(a) Saliva is light and transparent before the alcohol shrinks it into white strands or balls.

(b) Sputum usually presents as clusters of small opaque globules, usually dark in color but occasionally whitish.

When used as directed, the aerosol has proved completely nontoxic; the relatively uncommon difficulties with bronchospasm may be eliminated by paying heed to clinical evidence of asthma, emphysema, etc., and adopting the modifications in technique noted.

Bronchoscopy

Following, or occasionally concurrently with, the work-up of the lung cancer suspect by means of x-ray films and sputum cytology, bronchoscopy may be advised. Bronchoscopy is ordinarily done for the following reasons:

1. To assist in the differential diagnosis and possibly establish the diagnosis by visualization and biopsy of the lesion and by obtaining bronchial washings.

2. To assist in passing judgment on the nature, extent, and desirability of surgery insofar as is possible.

There are few, if any, absolute contraindications to bronchoscopy, but there are some relative ones:

1. The presence of the superior vena caval syndrome with attendant venous engorgement, edema, and dyspnea which may be worsened by this procedure. Since most lesions producing this syndrome do not lend themselves to visualization by bronchoscopy, there is even less reason to attempt it under these circumstances.

2. The presence of respiratory distress, either cardiac or pulmonary in origin, which may be further intensified by postbronchoscopy edema and spasm.

3. The presence of relatively brisk bronchopulmonary bleeding. On occasion, of course, bleeding may be interpreted quite differently. It may be an indication for bronchoscopy.

It has not been suggested that bronchoscopy per se, with or without bronchial washings, promotes dissemination of the disease.

If the physician in his office adheres to a policy of adequate sputum sampling early in the work-up, the number of bronchoscopies essential for diagnostic purposes can be reduced to less than 20% of all cases.

The thoracic surgeon, of course, may still wish to do bronchoscopy for the reasons noted, but if he is able to accomplish it with full knowledge of an established tissue diagnosis and often in a hospital setting in the immediate preoperative period, the circumstances are considerably more favorable.

The technique of bronchoscopy will not be dealt with here since it falls outside the province of the general office.

Value Of Bronchoscopy Alone

As a means of making the definitive diagnosis of lung cancer, bronchoscopy is often disappointing. It is possible to establish a biopsy diagnosis in less than 35 to 50% of all cases of lung cancer by this method, and the earlier the lesion, the less likely is it to be reached for bronchoscopic biopsy.

Value Of Bronchoscopy With Bronchial Washings

If, at the time of bronchoscopy, the tracheobronchial tree is washed with normal saline solution and the material submitted for cytologic study, it may be possible to make a diagnosis in an additional 30 to 40% of cases (total positive diagnoses equals approximately 80%). It must be emphasized that cytologic study of sputum alone can equal or exceed the total percentage of positive diagnoses possible using the far more complicated and disquieting combined approach just described.

Reasons For Limitations Of Bronchoscopy With Or Without Bronchial Washings

1. Substantial areas of the bronchopulmonary tree are inaccessible to bronchoscopy even under the best of conditions.

2. Bronchial washings represent a small sampling of a restricted area in a limited period of time using mechanical means for collection. Sputum, on the other hand, represents a fairly generous sampling of the secretions of the entire tracheobronchial tree which have pooled over an extended period of time as a result of natural exfoliation and transport.

The purpose of the foregoing is not to depreciate bronchoscopy but rather to assign it to its proper role and to specify what its contributions may be.

Exploratory Thoracotomy

Even after the first three avenues of diagnosis-x-ray, cytology, and bronchoscopy-have been diligently explored, there still remain a significant number of patients in whom no definitive diagnosis is possible. At this point it becomes necessary to consider the final member of the "big four" of lung cancer diagnosis- namely, exploratory thoracotomy. The family doctor and the thoracic specialist must weigh the pros and cons for the individual case and reach a decision which can then be urged upon the patient and his family.

1. On the one hand, if thoracotomy is not done, the diagnosis remains in doubt until follow-up studies and the natural history of the lesion over a period of weeks, months, or years clarify the situation. Even then, the diagnosis may be possible only if the lesion is malignant. If the lesion is benign, its exact nature may be no more certain after several years of observation than on the day it was first discovered. Meantime, benign or malignant, attempts at nonsurgical therapy must be based on presumption and probability and therefore subject to indecision and error. Finally, in such a situation, the physician, the patient, and his family are deprived of the security or relative certainty which goes with having an established diagnosis-benign or malignant, operable or inoperable-in hand.

2. On the other hand, if thoracotomy is done, one must accept the very real risk, however small, of operative mortality and morbidity as well as the expense involved in the surgery. The hesitancy which some physicians have for recommending a course which involves time, expense, major surgery, and possibly complications or death, for a lesion which may prove to be benign and innocuous is understandable.

It must be remembered that about 1 out of every 4 or 5 undiagnosed but suspicious pulmonary lesions in the adult will prove to be cancer at thoracotomy. In males over 45 years of age with a significant smoking history, the percentage is much higher, and a suspicious pulmonary lesion must be considered cancer until proved otherwise.

Our recommendation, therefore, is that thoracotomy be carried out in all patients with all suspicious, equivocal, or indeterminant pulmonary lesions which remain undiagnosed after x-ray, cytologic, and bronchoscopic work-up provided there is no over-riding medical contraindication.

Other Studies. Search For Primary Cancer Elsewhere

Look for possible primary cancer elsewhere. The lungs are common sites of metastatic deposits from lesions in other organs. The primary tumor may sometimes be relatively silent, and the metastatic lesions may simulate bronchogenic carcinoma. Virtually any cancer may do this, but the ones which are the most characteristic offenders are as follows:

1. Kidney

2. Breast

3. Thyroid

4. Stomach

5. Rectum and colon

Scalene node biopsy

This is commonly employed in the diagnosis of obscure intrathoracic disease. If positive for carcinoma, it not only establishes the diagnosis, but also is important in determining the choice of therapy. Of course, in certain cases of clinically obvious or suggestive metastatic lung cancer, microscopic confirmation of the impression may be obtained by biopsy of other nodes, e.g., cervical, supraclavicular, etc.

Aspiration Biopsy

Aspiration biopsy of an accessible lung mass is occasionally done in the case of obviously inoperable disease where tissue proof of the diagnosis is desired.

Pleural Biopsy

This is recommended by some if the lesion is relatively peripheral and accessible and especially if thoracotomy is thought to be contraindicted.

Skin Tests

A number of intradermal tests are available for testing patients. They include the following:

1. Tuberculin

2. Histoplasmin

3. Kveim (for Boeck's sarcoid)

4. Coccidioidin

It must be remembered, of course, that these tests do not rule out lung cancer even if positive. Lung cancer may be present in an individual reacting either negatively or positively. Skin tests may, nevertheless, provide additional evidence for consideration in the over-all assessment of the clinical situation.

X-Ray Studies Of The Bones

These are done primarily to rule out the presence of metastatic disease in symptomatic patients.

Cytologic Examination

Cytologic examination of the smear and cell block resulting from thoracentesis and withdrawal of pleural fluid may be helpful in diagnosis. However, this is often negative even when the effusion is due to pleural involvement so that only a positive study is of significance.