Primary pulmonary sarcomas etiology clinical assessment and prognosis with a comparison to pulmonary carcinomas a review of 41 cases and 394 other cases of the literature


Gebauer, C.

Japanese Journal of Surgery 12(2): 148-159

1982


Primary sarcomas of the human lungs occur at frequencies of 1:100, compared with carcinomas reported in retrospective studies covering 394 cases reported in the literature from 1957-1972 and 41 cases from 1957-1974. The average age was 45 yr, the disease usually occurred between the ages of 35-65, the peak being between 45-60 yr. Distribution between sexes was much the same as that seen in general. X-ray with rapid thoracotomy provided the best clinical results. The literature showed a postoperative survival time of 5 yr in 19% and 44% of the reported cases. The general metastasis, hematologenous and lymphogenous were more or less equal and recidive tendency in 7% essentially varied, as related to the single histological forms. Lymphosarcomas (28.6%) were the most frequent, the group of spindle-celled sarcomas, inclusive of leiomyosarcomas, occurred in 40%. Histological maturity of the tissues and the prognosis according to active therapy were in parallel. A comparison of 41 primary sarcomas of the lungs with the 192 cases of carcinomas seen showed no connection between sarcomas of the lungs and smoking of cigarettes, pollution of the environment, industrial toxins or chronic bronchitis. The findings relate to the peripheral localization and to the lack of incidence among men, with regard to pulmonary adenocarcinomas. An overall view of the characteristics led to the assumption of a probable endogenous tumor. A summarization of the characteristics of pulmonary sarcomas and carcinomas revealed the role of primary sarcomas in the total complex of malignant tumors of the lungs.

Review
article
Primary
Pulmonary
Sarcomas:
Etiology,
Clinical
Assessment
and
Prognosis
with
a
Comparison
to
Pulmonary
Carcinomas
—A
Review
of
41
Cases
and
394
other
Cases
of
the
Literature
Christoph
GEBAUER
ABSTRACT:
Primary
sarcomas
of
the
lungs
occur
at
frequencies
of
1:100,
as
compared
with
carcinomas
reported
in
our
retrospective
studies
cover-
ing
394
cases
reported
in
the
literature
from
1957
to
1972
and
41
cases
from
1957
to
1974.
The
average
age
was
45
years,
the
disease
usually
occurred
between
the
ages
of
35
and
65,
the
peak
being
between
45
and
60
years.
Dis-
tribution
between
sexes
was
much
the
same
as
that
seen
in
general.
X-ray
with
rapid
thoracotomy
provided
the
best
clinical
results.
The
literature
showed
a
postoperative
survival
time
of
5
years
in
19%
and
44%
of
our
own
cases.
The
general
metastasis,
haematologenous
and
lymphogenous
were
more
or
less
equal
and
recidive
tendency
in
7%
essentially
varied,
as
related
to
the
single
histological
forms,
Lymphosarcomas
(28.6%)
were
the
most
frequent,
the
group
of
spindle-celled
sarcomas,
inclusive
of
leiomyosarcomas,
occurred
in
40%.
Histological
maturity
of
the
tissues
and
the
prognosis
ac-
cording
to
active
therapy
were
in
parallel.
A
comparison
of
41
primary
sar-
comas
of
the
lungs
with
the
192
cases
of
carcinomas
seen
in
our
clinic
showed
no
connection
between
sarcomas
of
the
lungs
and
smoking
of
cigarettes,
pol-
lution
of
the
environment,
industrial
toxins
or
chronic
bronchitis.
These
findings
relate
to
the
peripheral
localization
as
well
as
to
the
lack
of
incidence
among
men,
with
regard
to
pulmonary
adenocarcinomas.
An
overall
view
of
the
characteristics
led
to
the
assumption
of
a
probable
endogenous
tumour.
A
summarization
of
the
characteristics
of
pulmonary
sarcomas
and
carci-
nomas
revealed
the
role
of
primary
sarcomas
in
the
total
complex
of
malig-
nant
tumours
of
the
lungs.
KEY
WORDS:
pulmonary
sarcoma,
pulmonary
carcinoma,
carcinogenesis.
INTRODUCTION
P
rimary
sarcomas
of
the
lungs
cannot
be
included
in
the
increase
of
frequency
of
car-
From
lInd
Medical
Clinic
of
the
University
of
Maintz,
Langenbeckstr.
1,
D-6500
Mainz,
Germany.
Reprints
requests:
Christoph
Gebaner,
Kunigunden-
damm
19,
8600
Bamberg,
West
Germany
cinomas
of
the
lungs.
As
only
compli-
cations
can
be
found
in
the
corresponding
literature
on
such
sarcomas,
1-8
the
100
cases
documented
are
probably
close
to
the
actual
numbers.
Very
often
the
reports
from
1900
to
1930
are
included
in
the
col-
lected
statistics.
The
occurrence
of
primary
sarcomas
before
1930
is
doubtful,
since
most
were
probably
bronchial
carcinomas,
metas-
JAPANESE
JOURNAL
OF
SURGERY,
VOL.
12,
No.
2,
pp.
148-159,
1982
Volume
12
Number
2
Pulmonary
sarcoma
149
tatic
formations,
pleural
tumours
or
medias-
tinal
tumours.
9-11
Difficulties
also
existed
with
regard
to
histomorphological
differen-
tiation
of
small-cell
carcinomas,
round-cell
sarcomas,
12
lymphosarcomas
13,14
and
retic-
ulum-cell
sarcomas.
15
Most
of
the
reports
are
limited
to
histological
descriptions,
e.g.,
lynaphosarcomas,
10,16-18
fibro-cell-sarcomas
and
spindle-cell-sarconaas,
19,20
leiomyosar-
comas13
,21-24
and
carcinosarcomas.
As
a
rule,
only
single
cases
are
described
and
discussed.
Thus,
it
is
difficult
to
record
all
cases
of
primary
sarcomas
of
the
lungs,
for
it
is
only
in
the
last
few
decades
that
precise
histomorphological
differentiation
and
exact
information
on
localization
have
become
feasible.
MATERIALS
AND
METHODS
From
1957
to
1972,
394
primary
sarcomas
of
the
lungs
were
reported
in
the
inter-
national
literature.
The
Japanese
and
South
American
documentations
have
not
been
taken
into
sufficient
consideration.
4,25
To
this
number,
41
of
own
cases
so-diagnosed
in
the
clinic
Zschadrass
from
1957
to
1974
were
added.'"
The
importance
of
cancer-
ogenic
toxins
is
analysed
and
findings
are
compared
with
those
of
41
primary
sarcomas
of
the
lungs
and
192
carcinomas
of
the
year
1969,
cigarette
smoking,
air
pollution,
in-
dustrial
toxins,
chronic
inflammations
and
anamnesis
of
the
tumour.
26,27
In
a
total
of
435
cases
of
primary
sarcomas
of
the
lungs,
frequency,
age
and
sex
disposition,
localization,
symptomatic,
diagnostic,
thera-
Table
1.
Comparison
of
Frequency
between
Primary
Sarcoma
of
the
Lungs
and
Bronchial
Carcinoma
in
the
Literature
from
1938
to
1972
and
Author's
Observ-
ations
of
the
Pulmonary
Clinic
Zschadrass
from
1957
to
1974.
Year
of
Publication
Carcinomas
Sarcomas
(%)
Neumann
11
1938
377
16
(4.3)
Pollack
et
a1
5
°
1938
800
6
(0.75)
Ochsner
et
al
51
1948
412
6
(1.47)
Salzer
by
Mtilly
52
1952
930
2
(0.2)
Barthell
1953
913
4
(0.4)
Drews
&
Willmann
15
1953
500
2
(0.4)
Vieten"
1953
500
2
(0.4)
Lorbeck
53
1954
930
2
(0.2)
Walter
by
Brunner
54
1954
57
(1.75)
Noehren
and
McKee
55
1955
800
(0.12)
Frey
and
Ladeckel
3
1958
400
8
(2.0
Haag
49
1961
1238
9
(0.7)
Otto
and
Frey
31
1961
1296
12
(0.9)
Hering
et
al
5
1962
90
2
(2.2)
Schroder
51
1963
384
4
(1.1)
Brunner
57
1964
178
3
(1.8)
Clagett
et
a1
57
1964
1434
23
(1.6)
Stohr
and
Sachs
61
1937
459
12
(2.6)
Rothe"
1965
400
7
(1.75)
Rink
5
°
1965
921
18
(2.0)
Kuhn?
1967
784
15
(1.9)
Eskenasy
2
1967
28
1
(3.5)
Author's
cases
4360
41
(0.96)
Total
(1.4)
150
Gebauer
Jpn.
J.
Surg.
March
1982
py,
metastasis
and
recidive,
prognosis
and
differentiation
of
malignity
of
the
single
histological
forms
of
sarcomsa
are
reported
and
discussed.
A
comparison
of
sarcomas
of
the
lungs
with
bronchial
carcinomas
is
included
in
the
results.
RESULTS
Frequency
The
frequency
of
primary
sarcomas
of
the
lungs
in
our
own
cases
from
1957
to
1974
was
a
proportion
of
41:4360,
that
is
about
1:100.
A
summary
of
24
reports
in
the
lit-
erature
(Table
1)
shows
the
rate
to
be
1.4%.
Age
and
sex
disposition
The
age
at
occurrence
was
from
1.5
to
80
years.
The
average
age
of
45
years
was
noted
in
419
available
reports.
In
Table
2,
the
statements
of
10
authors
are
compiled,
taking
an
essentially
smaller
number
of
cases
as
a
basis.
In
primary
lymphosarcomas
of
the
lungs,
the
average
age
of
50-53
years
28
is
about
7
years
higher,
than
our
own
statis-
tics
of
114
cases
in
which
the
average
was
52.3
years.
Our
statistics
showed
that
of
419
of
the
available
cases
(48%)
occurred
in
those
under
50
and
the
occurrence
was
52%
in
those
over
50
years
(Table
3).
Pulmonary
sarcomas
were
found
in
those
under
35.
The
peak
of
frequency
was
be-
tween
45
and
60
years
of
age.
In
those
over
65,
primary
sarcomas
of
the
lungs
were
rare
(Table
4).
Table
3.
Age
Distribution
of
Patients
with
Pulmonary
Sarcomas
Age
in
Years
Number
of
Patients
Percentage
1-25
59
14.0
26-50
165
38.0
51-75
203
47.3
75-
3
0.7
Table
4.
Age
and
Infection
of
Patients
with
Pulmonary
Sarcomas
Age
in
Years
Number
of
Patients
Age
in
Years
Number
of
Patients
1—
5
10
41-45
36
6-10
7
46-50
60
11-15
17
51-55
55
16-20
14
56-60
61
21-25
11
61-65
40
26-30
16
66-70
28
31-35
16
71-75
19
36-40
37
76-80
3
Table
2.
Average
Age
of
Patients
with
Pulmonary
Sarcomas
Author
Year
of
Average
Age
Publication
(years)
Stohr
and
Sachs
61
1963
40.0
Dyson
and
Trentalence
62
1937
40.5
Kuhn'
1967
41.6
Saltzstein
24
1963
42.2
Haag
49
1959
42.5
Shusterov
et
a1
34
1969
42.5
Leisner
63
1949
42.6
Hochberg
and
Crastnopol
6
1956
43.0
Meszaros
and
Simarski
22
1960
43.0
Iverson
2
°
1954
46.0
Average
age
in
ten
reports
42.4
378
Interpretable
Literature
Reports
44.0
(1957-1972)
41
Author's
Cases
(1957-1974)
50.0
419
Age
of
Sarcoma-Bearers
45.0
Volume
12
Number
2
Pulmonary
sarcoma
151
70
60
50
40
11
30
20
10
20
40
60
80
100
age
of
patients
Fig.
1.
Age
and
occurrence
of
sarcomas.
The
rare
incidence
in
men
1.5:1
in
426
available
sarcomas
of
the
lungs
corresponds
to
the
general
statistics
of
sarcomas
1.6:1.
29
(Fig.
1)
Sarcomas
of
the
lungs
generally
show
a
sex
distribution
of
1:1,
if
primary
lymphosarcomas
of
the
lungs
(men:
women
=1.8:1)
are
not
considered."
The
distri-
bution
in
385
cases
in
the
literature
from
1957-1972
was
236
men:
149
women,
the
male
occurrence
being
20/41
in
our
own
cases,
in
all
256
men:
170
women.
In
Table
5
our
results
are
compared
with
12
findings
in
the
literature
in
which
an
essen-
tially
smaller
number
of
cases
was
available.
Etiology
Out
of
41
sarcoma
patients,
66%
were
non-smokers,
whereas
only
16.6%
of
the
patients
with
carcinomas
were
non-smokers.
In
the
men
with
sarcomas,
70%
were
smok-
ers
and
only
21.4%
heavy
smokers.
In
those
with
carcinomas
90.6%
were
smokers,
and
here
76.5%
were
heavy
smokers
(10
to
20
cigarettes
a
day
or
more).
In
different
countries
and
countrysides
or
industrial
dis-
tricts,
the
habits
of
the
smokers
differ.
The
number
of
smokers
in
U.S.A.
was
47.8%
men
and
31.4%
women,
in
Great
Britain
68.6%
men
and
43.2%
women
31
and
in
urban
and
rural
district
of
Wurzen
(GDR)
with
industrial
and
rural
places,
within
the
medical
surveillance
of
the
lungs
at
clinic
Zschadrass,
53.4%
men
and
8.4%
women.
The
distribution
in
the
urban
residential
area
(sarcomas
51.2%:
carcinomas
48%)
and
in
the
rural
areas
(sarcomas
48.8%:
carcinomas
52.0%)
as
well
as
in
industrial
districts
(sarcomas
56%
:
carcinomas
53.1
%)
was
much
the
same
in
the
case
of
sarcomas
and
carcinomas
of
the
lungs.
(Table
6)
Exposure
to
dust
was
found
in
10.4%
of
those
with
carcinomas
and
thus
was
not
remarkably
higher
than
the
7%
found
in
those
with
sarcomas.
On
the
contrary,
the
coincidence
of
chronic
bronchitis
was
clini-
cally
or
bronchoscopically
confirmed
in
58.3%
of
those
with
carcinomas
compared
with
only
13.2%
in
those
with
carcinomas.
Table
5.
Tabular
Summary
of
Distribution
According
to
the
Sexes
Author
Year
of
Publication
Male
:
Female
Iverson
29
1954
2.2
:
1
Roth
59
1965
2
:
1
Schroder
56
1963
2
:
1
Dyson
and
Trentalence
62
1963
2
:
1
Kuhn'?
1967
1.75:
1
Author's
Cases
4
1980
1.5
:
1
Leisner
63
1949
1.5
:
1
Hochberg
and
Crastnopol
6
1956
1.4
:
1
Meszaros
and
Simarski
22
1960
1.3
:
1
Bankamp
19
1954
1.1
:
1
Haupt
and
Glockner
33
1957
1
:
1
Otto
and
Frey
37
1961
1
:
1
Shusterov
et
a
134
1969
1
:
1
Hering
et
a1
5
1962
1
:
1
152
Gebaaer
Jpn.
J.
Surg.
March
1982
Table
6.
Relationship
Between
Smoking
and
Carcinomas
and
Sarcomas
of
the
Lungs
in
a
Normal
Population
within
the
District
of
the
Pulmonary
Clinic
Zschadrass.
The
Correlation
Between
Smoking
and
Carcinomas
Does
Not
Correspond
to
Correlations
in
Case
of
Sarcomas
of
the
Lungs.*
Carcinomas
Sarcomas
Normal
Population"
Number
of
Cases
192
41
35,330
Sex
Distribution
Men:
Women
9.7:
1
1.5:
1
1:
1
Distribution
5:
1
1:2
1:
3.5
Smokers:
83.4%:
16.6%
34%
:
66%
Non-Smokers
(160):
(64)
(14):
(27)
Number
of
90.6%
48.8%
50%
Cases
in
Men
(174)
(20)
Distribution
9:
1
2.3:
1
0.87:
1
Smokers:
Non-
89.7%:
10.3%
70%:
30%
46.4%
:
53.4%
Smokers,
Men
(156)
:
(18)
(14):
(6)
Number
of
Heavy
Smokers
(10
76.5%
21.4%
38.1%
(cigarettes)
(119)
(
3
)
Number
of
Women
9.4%
51.2%
50%
(18)
(21)
Distribution
of
0.28:
1
100%
Non-
0.09:
1
Smokers:
Non-
21.4%:
78.8%
Smokers
8.4%
:
91.6%
Smoking
Women
(4)
:
(14)
*
Absolute
Number
of
Cases
in
Parenthesis
Table
7.
Adenocarcinomas
and
Pulmonary
Sarcomas
Correspond
as
to
the
Lack
of
Influence
of
Cancero-Genous
Toxins
and
Distribution
According
to
the
Sexes
Number
of
Cases
Sarcomas
Adeno-
carcinomas
All
inclusive
Carcinomas
Men
48.8%
40%
90.6%
Women
51.2%
60%
9.4%
Smokers
34.0%
40%
89.7%
Non-Smokers
66.0%
60%
10.3%
Chronic
Bronchitis
13.2%
24%
58.3%
No
exogenous
Toxins
56.0%
53%
8.3%
Miners
exposed
to
Radioactive
Rays
5.0%
18.2%
The
radioactive
ray
exposure
in
miners
was
found
in
18.2%
of
those
with
carcinomas,
such
being
significantly
higher
than
the
5%
found
in
those
with
sarcomas
(x
2
=4.508).
Histologically
differentiating
the
carcinomas,
the
adenocarcinomas
correspond
with
the
sarcomas,
whereas
the
other
histological
forms
of
carcinomas
correspond
to
the
gen-
eral
findings
in
the
case
of
carcinomas.
26,27
Systematic
investigations
of
the
anamne-
sis
of
tumors
show
1%
with
carcinomas
and
10%
with
sarcomas.
(Table
7)
Localization
The
proportion
of
involvement
on
the
Volume
12
Numbcr
2
Pulmonary
sarcoma
153
right
side
of
the
lungs
was
58.8%
:
the
left
41.2%,
the
incidence
being
much
the
same
in
those
with
sarcomas
and
those
with
car-
cinomas
(Fig.
2).
The
prevailing
localiza-
tion
was
related
to
lymphosarcomas,
right
71%,
left
29%.
Sarcomas
were
somewhat
more
frequently
localized
in
the
underlobes
(Fig.
2
and
Table
8).
Symptoms
There
were
no
predominant
symptoms
in
the
case
of
sarcomas.
The
histologic
differ-
entiation
was
non-specific.
Endobronchial
sarcomas
were
characterized
by
a
complex
of
symptoms
of
bronchostenosis.
Peripheral
sarcomas
of
the
lungs
were
in
the
beginning
asymptomatic.
Only
with
growth
of
the
tumour
were
there
occurrences
of
displace-
ment
of
the
neighbouring
organs
or
actual
invasion
into
the
bronchial
system.
The
21.0%
16.3%
21.5%
Fig.
2.
Localization
of
primary
sarcomas
of
the
lungs:
author's
study
of
395
in-
terpretable
cases
from
1957
to
1974.
most
frequent
symptoms
were
cough
and
pains
in
the
thorax.
Less
frequent
occur-
rences
were
expectoration,
fever
or
haemop-
tosis.
Diagnosis
X-rays
and
clinical
investigations
can
provide
evidence
of
a
tumour,
but
not
the
histological
diagnosis
or
verification
of
a
malignancy.
Clinical-laboratory
investi-
gations
do
not
produce
an
accurate
diagnosis,
for
93%
of
our
patients
had
normal
hema-
tological
findings.
Sarcomas
can
be
evidenced
as
coin
lesions
of
the
lungs,
as
termed
roentgenologically.
The
form
of
the
tumor
in
the
x-ray
of
our
41
patients
was
fairly
round
in
17,
often
oval
in
11
or
polycyclic
in
12,
and
rather
unsharp
in
14.
Out
of
our
41
cases,
28
were
diagnosed
by
x-rays,
10
by
casual
x-ray
examination
and
3
by
symptoms.
The
bronchoscopy
with
biopsy
and
following
cytological
exam-
ination
showed
25%
and
the
examination
of
the
bronchial
secretion
showed
a
5%
possible
malignancy.
We
prefer
to
do
a
thoracotomy
to
obtain
immediate
histological
evidence.
In
the
case
of
fibrous
sarcomas,
this
approach
is
the
most
effective.
Therapy
Early
operation
will
enable
the
most
promising
prognosis.
The
most
frequent
forms
of
resectional
treatment
are
lobectomy
and
pneumonectomy.
Sarcomas
are
not
so
sensitive
to
x-rays.
The
lymphosarcomas
22.2%
19%
Table
8.
Localization
of
Primary
Sarcomas
of
the
Lungs
Cases
Left
Lower-
Lobes
Upper-
Lobes
Lower-
Lobes
Right
Mid-
Lobes
Upper-
Lobes
Primary
Peripheral
Sarcomas
of
the
Lung
41
10
12
11
7
9
Sarcomas
in
the
Literature
1957-1972
354
96
112
109
84
108
Grouped
395
106
124
120
91
117
Percentage
100%
19%
22.2% 21.5%
16.3%
21%
154
Gebauer
Jpn.
J.
Surg.
March
1982
and
the
reticulum-cell-sarcomas
are
an
exception
to
this
rule.
One
patient
with
an
inoperable
endobronchial
lymphosarcoma
survived
5
years
after
only
x-ray
treatment.
Metastases
and
recurrence
In
the
literature,
a
general
metastases
reportedly
occurs
in
28.6%.
Out
of
435
cases,
we
found
131
reports
of
metastases.
Of
these
69,
18%
were
lymphogenous,
64
were
haematogenous
(17%)
and
21
were
simultaneously
lymphogenous
and
haemato-
genous
(5%).
In
the
case
of
haematogen-
ous
metastases,
often
several
organs
were
Table
9.
Metastases
of
involved.
In
one
patient,
metastases
were
found
in
the
heart,
pancreas,
spleen,
oe-
sophagus,
diaphragm,
mediastinum,
sper-
matic
cord,
parotid
gland
skull
and
pelvic
bones.
(Table
9)
There
were
27
reports
on
recurrences,
this
corresponding
to
7%
of
available
reports
of
literature.
This
tendency
was
predomi-
nant
in
cases
of
polymorphenous
and
spin-
dlecellular
sarcomas,
whereas
fibro,
lym-
phatic
and
reticulum-cell
sarcomas
rarely
recurred.
(Table
10)
Prognosis
The
average
postoperative
time
of
survival
of
the
435
cases
of
our
study
was
2.5
years
Pulmonary
Sarcomas
Table
10.
Recurrence
of
the
Histo-
morphological
Forms
of
Sarcomas
Organ
Number
of
Metastases
Lymphnodes
82
Lungs
35
19
Polymorphological
4
22.0%
Liver
20
Cellular
Sarcomas
Brain
20
44
Spindle-Cellular
5
11.4%
Pleura
17
Sarcomas
Kidney
12
41
Leiomyosarcomas
3
7.3%
Ribs
12
55
Fibered
Sarcomas
3
5.5%
Intestine
9
30
Reticulo-Cellular
1
3.3%
Adrenal
Gland
10
Sarcomas
Spinal
Cord
4
121
Lymphatic
Sarcomas
5
3.3%
Table
11.
Relative
Frequency
of
Histological
Forms
Histological
Forms
World
Literature
394
Author's
Cases
41
Collective
Data
Lymphatic
Sarcoma
114
7
121
Fibered
Fibrosarcoma
45
10
55
Spindle-Cellular
Sarcoma
33
11
44
Carcinosarcoma
42
42
Leiomyosarcoma
40
1
41
Reticulo-Cellular
Sarcoma
28
2
30
Polymorphic
Cellular
Sarcoma
18
1
19
Neurogenous
Sarcoma
14
5
19
Hodgkin's
Sarcoma
12
1
13
Round-Cellular
Sarcoma
10
2
12
Angiosarcoma
10
10
Diagnosis
"Sarcoma"
9
1
10
Rhabdomyosarcoma
5
5
Chondrosarcoma
5
5
Osteogenous
Sarcoma
4
4
Liposarcoma
3
3
Hamartochondrosarcoma
1
2
Mychosarcoma
Mostly
intensive
homo-
genous
Shading
and
sharp
Delination
(con-
nective
Tissue
Separation)
Non-Homogenous,
usually
unsharp
Outlines
of
the
Tumour
X-ray
Volume
12
Number
2
Pulmonary
sarcoma
155
(from
2
months
to
10
years).
The
number
of
patients
living
after
surgery
was
43%
after
two
years
and
19%
after
five
years.
Out
of
our
41
own
cases,
92%
of
patients
were
living
after
two
years
and
44%
after
five
years.
Our
good
post-operative
results
are
probably
due
to
rapid
diagnostics
as
a
consequence
of
early
x-ray
examinations
Table
12.
Comparison
Between
Sarcoma
and
Carcinoma
of
the
Lungs
and
Bronchi
Parameter
Sarcoma
Carcinoma
Frequency
1
100
Age
at
Mani-
45th-60th
Years
Over
50
festation
Average
Age
About
45
About
60
Men:
Women
About
1.5:
1
About
9:
1
Smokers:
Non-
1:
2
5:
1
Smokers
(Men
2.3:
1)
(Men
9:
1)
Accompanying
13.2%
58.3%
Bronchitis
Miners
Exposed
to
5%
18.2%
Radioactive
Rays
(10%
Men)
(21%
Men)
Localization
About
95%
Peripheral
Over
80%
Central
Extension
Mainly
Expansive
Mainly
Infiltrative
Infiltration
Late,
mostly
centrifugal
Early,
mostly
Centri-
to
the
Pleura
pedal
to
the
Hilus
Resection
of
the
Area
Obstructive
Pneumonia
or
Mostly
lymphatic
Dila-
rarely
Homolateral
tation
of
the
Hilus
and
Paresis
of
the
Diaphragm
obstructive
paren-
chymatic
Complications
Symptoms
Uncharacteristic,
late,
Early
with
Symptoms
of
rare
irritant
Cough
and
Stenosis
of
the
Haemoptysis
Bronchus
Bronchoscopy
Rarely
positive
Usually
Positive
and
Biopsy
Metastases
Usually
Late,
depending
on
Usually
earlier
and
the
Grade
of
Differentia-
more
Frequent
tion
of
the
Sarcoma
Operability
Usually
feasible
by
Often
Inoperable
because
peripheral
Localization
of
bronchial
Infiltra-
tion
and
early
Metastases
Radiosensitivity
On
Lymphatic
and
Reticu-
Generally
Slight
lumcellularsarcomas
Good,
otherwise
Poor
156
Gebauer
Jpn.
J.
Surg.
March
1.982
and
longer
postoperative
follow-up
periods.
The
single
histological
forms
show
con-
siderable
differences
within
the
scale
of
frequency.
Primary
lymphosarcomas
occur
most
frequently
and
occupy
a
special
clinical
and
prognostical
pOS1I1011.
24,30,32-34
The
group
of
spindlecellular
sarcomas
inclusive
of
leiomyosarcomas
numbered
40%.
The
relation
between
leiomyosarcomas
and
rhab-
domyosarcomas
is,
as
expected,
8:1.
(Table
1
1
)
The
scale
of
malignancy
of
primary
sar-
comas
of
the
lungs
begins
with
lymphatic
and
fibroid
sarcomas.
It
increases
over
spindle-cellular
sarcomas
and
round-cellular
ones
up
to
completely
undifferentiated
poly-
morphenous
cellular
sarcomas.
The
peak
of
malignancy
is
formed
by
the
carcinosar-
comas.
Myosarcomas,
neurosarcomas
and
reticulum-cell
sarcomas
hold
an
average
position.
35
'
36
Within
the
comparison
of
malignancy
of
endothoracal
sarcomas,
the
peripheral
sarcoma
of
the
lungs
corresponds
to
the
pleural
mesothelioma
of
the
sarcoma
type
and
to
the
mediastinal
sarcoma.
3
,
36
Table
12
shows
a
comparison
between
sarcoma
and
carcinoma
of
the
lungs
and
bronchi.
DISCUSSION
Primary
sarcomas
of
the
lungs
are
very
rare
and
appear
on
a
scale
of
distribution
of
tissues
and
organs
of
the
sarcomas
with
1.6%
to
1.8%.
29,37
In
spite
of
the
modern
diagnostics
their
number
remains
constant.
The
proportion
of
frequency
between
sarco-
mas
and
carcinomas
of
the
lungs
is
1:100
(Table
1).
The
average
age
of
operated
patients
with
sarcomas
of
the
lungs
is
45
years
(Table
2),
at
least
ten
to
fifteen
years
earlier
than
in
the
case
of
carcinomas.
A
prominent
incidence
among
the
young
does
not
apply
to
sarcomas
of
the
lungs
(Table
3
and
4,
Fig.
1).
Only
in
comparison
to
bronchial
carcinomas
is
there
no
abrupt
increase
in
frequency
with
aging.
For
this
reason,
sarcomas
are
generally
associated
with
a
higher
total
mortality,
and
shorter
average
expectation
of
life.
While
the
danger
of
the
occurrence
of
carcinomas
increases
with
aging,
primary
sarcomas
of
the
lungs
in
those
over
65
years
are
rare
(Fig.
1).
Contrary
to
carcinomas,
there
is
an
approximate
distribution
between
the
sexes
with
regard
to
sarcomas
of
the
lungs,
as
well
as
to
sarcomas
in
general
(Table
5).
In
connection
with
bronchial
carcinomas
and
smoking
of
cigarettes,
it
has
been
stated
in
retrospective
and
prospective
studies
38-42
that
the
rate
of
mortality
is
10.8%
43
The
morphological
findings
in
the
mucous
mem-
brane
of
heavy
smokers
44,46
and
in
those
with
chronic
bronchitis
relate
to
findings
in
those
with
layer-epithelium
carcinoma.
46,47
The
lack
of
correlation
between
cigarette
smoking
and
chronic
bronchitis
suggests
that
there
is
no
causual
relation
between
these
toxins
and
the
cause
of
primary
sarcomas
of
the
lungs
(Table
6).
With
bronchial
carci-
nomas,
the
radioactive
radiation
to
which
miners
are
exposed
is
regarded
as
an
en-
vironmental
harzard.
Radioactive
radia-
tion
as
stimulus
cannot
be
excluded
from
the
cause
of
sarcomas
5%
(10%
of
men).
However,
there
is
not
such
a
significant
cor-
relation
as
seen
in
the
case
of
carcinomas
18%
(21%
of
the
men).
The
lack
of
predominant
incidence
among
sexes,
the
higher
incidence
among
the
aged,
the
evidence
of
tumour
among
younger
persons,
the
often
lack
of
involve-
ment
of
the
mesenchyme
and
the
lack
of
direct
evidence
of
a
correlation
with
envi-
ronmental
toxins
all
suggest
an
endogenous
disposition
(tumours
in
anamnesis
10%).
The
rather
endogenously
arranged
adeno-
carcinomas
correspond
to
primary
carcino-
mas
of
the
lungs,
with
regard
to
peripheral
localization,
sex
distribution
and
the
lack
of
evidence
of
the
influence
of
a
cancer
(Table
7)
.
26,27
A
morphological,
differential
diagnosis
is
the
evidence
of
"coin
lesion"
in
the
lungs.
Prophylactic
x-rays
are
important
as
70%
of
pulmonary
sarcomas
were
so-detected,
Volume
12
Number
2
Pulmonary
sarcoma
157
despite
the
lack
of
pertinent
symptoms.
These
x-rays
in
endangered
risk
groups,
in
relation
to
bronchial
carcinomas
are
not
so
significant.
A
definite
diagnosis
of
sarcoma
cannot
be
made
without
performing
a
thoracotomy.
Cytological
examination
of
biopsy
material
is
not
so
productive.
As
a
rule,
a
diagnosis
from
single
cell
is
not
feasible
on
the
"not
easily
differentiated"
sarcomas.
That
is
why
we
recommend,
that
is,
in
dubious
cases
a
thoracotomy
with
immediate
histological
clarification
be
done.
Post-operative
x-ray
therapy
is
unnecessary
in
those
with
fibrous
and
other
forms
of
sarcomas
which
are
not
x-ray
sensitive,
if
there
is
no
evidence
of
neighbouring
lymphatic
nodule
metastases.
With
the
x-ray
sensitive
lymphatic
and
reticulum-cell-sarcomas,
postoperative
x-ray
or
chemotherapy
is
to
be
recommended.
Large
doses
of
x-rays
for
those
with
in-
operable
pulmonary
sarcomas
showed
a
9%
five-year
survival
rate
and
a
combination
with
cytostatics
showed
no
better
results.
48
The
tendency
toward
metastases
is
the
cardinal
symptom
of
malignancy
and
is
28.6%,
lymphatic
and
haematogenous,
to
the
same
extent.
The
figures
of
the
litera-
ture
from
1898
to
1959
vary
between
10%
to
65%
.
12,28,49
More
recent
publications
7,
32
show
conformity
with
our
results.
The
recurrences
of
7%
apparently
vary
accord-
ing
to
the
histology
of
the
sarcoma,
partic-
ularly
as
related
to
the
sarcoma
and
to
numerous
polymorphic
and
spindle-shaped
cellular
sarcomas.
The
shorter
the
time
between
tumour
diagnosis
and
resection,
the
more
effective
is
the
therapy.
Cellular
differentiation
and
morphological
grade
of
maturity
essentially
determine
the
prognosis.
Our
own
investiga-
tions
prove
beyond
any
doubt
that
the
grade
of
malignancy
increases
analogously
to
the
differentiation
of
the
tumour
tissue.
35,36
The
postoperative
prognosis
of
prima-
ry
sarcomas
of
the
lungs
is,
however,
more
promising
than
it
was
assumed
to
be
by
many
authors,
for
44%
of
our
sarcoma
pa-
tients
were
living
5
years
after
the
surgery
and
were
free
of
metastases
and
recurrences.
Whether
the
index
of
malignancy
of
car-
cinomas
of
the
lungs
is
higher
than
that
of
sarcomas
cannot
be
determined
with
any
accuracy.
Carcinoma
metastases
were
ob-
served
in
20%
of
the
cases
after
resection
therapy,
but
in
87%
of
the
cases
after
re-
sections.
32
(Received
for
publication
on
Jan.
25,
1981)
References
1.
Barthel,
M.:
The
frequency
and
relations
to
age
in
patients
with
carcinomas
and
sarcomas,
Z.
Alternsforsch.
16:
317,
1962
(in
German).
2.
Eskenasy,
A.:
Primary
pulmonary
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allg.
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110:
1-11,
1967
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Gebauer,
C.:
The
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comparison
of
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wesen
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1977
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1967
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525-529,
1941
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505-606,
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German).
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R.:
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the
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Frankf.
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566-589,
1938
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E.H.:
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