The National Cancer Institute of the United States recently sponsored three large-scale, randomized controlled trials of screening for early lung cancer. The trials were conducted at the Johns Hopkins Medical Institutions, the Memorial Sloan-Kettering Cancer Center, and the Mayo Clinic. Participants were middle-aged and older men who were chronic heavy cigarette smokers and thus at high risk of developing lung cancer. Screening procedures were chest radiography and sputum cytology, the only screening tests of established value for detecting early stage, asymptomatic lung cancer. In the Hopkins and Memorial trials the study population was offered yearly chest radiography plus sputum cytology every 4 months. The control population was offered yearly chest radiography only. In these trials the addition of sputum cytology appeared to confer no lung cancer mortality rate advantage. The Mayo Clinic trial compared offering chest radiography and sputum cytology every 4 months to offering advice that the two tests be obtained once a year. This trial demonstrated significantly increased lung cancer detection, resectability, and survivorship in the group offered screening every 4 months compared with the control group. However, there was no significant difference in lung cancer mortality rate between the two groups. The statistical power of these trials was somewhat limited. Nevertheless, results do not justify recommending large-scale radiologic or cytologic screening for early lung cancer at this time.

The initial (prevalence) radiologic and cytologic screening for lung cancer in the Mayo Clinic study (Mayo Lung Project) involved 10,933 outpatients. All were men at high risk for lung cancer, but none were suspected of having it when they entered the Mayo Clinic. Screening identified 91 lung cancers (8.3 per 1,000 screened). Nearly two thirds of the prevalence lung cancers were detected by chest roentgenography alone. Half of these cancers were resected. Only a fifth of the cancers were detected by sputum cytologic examination alone; however, all but 1 of these were resected. Compared with a group of lung cancers encountered in contemporary clinical practice at the Mayo Clinic, the prevalence cancers were more than twice as likely to be (1) resectable, (2) postsurgical Stage I or II (AJCC), and (3) associated with survival 5 yr after treatment.

During the first 10 years of the Mayo Lung Project, 68 roentgenographically inapparent ("occult") lung cancers were localized and apparently completely resected. A pathologic classification was developed based on depth of tumor infiltration. The five categories were (1) in situ carcinoma confined to surface epithelium or ducts of mucous glands or acini (23 cancers), (2) intramucosal invasion not greater than 0.1 cm from mucosal surface (12 cancers), (3) invasion to bronchial cartilages (11 cancers), (4) invasion to full thickness of bronchial wall (10 cancers), and (5) extrabronchial invasion (12 cancers). Multicentricity of lung cancer was studied in 54 patients, none of whom had a history of cancer of the respiratory tract, and all of whom had had "complete" surgical resection of the initial occult lung cancer (or cancers). Neoplasms that were initially multicentric occurred in 4 patients, and a subsequent primary lung cancer developed in 11. The rate of detection of second primary lesions was 42 per 1,000 person-years of observation. A high incidence of unresectable cancers and a low survival rate were noted among patients who had a subsequent primary tumor. These findings were primarily attributable to invasiveness of the subsequent primary cancer or to respiratory insufficiency that resulted from obstructive lung disease or previous pulmonary resection. Because of the high risk of development of a second primary cancer after initial surgical resection, it is important to treat the initial occult cancer as conservatively as possible consistent with "cure."

INVASIVE fibrous thyroiditis as herein defined is a rare clinicopathologic entity. The exact incidence cannot be ascertained readily from the literature, largely because many authors have not defined accurately the type of “thyroiditis” being reported. Thus, critical appraisal of all purported cases is necessary. Prior to 1932, it was widely held that Riedel's struma was an end stage of Hashimoto's disease. Graham (1), in a careful review of the literature up to 1929, emphasized the striking differences between the two diseases and considered only 41 cases of Riedel's struma 2) reported up to that time as authentic. Since Graham's review, surprisingly few additional cases have been reported (3). A considerable number of reports on Riedel's struma deal in part or entirely with granulomatous (subacute) thyroiditis (4–11). The number of cases in which a strict definition of invasive fibrous thyroiditis is adhered to is extremely small. Schilling (12) described 1 authentic case with necropsy findings and 1 additional case obtained from 3,750 admissions for thyroid disease in a study of 8,000 necropsies. Lindsay and associates (13) reported 2 cases of invasive fibrous thyroiditis occurring in a total of 6,571 thyroidectomies over a 30-year period. Perhaps the largest well-documented single series is that of Joll (14), in 1939, who described 5 previously unreported cases in a series of 5,650 thyroidectomies.

Hematoporphyrin derivative used in conjunction with the Mayo Clinic bronchofiberscopic fluorescence detection system allows accurate localization of radiographically occult early squamous cell carcinoma. Thirteen tumors were localized in 10 patients with radiographically occult lung cancer. Six were in situ with or without microinvasion and were also bronchoscopically occult. Localization of these 6 tumors was expedited by the use of hematoporphyrin derivative and the bronchoscopic fluorescence detection system. Hematoporphyrin-derivative fluorescence was not specific for carcinoma and was also detected in areas of moderate and marked squamous cellular atypia. Thus, although detection of hematoporphyrin-derivative fluorescence suggests the presence of cancer, proof depends on histologic or cytologic confirmation.

Retrospective review was undertaken of 137 patients with occult papillary carcinoma of the thyroid (lesions less than or equal to 1.5 cm in diameter) who were operated on at the Mayo Clinic, Rochester, Minn, between 1926 and 1955. Mean follow-up period was 25.3 years. Operations were conservative. No patient underwent bilateral total lobectomy. For 55 patients with lymph node involvement, lymphadenectomy generally involved selective node excision or modified neck dissection. Subsequent surgery was required in 12 patients; modified radical neck dissection was necessary in only four. No operative deaths occurred. Long-term follow-up showed that all patients were alive and without disease or were dead without proof of thyroid-related disease. Thus, occult papillary thyroid carcinoma with or without nodal metastasis is a nonlethal and curable disease when treated by conservative surgical means. Radical surgical or medical extirpation of all thyroid tissue is unnecessary in the treatment of this disease.

Hematoporphyrin is preferentially concentrated by cancer tissue and therefore is a potentially useful chemical marker. This report demonstrates the effectiveness of a photoelectric hematoporphyrin fluorescence detector used simultaneously with flexible fiberoptic bronchoscopy as a means of detecting and localizing bronchogenic carcinoma. The detector generates an audio signal when fluorescence is within the visual field of the bronchoscope. Of interest is that an audio signal was generated which indicated hematoporphyrin fluorescence in areas where no mucosal abnormality had been seen. These areas proved to be carcinoma in situ.

A review was made of the presentation, treatment, and follow-up of 20 patients with adenoid cystic carcinoma and 12 patients with mucoepidermoid carcinoma of the bronchus who were seen at the Mayo Clinic during the 50 year period 1927 through 1977. Three forms of therapy were employed: complete surgical resection, radiation therapy alone, and radiation therapy after endoscopic removal of tumor tissue. Superior results were obtained in the group with adenoid cystic carcinoma, when complete resection was possible. Significant survival and palliation of sepsis was achieved with subtotal resection. The mucoepidermoid carcinomas in this series were classified on the basis of histologic differentiation. Mucoepidermoid carcinoma of Grade 1 was managed by conservative pulmonary resection. Mucoepidermoid carcinoma of Grades 2 and 3 showed a greater propensity for malignancy. Widespread dissemination caused death with unresectable high-grade mucoepidermoid carcinomas of Grades 2 and 3.

Mesothelioma, even of the pleura alone, is a ubiquitous pathological designation. The diffuse variety is associated with an ominous prognosis. The localized mesothelioma generally has been assumed to be benign. A review of tumors from 60 patients with localized pleural mesothelioma seems to justify separation into benign (52 patients) and malignant (eight patients) variants. Histologic criteria are used primarily to make this division. No single clinical feature allowed preoperative predictability concerning benignity or malignancy, although extrathoracic osteoarthropathy was seen only with benign lesions (20 percent), usually those greater than 7 cm. Follow-up periods of as long as 24 years revealed recurrent tumor in only two of the 58 patients with benign lesions and revealed a survival curve identical to that of the general population. All of the patients with the malignant variety had recurrence or metastasis, and all but one were dead within 2 years of the initial operation. One patient died of tumor complications after 9 years. More aggressive local resection is indicated for the malignant variant.

Sixteen patients, aged 10 to 70 years, had carcinoid tumors of the lower respiratory tract treated by various resective tracheobronchoplastic procedures. These represent 8.8 percent of 181 patients with carcinoid lesions treated during a recent 20 year period. All 16 patients had respiratory symptoms, and one patient also had the carcinoid syndrome. Roentgenographic changes ranged from a mass or atelectasis (or both) through unilateral lung hyperinflation to clear lungs with subtle filling defects in major airways. All tumors were visualized endoscopically, and 13 patients had biopsies. Histopathologically, all tumors were "typical" carcinoids . Before operation, the patients had minimal or no respiratory insufficiency, although flow-volume and ventilation-perfusion abnormalities were noted when major airways were affected. Surgical management at thoracotomy was as follows: (1) simple wedge tracheobronchotomy without lung resection (five patients); (2) bronchial sleeve resection without lung resection (three patients); and (3) bronchial sleeve with upper lobe resection (eight patients). These 16 operations were performed with eight technical anatomic variations. No early or late deaths occurred. One patient had early transient atelectasis, and three patients required late endoscopic removal of suture granulation tissue. All patients were alive without recurrence of tumor or carcinoid syndrome or other respiratory complications 6 months to 19 years postoperatively. Pulmonary resection should be avoided unless there is histologic evidence of tumor extension into lung parenchyma or irreversible pulmonary suppuration distal to the obstructive tumor.

We have studied seven episodes of transient hyperthyroidism in three men and one woman, aged 19 to 38 years. No patient had fever or neck tenderness. All had palpable thyroid glands. Elevated serum thyroxine values persisted for 1 to 3 months. Thyroid131I uptake at 6 and 24 hours was low (1 to 3%). Erythrocyte sedimentation rates were normal or only slightly increased. Needle biopsy in four patients and a thyroidectomy specimen in one patient, all taken during the hyperthyroid phase, showed lymphocyte infiltration and extensive follicular disruption without oxyphilia. There was no evidence of granulomatous thyroiditis. Thyroglobulin antibodies were normal in all. In three patients, transient hypothyroidism followed the hyperthyroid episode. In two patients, the condition was recurrent. The findings are compatible with transient unregulated discharge of thyroid follicle content in some patients with lymphocytic thyroiditis. Recognition permits avoidance of unnecessary treatment with surgery, radioiodine, or antithyroid drugs.

Parathyroid pathology is an inexact science, and especially in parathyroid surgical procedures, the surgeon has to be the judge of what is significantly abnormal.

The Mayo Lung Project (MLP) is a screening program designed to detect bronchogenic carcinoma at a curable stage. Screening tests include chest roentgenograms, three-day "pooled" sputum cytology studies, and lung-health questionnaires. These are being applied every four months to a study population of outpatients who have a high probability of developing lung cancer. Initial patient acceptance of the screening program has been excellent. Small asymptomatic lung cancers have been detected both roentgenographically and cytologically. The two procedures have complemented each other with little overlap. Chest roentgenography has proved most useful in diagnosing peripherally situated cancers, whereas sputum cytology studies have been most effective in identifying early squamous cancer involving major airways. At present, more cancers have been detected roentgenographically than cytologically, but the cytologically detected cases appear to have a better prognosis. Roentgenographically occult cancers have been localized with regularity, although the localization process is complicated. Theoretically, vigorous application of radiologic and cytologic screening, combined with optimum use of localizing procedures and treatment, could increase the five-year survival rate among lung cancer patients to nearly 50 percent. However, the actual survivorship attained will ultimately be determined by currently imponderable factors such as patient acceptance of longterm screening, frequency of multicentric respiratory cancers, and incidence of noncancerous smoking-related diseases, especially chronic obstructive pulmonary disease and ischemic heart disease.

Disseminated inflammatory lesions constituting a multifocal granulomatous folliculitis in the thyroid are described. These lesions were present in the majority (greater than 83%) of thyroids removed surgically because of thyroid or nonthyroid (carcinoma of the larynx) disease. They also were found at autopsy in patients who died while hospitalized but not in those who died at home. An identical lesion was produced experimentally in dogs by vigorously squeezing their thyroids. The human folliculitis is believed to result from traumatic injury or rupture of isolated thyroid follicles caused by palpation of the gland (palpation thyroiditis). Palpation thyroiditis may have little, if any, clinical importance. The remote possibility that it might be associated with iatrogenically produced metastasis of thyroid carcinoma is being investigated.

During the initial 18 months of the Mayo Lung Project for detection and localization of early bronchogenic carcinoma, 13 patients were identified who had roentgenographically occult tumors. A specific protocol for investigation emphasizing continuous reevaluation and repeated bronchoscopic examinations has identified the site of the cancer in each case. Although the number of cases is small and the time since treatment short, initial results are encouraging and suggest that curable lung cancer can be detected by a carefully designed and applied screening program. During the initial 18 months of the Mayo Lung Project for detection and localization of early bronchogenic carcinoma, 13 patients were identified who had roentgenographically occult tumors. A specific protocol for investigation emphasizing continuous reevaluation and repeated bronchoscopic examinations has identified the site of the cancer in each case. Although the number of cases is small and the time since treatment short, initial results are encouraging and suggest that curable lung cancer can be detected by a carefully designed and applied screening program.