الفهرس 
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Abstract
The present study was carried out to evaluate the potential
significance of cytopatho10gic diagnosis of cancer rendered on pulmonary
cellular specimens (sputum and bronchial washings or aspirates).
in comparison to bronchial biopsy in the diagnosis of bronchogenic
carcinoma.
During the period of the study. a total of (92) diagnostic
fiberoptic bronchoscopic procedures were performed. The cases were
highly suspected of being, bronchogenic carcinoma on either clinical
or radiological ground or both. Non of these patients had evidence
of a primary neoplastic disease elsewhere in the body. neither was
there any history of chemotherapy or radiation in the past for malignant
diseases. Histologic evidence of cancer was available in (63)
cases. while (29) patients had diagnosis other than primary carcinoma
of the lung. Among (63) cases of confirmed lung cancer. 53 (84.1%)
cases were central while 10 (15.9%) cases were peripheral in location.
All the (63) cases of bronchogenic carcinoma had concomitant cytologic
specimens (sputum and bronchial washings or aspirates) and bronchial
biopsy.
The frequency of individual cell types in our patients reflected
their selection on the basis of the different sources of histologic
confirmation. It is not necessarily representative of all patients with
primary lung cancer. Among our (63) cases. 30 cases (47.6%) were squamous
cell carcinoma. and 16 cases (25.4%) were adenocarcinoma. Small cell
carcinoma was evident in 12 cases (19.1%) and large cell carcinoma in
5 cases (7.9%).
In these series of (63) cases 55 patients (87.3%) were males
and 8 cases (12.7%) were females. with a ratio of 6.9 :1. The age of
our cases ranged between 27 and 74 years with a mean value of 57.7.
The mean age was 57.1 yr. in males and 61.8 yr , in females. The frequency
of bronchogenic carcinoma is increased with age. 95.5% of our
cases were above the age of fourty while 3 cases (4.8%) only were below
the fourth decade. This make us to point to the fact that the youth
of any given patient can not rule out malignancy.
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The sex and age distribution have been studied in relation
to tumor structure. Most of the male patients (50.9%) were diagnosed
as squamous cell carcinoma. while most of the females (62.5%) were
diagnosed as adenocarcinoma. There was no significant difference between
· the mean age of the different histological types. The squamous
cell carcinoma and small cell carcinoma tend to increase with age.
while the highest proportions of adenocarcinoma were found in patients
less than 40 yr. of age.
The data presented in this work indicated that there is an
intimate relationship between smoking and the incidence of bronchogenic
c;rcinoma. There was 53 smokers (84.1%). of them only 12 patients
(22.6%) were mild smokers. Among the smokers. the squamous cell carcinoma
was the predominant type (52.8%) while the adenocarcinoma was the predominant
type in non-smokers. Among the smokers. the amount of
smoking,as measured by smoking index. seemed directly related to
the prevalence rate for small cell carcinoma. but not for other
cellular types. However. these data must be interpreted with caution
because they referred to a prevalence of a type of carcinoma within
persons in whom a carcinoma has already developed.
Considering the modes of presentation. pulmonary manifestations
represented the majority of complaints. The duration of symptoms had
an average of 5 months. and this means that patients do not seak medcal
advice except when the disease becomes clinically manifested and
the tumor reaches a somewhat advanced stage at which it becomes inoperaable.
A special note was directed to medical students to alert them
about the causes of delay in the management of lung cancer in Egypt.
The bronchoscopic findings in our work confirm with the orthodox
teaching where a fungating mass (61.9%) is the most typical finding. The
marked preponderance on the right side (64.2%) among 53 detailed studied
cases, was confirmed. and the right upper lobe and main bronchus were the
commonest site of affection. A fact which mean that apical lesions should
not be dogmatically accepted as tuberculosis if an unnecessary delay in
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the proper diagnosis is to be avoided. No complications were met with
in all cases included in the study during the fiberoptic bronchoscopic
procedure.
Of the (63) cases. with histologically proven carcinoma of
the lung. one or more sputum samples were collected from each patient
and examined cytologically. An unequivocal diagnosis of malignancy was
made in 41 cases (65%). Detection of malignant cells was 76.7% for squamous
cell carcinoma. 66.7% for small cell carcinoma. 50% for adenocarcinoma
and 40% for large cell carcinoma. However. there was no significant
differen~e in the detection of malignant cells in relation to different
histologic types. The yield of sputum cytology was 66% for central tumors
and 60% for peripheral lesions. This is statistically insignificant (P >
0.05). Cancer detection rates improved with the examination of multiple
specimens. where only 36.5% of cases with cancer had positive report on
the first sputum examination. while by the third specimen 60.3% of the
group had positive result and by the fifth specimen 65%. Reasons for unsatisfactory
specimens included no deep cough and excessive blood or
leucocytes.
The contribution of bronchial aspirates or washings towards
the establishment of a correct diagnosis of bronchogenic carcinoma was
evaluated. Of the (63) cases under study. bronchial aspirates or washings
showed unequivocal malignant cells in 44 cases (69.8%). Detection of malignant
cells was highest for squamous cell carcinoma (80%) and small cell
carcinoma (75%) and lowest for large cell carcinoma (40%). Statistically
there is no significant difference in the degree of positivity in relation
to the different histologic types (P> 0.05). Detection of malignant cells
was (77.4%) for central tumors as compared to (30%) for peripheral lesions.
This is statistically significant (P< 0.05). The percentage of unsatisfactory
specimens from those with cancer was 3.2%. Reasons for unsatisfactory
specimens included limited cellular material and excessive blood.
In our series • the overall diagnostic yield of bronchial biopsy
was 79.4% • Two types of bronchoscopic biopsy were done in our studied
group. the endobronchial biopsy and the transbronchial biopsy • The
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endobronchial type was positive in 45 cases (84.9%) out of 53 cases
while transbronchia1 biopsy showed evidence of malignancy in 5 cases
(50%) out of 10 cases. However. there is a significant difference in
the success rate of the two types of bronchial biopsy (P(0.05).
Detection of malignancy was highest for both squamous and small cell
carcinoma. being positive in 86.7% and 83.3% respectively. Statistically,
no significant difference was found between the degree of positivity
and the cellular type (P>0.05). Bronchial biopsy was positive in 84.9%
of the central lesions compared to 50% of the peripheral lesions. The
difference was statistically significant (P(0.05) •
.When the diagnostic yield was compared for sputum cytology.
bronchial aspirates or washings and bronchial biopsy. bronchial biopsy
gave the greatest number of positive results (79.4%) followed by bronchial
aspirates or washings and sputum cyto10gy.However. statistically
there was no significant difference between the results of the three
methods.
The overall diagnostic yield of washings or aspirates in our series
was (69.8%) and considerably better than that of sputum specimens (65%).
This can be explained by the fact that bronchial specimens are easier to
screen because of lesser cellularity than those in sputum specimens.
The collection of both sputum~~ecimens and bronchial aspirates
or washings from each case increas,ed the rate of lung cancer detection
to (82.5%). The combination of sputum cytology and bronchial biopsy
yielded a positive diagnosis in (90.4%) while the combination of bronchial
aspirates or washings with bronchial biopsy gave positive diagnosis in
(87.3%). The combined judicious use of all the three methods yielded
a positive diagnosis in (93.7%). The above results argue for the use
of as many samples and methods as possible in the diagnosis if a maximum
yield of diagnosis is to be obtained.
Sputum cytology and bronchial aspirates or washings procedures
were complementary to eaclJ other as shown in our study. This is
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strengthened by the following results :
[1] Their combined use increased the diagnostic yield to (82.5%).
[2] Cancer cells were identified unequivocally in (11) cases in
bronchial aspirates or washings. but not on sputum examination. About
half of these cases had concomitant positive bronchial biopsy. So.
there were (5) cases in which bronchial aspirates or washings provided
the only positive evidence of malignancy.
[3] Sputum cytology yielded the cancer diagnosis in (8) cases where
bronchoscopic cellular material failed. but most of these cases had
multiple specimens. Seven of these (8) cases had negative bronchial
biopsy. So. sputum was considered as the only source of diagnosis in
them.
It is important to note that in some cases with negative bronchial
biopsy. one or more types of cytologic specimens showed malignant cells.
So. cytologic techniques. by providing samples from areas other than those
sampled by biopsy material and by allowing examination of the whole isolated
cells may establish the diagnosis of lung cancer even when endoscopic
biopsies are negative. and they are particularly helpful in instances
when endoscopic biopsies suffer a low yield (peripheral lesions) or creat
considerable danger to the patients (iatrogenic hemorrhage).
We examined the accuracy of pulmonary cytology in (92) cases being
evaluated for lung cancer. Final diagnosis was established in (80) cases.
Among (17) patients with non-malignant lung diseases. only one case had
false-positive specimens. The overall diagnostic accuracy of cytology
showed (82.5%) sensitivity. (94.1%) specificity. (98.1%) predictive
value of positive specimen. and efficiency of 85%. These findings may
agree with the fact that pulmonary cytology is a definitive diagnostic
test and need not to be routinely confirmed with a tissue diagnosis and
this would justify the use of it as a basis for a definitive treatment
with either radiotherapy or chemotherapy. The figures obtained by sputum
cytology during statistical assessment of its accuracy encourage us to
recommended its use as a screening tool for early detection of lung cancer.
To evaluate the growing tendency in recent years to attribute more
diagnostic reliability to cytologic methods. we investigated the accuracy
of cytologic typing in specimens obtained from sputum and bronchial aspiratc~
or washings material. comparing the cytologic diagnosis with the known
histologic diagnosis
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Of the 41 sputum specimens 32 (78%) were correctly typed and
9 (22%) incorrectly typed with respect to the appropriate histologic
diagnosis. The figures given for the 44 specimens of bronchial aspirates
or washings were 77.3% and 22.7% respectively. However. statistically.
sputum and bronchial aspirates or washings do not differe significantly
in the proportion of correct cytologic typing (P> 0.05). Sputum was more
accurate than bronchial aspirates or washings for typing of squamous cell
carcinoma Bnd adenocarcinoma.The reverse was true for small cell carcinoma.
In general. regardless of the sampling methods. cytologic typing was always
more accurate for the squamous cell carcinoma and small cell carcinoma.
The different tumors types and their degrees of differentiation seem to
be the decisive factors in cytologic typing accuracy. The findings of
this study were compared with those of others and were found to be
consistent with the results of even larger series of cases. For some
types accuracy was higher than that reported in other series. whereas for
other types e.g., large cell carcinoma it was lower.
CONCLUSIONS:
* The frequency of bronchogenic carcinoma is increased with
age. However. the youth of any patient can not rule out
malignancy.
* There is an intimate relationship between smoking and the
incidence of bronchogenic carcinoma.
* The problem of lung cancer in Egypt is that of a late
presentation of the cases. which is a responsibility
equally shared by the patients and doctors.
* Fiberoptic bronchoscopy is a safe technique with few
complications and can be performed quickly with minimal
discomfort to the patients.
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* Pulmonary cytopathologic techniques (sputum cytology and
bronchial aspirates or washings)constitute the most simple
and least expensive investigative tools available today.
They have excellent sensitivity and accuracy in the diagnosis
of lung carcinomas.
a-They may establish the diagnosis of pulmonary carcinomas
when endoscopic biopsies give negative results.
b-They are particularly helpful in cases in which endoscopic
biopsies suffer from :
(a) Low yield (peripheral lesions)or
(b) Create a considerable danger to the patients (iatrogenic
haemorrhage)
* Multiplicity of specimens is a major factor in quality
of pulmonary cytopathologic diagnosis.
* The overall diagnostic yield of sputum cytology. bronchial
aspirates or washings and bronchial biopsy was not influenced
by the histologic cell types.
* Tumor location causes a significant differeoce in the diagnostic
yield for both bronchial aspirates or washings and bronchial
biopsy but not for sputum cytology.
* No one specimen type is of exclusive importance in lung
cancer diagnosis. Bronchial biopsy. sputum cytology and
bronchial aspirates or washings were complementary procedures
in diagnosing bronchogenic carcinoma. All methods
should be employed if maximum yield of diagnosis is to
be obtained.
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* Pulmonary cytology is a definitive diagnostic test and
need not be routinely confirmed with a tissue diagnosis
.if the letter is not avaialable.
* Cytologic typing accuracies were highest in squamous
cell carcinoma and small cell carcinoma. Conversely in
adenocarcinoma and large cell carcinoma , the correct
cytologic typing performance was much lower.
Recommendations
* The problem of lung cancer in Egypt is that of a late
presentation of the cases. So. if a true combat of the
disease is aimed at. much stress should be put on improving
the degree of suspicion. As regards the patients
this can be done by advertisements in news papers. radio
and television so the patient will seak medical advice
early. As regards the physicians. they should ask for
chest roentgenograms (PA and lateral views) for any chest
complaint if it lasts for more than 2 weeks or if it is
recurrent specially in old males who are chronic heavy
cigarette smokers. Apicogram. lateral chest X-rays and
films in full inspiration and full expiration may be of
great help. Sputum cytology should be done and preferably
repeated. Bronchoscopy.which is essential for diagnosis.
should be done.even if there is no abnormality detected.
* Sputum cytology should receive more interest among chest
clinics. it has a dual advantage of being non-invasive
and of high diagnostic value.
* We recommended trans-bronchial lung biopsy as a safe
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informative procedure. when carefully performed. to
establish a diagnosis in patients with unexplained
pulmonary infiltrates.
* Until now we advised the use of as many samples and
methods as possible in diagnosis if maximum yield and
accuracy of diagnosis is to be obtained.Prospective.
multicen~re studies are needed to answer the question
of what diagnostic tests should be employed to provide
an accurate diagnosis of cancer with minimum expense
and ~isk to patients.
* We recommended wider use of the information provided
by simultaneous evaluation of both cytologic smears
and tissue sections in order to achieve a more accurate
appraisal of tumor type. Another study is needed for
judging the accuracy of cytologic diagnosis and typing
on the histologic evaluation of the entire resected
lesion. rather than on biopsy specimens.