J.Jpn. Surg. Soc.. 56(6): 686-694, 1955

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宿題報告

Diagnosis and Differential Diagnosis of Pulmonary Cancer

1) Dfficulty of Eady Diaguoais
The difficulty of early diagnosis is due to lack of characteristic symptoms, as shown by our 115 cases which showed early manifoesstations of cough, sputum, bloody iexpectoration, fever, general weakness, and chest pain. About 2.8 months on the average elapse before these cases come to consultation while 4 more months are passed before they are referred to surgeons. So that at the time of admission only 3.6% of the cases were asymptomatic and 36% showed mild symptoms while 60% showed definite or terminal symptoms. It was shown that the symptoms were related to location of the tumors, thus hilar cancers showed bronchopulmonary symptoms: peripheral cancers began with "complicating symptoms" : cancers of the intermediate areas manifested late. In general the first two groups had a shorter period from the onset to the initial consultation than the last group of cases. In short, it is noted that the difficulty of early diagnosis, and hence, the most important factor related to prognosis, is dependent upon the site of origin of the tumor.
X-Ray Diagnosis
X-ray shadows of lung cancer can be divided into 4 types : nodular, infiltrative, mixed, and secondary changes. The type with secondary changes consist mainly of changes secondary to lung cancer and occur usually in the terminal stages. Atelectasis due to bronchial obstruction is an important X-ray picture of lung cancer among these secondary changes. The Nodular type is generally more frequent in S₁ and S₂ while the mixed type is almost always found in the hilar region and hence, in the hilar type. The so-called cancer foot consists not only of carcinomatous lymphangitis as mentioned in textbook, but also of cancer infiltrations and thickening of the bronchial and vessel walls. This is due to the peculiarity of the site of their appearance—the hilar regon. In the infiltrative type, the tumor infiltrates through the bronchial wall or along the bronchial wall. Cases of this nature were followed and studied by X-ray and were found to have the following formation of the early X-ray shadows and subsequent developments. Before the appearance of the tumor itself on the X-ray film, it manifests itself first as a transitory infiltration through its irritation or an infection, and as it develops further it manifests as atelectasis by obstructing the bronchial lumen, as a tumorous shadow by breaking through the bronchial wall and developing outward, or as an infiltration by developing into or along the bronchial wall.
Confirmative Diagnosis of Pulmonary Cancer.
We evaluated bronchoscopic and cytologic examinations which are usually used to confirm the X-ray findings as cancer and found the bronchoscopy to be of value to the extent of 47%. It follows, therefore, that peripheral cancers should depend mainly on cytologic exanimation of the bronchial secretion. The cytologic examinations was found positive in 56% of the total, while 46% of the negative bronchoscopic examinations was found positive by the cytologic examination. The peripheral cancers are in general, more frequently negative on cytologic examination, but the result can be improved by using bronchial washing Bouin's method of fixation and sectioning of the sputum.
Diagnosis Using the Isotope
This method of diagnosis is an entirely new study. We conducted a series of basic experiments on the use of P³² as a diagnostic tool and succeded in its clinical application. We performed radioautograph, DNA reaction, and counting of the experimental materials, cadavers of pulmonary cance cases and resected lung tissues from other lung diseases, and found the possibility of differentiating lung cancer from other diseases. We next constructed several types of counters and practiced counting over the lung surface throug the thoracoscope or on the inner surface of the bronchial wall through the bronchoscope. We were thus able to confirm the diagnosis in 50% of the cases which had been negative on smear test and/or bronchoscopic examination. However, it should be added that the method used through the thoracoscope is of value only when the tumor is superficial and that the bronchoscopic counter can be inserted only as far as a main bronchus, which fact still limiting its usefulness until further improvement of the counter.
Differential Diagnosis
All chest diseases occurring in the cancer age groups require differentiation. There were 56 cases requiring differential diagnosis and most of them were tuberculoma, lung abscess, chronic pneumonia, mediastinal or chest wall tumor, or pleural infections. They were all negative on confirmative diagnosis but, because they belonged to the cancer age groups and had suspicious X-ray shadows, they were operated.
A tuberculoma and a coin-shaped shadow of early cancer in old age is a most difficult diagnostic problem, and despite the value of blood sedimentation rate and tubercle bacilli examination, because of the co-existence of lung cancer and tuberculosis in 17% of autopssy cases and demonstration of tubercle bacilli in 4.5% of lung cancer cases, cancer cannot be ruled out simply for the presence of tubercle bacilli. We evaluated the differential X-ray findings between cancer and tuberculosis and presented some pertinent facts.
We also presented our experiences and ideas regarding differental diagnosis from other diseases. In summary, We emphasized that in case of doubt we should not hesitate or delay in performing exploratory thoracotomy.
(author's abstract)

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