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Perfusion Lung Scanning in Evaluation of Patients with Bronchogenic Carcinoma
Perfusion Lung Scanning in Evaluation of Patients with Bronchogenic Carcinoma WILLIAM S. MAXFIELD, M.D. HURST B. HATCH, JR., M.D. JOHN L. OCHSNER, M.D.
Use of scintillation scanning of the lungs after an intravenous injection of radioiodinated macroaggregated albumin (13IIMAA) to demonstrate regional blood flow within the lung has been well documented.s, 5,6-9 This technique has proved to be a safe, sensitive method for demonstrating abnormal blood flow through the pulmonary artery in a wide variety of diseases. Most reported experience with this technique has been to demonstrate abnormalities produced by pulmonary embolism, pneumonia, and chronic pulmonary disease. W & previously reported the value of lung scanning in the evaluation of patients with bronchogenic carcinoma. Additional experience has substantiated this observation.
METHOD
The day before administration of the macro aggregated albumin, 1.5 cc. of Lugol's solution is given in three doses to block the thyroid gland. This step decreases the amount of 13I! reaching the thyroid gland as the iodine is broken free from the macro aggregated albumin during its metabolism in the body. Just before scanning, 200 p.c. of the 13lIMAA is injected intravenously with the patient recumbent. Scanning of the lungs is started immediately as the 100 micron particles of the 13lIMAA lodge in the pulmonary capillaries upon initial passage through the lungs. Lung scans are obtained with a commercially available 3-inch scintillation scanner which records the scan data on the film through a photorecording mechanism. From the Department of Biophysics, the Section on Chest Diseases, and the Department of Surgery, Ochsner Clinic, New Orleans, Louisiana
1389
1390
WILLIAM S. MAXFIELD, HURST B. HATCH, JR., JOHN L. OCHSNER
Routinely, anteroposterior and postero-anterior projections are obtained. Under certain circumstances, a lateral scan may be of value.
PERSONAL EXPERIENCE
In our first 50 patients, the lung scan demonstrated abnormal blood flow in the pulmonary arteries of all but 2 patients with proved bronchogenic carcinoma. The following cases demonstrate the advantages and limitations of perfusion lung scanning. CASE I. A 70-year-old white man came to the Clinic complaining of pain in the right arm and shoulder for the preceding three months. A mass at the apex of the right lung with destruction of the posterior portion of the right second rib was visualized in the roentgenogram of the chest (Fig. 1, A). On cytologic examination of the sputum, malignant cells were found. The lung scan on the anteroposterior projection showed a normal pattern for both sides of the lung. The cardiac silhouette in the inferior medial aspect of the left side is well shown in this view (Fig. 1, B).
Figure 1. A, Pancoast tumor of the right apex with invasion of the posterior portion of the right second rib. B, Anteroposterior lung scan appears normal. C, Posteroanterior lung scan again shows no abnormality.
LuNG ScANNING oF PATIENTs WITH BRoNcHOGENIC CARCINOMA
1391
The postero-anterior projection (Fig. 1, C) also failed to demonstrate any abnormality in the apex of the right side of the lung other than that attributable to minimal old scarring. On the posterior projection, the cardiac outline was not well shown in the inferior position of the left pulmonary field. CASE II.* A 52-year-old man consulted us because of persistent nonpleuritic soreness in the left hemithorax laterally and anteriorly, apparently aggravated by change in position. The patient had lost 10 pounds in weight during the previous month and had had progressive increase in cough for the preceding three years. The sputum contained malignant cells on three examinations. A nodular mass was noted inferior to the left hilum on roentgenography of the chest (Fig. 2, A). The anteroposterior lung scan appeared normal (Fig. 2, B), but the lateral film of the chest demonstrated that inability of the lung scan to show the lesion was due to its location in the apical portion of the left lower lobe (Fig. 2, C). The posterior location of the lesion was out of range of focus of the scanner's collimeter, which is about 3 inches. Had a postero-anterior projection been obtained, the lesion probably would have been visualized.
•.
Figure 2. A, Nodular lesion inferior to left hilum. B, Anteroposterior lung scan appears normal. C, Lateral roentgenogram of chest demonstrates nodular lesion as in the apical segment of the left lower lobe. This lesion was located too far posteriorly for the lung scan to demonstrate it from the anterior view, since it was out of range of the focus of the collimator for the scintillation scanner.
*Previously reported by Hatch and associates.2
1392
WILLIAM
S.
MAXFIELD, HURST
B.
HATCH, JR., JOHN
L.
OCHSNER
Figure 3. A, Mass in left hilum; left pulmonary field otherwise appears normal· B, Lung scan shows no pulmonary artery flow to the left upper lobe.
Figure 4. A, Nodular lesion in left midpulmonary field with extension to the pleural surface. B, Anteroposterior lung scan shows defect in left lung that corresponds to the size of the nodular lesion. C, Postero-anterior lung scan again demonstrates lesion in left pulmonary field with no other abnormality.
1 LUNG SCANNING OF PATIENTS
WITH
BRONCHOGENIC CARCINOMA
1393
Figure 5. A, Roentgenogram interpreted as' showing no abnormality in patient with positive result of cytology and hemoptysis. B, Anteroposterior lung scan demonstrates lack of pulmonary artery blood flow to left upper lobe. CASE III. A 52-year-old white man came to the Clinic because of thoracic pain and loss of weight for several weeks. The sputum contained no malignant cells on three separate examinations. In the roentgenogram of the chest, a mass was visualized in the left hilum with extension into the left pulmonary field (Fig. 3, A). The diagnosis of metastatic bronchogenic carcinoma was made by biopsy of the right third rib. The lung scan demonstrated obstruction of blood flow to the upper half of the left pulmonary field (Fig. 3, B). The pronounced interference with blood flow to the left lung was not appreciated on routine roentgenography of the chest. CASE IV.· A 58-year-old white man was referred to us for evaluation of a mass in the left lung detected on routine roentgenography performed because of high fever that developed after appearance of a furuncle on the hand. Five days after development of the furuncle, pleuritic pain was experienced on the left side of the chest. On roentgenography of the chest a mass was visualized in the mid-left pulmonary field with extension to the pleural surface (Fig. 4, A). A defect the size of the mass was demonstrated on both the anteroposterior and postero-anterior lung scans (Fig. 4, B, 4, C). No other abnormality on the lung scan was identified. The minimal decrease in localization in the inferior medial aspect of the left lung on the postero-anterior projection can be produced by slight cardiomegaly. CASE V.· A 72-year-old man came to the Clinic because of blood-streaked sputum noted several weeks before admission. At that time, he was admitted to the local hospital for evaluation. No abnormalities could be detected on roentgenography of the chest or bronchoscopy. The patient stopped smoking, and for two weeks he had no cough or bleeding. When the hemoptysis recurred, he consulted us. The routine roentgenogram of the chest showed no abnormalities (Fig. 5, A). On physical examination no abnormality could be detected. The lung scan demonstrated absence of blood flow to the left upper lobe of the lung (Fig. 5, B). At pneumonectomy, nodes in the left hilum were found to be compressing a pulmonary artery. The pulmonary arteries had not been invaded. CASE VI. A 48-year-old man consulted us because of loss of weight, malaise, and cough of several months' duration. On roentgenography of the chest a large mass was demonstrated in the left hilum with pleuritic masses in both lateral pulmonary fields and metastasis to the anterior portion of the right second rib (Fig. • Previously reported by Hatch and associates.·
1394
WILLIAM S. MAXFIELD, HURST
B.
HATCH, JR., JOHN L. OCHSNER
Figure 6. A, Mass in the left hilum with pleural metastasis bilaterally and involvement of the anterior end of the right second rib. B, Lung scan, though technically poor, demonstrates no pulmonary artery blood flow to the left lung. C, Roentgenogram six weeks after completion of radiation therapy to the mediastinum and left hilum demonstrating regression of the left hilar lesion but progression of other metastatic lesions. D, Lung scan shows return of pulmonary artery perfusion to the left lung six weeks after radiation therapy. 6, A). The roentgenogram, however, did not indicate absence of pulmonary artery perfusion to the left lung, which was clearly demonstrated by the lung scan (Fig. 6, B). Although metastasis was present, radiation therapy to the mediastinum and left hilum was employed because of beginning dysphasia and the possibility of infection secondary to almost complete obstruction of the left mainstem bronchus. Irradiation resulted in considerable shrinkage of these areas with subjective improvement though the metastatic lesions progressed (Fig. 6, C). Lung scan six weeks after completion of radiation therapy showed return of normal pulmonary artery blood flow to the left lung (Fig. 6, D).
CASE VII. A 35-year-old white man consulted us because of cough and anterior thoracic pain for three weeks. The routine roentgenogram (Fig. 7, A)
~
I LUNG SCANNING OF PATIENTS WITH BRONCHOGENIC CARCINOMA
1395
I
1
I
!
I
I
Figure 7. A, Infiltrate in pericardial area of left pulmonary field in patient with positive result of cytology and thoracic pain. Left pulmonary field otherwise appears normal. B, Anteroposterior lung scan shows considerable interference of pulmonary artery perfusion to the entire left lung. C, Apparent improvement one month after radiation therapy to the mediastinum and left hilar area. D, Lung scan shows no improvement in pulmonary artery blood flow to the left lung after radiation therapy. showed increased prominence of the inferior portion of the left hilum. The sputum contained malignant cells. At exploratory thoracotomy invasion of the pericardium and mediastinum was extensive enough to make resection inadvisable. The biopsy diagnosis was metastatic undifferentiated carcinoma. The lung scan demonstrated great decrease in flow to the entire left lung (Fig. 7, B). The slight decrease in flow to the superior portion of the right lung was considered to be due to fibrotic scarring. Radiation therapy to the mediastinum and left hilar area resulted in apparent improvement (Fig. 7, C). The patient noted considerable decrease in pain and improvement in breathing. The lung scan obtained at the same time (Fig. 7, D), however, showed no improvement in pulmonary artery blood flow to the left lung. Recurrence of the tumor in the left hilar area substantiated the incomplete response to irradiation shown by the lung scan. The patient eventually died from hepatic metastasis. At necropsy, the primary tumor was found to be carcinoma of the tail of the pancreas. CASE VIII. A 59-year-old white man was referred to us for evaluation of a mass in the inferior portion o(the right hilum detected on routine roentgenography
r 1396
WILLIAM
S.
MAXFIELD, HURST
B.
HATCH, JR., JOHN
L.
OCHSNER
Figure 8. A, Mass in the right lower pulmonary field in a patient with positive sputum cytology. Pulmonary fields otherwise appear normal. B, C, Considerable decrease in blood flow to the superior portion of the right pulmonary field and decreased flow to the left pulmonary field. Pulmonary function studies confirmed abnormal perfusion 118 demonstrated on the lung scan.
(Fig. 8, A). Pulmonary function studies showed mild hypoxia, with mild, uncompensated respiratory alkalosis though ventilation was normal. The sputum contained malignant cells. The lung scan demonstrated that though the lesion was located in the right lower lobe, perfusion of the right lung was predominantly in the lower lobe with no flow to the upper lobe, and that flow to the entire left lung was greatly decreased (Fig. 8, B, C). This pattern of perfusion of the pulmonary fields shown by the lung scan, together with the abnormal pulmonary function, contraindicated removal of the lesion.
DISCUSSION
Perfusion lung scanning is a safe method of providing useful information in addition to that obtained from routine roentgenography in evaluation of the patient with known or suspected bronchogenic carcinoma. The information obtained from the perfusion lung scan is the same as that obtained from angiography of the pulmonary arteries but the method is safer and less traumatic. 8 , 9 The pattern of abnormal blood flow demonstrated by
LUNG SCANNING OF PATIENTS WITH BRONCHOGENIC CARCINOMA
1397
the lung scan is not specific for bronchogenic carcinoma. The lung scan, therefore, must be interpreted in light of the symptoms, result of cytologic examination of the sputum, and roentgenographic observations. Cases I and II demonstrate that small peripheral lesions or failure to obtain the correct view of the lung scan may yield a normal scanning pattern even though abnormality within the pulmonary field exists. Such an occurrence is apparently rare, since in all but 2 of our 50 patients with bronchogenic carcinoma, some abnormality of regional blood flow was demonstrated. The two most frequently observed patterns in bronchogenic carcinoma are those demonstrated in Case III with a mass in the hilar area obstructing circulation to a segment or lobe of the lung and in Case IV with a peripheral lesion which shows only a defect on the lung scan that corresponds to the size of the lesion. In disagreement with the opinion of Dotter, 1 the pattern of abnormal pulmonary artery blood flow demonstrated by Case III is not an indication of a nonresectable tumor. In most of our patients the abnormal circulation was produced by nodes pressing on the pulmonary artery rather than invading it. In several patients with malignant cells in the sputum and normal roentgenograms of the chest, the lesion has been located by lung scanning. Case V is an example. Had the bronchoscopist not known of the abnormality in the left upper pulmonary field, the lesion in the upper lobe bronchus might have been missed, since it was visualized only through the right angle bronchoscope and a determined search for the cause of the abnormality noted on the lung scan. Cases VI and VII are examples of use of the lung scan to demonstrate the result of radiation therapy. A lung scan may be of greater help in evaluating the effect of the course of radiation therapy than is in the routine roentgenogram. Perhaps one of the greatest values of the lung scan is to visualize the areas of abnormal pulmonary artery perfusion in patients with abnormal pulmonary function. We have noted excellent correlation between an abnormal pattern in the lung scan and abnormal pulmonary function. Case VIII is an example of such correlation.
SUMMARY
The perfusion lung scan with radioiodinated macro aggregated albumin IMAA) is a safe, sensitive procedure that has been an aid in evaluation of patients with known or suspected bronchogenic carcinoma. It may help in the initial diagnosis or may show that the disease is more extensive than indicated by routine roentgenograms. It may also confirm the fact that other pUlmonary disease would make removal of the lesion inadvisable. The lung scan can also be used to follow the course of the disease after therapy. ( 181
1398
WILLIAM
S.
MAXFIELD, HURST
B.
HATCH, JR., JOHN
L.
OCHSNE:K
REFERENCES 1. Dotter, C. T., Steinberg, I., and Holman, C. W.: Lung cancer operability. Am. J. Roentgen. 64: 222, 1950. 2. Hatch, H. B., Jr., Maxfield, W. S., and Ochsner, J. L.: Radioisotope lung scanning in bronchogenic carcinoma. J. Thorac. & Cardiov. Surg. 50: 634, 1965. 3. N abatoff, R. A.: Contrast visualization of the pulmonary vessels as an aid in the early diagnosis of pulmonary neoplasms. Ann. Surg. 133: 270, 1951. 4. Neuhof, H., Sussman, M. L., and Nabatoff, R. A.: Angiocardiography in the differential diagnosis of pulmonary neoplasms. Surgery 25: 178, 1949. 5. Quinn, J. L., III, Whitley, J. E., Hudspeth, A. S., and Pritchard, R. W.: Early clinical application of lung scintiscanning. Radiology 82: 315, 1964. 6. Taplin, G. V., Dore, E. K., and Johnson, D. E.: Suspensions of radioalbumin aggregates for photoscanning of the liver, spleen, lung, and other organs. J. Nuc!. Med. /i: 259, 1964. 7. Taplin, G. V., Dore, E. K., Johnson, D. E., and Kaplan, H. S.: Colloidal radioalbumin aggregates for organ scanning. Reprint of Scientific Exhibit, presented at the 10th Annual Meeting of the Society of Nuclear Medicine, Montreal, Canada, June 26-29, 1963. 8. Wagner, H. N., Jr., Sabiston, D. C., Jr., Masahiro, I., McAfee, J. G., Meyer, J. K., and Langan, J. K.: Regional pulmonary blood in man by radioisotope scanning. J.A.M.A. 187: 601, 1964. 9. Wagner, H. N., Jr., Sabiston, D. C., Jr., McAfee, J. G., Taw, D., and Stern, H.: Diagnosis of massive pulmonary embolism in man by radioisotope scanning. New England J. Med. 271: 377,1964.
Use of scintillation scanning of the lungs after an intravenous injection of radioiodinated macroaggregated albumin (13IIMAA) to demonstrate regional blood flow within the lung has been well documented.s, 5,6-9 This technique has proved to be a safe, sensitive method for demonstrating abnormal blood flow through the pulmonary artery in a wide variety of diseases. Most reported experience with this technique has been to demonstrate abnormalities produced by pulmonary embolism, pneumonia, and chronic pulmonary disease. W & previously reported the value of lung scanning in the evaluation of patients with bronchogenic carcinoma. Additional experience has substantiated this observation.
METHOD
The day before administration of the macro aggregated albumin, 1.5 cc. of Lugol's solution is given in three doses to block the thyroid gland. This step decreases the amount of 13I! reaching the thyroid gland as the iodine is broken free from the macro aggregated albumin during its metabolism in the body. Just before scanning, 200 p.c. of the 13lIMAA is injected intravenously with the patient recumbent. Scanning of the lungs is started immediately as the 100 micron particles of the 13lIMAA lodge in the pulmonary capillaries upon initial passage through the lungs. Lung scans are obtained with a commercially available 3-inch scintillation scanner which records the scan data on the film through a photorecording mechanism. From the Department of Biophysics, the Section on Chest Diseases, and the Department of Surgery, Ochsner Clinic, New Orleans, Louisiana
1389
1390
WILLIAM S. MAXFIELD, HURST B. HATCH, JR., JOHN L. OCHSNER
Routinely, anteroposterior and postero-anterior projections are obtained. Under certain circumstances, a lateral scan may be of value.
PERSONAL EXPERIENCE
In our first 50 patients, the lung scan demonstrated abnormal blood flow in the pulmonary arteries of all but 2 patients with proved bronchogenic carcinoma. The following cases demonstrate the advantages and limitations of perfusion lung scanning. CASE I. A 70-year-old white man came to the Clinic complaining of pain in the right arm and shoulder for the preceding three months. A mass at the apex of the right lung with destruction of the posterior portion of the right second rib was visualized in the roentgenogram of the chest (Fig. 1, A). On cytologic examination of the sputum, malignant cells were found. The lung scan on the anteroposterior projection showed a normal pattern for both sides of the lung. The cardiac silhouette in the inferior medial aspect of the left side is well shown in this view (Fig. 1, B).
Figure 1. A, Pancoast tumor of the right apex with invasion of the posterior portion of the right second rib. B, Anteroposterior lung scan appears normal. C, Posteroanterior lung scan again shows no abnormality.
LuNG ScANNING oF PATIENTs WITH BRoNcHOGENIC CARCINOMA
1391
The postero-anterior projection (Fig. 1, C) also failed to demonstrate any abnormality in the apex of the right side of the lung other than that attributable to minimal old scarring. On the posterior projection, the cardiac outline was not well shown in the inferior position of the left pulmonary field. CASE II.* A 52-year-old man consulted us because of persistent nonpleuritic soreness in the left hemithorax laterally and anteriorly, apparently aggravated by change in position. The patient had lost 10 pounds in weight during the previous month and had had progressive increase in cough for the preceding three years. The sputum contained malignant cells on three examinations. A nodular mass was noted inferior to the left hilum on roentgenography of the chest (Fig. 2, A). The anteroposterior lung scan appeared normal (Fig. 2, B), but the lateral film of the chest demonstrated that inability of the lung scan to show the lesion was due to its location in the apical portion of the left lower lobe (Fig. 2, C). The posterior location of the lesion was out of range of focus of the scanner's collimeter, which is about 3 inches. Had a postero-anterior projection been obtained, the lesion probably would have been visualized.
•.
Figure 2. A, Nodular lesion inferior to left hilum. B, Anteroposterior lung scan appears normal. C, Lateral roentgenogram of chest demonstrates nodular lesion as in the apical segment of the left lower lobe. This lesion was located too far posteriorly for the lung scan to demonstrate it from the anterior view, since it was out of range of the focus of the collimator for the scintillation scanner.
*Previously reported by Hatch and associates.2
1392
WILLIAM
S.
MAXFIELD, HURST
B.
HATCH, JR., JOHN
L.
OCHSNER
Figure 3. A, Mass in left hilum; left pulmonary field otherwise appears normal· B, Lung scan shows no pulmonary artery flow to the left upper lobe.
Figure 4. A, Nodular lesion in left midpulmonary field with extension to the pleural surface. B, Anteroposterior lung scan shows defect in left lung that corresponds to the size of the nodular lesion. C, Postero-anterior lung scan again demonstrates lesion in left pulmonary field with no other abnormality.
1 LUNG SCANNING OF PATIENTS
WITH
BRONCHOGENIC CARCINOMA
1393
Figure 5. A, Roentgenogram interpreted as' showing no abnormality in patient with positive result of cytology and hemoptysis. B, Anteroposterior lung scan demonstrates lack of pulmonary artery blood flow to left upper lobe. CASE III. A 52-year-old white man came to the Clinic because of thoracic pain and loss of weight for several weeks. The sputum contained no malignant cells on three separate examinations. In the roentgenogram of the chest, a mass was visualized in the left hilum with extension into the left pulmonary field (Fig. 3, A). The diagnosis of metastatic bronchogenic carcinoma was made by biopsy of the right third rib. The lung scan demonstrated obstruction of blood flow to the upper half of the left pulmonary field (Fig. 3, B). The pronounced interference with blood flow to the left lung was not appreciated on routine roentgenography of the chest. CASE IV.· A 58-year-old white man was referred to us for evaluation of a mass in the left lung detected on routine roentgenography performed because of high fever that developed after appearance of a furuncle on the hand. Five days after development of the furuncle, pleuritic pain was experienced on the left side of the chest. On roentgenography of the chest a mass was visualized in the mid-left pulmonary field with extension to the pleural surface (Fig. 4, A). A defect the size of the mass was demonstrated on both the anteroposterior and postero-anterior lung scans (Fig. 4, B, 4, C). No other abnormality on the lung scan was identified. The minimal decrease in localization in the inferior medial aspect of the left lung on the postero-anterior projection can be produced by slight cardiomegaly. CASE V.· A 72-year-old man came to the Clinic because of blood-streaked sputum noted several weeks before admission. At that time, he was admitted to the local hospital for evaluation. No abnormalities could be detected on roentgenography of the chest or bronchoscopy. The patient stopped smoking, and for two weeks he had no cough or bleeding. When the hemoptysis recurred, he consulted us. The routine roentgenogram of the chest showed no abnormalities (Fig. 5, A). On physical examination no abnormality could be detected. The lung scan demonstrated absence of blood flow to the left upper lobe of the lung (Fig. 5, B). At pneumonectomy, nodes in the left hilum were found to be compressing a pulmonary artery. The pulmonary arteries had not been invaded. CASE VI. A 48-year-old man consulted us because of loss of weight, malaise, and cough of several months' duration. On roentgenography of the chest a large mass was demonstrated in the left hilum with pleuritic masses in both lateral pulmonary fields and metastasis to the anterior portion of the right second rib (Fig. • Previously reported by Hatch and associates.·
1394
WILLIAM S. MAXFIELD, HURST
B.
HATCH, JR., JOHN L. OCHSNER
Figure 6. A, Mass in the left hilum with pleural metastasis bilaterally and involvement of the anterior end of the right second rib. B, Lung scan, though technically poor, demonstrates no pulmonary artery blood flow to the left lung. C, Roentgenogram six weeks after completion of radiation therapy to the mediastinum and left hilum demonstrating regression of the left hilar lesion but progression of other metastatic lesions. D, Lung scan shows return of pulmonary artery perfusion to the left lung six weeks after radiation therapy. 6, A). The roentgenogram, however, did not indicate absence of pulmonary artery perfusion to the left lung, which was clearly demonstrated by the lung scan (Fig. 6, B). Although metastasis was present, radiation therapy to the mediastinum and left hilum was employed because of beginning dysphasia and the possibility of infection secondary to almost complete obstruction of the left mainstem bronchus. Irradiation resulted in considerable shrinkage of these areas with subjective improvement though the metastatic lesions progressed (Fig. 6, C). Lung scan six weeks after completion of radiation therapy showed return of normal pulmonary artery blood flow to the left lung (Fig. 6, D).
CASE VII. A 35-year-old white man consulted us because of cough and anterior thoracic pain for three weeks. The routine roentgenogram (Fig. 7, A)
~
I LUNG SCANNING OF PATIENTS WITH BRONCHOGENIC CARCINOMA
1395
I
1
I
!
I
I
Figure 7. A, Infiltrate in pericardial area of left pulmonary field in patient with positive result of cytology and thoracic pain. Left pulmonary field otherwise appears normal. B, Anteroposterior lung scan shows considerable interference of pulmonary artery perfusion to the entire left lung. C, Apparent improvement one month after radiation therapy to the mediastinum and left hilar area. D, Lung scan shows no improvement in pulmonary artery blood flow to the left lung after radiation therapy. showed increased prominence of the inferior portion of the left hilum. The sputum contained malignant cells. At exploratory thoracotomy invasion of the pericardium and mediastinum was extensive enough to make resection inadvisable. The biopsy diagnosis was metastatic undifferentiated carcinoma. The lung scan demonstrated great decrease in flow to the entire left lung (Fig. 7, B). The slight decrease in flow to the superior portion of the right lung was considered to be due to fibrotic scarring. Radiation therapy to the mediastinum and left hilar area resulted in apparent improvement (Fig. 7, C). The patient noted considerable decrease in pain and improvement in breathing. The lung scan obtained at the same time (Fig. 7, D), however, showed no improvement in pulmonary artery blood flow to the left lung. Recurrence of the tumor in the left hilar area substantiated the incomplete response to irradiation shown by the lung scan. The patient eventually died from hepatic metastasis. At necropsy, the primary tumor was found to be carcinoma of the tail of the pancreas. CASE VIII. A 59-year-old white man was referred to us for evaluation of a mass in the inferior portion o(the right hilum detected on routine roentgenography
r 1396
WILLIAM
S.
MAXFIELD, HURST
B.
HATCH, JR., JOHN
L.
OCHSNER
Figure 8. A, Mass in the right lower pulmonary field in a patient with positive sputum cytology. Pulmonary fields otherwise appear normal. B, C, Considerable decrease in blood flow to the superior portion of the right pulmonary field and decreased flow to the left pulmonary field. Pulmonary function studies confirmed abnormal perfusion 118 demonstrated on the lung scan.
(Fig. 8, A). Pulmonary function studies showed mild hypoxia, with mild, uncompensated respiratory alkalosis though ventilation was normal. The sputum contained malignant cells. The lung scan demonstrated that though the lesion was located in the right lower lobe, perfusion of the right lung was predominantly in the lower lobe with no flow to the upper lobe, and that flow to the entire left lung was greatly decreased (Fig. 8, B, C). This pattern of perfusion of the pulmonary fields shown by the lung scan, together with the abnormal pulmonary function, contraindicated removal of the lesion.
DISCUSSION
Perfusion lung scanning is a safe method of providing useful information in addition to that obtained from routine roentgenography in evaluation of the patient with known or suspected bronchogenic carcinoma. The information obtained from the perfusion lung scan is the same as that obtained from angiography of the pulmonary arteries but the method is safer and less traumatic. 8 , 9 The pattern of abnormal blood flow demonstrated by
LUNG SCANNING OF PATIENTS WITH BRONCHOGENIC CARCINOMA
1397
the lung scan is not specific for bronchogenic carcinoma. The lung scan, therefore, must be interpreted in light of the symptoms, result of cytologic examination of the sputum, and roentgenographic observations. Cases I and II demonstrate that small peripheral lesions or failure to obtain the correct view of the lung scan may yield a normal scanning pattern even though abnormality within the pulmonary field exists. Such an occurrence is apparently rare, since in all but 2 of our 50 patients with bronchogenic carcinoma, some abnormality of regional blood flow was demonstrated. The two most frequently observed patterns in bronchogenic carcinoma are those demonstrated in Case III with a mass in the hilar area obstructing circulation to a segment or lobe of the lung and in Case IV with a peripheral lesion which shows only a defect on the lung scan that corresponds to the size of the lesion. In disagreement with the opinion of Dotter, 1 the pattern of abnormal pulmonary artery blood flow demonstrated by Case III is not an indication of a nonresectable tumor. In most of our patients the abnormal circulation was produced by nodes pressing on the pulmonary artery rather than invading it. In several patients with malignant cells in the sputum and normal roentgenograms of the chest, the lesion has been located by lung scanning. Case V is an example. Had the bronchoscopist not known of the abnormality in the left upper pulmonary field, the lesion in the upper lobe bronchus might have been missed, since it was visualized only through the right angle bronchoscope and a determined search for the cause of the abnormality noted on the lung scan. Cases VI and VII are examples of use of the lung scan to demonstrate the result of radiation therapy. A lung scan may be of greater help in evaluating the effect of the course of radiation therapy than is in the routine roentgenogram. Perhaps one of the greatest values of the lung scan is to visualize the areas of abnormal pulmonary artery perfusion in patients with abnormal pulmonary function. We have noted excellent correlation between an abnormal pattern in the lung scan and abnormal pulmonary function. Case VIII is an example of such correlation.
SUMMARY
The perfusion lung scan with radioiodinated macro aggregated albumin IMAA) is a safe, sensitive procedure that has been an aid in evaluation of patients with known or suspected bronchogenic carcinoma. It may help in the initial diagnosis or may show that the disease is more extensive than indicated by routine roentgenograms. It may also confirm the fact that other pUlmonary disease would make removal of the lesion inadvisable. The lung scan can also be used to follow the course of the disease after therapy. ( 181
1398
WILLIAM
S.
MAXFIELD, HURST
B.
HATCH, JR., JOHN
L.
OCHSNE:K
REFERENCES 1. Dotter, C. T., Steinberg, I., and Holman, C. W.: Lung cancer operability. Am. J. Roentgen. 64: 222, 1950. 2. Hatch, H. B., Jr., Maxfield, W. S., and Ochsner, J. L.: Radioisotope lung scanning in bronchogenic carcinoma. J. Thorac. & Cardiov. Surg. 50: 634, 1965. 3. N abatoff, R. A.: Contrast visualization of the pulmonary vessels as an aid in the early diagnosis of pulmonary neoplasms. Ann. Surg. 133: 270, 1951. 4. Neuhof, H., Sussman, M. L., and Nabatoff, R. A.: Angiocardiography in the differential diagnosis of pulmonary neoplasms. Surgery 25: 178, 1949. 5. Quinn, J. L., III, Whitley, J. E., Hudspeth, A. S., and Pritchard, R. W.: Early clinical application of lung scintiscanning. Radiology 82: 315, 1964. 6. Taplin, G. V., Dore, E. K., and Johnson, D. E.: Suspensions of radioalbumin aggregates for photoscanning of the liver, spleen, lung, and other organs. J. Nuc!. Med. /i: 259, 1964. 7. Taplin, G. V., Dore, E. K., Johnson, D. E., and Kaplan, H. S.: Colloidal radioalbumin aggregates for organ scanning. Reprint of Scientific Exhibit, presented at the 10th Annual Meeting of the Society of Nuclear Medicine, Montreal, Canada, June 26-29, 1963. 8. Wagner, H. N., Jr., Sabiston, D. C., Jr., Masahiro, I., McAfee, J. G., Meyer, J. K., and Langan, J. K.: Regional pulmonary blood in man by radioisotope scanning. J.A.M.A. 187: 601, 1964. 9. Wagner, H. N., Jr., Sabiston, D. C., Jr., McAfee, J. G., Taw, D., and Stern, H.: Diagnosis of massive pulmonary embolism in man by radioisotope scanning. New England J. Med. 271: 377,1964.