In Reply: To Needle, Brush, Cut or What?

COMMUNICATIONS TO THE EDITOR centers by qualified chest physicians can be described as "cavalier" or based on "mistaken and potentially dangerous belief ( s ) ." In fact, I strongly suspect that were those of us who perform fiberoptic bronchoscopy to meet together, we would find that, in addition to profitably sharing our experiences, we would agree on most basic procedural points. E . G . King, M.D., F.C.C.P.' Edmonton, Alberta 'Director, Intensive Care Unit, University of Alberta Hospital.

To Needle, Brush, Cut or What?

dence of and mortality from this complication compare with the mortality rate from immediate resection of localized lesions in those individuals later shown to have benign disease? These questions do not even take into account the possible risk of "false negative" biopsy results. Until answers to the above are available, it would seem that the best advice one could offer the worried individual with an indeterminate lung lesion is "I defer my opinion until it (the resected lesion) is in the formalin bottle." Hamey Wolinsky, M . D.' Bronx, New York 'De artments of Medicine and Pathology, Albert Einstein

To the Editor: In their report of,' and editorial on2 the use of aspiration needle biopsy of indeterminate lung lesions to establish diagnosis, Zelch et al and Neff, respectively, are advocating what some would consider a quantum change in management of these cases. I wish to offer a note of caution before this step is taken, lest real harm is done to that small group of patients with localized lung cancer who enjoy a relatively favorable prognosis compared to the far greater number whose outlook is dismal from the onset because of extended disease. The above-mentioned report and editorial have not adequately come to grips with the problem of whether a curable lesion may be rendered incurable by the needle procedure they have advocated. One cannot deny that large series of aspiration biopsies are reported without mention of tumor dissemination.=However, it is established that the use of both aspiration and cutting type needles is associated with a smaU but real risk of dissemination of tumor cells into the tracPs5 and into the pleural space.6 The post-biopsy followup and survival experience of the patients in Zelch's study are not given. Additional variables are the sporadic use of postoperative radiation therapy, the tendency for cancer patients to receive their post-surgical care and followup from a diverse group of physicians not particularly alerted to the special question of dissemination, and the fact that even in this favorable localized group, more unbiopsied individuals die with cancer than survive five years. What is required, in my opinion, before the surgical approach to the indeterminate lung lesion is abandoned is that two questions be answered: (1) how does the five-year survival rate of individuals with localized cancer who have biopsy followed by resection compare with those who have only resection (postoperative chest irradiation should be administered or withheld from all) and, if cases of tumor implantation occur, ( 2 ) how does the inci-

of Medicine, Bronx, New York.

REFERENCES 1 Zelch JV, Lalli AF, McCormack LJ, et al: Aspiration biopsy in diagnosis of pulmonary nodule. Chest 63:149, 1973 2 Neff TA: Editorial: To needle, brush, cut or watch? Chest 63:134, 1973 3 Dahlgren S, Nordenstrom B: Transthoracic Needle Biopsy Chicago, Year Book Medical Publishers Inc., 1966 4 Dutra FR, Geraci CL: Needle biopsy of the lung. JAMA 155:21, 1954 5 Wolinsky H, Lischner MW: Needle track implantation of tumor after percutaneous lung biopsy. AM Int Med 71: 359, 1969 6 Berger RL, Dargan EL, Huang BL: Dissemination of cancer cells by needle biopsy of the lung. J Thor and Cardiovasc Surgery 63:430, 1972

To the Editor: Dr. Wolinsky's comments are those of the majority of physicians dealing with pulmonary lesions and represent the reason for continued publication of aggressive diagnostic procedures. I enjoyed his phrase, "quantum change in management"-for this is exactly the implication and even stronger, the recommendation. There is no question that the overwhelming practice is (pulmonary nodulethoracotomy). The question of tumor dissemination is once again the underlining fear. The references Dr. Wolinsky quotes include the first recorded needle tract dissemination of Dr. Dutra, and his own publication in 1969, where he gave the second documented case of needle tract implantation. Both of these patients had peripheral carcinoma involving the pleura and were biopsied using a Vim-Silverman type needle. The final reference to Dr. Berger presents two cases where pleural effusion was positive (not true needle tract dissemination); however, no follow-up is given to either case. These slides were reviewed by Dr. Bernard Naylor, Professor of Pathology at the University of Michigan Medical Center, and his interpretation tends to refute the CHEST, VOL. 65, NO. 1, JANUARY, 1974

COMMUNICATIONS TO THE EDITOR presented article.' At any rate, this represents four positive cases over a series which now must number close to 10,000 aspirations on a worldwide basis. Dr. Wolinsky's point as to follow-up is clearly essential. We have these raw data available on our cases. Since our initial review of 208 cases, we have performed over 500 aspirations at the Cleveland Clinic and have access to an additional 350 cases which Dr. Lalli performed at the University of Michigan. It is our intent to review this material and attempt to outline a reasonable approach to the patient suspected of lung cancer and determine the effects of aspiration biopsy on this select group of patients. James V . Zelch, M.D. Cleveland Clinic, Cleveland

1 Naylor B: Dissemination of cancer cells after needle biopsy of the lung. J Thorac Cardiovas Surg 64:324, 1972

To the Editor: Dr. Wolinsky's letter raises the very important question of: "How often does a percutaneous needle lung biopsy change a curable resectable primary lung cancer into an incurable unresectable cancer, by mechanically spreading tumor cells from the localized tumor into the pleural space and/or chest wall"? This is an important theoretic question and the final answer to this question is not yet available. I agree with Dr. Wolinsky that every effort should be made to obtain a longterm post needle biopsy followup so that if this complication occurs, an accurate tabulation of its frequency can be known and reported. Very few cases of tumor implantation along the needle tract have been reported in the literature up to this time. Almost all of the few cases occurred in patients who by history (symptom of chest pain, etc) or other data suggest that the tumor had already invaded the chest wall before biopsy. These cases in reference 1-3 (except 2nd case reference 3) were not surgical candidates because of this or because of their overall medical status and therefore were not rendered incurable by this procedure. In point of fact a needle biopsy procedure is often the most humane palliative approach to a patient to confirm the diagnosis of an inoperable cancer so that the appropriate palliation and prognosis can be given. As of this moment, I am unaware of any report that mortality due to needle lung biopsy from spread of tumor cells has occurred. Therefore, I agree with Dr. Wolinsky's original statement in his article: "This complication is so rare that a return to CHEST, VOL. 65, NO. 1, JANUARY, 1974

prior skepticism surrounded this procedure and is not justified."' In patients between the ages of 40-70 years with a history of heavy smoking, where a likelihood of a primary bronchogenic cancer is high, proceeding to direct diagnostic thoracotomy certainly may be the best and most reasonable approach. However, unfortunately many of these patients have additional cardiopulmonary disease which puts them into a rather high operative morbidity and mortality risk category. I feel the benefit of the knowledge gained from percutaneous needle biopsy in such patients outweighs the risk of this procedure and of those occurring with diagnostic thoracotomy with resection. There is to date no "double blind study" as Dr. Wolinsky recommends, so I presume that needle enthusiasts will continue to quote their statistics and results and compare them to the similar statistics and results of diagnostic thoracotomy. My review of the "statistical" literature to date and our limited experience still leads me to recommend needling of high risk surgical candidates and direct operation of the better risk surgical patients. Regardless of whether a double line control study can be done by each individual physician or group, I wholeheartedly agree that an open minded attitude with longtem followup for objective results is always needed for new and as well as old procedures. Thomas A. Neff, M.D.' Denuer 'Chief, Pulmonary Senice, Denver General Hospital.

1 Wolinsky H, Lischner MW: Needle track implantation of tumor after percutaneous lung biopsy. Ann Int Med 71: 359,1989 2 Dutra FR, Geraci CL: Needle biopsy of the lung. JAMA 155:21, 1954 3 Berger RL, Dargan EL, Huang BL: Dissemination of cancer cells by needle biopsy of the lung. J Thor Cardiovas Surg 63:430, 1972

Is Tuberculosis Preventable? To the Editor: When I read Dr. Phyllis Edward's excellent editorial in Chest (April, 73) and came to the sentence, 'Tuberculosis today is preventable," I thought we were going to receive an endorsement of BCG immunization in this country. I was disappointed. This is clearly not the place to reopen the arguments for and against BCG immunization; however, it may be appropriate to make a few statements which reflect my personal convictions. Isoniazid