Document 2RM2yzbNvjNG9ejx18NavO777

s SOME ASPECTS OF !CARCINOMA OF THE BRONCHUS ' AND OTHER MALIGNANT DISEASES ` ` * ` .. OF THE LUNG ! .. A SYMPOSIUM held at King Edward VII Hospital, Midhurst Edited for King Edward VI! Hospital by . Douglas Tcarc, M.B., B.Chir. ' and ` Joan Fenning, A .M .R . .' With a foreword by ' . m. Sir Geoffrey Todd, K.C.Y.O., O.B.E., M.B,, Ch.M., F.R.C.P., F X A .C .P . July 4th and 5th, 1966 * * - . ' * . . * ` . >,r" ' * . . *i *, Source: http://industrydocuments.library.ucsf.edu/tobacco/docs/zpcg0003 50285 9055 INTRODUCTION *Discussion \ CONTENTS R R. Barrett JSR ACC ! Page - .*. INDUSTRIAL LUNG CANCER The Statistical Approach to Industrial Lung Cancer Discussion ` Chairman: Dr, Neville Oswald .. . . Richard Doll , ' Asbcstosis and Neoplasia .................................................. Pleural Manifestations following the Inhalation of Asbestos in Relation to Malignant Change . . 0 .* * Discussion ;. Environmental Factors in'Lung Cancer Discussion t * K. F. W. Hinson .. R Lloyd Rusby , , P. J. Lawther 5. * 17555 19 f 1755 23 * 17557 29 i 17558 PATHOLOGY c 1 Chairman: Professor J. S. Chapman Sputum Cytology in the Diagnosis of Carcinoma of the Bronchus Discussion ...................................... ,, .... .. * W .l. Gordon 33 C Carcinoma-in-Situ of the . BronchuCrs .. -Discussion . . .1 .,/ '' Gordon Canti * : 41 Unusual Histological Types of Lung Cancer . . . . ; . . t H. Spencer " * 'i . Discussion - : ' , ' SI # 17559 * 17550 17561 PRIMARY BRONCHOGENIC CARCINOMA -Chairman: Some Thoughts on the Incidence, Possible Causation, Diagnosis, Natural History and Survival Factors .. . i . . . . Professor J, 5. Chapman * 0_ H. McLeod Riggins 57 Approaches to the Pathological Classification of ', Carcinoma of the Bronchus ..................................................F . Becker 69 i Discussion .. 17562 17553 Source: http://industrydocuments.library.ucsf.edu/tobacco/docs/zpcg0003 en O w 0 sn 4 o O1/1s HORMONE*PRODUCING CANCER OF THE LUNG ' Metabolic Consequences of Carcinoma of the Bronchus . . - .................. Discussion ` Lung Tumour with Cushing's Syndrome and Fifteen Years Survival .. . ' IS&R ACC KO " ' " " " ........ ' Page Chatm an; Sir Geoffrey Marshal! . E. J. Ross 74 # V /$ S k . . J. E. Stark S6 * W t i RADIOLOGY Radiographic Aspects of Carcinoma of the Lung Discussion . . Chairman: , Sir Geoffrey Marsha!! . . . ^ George Simon 87 RADIOTHERAPY Megavoltage Radiotherapy of Carcinoma o f the Bronchus ............................... . Discussion . Chairman: Sir Geoffrey Marsha!! ** ,, Arthur Jones - 95 SURGERY '' . Chairman: Dr. H. McLeod Higgins Indications for Surgery and Choice of Operation . . . . . . . J, R. Belcher 100 Prognostic Factors which may Influence Surgical Management .. .................. ... .. H. C. Nohl-Oser 105 Multiple Primary Lung Carcinoma ........................ .. . . R. Abbey Smith 110 i 1?5&7 Discussion . ' o , '-j ' PRESENTATION' OF CASES BY THE STAFF Chairman: Sir Geoffrey Todd ',, OF KING EDWARD VII HOSPITAL, M ID H U R ST.......................... ' . . . . '! Discussion following each case . .- ' ' ` . . to c" ve o cn t , - 29 ENVIRONMENTAL FACTORS IN LUNG CANCER * /, ______ by P. 3. L w thcr. ... ___ _____ .,, ... **-- - . * ' ' ' London . ' Too often the wrong question is asked concerning the aetiology o f lung cancer;* * we should not merely ask *Vhat causes the disease?** but rather "what has caused the dramatic increase in the number o f cases?**. Dr. Doli has discussed several important industrial causes o f lung cancer and Dr, Hinson and Dr, Lloyd Rusby have talked in greater detail about asbestos as a carcinogen. But all these industrial causes together can be blamed for but a small fraction of the casts we sec and there is a need, therefore, to consider the rle o f other - environmental factors. .* The observed rise in the number of cases o f lung cancer is consistent with the appearance, at or shortly after the turn of the century, of a new factor which spread among the community affecting men before women and, it seems likely, townsfolk before country dwellers. No one attending this Symposium can now' have any serious doubts that this factor is predominantly the smoking of cigarettes. There are, however, many who believe tharurban air. pollution Is a serious cause of lung cancer and some ere more specific is allotting the blame to motor vehicle exhaust products. , The existence of an urban/rural gradient in the prevalence o f lung cancer is widely recognised and Stocks and his co-workers (Stocks and Campbell, 1955) have done much work to demonstrate the close correlation between smoke concentrations in the air of many British towns and the lung cancer mortality therein, The correlation Is impressive among the towns Stocks (i960) studied in the North West o f England but it becomes very much less pronounced when th selection o f towns is increased, for example when a larger group of County Boroughs for which < pollution measurements were available is studied. . 1 / - There are other weaknesses in the argument In which urban smoke is blamed for causing the observed rise tn lung cancer. If smoke--or any other pollutant--were the cause it might be expected to act equally on men and women, whereas the observed differences in mortality rates are well marked; the urban/rural gradient is demonstrable in countries such as Norway and Finland in which there is little pollution arid certainly very little difference between pollution in rural and urban districts. But probably the most important weakness in the argu* meat is that lung cancer has risen as pollution by smoke has been decJinog._.^t.th stage th e re ,. is a need to consider the nature of urban air pollution, I f carbonaceous fuels are burnt in an adequate supply of air the resultant products are mainly carbon dioxide and water, if, however, the air supply is deficient, smoke may be produced and frequently the carbon particles of which It consists are accompanied by traces o f polyeydk aromatic hydrocarbons, some of which are carcinogenic to skin. The most notorious f these compounds is 3 :4 benzpyrene which is relatively abundant in coal-tar and pitch; it, or closely related carcinogens, are almost certainly the cause of the skin cancer found in tar workers and the bygone mule spinners, who were soaked in shale oil, and the scrotal cancer of chimney sweeps was no doubt due to polycyclic hydrocarbons present in chimney so o t., , In Great Britain the odd custom of virtually distilling coal on open grates produces a tarry aerosol which is relatively rich in carcinogen compounds. There would seem, therefore, ' to be good reason to suspect air pollution o f causing lung cancer. There is, however, ample . evidence that pollution by tarry smoke has been declining whilst lung cancer has been increasing, and it is certain that the air of British towns was heavily contaminated by coal smoke for a long time before the recent epidemic o f lung cancer, ` Dr. Doll has spoken of the excess lung cancer deaths among retort house workers in gas works, Whilst he and his colleagues in the Gas Boards were collecting and studying . mortality data among gas workers (Doll cl oA, 1965), we studied the pollution o f the air inside old horizontal retort houses, of the type which used to be very common, and the more modern intermittent and continuous vertical retort houses (Lawiher, Commins and Waller, 1965). The shift exposures of certain workers were enormous in comparison with the exposure suffered by the ordinary town dwellers--the air at the top of one retort house contained 10,000 times the amount o f benzpyrene found in " average" London air--and yet, as Dr, Doll has said, the excess "mortality, though dearly demonstrable, is not commensurate with this massive exposure. . The carcinogen 3 *. 4 benzpyrene is present in only small amounts in cigarette tar condensates (Hoffmann and Wyndcr, 1963) and this fact, together with the evidence from the gas works studies, lead s one to think that perhaps this compound has received too.much attention in the consideration of tire aetiology of lung cancer. . , Although pollution by coal smoke has declined during the last decades, contamination of the air by exhaust products from motor vehicles has increased and merits consideration as a factor in the pfoduction of lung cancer. The diesel (compression ignition) engine is an efficient machine which produces virtually no carbon monoxide, a notorious and dangerous component o f the exhaust from spark* ignition engines, but when worn, badly operated or maladjusted, it can produce objectionable black smoke which may contain traces o f polycyclic hydrocarbons. Recent work (Waller, Commins and I.a\viher, 1965) has shown that the contribution to the polycyclic hydrocarbon , content of town sir by diesel vehicles is insignificant against the background o f coal smoke, but more important Is the fact that diesel engines came into general use only in the mid nineteen* - thirties by which time the trend o f the rise in lung cancer was well established. Thus, even if diesel exhaust products were carcinogenic, and there 1$ no epidemiological evidence to support this popular hypothesis, the rise in lung cancer observed until very recent times remains to be explained in terms of some other factor. - . . The exhaust of petrol engines deserves more serious consideration because the petrol engine has been polluting the air for about the right length of lime to be suspect as the cause of the rise in lung cancer. Fortunately there is again no evidence on which to incriminate this factor since lung cancer is not especially common among those who, by virtue o f their occupation,. are exposed to high concentrations o f exhaust products. ` When all these arguments have been set forth, albeit in brief and inadequate form, and the overwhelmingly important rle of the cigarette is recognised, it must be conceded that an "urban factor" exists, in addition to the occupational factors already discussed, but it is tin* doubtedly a minor factor. We do not know what it is, whether it is a carcinogen or a co-caicinogcn, ' a simple factor or many substances which may act singly or synergisticolly; but there is great danger in forgetting, while we search for other environmental factors, that the prime cause is already known and that if cigarette smoking were to cease there would be little need for such a Symposium as the one to which this short essay is but a meagre contribution. ' 6S06 SOS /rtWirciinffo/ Factory 31 REFERENCES DoBllr.hRJJ.,iuFitnisilri.eMr,cRd..,E2.2,Wl.., Gammon, E. J., Gurm, \V , Hughes, G. 0, .1 T)'rcf, F. H. & Wilson, W. (I9fi). Hoffnwrm, t>, & Wymler, E, L (1963). J.wt.Cenrer hnt., >0, $7, j . , LSt*owctkhse.rP, .p(,I}9.6, 0C),omBrmirJf.isC, eBn. wT., Walter, 14,397. R, E, (IS6J), D rtiJ .h ith tttrM a L iX ly I II. ------- & Campbell, J. M. (1955), Brii.meU., ft, 923, ' '' o Waller, ft. E., Commins, B, T. i lawiher, P. J. (19&). BrUJJmhutr.Mrd,, 23,118, ' . >t . ' ' < .' - ' ' .. DISCUSSION ; Chairm n; Or, ASnffc Osvotd _ ' - Dr, Simen: May I ask Dr. L^oyd Rusby where the pleural calcifications are? U there any knowledge o f this, because in she cose he described, which had the effusion, the visceral pleura came away and the parietal pleura end the calcification were left in the same position. In other words, the calcified plaques did not join the two pleural layers together, so they must have been on the other side of the parietal picure, Is this correct and, if so, how* do they get there from the lung? Dr, Rusbyt Certainty this calcification is on the parietal pleura hut I think that it is also on the visceral pleura. Perhaps Dr. Hinson will be able 10 support this. How the calcification gets to the parietal pleura, I do not know, ' ,. Dr. 1liasen: 1 do not think anybody knows, but it is demonstrable. Mr. NoM-Osrr: l had occasion to operate on one case of asbestos!* with pleural plaques. Site was a lady, aged 47, who worked in an asbestos factory in Rochdale for four years. She was sent to me with pleural plaques and calcification of the diaphragm. Her respiratory function-tesis were absolutely appalling with one o f the worst respiratory excursions 1 have ever seen; she was slightly eynoscd, Clinically she ted massive showers of crepitations in the louver lobes, as one associates with asbestos!*, and I thought she had mainly parenchyma! disease and that decortication would not do her any good. Nine months fitter she was sent back to me because she had developed complete dysphagia and a barium swallow showed a very tight stricture o f the oesophagus with a hiatus hernia. Something had to be done so 1 did a preliminary dilatation and then a thoracotomy and a decortication of the parietal pleura which was very easy. 1 was also able to lake a hardened, calcified plaque off the diaphragm and the immobile diaphragm then became really mobile. Next 1did the hiatus " hernia repair and we had her on the ventilator for three days, Ket respiratory function tests improved beyond all recognition and she is so much beuej that the does not want the other tide done, but l am very much tempted tod oit. . Professor Chapman; In the United States it has been reported by a number o f individuals who have been studying the talc industry that talc also produces plaques on the pleura ond calcification which in all respects resemble those (hat have been demonstrated from asbestos. I do sot know, however, if these are associated with mesothelioma and l would be grateful if someone could enlighten me. n Dr. Latubrr: When I was to the Uni;} States a short time ago studying the chemistry of asbestos f r In relation to contamination by oils I learnt to my horror that many o f the toilet preparations o f talc contain up to about 40 per cent of chrysolite. ' - >S Professor Chapman: So your impression would be that if talcosrs, as it has been called, reaches this 'e level. It is probably more likely to be asbestosis, .. Dr, Lowthcr; f think thefc is quite likely to be enough asbestos in some o f the tales. Dr.Hinson; I h a been able to see lobes removed after a tale pkurodesis before a tourniquet resection; 0906 S 8Z 0S * t ** i. ii 1 32 Lawlhcr ' you may remember pleurodesis wa* <!on< by pharmacists* u le with iodine. They had tale granuloma! which I think are Quite different front the sort o f thins we are discussing. Professor Chapman: They arc not forms of calcification? . , ' Dr. Hinson: Ko. Of course, what one Is looking for b t coronary s e who had asbestos blown into hb pericardium. , Professor Scudding: It is rather disturbing to fee! that cosmetic talc has all this asbestos In it, and I hope that the tale that surgeons have blown rather freely into the pleura has not a t got asbestos in it, b the talc supplied by pharmacies contaminated with asbestos, and why should talc used for eosntctic purposes be contaminated with asbestos? Dr. Lawther: Asbestos is associated with late in the mineral deposit; -it is not*deliberately added. Professor Scudding; So thtfprobability is that even the talc produced for allegedly therapeutic purposes contains asbestos? . Dr. Lawthcr; It U quite possible. We have not examined many samples yet but certainly one manufacturing company has been quite frank about this; they said that many samples o f commercial tab have associated with them not only tale and tremolite, but indeed they have some chrysolite associations. I do not know whether this is still the case. o * - . - Professor Scadding; It makes rv,eextremely pleased that I myselfhave never on ary occasion advocated the use of {ylc for spontaneous pneumothorax. '' Dr. llinson: In the lungs of people with a tale pneumoconiosis it is not t^fibly difficult to find structures Indistinguishable from asbestos bodies which presumably a iremolUe or eheysotfle. Dr. Cant: l haw had very brief experience o f trying to diagnose these mesotheliomas from pleural fluid. On one occasion there were some very odd cells, more the fibrosarcomatous type, and on another occasion mcsolhclial cells which were really, I thought, indistinguishable from the very active mcsothclial cells one might get in an inflammatory pleural traction. . ., . ' * iSfc. * r- t O rittn-z/lsnanvlihrarv rnisf erti.M /h.sw iaaO nM oV Kr U1 too*