JURNAL READING VI Early detection of central airway lung cancer in smokers with silicosis

A.L.L. Lo, Y. Huang, S.Y. Lam, A.H.K. Cheung, R.Au, C. C. Leung, W. K. Lam, M. S. M. Lp, M. Chan-Yeung,B.Lam

dr.Mohammad Ramadhani Soeroso

Supervisor : Dr. Pandiaman Pandia Sp.P(K)

MATERIALS AND METHODS

From June 2006 to March 2009, all patients followed up at the designated Pneumoconiosis Clinic of Hong Kong were invited to join the study if they fulfilled the following inclusion criteria: 1) age 40 years; 2) smoking history of 20 pack-years; and 3) confirmed diagnosis of silicosis. The diagnosis of silicosis was based on significant occupational exposure to silica-containing dust and radiographic changes consistent with silicosis, with or without histological proof.

SPUTUM EXAMINATION
Subjects were asked to provide early morning sputum for 3 consecutive days. All fresh specimens were examined by trained cytotechnologists under the supervision of a pathologist (SYL) in the Cytology Laboratory of the Department of Health. The results were reported as unsatisfactory, normal, atypia, suspicious for cancer and cancer. all sputum samples were sent for cytometry examination using an automated high-resolution image cytometer.

BRONCHOSCOPY

Was performed under local anaesthesia in the endoscopy suite. Conventional WLB was performed first, followed by autoflourescence bronchoscopy. All abnormal sites were videotaped, recorded, and biopsied.

SPIROMETRY

Standard spirometry was performed before bronchoscopy. FEV1 & FVC were measured and expressed as a percentage of the predicted value based on a prediction equation for the Chinese population. Airflow limitation was defined as a ratio of FEV1 to FVC of <70%

MANAGEMENT
Subjects with intraepitheliel lung cancer(severe dysplasia and CIS) were treated with endobrochial cryotherapy and reassesed periodically with WLB and autoflourescence bronchoscopy every 3, 6, 12, and 24 months. Subjects with pre-neoplastic lesions(squamous metaplasia and dysplasia) were followed up with WLB and autoflourescence bronchoscopy every 6 months until the lesion regressed. All abnormal sites detected and sites that received treatment were biopsied at reassessment. Physicians advice for smoking cessation were given to all participants in the study.

OUT COME
The outcome of this cohort, including the number of patients with lung cancer and the stage distribution, was determined from patient records reviewed in July 2009.

ETHICAL CONSIDERATIONS
Ethical approval was obtained from institutional review board of both the Department of Health and the University of Hong Kong. Informed consent was obtained from each subject.

STATISTICAL ANALYSIS
Subjects were divided into 2 groups for analyses. Group 1 includes patients with endobronchial biospy revealing squamous metaplasia or above. Group 2 are those without endobronchial lesion or biopsy showing hyperplasia or below. Continous data were expressed as mean standard deviation(SD) and categorical data were presented as percentage. Fishers exact test and the 2 independent sample t-tests were used to compare dichotomous and continuous data between the 2 groups.

RESULTS
From June 2006 to March 2009, we screened 720 subjects with silicosis. A final total of 48 eligible Chinese male subjects with sputum abnormalities were recruited into the study. The mean age of this cohort was 63 10 years (range 4882), with an accumulated smoking history of 51 30 pack-years.

DISCUSSION
Squamous cell carcinoma develops in a gradual and stepwise fashion therefore if the pre-cancerous and pre-invasive lesions can be detected in eary stages and treated, the development of lung cancer may be arrested. Combination of sputum cytology/ cytometry and autofluorescencebronchoscopy as a screening tool, shows 4.2% of the silicotic patients with sputum abnormality had intraepithelial (Stage 0) lung cancer.

DISCUSSION
In our cohort, squamous metaplasia and mild to moderate dysplasia were detected in 29.2% of the subjects and up to 9% of patients progress to intraepithelial lung cancer with a median follow-up of 21 months. Subjects harbouring these lesions should also therefore be followed up. Current smoking and a history of asbestos exposure were associated with an increased risk of such lesions. The findings suggest that autofluorescencebronchoscopy is essential for silicotic patients presenting with sputum abnormalities.

CONCLUSION
Sputum examination followed by autoflourescence bronchoscopy may be a useful way of identifying cancerous/pre cancerous lesions among silicotic smokers. Current smoking and asbestos exposure were associated with this lesions.

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