Emphysema: An Early Roentgen Sign of Bronchogenic Carcinoma

Abstract

The increasing incidence of carcinoma of the lung represents one of the urgent problems facing the medical profession. Whether this increase is real or relative, it is certainly true that the number of cases encountered seems to be greater each year. Surgical procedures have been developed to such a degree that the mortality has been reduced to as low as 5 per cent in one series (3), and five-year survivals after pneumonectomy are now in no sense rare. The importance of early diagnosis of bronchogenic carcinoma, therefore, is self-evident. For purposes of detection of the disease, to give the evidence which will lead to further investigation so that a definitive diagnosis may be made, x-ray examination is, without doubt, the only widely applicable method. The possibilities and limitations of the roentgen examination in the diagnosis of carcinoma of the bronchus are well known and will not be considered here. We propose rather to describe an early roentgen sign which has been insufficiently stressed, namely, obstructive emphysema. Although Nils Westermark (6, 7) in 1938 first directed attention to the emphysema caused by the bronchostenosis accompanying bronchial tumors, it is notable and rather remarkable that there are so few references to such cases in the American literature. Morlock (4) reported a case of carcinoma of the left main bronchus in which there was obstructive emphysema of the entire left lung. X-ray examination showed an enlarged left hilum shadow. Bronchoscopic examination revealed a new growth at the junction of the left upper and left main bronchi. Cohen (1) reports a case in which atelectasis and obstructive emphysema caused by the same malignant neoplasm were coexistent in the same lung. The tumor was located in the main bronchus so that the orifices of the upper and middle bronchi were completely obstructed, while only a check-valve type of obstruction was produced in the lower bronchus. Vinson (5) states that emphysema beyond the point of obstruction is rarely present in carcinoma of the bronchus. He does, however, report the case of a twenty-nine-year-old man with carcinoma of the bronchus associated with emphysema. Westermark (6) divided the effects of bronchostenosis into three separate stages similar to those described by Jackson (2) for foreign bodies. In the first stage there is diminution of aeration as a result of a minimal stenosis. Some impediment to the ingress and egress of air occurs and it is possible that there may be some decreased radiability of the affected lung. Cases in this stage are difficult to detect on x-ray examination and are rarely encountered. The second stage occurs when the stenosis becomes of higher grade so that a check-valve action takes place. With the diminution of the bronchial lumen occurring during expiration, there is presented a much greater difficulty for the egress of air than for its ingress during inspiration.