Document VQQr35B8K5ryzQww7DBRZ4mq

Downloaded from caonline.amcancersoc.org by on May 6, 2010 (American Cancer Society, Inc.) Primary Malignant Growths of the Lung Isaac A. Adler CA Cancer J Clin 1980;30;295-301 DOI: 10.3322/canjclin.30.5.295 This information is current as of May 6, 2010 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://caonline.amcancersoc.org To subscribe to the print issue of CA: A Cancer Journal for Clinicians, go to (US individuals only): http://caonline.amcancersoc.org/subscriptions/ CA: A Cancer Journal for Clinicians is published six times per year for the American Cancer Society by Wiley-Blackwell. A bimonthly publication, it has been published continuously since November 1950. CA is owned, published, and trademarked by the American Cancer Society, 250 Williams Street NW, Atlanta GA 30303. (American Cancer Society, Inc.) All rights reserved. Print ISSN: 0007-9235. Online ISSN: 1542-4863. Downloaded from caonline.amcancersoc.org by on May 6, 2010 (American Cancer Society, Inc.) position to diagnosticate a primary lung tumor as often as might be, and the be lief in the extreme rarity of these cases is still maintained. To add to these diffi culties, even the diagnoses made on the autopsy table are not always reliable. There are still careless or insufficiently trained persons called upon to do this rather delicate work. It may happen also that the most careful and searching au topsy will not furnish the true diagnosis until a thorough microscopical examina tion has been made. Take for example the case of Walter Kretschmar;3 also of Morelli.* This latter case is remarkable for a number of unusual features: the youth of the patient--a female aged 28-- the sudden onset after cold, with fever and cough, the clinical symptoms of a pneumonic consolidation in right base with pleural effusion and endocarditis. The sputum showed diplococci. On au topsy both lungs showed white nodules, corresponding to blood vessels, and con nective tissue strands not infrequently seen after pneumonic processes. No tu mor could be recognized, and only upon microscopic examination were nests of epithelial cells discovered in the lymph spaces of the fibrous tissue, and epithelial clusters in the alveoles and in the alveolar septa. Furthermore, v. Hansemann4 relates that in his experience at the Friedrichshain Hospital there were 711 carcino mata out of 7,790 autopsies, of which 156, or 21.94 percent, were not diagnos ticated during life, not even as tumors. Among these 156 cases there were 16 bronchial and pulmonary tumors. Is it not somewhat humiliating to realize that the difficulties of diagnosis are still so great as to prevent the best and most experienced medical men, with all the advantages of a large hospital, from dis covering almost one-fifth of all the car cinomata that come before them? If these figures hold good generally, about nefifth more carcinoma cases should be added to our ordinary statistics. Another important addition to the difficulties to *Table I, No. 201 (not reprinted here). be contended with lies in the fact that in many countries, as for example our own, justly claiming an advanced stage of civ ilization, the overwhelmingly great ma jority of the dead are not subjected to any post-mortem examination, and the death certificates on which burial permits are officially given are often ludicrously insufficient. For this reason the United States Census is entirely useless for our purposes. As an example of the mislead ing diagnoses and insufficient observa tions which hamper one in getting up the literature of this subject, look up the fol lowing: Two Cases of Melanotic Tumors in the Lungs.5 Reliable autopsies, in the majority of cases, there are not, and many autopsy notes that have been re corded are so insufficient in their data and descriptions that a conclusive opin ion on the case cannot be formed. The same applies to the clinical notes. It is therefore impossible to say, from the fig ures given by the United States Census concerning causes of death, how many persons mentioned as having died from tuberculosis, pneumonia, or kindred dis eases, may not really have died from lung tumors. Considering all this, it seems pri marily necessary to procure enlighten ment on the question: Are malignant tu mors of the lung as rare as has been sup posed? And if they are not so rare, is their more frequent occurrence due to a supposed general increase in the inci dence of malignant growths? Williams,6 an enthusiastic exponent of the increase of carcinoma as a whole and the corre sponding decrease of tuberculosis, sup ports his view with a great mass of statis tical figures, of which some few are quoted here (Table 1). As to Newsholme's contention7 that the registered increase is only apparent, being actually due to improved methods of diagnosis and death certification, Wil liams's answer is that (1) the uniformity in increase is too marked to be due to improved diagnosis, and (2) the very improvements cited have also caused subtractions from the cancer total, since many diseases formerly erroneously 296 CA-A CANCER JOURNAL FOR CLINICIANS Downloaded from caonline.amcancersoc.org by on May 6, 2010 (American Cancer Society, Inc.) CA-A CANCER JOURNAL FOR CLINICIANS 298