
the way to further procedures which may lead to a diagnosis. Unfortunately
the picture is usually much more complex and difficult of interpretation due
to the complications resulting from the continued growth of the tumour.
Obstruction to a bronchus, either partial or complete, produces various
results, both immediate and remote. The first result of complete obstruction
is atelectasis of the area of lung supplied by the obstructed bronchus. If
the obstruction is only partial, an area of lung may be poorly aerated, or on
the other hand may be the site of obstructive emphysema due to a ball-valve
like the action of an endobronchial tumour. The exact location of the tumour
may be demonstrated at times after injection of lipiodol.
A common, if not invariable, result of atelectasis, is infection, which may
manifest itself in various ways. The patient may have a sudden febrile attack
and rontgenological examination will show a more or less circumscribed area
of infiltration in the lung which may be described as a pneumonitis. If the
patient is known to have a bronchiogenic carcinoma the true nature of the in-
flammatory process will be recognised; otherwise the condition maybe diagnosed
as a simple and inflammatory process. Another complication which may cause
mistake or great difficulty in diagnosis is an infected cavity within the tumour.
A third and important result of infection is the production of
bronchiectasis. I believe this to be the true sequence, namely, atelectasis
followed by infection and infection followed by bronchiectasis. It is now
generally recognised that bronchiectasis is in the majority of cases due to
infection of the bronchial mucosa which destroys the elastic fibres in the walls
of the bronchi. It is hardly conceivable that the obstruction of a bronchus
due to a tumour could produce true bronchiectasis in an otherwise healthy
bronchus. The bronchiectasis may become so extensive, however, that it
completely obscures the original disease. The carcinoma may remain small
and will escape discovery even at autopsy unless special search is made for it.
The cause of obstruction to a bronchus by carcinoma is not always an
endobronchial growth. The invasive type of tumour which grows out into the
lung structure may so surround a small or even a large bronchus and produce
such constriction as to partially or completely obliterate the lumen. Farinas15
has demonstrated such constrictions by his method of serial bronchography.
Another complication which sometimes completely obscures the lung
field is pleurisy with effusion. Since the tumours which cause pleural involve-
ment are often those at the periphery instead of those located in the main
bronchi, there is no means of making a diagnosis unless the pleural fluid
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148 A. C. Christie
itself discloses the true condition. If the fluid is bloody, malignant disease
will be suspected. Even when the fluid is clear, if there is no evident cause for
the pleurisy, it is well to have the fluid examined for its histological contents.
This is best accomplished by centrifuging the fluid and embedding and
sectioning the precipitated coagulum just as one would a piece of tissue. If
the cells remain in a watery solution after centrifuging, any clear cell-free
serum such as that used for typing or Wassermann reaction may be added to
produce coagulation, as recommended by Konzelmann.37
An additional aid to rontgenological examination in chest tumours is
the diagnostic pneumothorax. It has limited application to those cases in
which the evidence is fairly conclusive that one is dealing with a new growth.
It enables one to determine the presence or absence of pleural adhesions, to
localise the tumour with relation to the lobes of the lung and the hilar
structures, and to obtain a good idea of its size.
It is apparent from the previous discussion that the rontgenological
evidence alone is often not sufficient to establish a diagnosis of bronchiogenic
carcinoma. Careful correlation of all the evidence obtainable by the
rontgenological examination with the history, the clinical course and the
symptoms will in a considerable percentage of cases make the diagnosis fairly
certain, and will point the way to further examination which may establish
it definitely.
BRONCHOSCOPY
A valuable addition of recent years to diagnostic methods is bronchoscopy.
It should always be preceded by careful rontgenographic study so that the site
of the lesion may be located as accurately as possible through the presence
of atelectasis, obstructive emphysema and bronchography. The greatest
value of bronchoscopy lies in the possibility of obtaining tissue for biopsy.
If the method is to come into general use we must have more well-trained
bronchoscopists located in every centre of population. Certain precautions
must be observed in removing tissue for biopsy. It must be recognised that
the method is applicable only to those growths which are plainly visible within
the bronchial lumen. In growths of the deeply invasive type which cause
only a distortion of the bronchial wall by pressure, Jackson and others warn
against attempts to remove tumour tissue by cutting through normal bronchial
mucosa. Such attempts may result in serious haemorrhage, in rapid extension
of the malignant growth or in emphysema and subsequent mediastinal infection.
When the growth is seen it is important that the biopsy specimen be
secured from the actual tumour and not from a superficial necrotic or inflam-
matory area, or from exuberant granulations which may accompany the
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The Diagnosis and Treatment of Primary Cancer of the Lung 149

growth. It is important to emphasise this point. The pathologist does not
always find it easy to distinguish between various types of inflammatory
hyperplasia or tuberculous, syphilitic or mycotic granulomatous tissue and
true malignant disease. He also finds real difficulty at times in distinguishing
between benign adenoma and adenocarcinoma. There is little doubt that some
of these growths which behave clinically as benign neoplasms, in that they are
not invasive and do not metastasise, have been considered malignant and have
found their way into the literature as reported cures of bronchiogenic cancer.
It is emphasised by Jackson that the experienced bronchoscopist can
recognise narrowing of the lumen and fixation of the bronchial walls which
may lead to a diagnosis of carcinoma in certain cases even when he cannot
actually see the growth.
Bronchoscopy is valuable, then, in well-trained hands, for the recognition
of the considerable percentage of carcinomas which present themselves within
the lumen of a main bronchial trunk. The only exception to this is tumour
of the upper lobe trunks. In this location they can be seen only when they
originate at the orifice of the upper lobe trunk or late in the disease when they
have grown down to the orifice. For the relatively small percentage of tumours
which occur far out in the secondary or tertiary branches of any of the bronchi
it is obvious that bronchoscopic examination is of no value. Practically,
then, we must recognise that a positive report of the presence of bronchiogenic
carcinoma after bronchoscopy is of absolute value, but that the negative report
must be received with reserve.

DIFFERENTIAL DIAGNOSIS
Bronchiedasis
There are cases of bronchiectasis in which it is difficult to exclude
carcinoma either as the original disease or as secondary to the bronchiectasis.
If the disease is unilateral and bronchography shows blocking of a bronchus
the rontgenological signs are strongly presumptive and it will usually be
possible to make a positive diagnosis by bronchoscopy. When the history
is that of long-standing bronchiectasis, which is revealed by bronchography,
it is often impossible to diagnose the presence of carcinoma within the bron-
chiectatic lung unless the lesion is seen bronchoscopically or if, upon the
removal of what is supposed to be granulation tissue, microscopic examination
reveals malignant cells.
Lung Abscess
The fact that cavities within bronchiogenic carcinomas have been
mistaken more than once for chronic lung abscess must keep the diagnostician
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150 A. C. Christie
alert for this possibility. Bronchoscopy with a positive finding of carcinoma
is the only way to be absolutely certain in these cases, unless the abscess
breaks into the pleural cavity and the fluid can be aspirated and examined.
The following brief history illustrates the difficulties of diagnosis in these cases:
Mrs. M. W., aged 35 years. About three years prior to her first admission
to the hospital, which was in October, 1933, she had had a haemorrhage from
the lung, at which time she was kept in bed for three months and afterwards
treated by pneumothorax. For ten days before admission to hospital she had
high evening temperature, dry cough and pain in lower right chest. Fluid
aspirated at that time showed pus with numerous cocci, small gram negative
bacilli and some spirillae and fusiform bacilli. No tubercle bacilli. Rib was
resected and a lung abscess evacuated. Discharged in two weeks as improved.
Re-admitted in December with diagnosis of bronchiectasis. Lobectomy of
right lower lobe and massive bronchiogenic carcinoma found.
Dernwid Cysts
These tumours are often recognisable rontgenographically by their smooth,
well-circumscribed contour, and especially if they contain calcined material or
teeth. If they are accessible to aspiration the epithelial contents often reveal
their nature. It is only when a dermoid cyst begins to increase in size and
because of its pressure upon bronchi causes atelectasis or pneumonic attacks
that it may be mistaken for cancer.
Thynwma
Tumours of the thymus gland may at certain stages of their development
simulate bronchiogenic carcinoma. Their position immediately behind the
sternum as revealed in lateral rontgenograms and their prompt response to
radiation therapy are their distinguishing features.
Pleural Effusion
The microscopic examination of aspirated pleural effusion has already
been described, but some of the difficulties and uncertainties of aspiration
biopsy are illustrated by the following cases:
A man, 65 years of age, presented because of fatigue, loss of weight and
shortness of breath. Rontgenological study showed fluid at the right base
and a circumscribed area of opacity in the mid-portion of the right lung field.
Study of the sediment from the aspirated pleural fluid resulted in the diagnosis
of malignant disease, presumably of the lung. The patient improved under
deep X-ray therapy but later became worse and died after about six months.
At autopsy the pleura was found thickened in the neighbourhood of the region
which was presumably involved in the malignant process, but no malignant
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The Diagnosis and Treatment of Primary Cancer of the Lung 151

disease could be found. There was present an almost complete stenosis of the
aortic valve. It was evident that the aortic stenosis with accompanying
cardiao-renal changes could account for the history, rontgenological findings,
and the death of the patient. There is still the possibility that a radio-sensitive
malignant tumour was present and accounted for the histological findings
in the aspirated pleural fluid.
In another case, a man aged 26 years, there was a well-circumscribed
mass in the lateral aspect of the base of the left lung. The pathologist reported
the results of the needle biopsy as follows: " . . . a mass of round cells which
are apparently tumour cells. No mitotic figures are seen and it is impossible
to tell from the cells that are present whether they are sarcomatous or carcino-
matous. In some areas they have a resemblance to primary carcinoma of the
lung." The mass disappeared under moderate dosage of X rays. About two
months later the patient became jaundiced and a large tumour was demon-
strated in the head of the pancreas. This also disappeared after irradiation.
The patient remained in good health for about six weeks and died suddenly
from cerebral haemorrhage. An incomplete autopsy report by the coroner
stated that death was due to cerebral abscess with haemorrhage. The diagnosis
in this case remains in doubt, but the sequence of events may have been
primary lung tumour, metastasis to the pancreas and metastasis to the brain.
Apical Tumours
Malignant tumours in the apex of the lung have received considerable
attention in recent years. It has now been sufficiently demonstrated by
different observers7- 23> 60> 75 that various types of apical tumour may produce
much the same clinical picture, namely pain in the region of the apex, shoulder
and neck and Horner's syndrome (miosis, ptosis, enophthalmos, and unilateral
parsesthesia of the face). The rontgenological findings of opacity in the apical
region and partial destruction of one or two ribs may occur in quite dissimilar
malignant neoplasms. There have come under my own observation several
cases of bronchiogenic carcinoma, several cases of metastatic carcinoma
and one case of neuroglioma or sympathoblastoma, all producing the common
symptoms and signs of apical lung tumour.
The diagnosis of bronchiogenic carcinoma is in the end a matter of the
most careful co-operation between the clinician, the radiologist, the broncho-
scopist and the pathologist. A certain percentage of cases may be recognised
with a high degree of certainty upon the rontgenographic findings supported
by the history and symptoms. Bronchoscopy will add to the certainty in
many of these cases and will serve to diagnose some that could not otherwise
be recognised. A few cases will be brought to light by examination of aspirated
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152 A. C. Christie
pleural effusion. Mediastinal tumours due to lymphosarcoma or Hodgkin's
disease may be distinguished from bronchiogenic carcinoma by their rapid
disappearance under relatively small doses of radiation. A few others can be
cleared up by removal and examination of a palpable gland in the cervical or
axillary region. It is well to remind ourselves that a metastatic lesion may
cause the only symptoms of which the patient is conscious and especially that
symptoms of a brain tumour should direct our attention to the possibility of
primary bronchiogenic carcinoma. Finally there are a few cases in which
exploratory thoracotomy is a justifiable procedure. This should be undertaken
only in those cases in which the evidence is very strong for the presence of
bronchiogenic carcinoma and which by the standards now recognised are
operable cases.

TREATMENT
The situation with regard to treatment of bronchiogenic carcinoma has
been quite hopeless until very recent years. At the present time it is one of
hopeful expectancy based upon a few established cures.
Cancer in any part of the body is curable, in our present state of knowledge,
only when it remains localised and is in a situation accessible to present means
of attack. In the past, bronchiogenic carcinoma has usually not been recognised
until it was no longer a strictly local disease, and its late recognition is still
one of its most discouraging features. With regard to accessibility we are just
now in the midst of developments in thoracic surgery which give promise
of cure in a certain limited class of cases. Not until it was demonstrated that
lobectomy and later pneumonectomy could be performed with a fair prospect
of survival of the patient was there hope for the cure of bronchial cancer by
surgical means. Following the pioneer work of Sauerbruch72 and Lilienthal49
and of Colonel Wm. H. Keller39' 40> 41 of the United States Army on cases
of post-war chest infections, there have arisen in several countries a few
skilful and daring surgeons who have demonstrated that the thoracic cage
can be opened and diseased contents removed, followed by recovery in a fair
percentage of patients. A review of recent articles by thoracic surgeons
indicates that pneumonectomy has superseded the earlier operation of lobectomy
in cases of bronchiogenic carcinoma. There seems to be little uniformity as
yet in the technique of operations on the chest and scarcely a score of successful
pneumonectomies have been reported, with a much smaller number of authentic
cures of lung cancer. Any cures at all in a disease which has been uniformly
fatal must lead us to study the possibilities of the method.
In the present enthusiasm for radical chest surgery in bronchial cancer
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The Diagnosis and Treatment of Primary Cancer of the Lung 153

it is important to establish some definite criteria of operability. Otherwise
high operative mortality and failure of cure in a high percentage of cases may
halt all progress along this line. The contra-indications to operation for
bronchiogenic carcinoma which are already recognised, are as follows:
1. Wide local extension of the disease with involvement of the mediastinum.
2. Glandular metastasis which is recognised by enlargement of supraclavicular
or axillary nodes. 3. Distant metastases to brain, liver, bones, pancreas or
other organs. 4. The presence of pleural nodules or extensive pleural adhesions.
5. Involvement of the carina or extension into the trachea or into the bronchus
on the opposite side. Most of these contra-indications can be recognised by
the usual methods of examination, but others are revealed only by exploratory
thoracotomy. The operative mortality in pneumonectomy is still apallingly
high, but it should be remembered that thoracic surgery is only in its infancy.
We can expect it to become much safer as a standard technique is developed
and as more surgeons become trained in this special field.
As I have already indicated, there are reports in the medical literature
of a few authentic cures of bronchiogenic carcinoma by lobectomy or
pneumonectomy. I have personal knowledge of one case which has never
been reported. I am permitted by Colonel Wm. H. Keller, who operated
on this patient, to mention it here. It will be reported in detail by him
later.
G.T.D. Female about 35 years of age. Operation on chest by Colonel
Wm. H. Keller, M.C., U.S. Army, in several stages; first stage September 5,
1928, removal of 7th, 8th and 9th ribs, right, post-axillary line; removal of
tumour and part of right lung in successive stages by electric cautery over a
period from October 3, 1928, to December 13, 1928. Deep X-ray therapy
through the open wound was begun on January 7, 1929, and was given in
two series, January 7 to January 11, and March 27 to April 25, 1929. The
wound was closed by plastic operation on June 28, 1929. Tissue removed on
October 3, 1928, was sent to the Army Medical Museum for histopathological
examination, and was reported upon as follows by Major George R. Callender,
M.C., U.S. Army: "Adeno-carcinoma of the lung, columnar cell type."
Recently when this case came under review, tissue from the preserved
specimen was re-examined and there was some suspicion that the tumour
might be of mesothelial origin. It was therefore sent to Dr. James Ewing,
who rendered the following report: "The bulk of this tumour presents structures
which belong to adenocarcinoma of the lung, and which I have never seen
in any tumour derived from the pleural endothelium. Most of the tumour is
composed of small cells in strands, alveoli and cords, and closely resembles
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154 A. C. Christie
some of the tumours presented by Crawford of Philadelphia last year, at the
Pathological Society meeting, from undoubted papillary adenocarcinomas of
the bronchi. I am therefore inclined to think that this tumour is such a type,
adenocarcinoma and not pleural endothelioma."
It is worthy of note that this patient received a considerable dosage of
X-radiation through the open wound. The records do not show the exact
dosage, but I have estimated from the factors involved that she received
approximately 5,500 r through 0-5 mm. Cu and 1 mm. Al at 200 K.V. This
patient is alive and well after more than eight years.
This brings us to consideration of radiation therapy. So far as I have
been able to discover there are no absolutely reliable reports of cure of
bronchiogenic carcinoma by radiation. Every radiotherapist will be able to
recall cases in which clinical, radiographic or even bronchoscopic evidence of
neoplasm has disappeared after administration of rontgen or radium irradiation,
but with recurrence or metastasis. Such results, which are common in the
experience of radiologists everywhere, encourage us to seek extension and
improvement of our methods of radiation therapy in otherwise hopeless cases
of bronchiogenic carcinoma.
The question of grading becomes of importance in considering the
possibility of curing bronchiogenic carcinoma by radiation. Recent experience
in treatment of carcinoma of the larynx may be of value here. There is now
record of a considerable number of laryngeal carcinomas cured by means of
rontgen therapy. If the tumour is of Grade III or IV we may rather confidently
hope to cure it by rontgen therapy, but if it is highly differentiated it is almost
completely radio-resistant. The same principle undoubtedly prevails in
bronchiogenic carcinoma. I have called attention to the studies of Tuttle
and Womack76 which show convincingly that the parenchymal type of
bronchiogenic carcinoma is usually composed of a mass of indifferent basal
cells or of only slightly differentiated squamous cells. Such tumours, because
of their rapid growth and great malignancy, are not well adapted to surgical
removal. If they can be brought to treatment before distant metastasis occurs
some cures should be expected in this group by perfected methods of irradiation.
In those tumours of the hilar group which are considered inoperable, radiation
therapy should be given a thorough trial in every case in which biopsy shows
a Grade III or IV tumour, either squamous cell or adenocarcinoma. A word of
caution should be expressed here with regard to placing too great reliance upon
histological grading. Although it is usually true that tumours of Grades I
and II will not respond to irradiation, there have been many exceptions to
this rule. Practically the only way to determine whether a tumour is radio-
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The Diagnosis and Treatment of Primary Cancer of the Lung 155

sensitive is to administer to it about 3,000 r with the proper factors of
voltage and nitration.
There are a few points in the technique of treatment of those tumours
suitable for X-ray therapy which should be emphasised. The tumour should
be well localised, rontgenographically and bronchoscopically, so that it may
be treated through several relatively small portals. By using high filtration,
at least 2 mm. of copper for rays generated at 200 K.V. and giving the dose
daily over a period of 60 to 70 days one may give a total dose approximating
12,000 r measured in air. We have learned that we must not be deterred
from giving adequate dosage because of the production of rontgen pleuro-
pneumonitis. The latter is a certain occurrence if sufficient dosage is adminis-
tered to destroy a bronchiogenic carcinoma.
The final question that we must answer concerns the place of radiation in
connection with surgery. It is obvious that pre-operative irradiation is not
likely to find any place in treatment of cancer of the lungs. There is a
good deal to be said, however, for post-operative irradiation in certain cases.
It is quite possible that a judicious use of radiation in dealing with a residue
of tumour left after operation would lessen the operative mortality by
preventing attempts at complete removal when the tumour involves the hilar
structures or extends close to the bifurcation. In such cases it would seem
good practice to give rontgen therapy in relatively large dosage directly
through the open wound such as was given in the case I have presented, and
such as was given in cases reported by Sherwood Moore and others. If radium
is used instead of X rays it is my belief that it should be applied by surface
application and not by interstitial insertion of radon tubes or radium needles.
Nothing has been more thoroughly proven than the fact that radium does
much harm when in close contact with cartilage. It would seem a priori that
the intrathoracic application of X rays to the stump of a tumour which the
surgeon could not safely remove might be ideally given by the new low-voltage
X rays known as the Chaoul method. We could thus secure a large amount of
soft radiation at the exact area where needed without the danger of injury
to other structures.
These suggestions are made not with the idea of offering new methods,
but that there may be suggested to us the importance of careful trial of every-
thing that seems to offer any chance for progress in this most difficult field.
Since the surgeon is bound to be very limited in the tumours that he can
attack even if he develops the surgical method far beyond its present status,
it is very important for the radiologist to grasp every chance for improvement
in his own method.
 MARCH 1937

156 A. C. Christie
In conclusion there are two points to be emphasised. The first is the
necessity for much earlier diagnosis than is now the rule. This depends not
only upon the constant use and perfection of the methods which have been
developed, but especially upon the alertness of the general practitioner to
recognise the possibility of the presence of lung cancer from seemingly un-
important symptoms.
The second is the importance of co-operation among all of those who
must have a part in the diagnosis and treatment of this disease. If any
progress is to be made it will tax the combined abilities of the surgeon, the
bronchoscopist, the pathologist and the radiologist. I know of no problem in
medicine where careful teamwork is more essential than it is in the recognition
and treatment of bronchiogenic carcinoma.
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