J.Jpn. Surg. Soc.. 56(6): 666-685, 1955
宿題報告
PATHOLOGY AND IMPAIRED PHYSIOLOGY OF LUNG CANCER
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Departm ent of Surgery, Keio University School of Medicine Shichiro ISHIKAWA |
The present study covered 118 cases and 116 of them were primary carcinoma of the lung. Pathologic study was, therefore, based mainly on the lung cancer.
I. Gross findings—— Two types were recognized : the localized and the diffuse. The localised type is subdivided into three types according to the manner of development :
(1) Nodular― well demarcated, rich interstitial hyperplasia. (2) Expansive-concentric, globular development, surrounded by atelectatic zone. (3) Infillralive-irregular in shape, develops diffusely into the surrounding lung tissues, and poor in inlerstitial cells. The diffuse type is also subdivided into three types: (1) The tumor develops by infiltraling intramurally, so that each bronchial wall is thickened. (2) Marked subplcural infiltration of the chest wall, without intrapulmonary tumor. (3) Miliary and nodular spread all over the lung field. There are, in addition, two special types in the course of development : (1)Pancoast tumor― starts from the pulmonary apex and infiltrates the chest wall. (2) Mediastinal from―originates mostly from a large bronchus and develppes in the mediastinum.
The incidence according to the gross findings shows that a large majority (82%) is the localised type which offers benefit from surgical therapy. The diffuse type is infrequent and is moew difficult to diagnose.
Sites of origin——the tumor originates frequently in the right upper, left upper, both lower, and middle lobes in that order. The incidence is greater in the smaller bronchi (62%), bronchi smaller than the segmental, than in the larger bronchi (33%), the lober bronchi and larger ones.
II . Histological findings——It was divided into three main types : Squamous epithelial, Adenocarcinoma, and Undifferentiated cell carcinoma. Taking 106 cases, the undifferentiated type (41%) was most frequent, followed by the squamous epithelial carcinoma (32%) and adenocarcinorna (27%). Sex distribution shows that the squamous epithelial carcinoma was four times more frequent in male than in female, while adenocarcinoma was twice as in male, and the undifferentiated cell type was about equally distributed. It was shown that the squamous epithelial type has tendency to occur more frequently in the larger bronchi and adenocarcinoma in the lesser bronchi while the undifferentiated type showed no such tendency.
III. Metastasis——Lymphogenic, hemalogenic, and aerogenic routes were recognized. An interesting illustration of the last type was presented.
Among 39 cases of resection, 61.5% showed lymphatic metastasis histologically while 38.5% did not show metasis.
IV. Histogenesis—— (1) Two extremely early cases were analized. One was adenocarcinoma complicating bronchiectasis. The other was basal cell carcinoma about the size of half a grain of rice, occurring at the bifurcation of the right mid-lobe bronchus, and seemed to be a carcinoma in situ that had started to infiltrate. (2) Metaplasia into flat cell carcieoma and hyperplasia of the bronchial mucosa in 33 cases of cancer and 50 cases of chronic lung diseases were examined, but there was no evidence of cancerous change. Histogenesis of lung cancer is yet an undeveloped field the world over and requires analysis of numerous early cases.
IMPAIED PHYSIOTOGY
I. Clinical examinations——In general, marked degrees of anemia, hypoproteinemia, increased blood sedimentation rate, low 17-Ketosteroid, and hepatic hypofunction were found. These were, however, common to most cancer patients and not specific for lung cancer. Necrosis of the tumor and secondary infection in the surrounding lung tissues seemed to correlate with blood sedimentation and hepatic functions. Cancer cells can be demonstrated relatively early in the bone marrow blood, so that it may be a diagnostic aid.
II. Pulmonary Functions——Cancer patients have pre-operative functional disturbance of the air and blood phases in a complicated manner producing a viscious circle. It is characterized by chronic anoxia and hypercapnea. The degree of functional disturbance is much greater than that in other chronic lung diseases requiring pneumonectomy. it should also be pointed out that a great surgical intervention has to be performed in the old age, and this fact necessitates a thorough pre-operative evaluation of the lung functions.
Cases with increased buffer bases or markedly low cardiac index do not indicate surgery. Cases with low alveolar ventilation and effective pulmonary blood flow require scrutiny.
Factors and their limits which allow a safe pneumonectomy were considered as follows: vital capacity and maximum breathing capacity above 70% of the predicted normail, RV/TC below 45%, intrapulmonary gas mixing less than 2.0%, ventilation reserve above 80% (70% level should require scrutiny). These data should be well considered in deciding whether to perform pncumoneclomy or lobectomy.
Post-operative lung functions show little effects from lpbectomy while a certain degree of disturbance is produced after pneumonectomy. This is brought about by the removal of one lung, hyper-expansion of the remaining lung, reduction in the mobility of the chest wall, and mediastinal shift. These adverse effecta are produced together with beneficial effects of eradication of cancer. The beneficial effects are removal of anoxia and improvement of hypercapnea, brought about by increasing ventilation in the dead space. It means that such patients have less reserve than normal people of the same age.
We have two cases of relatively long-term survival 3 years 8 months and one year 11 month, both well and engaged in regular work now.
(author's abstract)
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