distal pulmonary vascular resistance." It has also been possible to unmask aortic valve stenosis in patients with systemic hypertension by using a dilator such as regitine. These observations illustrate the limitations of the hydraulic formula and the need for careful overall clinical assessment in evaluating such conditions. Liedtke and associates also demonstrated the importance of biplane cineangiography of the left ventricle in determining ventricular function and ejection fraction in the presence of associated coronary artery disease. In the absence of documented coronary artery disease, a single plane right anterior oblique (RAO) view could be assumed to be representative for calculation of ejection fraction. However, in the presence of coronary artery disease, segmental abnormalities were encountered and resulted in lower ejection fractions based on RAO calculations as compared to left anterior oblique calculations. This relationship has been well documented in previous studies.v" Although cardiac ultrasound procedures proved to be excellent for observing ventricular function on a serial basis, if coronary artery disease is present, ultrasound studies would tend to overestimate the systolic ejection fraction. This occurs because single crystal ultrasound calculations are similar to the left anterior oblique view. In the absence of coronary arterv disease. however, cardiac ultrasound would be a r~asonabl~ way to follow left ventricular function in serial fashion.
IohnH. K. Vogel, M.D., F.G.G.P. Santa Barbara, Galifornia REFERENCES
1 Kouchoukos NT: Early surgical intervention in valvular heart disease. Adv Cardiol 17:217, 1975 2 Litwak RS, Silvay J, Gadboys HL, et al: Factors associated with operative risk in mitral valve replacement. Am J CardioI23:335-348, 1969 3 Fishman NH, Edmunds LH, Hutchinson JC, et aI: Five year experience with the Smeloff-Cutter mitral prosthesis. J Thorac Cardiovasc Surg 62:345-356, 1971 4 Mullin EM Jr, Glancy DL, Higgs LM, et al: Current results of operation for mitral stenosis: clinical and hemodynamic assessments in 124 consecutive patients treated by closed commissurotomy, open commissurotomy or valve replacement. Circulation 46:298-308, 1972 5 Silove ED, Vogel JHK, Crover RF: The pressure gradient in ventricular outflow obstruction: influence of peripheral resistance. Cardiovasc Res 2:234-242, 1968 6 Vogel JHK, Blount SG: Masked infundibular pulmonary obstruction in ventricular septal defect with pulmonary hypertension. Circulation 31 :876-887, 1965 7 Vogel JHK, Hutcherson JD, Rosenkrantz JG, et al: Pulmonary artery banding for high pulmonary vascular resistance. Adv CardioI5:172-185, 1970 8 Vogel JRK, Cornish D, McFadden RB: Underestimation of
CHEST, 69: 2, FEBRUARY, 1976
ejection fraction with singleplane angiography in coronary artery disease: role of biplane angiography. Chest 64:217221, 1973 9 Gentzler RD II, Gault JR, Hunter AS, et al: Asymmetric left ventricular contraction in patients with previous myocardial infarction. Circulation 48:352, 1973
Accepting the Challenge of Lung Cancer The :urrent statisti~al :ecord of incidence, morbidity, and mortality III lung cancer clearly demands a reassessment of traditional concepts of management for patients suffering from this dread disease. Attention must properly be directed at all stages of the malignant process, from carcinogenesis, through the establishment of the primary disease, to the final development of a viable systemic component. Failure to prevent the disease requires greater professional involvement in programs designed to lower the smoking rates for all segments of the population. The fact that death following treatment of the primary lesion is usually due to disseminated disease must also stimulate greater interest in prophylactic systemic therapy. Fundamental though these needs may be, currently available-although usually neglected-techniques offer hope that treatment of the primary lesion at an earlier and more favorable stage in its natural history may be the key that will open the door to initial improvement in the statistical picture. The clinical observation that survival rates improve so strikingly when the lesion is either asymptomatic or radiologically occult (in comparison with those achieved when one waits for the disease to declare itself) defines an area of management which has not been fully explored as yet. There are several reasons why screening programs have not been pursued more diligently. In the first place, as is true for all efforts to screen the public for disease which remains asymptomatic, high-risk subjects characteristically fail to utilize the service when it is offered. In order to overcome this reticence, coordinated action must be undertaken by government, the health agencies, and the profession itself so that we may ensure wider availability and provide more sophisticated publicity. In the second place, single screening techniques have in the past been assessed on their own and all too often found to be wanting. Unfortunately, utilization of the available tests, even in this limited fashion, has also been usually at fault. Radiologic screening must be repetitive if significant persisting change is to be identified and developing changes pinpointed when they are only
EDITORIALS 141
apparent on comparative evaluation of the x-ray film findings. Cytologic screening must also be sequential, since progression of changing cytologic characteristics from significant dyskaryosis to frank malignancy has been demonstrated in continuing smokers.' It is to be clearly recognized that sputum cytologic sampling must meet two basic requirements: ( 1) Adequate multiple samples must be procured; and in the asymptomatic patient (without a productive cough), measures to stimulate expectoration are necessary. With proper collection-and this requires both instruction and supervision-suitable samples can be obtained in almost every instance.' (2) In addition, the difficulty encountered previously in locating radiologically occult disease when it was declared by a positive sputum sampling alone led to a sense of defeatism since retrieval of favorable case material was so frustratingly infrequent. However, fiberoptic bronchoscopy now permits a detailed study of individual bronchial segments and successful identification of the source of the malignant cells in nearly every instance-and without undue delay." Mastery of this technique is but a matter of time. Obviously, in order to meet the requirements for
worthwhile screening, special facilities are required. Some early cases will be recognized as a result of clinical suspicion, some brought to light by radiologic change, and some by positive sputum cytologic samplings. Multiphasic programs are, therefore, necessary. As usage of this type of facility improves cost, experience and dividends will also be expected to improve. The potential prognostic improvement which might be anticipated if coordinated action were to be undertaken represents a compelling reason for the profession to support such a program-with initiative and enthusiasm! Norman C. Delarue, 'M.D., F.G.G.P." Toronto "Professor of Surgery, Faculty of Medicine, University of Toronto. REFEREl\'CES
Dclarue NC, Pearson FG, Thompson DW, et al: Sputum cytology screening for lung cancer. Geriatrics 26: 130, 1971 2 Fontana R, Sanderson DR, Woolner B, et al: The Mayo Lung Project for early detection and localization of bronchogenic carcinoma: A status report. Chest 67:511-522, 1975
ANNOUNCEMENTS Refresher Course in Cardiac Radiology A refresher course in cardiac radiology will he presented by the North American Society for Cardiac Radiology, at the Sir Francis Drake Hotel, San Fran-
cisco, March 21-25. For further information, please write to Dr. Eric Carlsson, Department of Radiology. University of California, San Francisco 94143.
National Cancer Conference on Classification and Staging Sponsored by the American Joint Committee for Cancer Staging and End Results Reporting, the National Cancer Conference on Classification and Staging will be held March 27-28 at the Regency
Hyatt Atlanta Hotel, Atlanta. For additional infonnation, write the American Joint Committee, 55 East Erie Street, Chicago 60611.
Radiology Seminars The Department of Radiology, University of Miami, will sponsor two radiology seminars; Sixth Annual Special Procedures Seminar, "Why and How to do Special Procedures," March 21-24 at the Hyatt House, Miami Beach; and 14th Clinical Radiology Seminar,
142 EDITORIALS
"How and Why We do Specific Radiology Procedures," March 24-28, also at the Hyatt House, Miami Beach. For further information, contact Mrs. Lucy R. Kelley, Department of Radiology, Jackson Memorial Hospital, Miami, Florida 33136.
CHEST, 69: 2, FEBRUARY, 1976
IohnH. K. Vogel, M.D., F.G.G.P. Santa Barbara, Galifornia REFERENCES
1 Kouchoukos NT: Early surgical intervention in valvular heart disease. Adv Cardiol 17:217, 1975 2 Litwak RS, Silvay J, Gadboys HL, et al: Factors associated with operative risk in mitral valve replacement. Am J CardioI23:335-348, 1969 3 Fishman NH, Edmunds LH, Hutchinson JC, et aI: Five year experience with the Smeloff-Cutter mitral prosthesis. J Thorac Cardiovasc Surg 62:345-356, 1971 4 Mullin EM Jr, Glancy DL, Higgs LM, et al: Current results of operation for mitral stenosis: clinical and hemodynamic assessments in 124 consecutive patients treated by closed commissurotomy, open commissurotomy or valve replacement. Circulation 46:298-308, 1972 5 Silove ED, Vogel JHK, Crover RF: The pressure gradient in ventricular outflow obstruction: influence of peripheral resistance. Cardiovasc Res 2:234-242, 1968 6 Vogel JHK, Blount SG: Masked infundibular pulmonary obstruction in ventricular septal defect with pulmonary hypertension. Circulation 31 :876-887, 1965 7 Vogel JHK, Hutcherson JD, Rosenkrantz JG, et al: Pulmonary artery banding for high pulmonary vascular resistance. Adv CardioI5:172-185, 1970 8 Vogel JRK, Cornish D, McFadden RB: Underestimation of
CHEST, 69: 2, FEBRUARY, 1976
ejection fraction with singleplane angiography in coronary artery disease: role of biplane angiography. Chest 64:217221, 1973 9 Gentzler RD II, Gault JR, Hunter AS, et al: Asymmetric left ventricular contraction in patients with previous myocardial infarction. Circulation 48:352, 1973
Accepting the Challenge of Lung Cancer The :urrent statisti~al :ecord of incidence, morbidity, and mortality III lung cancer clearly demands a reassessment of traditional concepts of management for patients suffering from this dread disease. Attention must properly be directed at all stages of the malignant process, from carcinogenesis, through the establishment of the primary disease, to the final development of a viable systemic component. Failure to prevent the disease requires greater professional involvement in programs designed to lower the smoking rates for all segments of the population. The fact that death following treatment of the primary lesion is usually due to disseminated disease must also stimulate greater interest in prophylactic systemic therapy. Fundamental though these needs may be, currently available-although usually neglected-techniques offer hope that treatment of the primary lesion at an earlier and more favorable stage in its natural history may be the key that will open the door to initial improvement in the statistical picture. The clinical observation that survival rates improve so strikingly when the lesion is either asymptomatic or radiologically occult (in comparison with those achieved when one waits for the disease to declare itself) defines an area of management which has not been fully explored as yet. There are several reasons why screening programs have not been pursued more diligently. In the first place, as is true for all efforts to screen the public for disease which remains asymptomatic, high-risk subjects characteristically fail to utilize the service when it is offered. In order to overcome this reticence, coordinated action must be undertaken by government, the health agencies, and the profession itself so that we may ensure wider availability and provide more sophisticated publicity. In the second place, single screening techniques have in the past been assessed on their own and all too often found to be wanting. Unfortunately, utilization of the available tests, even in this limited fashion, has also been usually at fault. Radiologic screening must be repetitive if significant persisting change is to be identified and developing changes pinpointed when they are only
EDITORIALS 141
apparent on comparative evaluation of the x-ray film findings. Cytologic screening must also be sequential, since progression of changing cytologic characteristics from significant dyskaryosis to frank malignancy has been demonstrated in continuing smokers.' It is to be clearly recognized that sputum cytologic sampling must meet two basic requirements: ( 1) Adequate multiple samples must be procured; and in the asymptomatic patient (without a productive cough), measures to stimulate expectoration are necessary. With proper collection-and this requires both instruction and supervision-suitable samples can be obtained in almost every instance.' (2) In addition, the difficulty encountered previously in locating radiologically occult disease when it was declared by a positive sputum sampling alone led to a sense of defeatism since retrieval of favorable case material was so frustratingly infrequent. However, fiberoptic bronchoscopy now permits a detailed study of individual bronchial segments and successful identification of the source of the malignant cells in nearly every instance-and without undue delay." Mastery of this technique is but a matter of time. Obviously, in order to meet the requirements for
worthwhile screening, special facilities are required. Some early cases will be recognized as a result of clinical suspicion, some brought to light by radiologic change, and some by positive sputum cytologic samplings. Multiphasic programs are, therefore, necessary. As usage of this type of facility improves cost, experience and dividends will also be expected to improve. The potential prognostic improvement which might be anticipated if coordinated action were to be undertaken represents a compelling reason for the profession to support such a program-with initiative and enthusiasm! Norman C. Delarue, 'M.D., F.G.G.P." Toronto "Professor of Surgery, Faculty of Medicine, University of Toronto. REFEREl\'CES
Dclarue NC, Pearson FG, Thompson DW, et al: Sputum cytology screening for lung cancer. Geriatrics 26: 130, 1971 2 Fontana R, Sanderson DR, Woolner B, et al: The Mayo Lung Project for early detection and localization of bronchogenic carcinoma: A status report. Chest 67:511-522, 1975
ANNOUNCEMENTS Refresher Course in Cardiac Radiology A refresher course in cardiac radiology will he presented by the North American Society for Cardiac Radiology, at the Sir Francis Drake Hotel, San Fran-
cisco, March 21-25. For further information, please write to Dr. Eric Carlsson, Department of Radiology. University of California, San Francisco 94143.
National Cancer Conference on Classification and Staging Sponsored by the American Joint Committee for Cancer Staging and End Results Reporting, the National Cancer Conference on Classification and Staging will be held March 27-28 at the Regency
Hyatt Atlanta Hotel, Atlanta. For additional infonnation, write the American Joint Committee, 55 East Erie Street, Chicago 60611.
Radiology Seminars The Department of Radiology, University of Miami, will sponsor two radiology seminars; Sixth Annual Special Procedures Seminar, "Why and How to do Special Procedures," March 21-24 at the Hyatt House, Miami Beach; and 14th Clinical Radiology Seminar,
142 EDITORIALS
"How and Why We do Specific Radiology Procedures," March 24-28, also at the Hyatt House, Miami Beach. For further information, contact Mrs. Lucy R. Kelley, Department of Radiology, Jackson Memorial Hospital, Miami, Florida 33136.
CHEST, 69: 2, FEBRUARY, 1976
