Bronchography in Diagnosis of Bronchogenic Carcinoma in Two Patients with Apparently Normal Chest Films

Abstract

The value of bronchography, in demonstrating partial or complete bronchial obstruction caused by carcinoma arising in the larger bronchi, has been stressed by Graham, Singer, and Ballon (6), Fariñas (5), Westermark (15), and Di Rienzo (4), to name but a few. It is the purpose of this paper, first, to discuss the usefulness of bronchography in revealing bronchogenic carcinoma of the larger bronchi; second, to discuss the problem of the normal chest film in patients with bronchogenic carcinoma of the larger bronchi. The bronchographic signs of bronchostenosis are easily understood if the appearance of the normal bronchial tree is kept in mind. The normal bronchial walls taper gradually and smoothly from the large bronchi to the periphery, and the bronchial branches maintain normal spatial relationships to each other. The signs of obstruction are usually easy to demonstrate and are often present when bronchoscopic findings are negative, as in neoplasms of the upper lobes. Even in cases which offer no radiographic problem in diagnosis, bronchography localizes the exact point of bronchial obstruction beyond the visual field of the bronchoscope. In a recent report Zheutlin, Lasser, and Rigler (16) described pathognomonic bronchographic patterns for alveolar-cell carcinoma, namely, uniform diffuse narrowing of segmental bronchi in areas of lung involvement, bronchial rigidity and elongation, filling rather than coating of bronchi, and a lack of filling of terminal bronchioles and alveoli in segments supplied by these bronchi. Bronchographic evidence of bronchostenosis or occlusion may, however be associated with conditions other than bronchogenic carcinoma. Some of these are benign bronchial tumors, foreign bodies, mucus plugs, inflammatory stricture or granulation associated with bronchiectasis or tuberculosis, hydatid cysts, and bronchial agenesis. Bronchography is a safe office procedure when properly performed. In the investigation of obscure pulmonary disease, it serves a function similar to the gastrointestinal series, the cholecystogram, and the pyelogram in the study of abdominal disease. This point is illustrated by the following cases. Case I: F.H., a white male, aged 56 years, was admitted to the Manhattan Eye, Ear and Throat Hospital in October 1951, complaining of cough and expectoration and a weight loss of 8 lb. during the preceding three months. During the past month a wheeze had developed and the patient had begun to raise bloody sputum. He had no fever or chest pain. He had smoked one package of cigarettes a day for the past forty years. His previous history revealed two attacks of pneumonia in childhood and typhoid fever at the age of twenty-two. On physical examination, some curving of the finger nails was observed, with slight increase of cyanosis of the nail beds. In the lower pole of the left lobe of the thyroid gland was a hard, round nodule 2.5 cm. in diameter.