Statistical, Medical And Biological Aspects Of The Sputum Cytology Program For Uranium Workers In Ontario.

The Department of Thoracic Surgery and Pathology at the Toronto General Hospital have had a long standing interest in the early detection and treatment of carcinoma of the lung. Our initial experience was with a population at risk due to a prolonged period of cigarette smoking. More recently our efforts have turned to industrial exposure, specifically in the nickel and uranium industries. [Initial Screening Project] (1) For a three year period 1963 to 1966 a cytology screening program was carried out through the Out-Patient Department. The study was limited to cigarette smokers over 40 in age. A total of 1586 patients were examined. Of the sputa collected, the classification is seen in Table 1. There were 11 malignant sputa present. Added to this number were 25 patients with symptoms, normal chest X-rays, but malignant cells on cytology, and a further 5 patients in whom an abnormality (eventually proven non-malignant) showed on X-ray, and sputum showed malignancy which was radio logically occult. (Table II). This gave a total of 41 patients with malignant sputum who were evaluated between 1960 and 1966. The clinical course of these patients is seen in Table III. Only 19 of 41 patients had localization and treatment of their tumour during that study period and this low rate of localization attests to the technical difficulties endoscopy in that day presented. The method of localization was as follows: a) 6 patients showed an area of segmental pneumonitis somewhere in this time period b) Using the rigid bronchoscope localized the tumour in 9. This was proven by direct biopsy, and frequently required more than one bronchoscopy over a prolonged time period. c) bronchograms and tomograms showed abnormalities in 5 patients. Of these 19 patients, 5 were treated by radiotherapy because of general condition or refusal of surgery. Three of the irradiated patients died of recurrent cancer within three years. The other two died within one year of unrelated disease. Fourteen patients underwent resection, with one operative mortality. At pathology, the tumours were "in situ" in 6 and invasive in 13. There was no evidence of nodal spread. When last followed up in 1979, there were no cases of recurrent tumour and no cases of second lung primary tumours. Similar experiences have been reported from the Mayo Clinic (2), Johns Hopkins (3) and Memorial Hospitals (4). Early detection of radiologically occult tumours which are in situ or minimally invasive has given uniformly good results. There have been no deaths from recurrent or metastatic cancer in surgically resected patients, and only one second primary tumour has been detected. Interestingly, the Hopkins group reports that 5 patients with Stage I squamous cell tumours refused operation. One refused any treatment and died of disease at 12 months. Three were radiated, and were alive from 14-38 months post-treatment, all with evidence of recurrent disease. [Sudbury Sintering Plant Study](5) From 1948 to 1963 an open travelling-grate sintering process was employed to convert nickel sulfide to nickel oxide at an International Nickel Company operation. The environment in this plant was particularly dusty and filled with fumes. It became apparent by 1969 that the incidence of bronchogenic carcinoma was markedly increased in workers from this plant. A concerted effort was made to track down all workmen with this exposure. During 1973 and 1974, 268 men were studied. Chest radiographs were done and showed no mass lesions. Sputum was collected on three consecutive days and analyzed. There were 12 men with malignant sputum, all of the squamous cell variety. Two refused any investigation, one presenting 31/2 years later with extensive hronchogenic carcinoma, and the other 5 years later with extensive carcinoma of the maxillary sinus. In the remaining ten patients careful rhinolaryngeal examination as well as a detailed bronchoscopy, involving examination, brushings and biopsy of all pulmonary segments was carried out. One patient was found to have laryngeal carcinoma and was treated by radiation. In nine patients, the malignancy was localized to the lung, leading to six lobectomies, two pneumonectomies and one sleeve lobectomy at operation. However, the follow-up in these cases suggests a different biological behaviour with these industrially related tumours. While no tumour has recurred locally, one patient has died of metastatic cancer and two patients have developed second and one patient a third pulmonary primary cancer. However, survival has still been much better than wits radiographically manifest lung cancer. [Technique of Localization] (6) Following a careful rhinolaryngeal examina examined and then the lower respiratory tract is examined. This is all performed under general anaesthesia. The trachea is examined with the rigid Jackson bronchoscope, collect-