Bronchial adenoma: review of 18-year experience the ... · Seventy-three operative procedures comprised two endoscopic removals, two wedge resections, six bronchotomies, five pneumonectomies,

Thorax (1976). 31, 245.

Bronchial adenoma: review of an 18-yearexperience at the Brompton Hospital

R. M. LAWSON, L. RAMANATHAN, G. HURLEY,K. W. HINSON, and S. C. LENNOX

Brompton Hospital, Fulham Road, London SW3

Lawson, R. M., Ramanathan, L., Hurley, G., Hinson, K. W., and Lennox, S. C. (1976).Thorax, 31, 245-253. Bronchial adenoma: review of an 18-year experience at the Bromp-ton Hospital. Conitinued uncertainty about the prognosis for patients with bronchialadenomata led to a review of the experience of this condition in the Brompton Hospital.Of 72 patients seen between January 1955 and December 1972, 39 were women and33 men, mean age 45 years, range 9-73 years. The commonest presenting symptomswere haemoptysis, cough, sputum, and repeated chest infections. Positive broncho-scopic biopsy occurred in 35 of 43 cases; five of these were originally reported as car-cinomata, of oat-cell type in four. Plain chest film abnormality occurred in 69 patients.Seventy-three operative procedures comprised two endoscopic removals, two wedgeresections, six bronchotomies, five pneumonectomies, and 58 lobectomies (seven withsleeve resection). Recurrence in three of six bronchotomies-two with adenoid cysticcarcinomata (cylindromata)-necessitated further surgery. Lobectomy and lymph nodedissection is usually the operation of choice. Histology confirmed 67 carcinoids (eightwith atypical histology or lymph node metastases), two adenoid cystic carcinomata, onemuco-epidermoid, and two mucous gland adenomata. Prolonged follow-up is especiallyindicated in patients with adenoid cystic carcinoma and in those with atypical ormetastatic carcinoid histology. Although such pathology is not incompatible with longsurvival, of 10 patients in these categories, all five late deaths were probably related tothe tumour. However, of 57 patients considered to have had typical carcinoid histologyand adequate removal of the tumour, there has to date been no tumour-related death,but one patient developed radiosensitive atypical carcinoid tracheal tumours nine yearslater. The actuarially assessed survival of 71 patients undergoing surgery for bronchialadenomata was 75% at 15 years. Specific tumour types should replace the termbronchial adenoma.

When adding 22 cases of bronchial adenomataseen in the Brompton Hospital to the more than100 cases previously documented, Foster-Carter(1941) stated that no death had ever been recordedfrom malignant change in a bronchial adenoma.Price-Thomas (1954), reporting a personal seriesof 41 bronchial adenomata treated in the Bromp-ton and Westminster Hospitals, concluded that'the incidence of malignancy is so low that it ispossible for practical purposes to ignore it'. Morerecent papers have, however, questioned the use ofthe term bronchial adenoma, emphasizing notonly the varying behaviour of the four tumourtypes included in the term-the bronchial carci-noid, the adenoid cystic carcinoma (cylindroma),

the muco-epidermoid tumour, and the truebronchial mucous gland adenoma-but also thediffering degrees of malignancy of the bronchialcarcinoid itself (Donahue, Weichert, and Ochsner,1968; Meffert and Lindskog, 1970; Tolis et al.,1972; Turnbull et al., 1972). In a Mayo Clinicseries of 215 cases of bronchial carcinoid(Arrigoni, Woolner, and Bernatz, 1972), 23 (11%)were considered to have atypical histologicalfeatures and, of these, 70% metastasized and 30%/Owere dead after a mean survival of 27 months.This is to be contrasted with the usual bronchialcarcinoid five-year survival of 80% or more(Overholt, Bougas, and Morse, 1957; Donahueet al., 1967).

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R. M. Lawson, L. Ramanathan, G. Hurley, K. W. Hinson, and S. C. Lennox

Bronchial adenomata are uncommon tumoursand no single surgeon can have a vast experienceof their management. It was against this back-ground of changing views on the benignity orotherwise of bronchial adenomata that we decidedto update our experience of all such tumours seenat the Brompton Hospital between January 1955and December 1972.

HISTORICAL

Mueller (1882) first described the carcinoid type ofbronchial adenoma found at necropsy on a youngwoman who had suffered from haemoptysis anda chronic productive cough. From 1930 the termbronchial adenoma was used to differentiate thisgroup of tumours, which differed in both morpho-logy and behaviour, from the bronchogenic car-cinoma (Kramer, 1930). In 1937 they were furthersubdivided into two histological subgroups, thecarcinoids and the cylindromata (Hamperl, 1937).In 1952 Reid, noting the distinctive histology, themale predominance, the pronounced infiltrativetendencies, and a 25% incidence of distant meta-stases in patients with cylindromata, termed thesetumours cystic adenoid carcinomata.Hamperl believed that the bronchial carcinoid

resembled the intestinal carcinoid, and his con-tention was challenged until Mattingly's associa-tion of the carcinoid syndrome with a bronchialcarcinoid (Mattingly, 1956). The atypical carcinoidwas first described in 1944 (Engelbreth-Holm,1944) and the muco-epidermoid adenoma in 1945(Smetana, Iverson, and Swan, 1952), and in 1956a further variety, the cystadenoma or bronchialmucous gland adenoma, was added (Gilman,Klassen, and Scarpelli, 1956).

MATERIAL AND METHODS

The series includes all patients admitted to theBrompton Hospital between January 1955 andDecember 1972 in whom a diagnosis of bronchialadenoma was made on bronchial biopsy and/or onthe resected lung specimen. The original histo-logical findings in all 72 cases have been reviewedwithout the pathologist knowing the subsequentfate of the patient. The 72 plain chest radiographs,28 tomograms, and nine bronchograms performedon these patients have also been re-examined.A follow-up to July 1975 was then attempted on

all 59 known survivors.

RESULTS

CLINICAL MATERIAL Among the 72 patients therewas a slight predominance (54%) of females. Al-

though the age range of the series varied from 9to 73 years, 74% were between 30 and 60 (Fig. 1),the mean age being 45 years.

(1)

:z

0 10 20 30 40 50 60 70 80 90Age (years)

FIG. 1. Clinical material--age distribution.

SYMPTOMATOLOGY The symptomatology (TableI) is similar to that recorded in previous series.Haemoptysis had a considerable effect in hasten-ing the diagnosis of adenoma, the average durationof symptoms with haemoptysis being 17 months(range 3 weeks-8 years) and without haemoptysis42 months (range 3 weeks-25 years). There was nocase of carcinoid syndrome in the series.

TABLE ISYMPTOMATOLOGY

Symptom No.

Haemoptysis 34 47Persistent cough 26 36Recurrent infection 10 14Pain 9 12Wheeze 8 11Incidental x-ray 13 18

BRONCHOSCOPIC FINDINGS The bronchoscopicfindings are shown in Table II. Bronchoscopy wasfrequently omitted in patients with peripheral

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Bronchial adenoma: review of an 18-year experience at the Brompton Hospital

TABLE IIBRONCHOSCOPIC FINDINGS

Number of patients 72Bronchoscopy performed 60Tumour visible 51

f 33 AdenomaBiopsy taken 43 2 Carcinoma

1 8 Inflammatory

tumours. An initial diagnosis of carcinoma (onereported as oat-cell and the other as 'probablecarcinoma') was noted on bronchial biopsy in twopatients. Subsequent examination of the operativespecimens, however, revealed bronchial carcinoidsin each. A further three patients were referredwith alleged oat-cell carcinomata but a repeatedbronchial biopsy and histological examinationshowed bronchial carcinoids in two and 'inflam-matory changes' in the third. Examination of thesubsequent operative specimens confirmed bron-chial carcinoids in all three cases. Because of thepossibility of bleeding, bronchial biopsy of thetumour was not always performed; on oneoccasion a swab of the tumour taken at broncho-scopy revealed carcinoid cells. However, noepisode of severe bleeding followed biopsy in thisseries.

RADIOLOGICAL FINDINGS In 69 of the 72 cases anabnormality was noted on the plain chest radio-graph (Table III). The common radiological pre-sentation was of bronchial obstruction resultingin collapse and/or consolidation of a lung, lobeor segment. Fifty-three cases presented in thisfashion and all were symptomatic. Compensatoryemphysema was evident in the more severe casesof collapse. Three patients presented withobstructive emphysema due to incomplete obstruc-tion by a ball-valve adenoma. A discrete, well-defined opacity was noted in 13 asymptomaticpatients; these tumours arose from peripheralbronchi or as dumb-bell extrabronchial extensions

TABLE IIIRADIOLOGICAL FINDINGS ON PLAIN CHEST FILM

Radiological Finding No.

Normal 3Abnormal 69

Collapse/consolidation 53With bronchiectasis 25Discrete opacity 13With calcification 3Obstructive emphysema 3

from larger bronchi. In three patients no abnor-mality was seen on a plain chest radiograph, andin each a small non-obstructive tumour was seenin a main-stem bronchus at bronchoscopy; tomo-graphy subsequently demonstrated one of thesetumours. Three adenomata showed radiographicevidence of calcification which was subsequently,in two, shown to be due to osseous metaplasia. In25 patients, bronchiectasis had developed distalto a tumour, and in one patient two separate sub-pleural adenomata were found. Lytic osseousmetastases occurred in two patients.

SURGICAL PROCEDURES The various proceduresemployed are illustrated in Figures 2, 3, and 4.Endoscopic removal was performed on a frail 70-year-old woman for a carcinoid tumour which

BronchotomyBronchoscopic Removal

©)

FIG. 2. Operative procedure-bronchoscopic removaland bronchotomy.

Pneumonectomy 5Wedge Resection

FIG. 3. Operative procedure-wedge resection andpneumonectomy.

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ring four months after a left upper lobectomy fora carcinoid tumour. Nine years later he developedmultiple tracheal tumours of an atypical carcinoidhistological type. Although these responded wellto radiotherapy he now awaits investigation of afurther stricture at the site of the previous sleeveresection. There is no evidence to date, however,that the stricture is due to further tumour.

Sleeve Resection in (R) Upper Lobe 4/11

Sleeve Resection in (L) Upper Lobe 3/10

FIG. 4. Operative procedure-lobectomy.

would otherwise have necessitated a pneumonec-tomy. Temporary airway relief followed but therewas a recurrence and she died eight months later.A second patient had a main-stem carcinoidtumour removed bronchoscopically and remainswell 15 years later. Two of the six bronchotomieswere performed on patients with main-stem cysticadenoid carcinoma and in both the tumour re-curred (3 and 13 years later); each patient thenrequired a pneumonectomy. The remaining fourbronchotomies were performed for carcinoidtumours; two patients remain well 14 and 17 yearslater, and in a third the tumour recurred after fiveyears, necessitating a lobectomy after which thepatient remained well for a year and was thenlost to follow-up. The fourth patient was also lostto follow-up after a main-stem bronchotomy.The two patients who underwent wedge re-

section remain well four and 10 years later.Lobectomy or bilobectomy has been performed on

58 patients, in association with sleeve resection ofthe main-stem bronchus in seven of 21 upperlobectomies. The right lower lobe has been thecommonest site of tumour origin. In five patientsprogressive inflammatory destruction of the lungnecessitated a pneumonectomy.

MORTALITY AND MORBIDITY The single operativedeath in the series occurred in a 39-year-oldwoman proved at necropsy to have been due topulmonary embolus. One patient required severalbronchial dilatations after a lobectomy with sleeveresection, and another required closure of a

bronchopleural fistula four months after a pneu-

monectomy. Both patients are well six and 11years later. Another patient required a main-stem sleeve resection for a fibrous stricture occur-

SPECIMEN HISTOLOGY The series has been classi-fied into the four tumour types present, and thecarcinoid tumours have been further subdividedinto histologically typical, atypical, and meta-stasizing types, that is, metastases occurring inlymph nodes in the operative specimen .(Table IV).

TABLE IVSPECIMEN HISTOLOGY

Histology No.

559 TypicalCarcinoid adenoma 67 3 Atypical

S MetastasizingCystic adenoid carcinoma 2Muco-epidermoid tumour IAdenoma of mucous glands 2

Although the morphology of the typical carcinoidmay vary from a highly differentiated structureconsisting of tubules and glandular alveoli tosheets or clumps of cells, the cellular arrangementremains orderly with separation by stromal tissueseptae of varying vascularity and thickness. Thecells are small and regular, mitotic figures arerare, and capsular invasion does not occur(Fig. 5).The atypical carcinoid is characterized by

pleomorphism, nuclear irregularity with pro-minent nucleoli, hyperchromatism, increasedmitotic activity, tumour necrosis, architecturaldisorganization, and capsular invasion (Fig. 6).Of the five metastasizing carcinoids, two were

histologically atypical and three were typical.

ASSOCIATED LESIONS In one patient a carcinoidwas associated with active tuberculosis, in anotherwith a haemangioma, and in two others pulmonaryossification was noted. A further patient had aright upper lobe carcinoid treated with radonseeds in 1934, reappeared with a destroyed rightupper lobe 27 years later, underwent right upperlobectomy, and remains well a further 14 yearslater. Histological examination of the operative

Lobectomy 58

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Bronchial adenoma: review of an 18-year experience at the Brompton Hospital6;w , ,- B W .L_K -4.F.wwv--7 1J *a,,,__vlwm_.-" x W.*_;cW

FIG. 5. Typical carcinoid histology. An orderly arrangement of regularly sized cellsto form well-differentiated sheets and clumps of cells separated by stromal tissueseptae is illustrated. A similar histological pattern was noted in all cuts of the tumourspecimen (Haematoxylin and eosin X118).

FIG. 6. A typical carcinoid histology. The field illustrates many pleomorphic, hyper-chromatic cells with increased mitotic figures. Typical carcinoid histology was notedin other fields from the same slide (H and E XI 18).

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specimen revealed recognizable carcinoid cellssurrounded by calcium.

FOLLOW-UP Thirteen patients are known to havedied, and of the 59 survivors, nine have been lostto follow-up within five years of surgery and afurther seven have been followed up for at leastfive years and subsequently lost. The two patientswith mucous gland adenomata remain well sixyears after resection. The single patient with amuco-epidermoid tumour died 10 years later of acerebral haemorrhage. One of the patients with acystic adenoid carcinoma died from metastases16 years after initial bronchotomy and 13 yearsafter a pneumonectomy for a recurrence; theother remains well 15 months after pneumonec-tomy for a main-stem recurrence 13 years aftera bronchotomy.Of the five metastasizing carcinoids, three are

well at two, six, and eight years after operation,and two have died of multiple skeletal andvisceral metastases at nine and 29 months. Twopatients with atypical carcinoids died 7j and 10±years postoperatively; in one, multiple hepaticmetastases were confirmed at necropsy and al-though necropsy was not performed in the other,clinical and radiological findings were suggestiveof recurrent pulmonary tumour with cerebralmetastases. The third patient with atypical car-cinoid has recently presented 14 years later withhistologically proven mediastinal carcinoidmetastases.Seven patients with typical carcinoid have since

died, one in the early postoperative period of apulmonary embolus and another eight monthsafter partial endoscopic removal. A third died onadmission, having refused surgery a year earlier;necropsy confirmed a lung abscess distal to amain-stem carcinoid. The remaining four deaths(5, 9, 12, and 16 years postoperatively) did notappear to be related in any way to the originalhistology.

Actuarially assessed survival of all 71 patientsundergoing surgery indicates an 86% 10-year anda 75% 15-year postoperative survival (Fig. 7)(Anderson et al., 1974). The longest survivor inwhom a bronchial carcinoid was diagnosed andtreated by radon seeds in 1934, and who under-went a lobectomy in 1961, remains well 41 yearslater.

DISCUSSION

The sex distribution, average age, and symptoma-tology of this series of bronchial adenomata is

90-

80

70-.5; 6o -

' 50

,i 40-U +

f 30-I Standard error

20 -

0

00 2 4 8 0 12 14 16 18 20 22Years postoperative

FIG. 7. Actuarially assessed survival following re-moval of bronchial adenoma (71 patients). Plus orminus one standard error of the mean gives anapproximate 67 % confidence interval.

similar to those of others (Foster-Carter, 1941;Overholt et al., 1957; Weisel, Lepley, and Watson,1961; Zellos, 1962; Meffert and Lindskog, 1970).The duration of symptoms, however, even in thepresence of haemoptysis, is still disturbingly long.The importance of early bronchoscopy for patientswith unilateral wheeze, repeated chest infections,non-productive cough, and haemoptysis (Price-Thomas, 1954) needs to be re-emphasized.

Difficulty in distinguishing between oat-cellcarcinoma and bronchial carcinoid in a bronchialbiopsy occurred on four occasions, three inpatients referred as having oat-cell tumours.Similar diagnostic problems have been noted pre-viously (Overholt et al., 1957; Zellos, 1962; AbbeySmith, 1969). Acceptance of the entity atypicalcarcinoid is unlikely to make this problem anyeasier and emphasizes the importance of carefulhistological examination of the whole of theexcised operative specimen (Arrigoni et al., 1972)by an experienced histopathologist. Althoughsputum cytology was negative in all patients inwhom it was performed (as in almost every docu-mented series), an accurate diagnosis of bronchialcarcinoid was achieved by bronchial swabbing onthe one occasion it was tried. The diagnosticaccuracy of brush biopsy in bronchial adenoma isso far not established.As in other series, the chest radiographs were

abnormal in almost all cases (Bower, 1965; Meffert

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and Lindskog, 1970). The usual siting of bronchialadenomata in main-stem and second- and third-order bronchi was reflected in the common radio-logical presentation of collapse and/or consolida-tion (McBurney, Clagett, and McDonald, 1952;Soutter, Sniffen, and Robbins, 1954). Althoughplain film evidence of bronchial obstruction islikely to be due to carcinoma, the appearance ofobstruction in a younger patient, especially afemale, with a long history of respiratory infec-tions should suggest the diagnosis of bronchialadenoma. Evidence of bronchial dilatation, usuallybest shown by tomography, or an abrupt cut-offand absence of rat tailing on bronchography(Foster-Carter, 1941) proved helpful in suggestingthe diagnosis in several patients. Tomography alsoproved useful in establishing the bronchus oforigin of the tumour, a point of surgical import-ance. Pulmonary osseous metaplasia occurred intwo patients (Price-Thomas and Morgan, 1958)and skeletal lytic metastases were noted in twoothers (Guistra and Stassa, 1969). Multiplebronchial adenomata, usually sited peripherally,are rare (Heimburger, Kilman, and Battersby,1966); a further case occurred in this series. Weagree with Zellos (1962) and Abbey Smith (1969)that lobectomy is usually the operation of choice,with sleeve resection of either main-stem bronchusif indicated. Contiguous lymph nodes should alsobe removed and examined for possible metastases.Pneumonectomy may be required if the lung hasbeen destroyed distal to a main-stem adenoma.Bronchotomy is acceptable in main-stem lesionsonly if the tumour can be totally removed. Al-though long survival may follow bronchotomyperformed on second-order bronchi, lobectomyoffers a better chance of total removal of thetumour. Endoscopic removal should be reservedfor unfit patients requiring relief of respiratoryobstruction. Radon seed implantation producedtemporary palliation in one patient with recurrentcystic adenoid carcinoma and in another withcarcinoid, and radiation therapy has controlledatypical carcinoid tracheal tumours in a thirdpatient.Our series confirms the tendency for cystic

adenoid carcinoma to recur and for mucous glandadenoma to remain benign. The possibility oflate cystic adenoid carcinomatous recurrencenecessitates prolonged follow-up and regularbronchoscopy in these patients. The single muco-epidermoid tumour in the series seemed benign,in contrast to the malignant type reported byOzlu, Christopherson, and Allen (1961) andTurnbull et al. (1972). Follow-up of the bronchial

carcinoid patients confirms the poorer prognosisfor those with atypical histology or nodal meta-stases in the operative specimen. Of eight suchpatients, four died from nine months to 10+years postoperatively, three with metastasesproved at necropsy, and a fourth with clinicalevidence of recurrence. Similar findings have beennoted by Donahue et al. (1968) and Arrigoniet al. (1972), but Abbey Smith (1969) concludedthat histopathology alone did not offer a reliableprognosis. The presence of lymph node metastasesin the operative specimen, even of an atypicaltype, is compatible with prolonged survival, asillustrated by an eight-year survivor in our series.However, of 57 patients undergoing adequateexcision of a typical carcinoid tumour, none ofthe four known late deaths was related to thetumour. One patient, with typical carcinoid in theoriginal lobectomy specimen, developed multipleradiosensitive tracheal tumours nine years later,histology on this occasion revealing atypicalcarcinoid. Recurrence in a patient with typicalcarcinoid histology in the absence of lymph nodeinvolvement in the operative specimen has thusfar been unique to this patient. The 86% 10-yearand 75% 15-year actuarially assessed overall sur-vival reflects the large number of patients withtypical carcinoid histology in our series. A com-mon cellular origin for oat-cell carcinoma andbronchial carcinoid has been suggested (Benschet al., 1968); they may represent extremes of aspectrum of malignancy, the atypical and meta-stasizing carcinoids occupying an intermediateplace. We would suggest the term carcinoid car-cinoma for these intermediate types as beingindicative of their metastatic potential. Becauseof the wide variation in malignancy of tumourshitherto termed bronchial adenomata (and therelated prognosis for the patient) the collectiveterm should now be abandoned and replaced bythe specific tumour types.

We wish to thank Mr. N. R. Barrett, Lord Brock,Mr. W. P. Cleland, Mr. M. Paneth, and Mr. 0. S.Tubb3 for permission to include their patients in thisseries. We are indebted to Mr. Grunkemeier forproduction of the life table and the actuariallyassessed survival curve.

REFERENCES

Abbey Smith, R. (1969). Bronchial carcinoid tumours.Thorax, 24, 43.

Anderson, R. P., Bonchek, L. I., Grunkemeier, G. L.,Lambert, L. E., and Starr, A. (1974). The analysisand presentation of surgical results by actuarialmethods. Journal of Surgical Research, 16, 224.

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Arrigoni, M. G., Woolner, L. B., and Bernatz, P. E.(1972). Atypical carcinoid tumors of the lung.Journal of Thoracic and Cardiovascular Surgery,64, 413.

Bensch, K. G., Corrin, B., Pariente, R., and Spencer,H. (1968). Oat-cell carcinoma of the lung. Itsorigin and relationship to bronchial carcinoid.Cancer, 22, 1163.

Bower, G. (1965). Bronchial adenoma. A review of 28cases. American Review of Respiratory Diseases,92, 558.

Donahue, J. K., Weichert, R. F., and Ochsner, J. L.(1968). Bronchial adenoma. A nnals of Surgery,167, 873.

Engelbreth-Holm, J. (1944). Benign bronchialadenomas. Acta Chirurgica Scandinavica, 90,383.

Foster-Carter, A. (1941). Bronchial adenoma.Quarterly Journal of Medicine, 10, 139.

Gilman, R. A., Klassen, K. P., and Scarpelli, D. G.(1956). Mucous gland adenoma of bronchus;report of a case with histochemical study ofsecretion. American Journal of Clinical Patho-logy, 26, 151.

Guistra, P. E. and Stassa, G. (1969). The multiplepresentations of bronchial adenomas. Radiology,93, 1013.

Hamperl, J. (1937). Ober gutartige Bronchialtumoren(Cylindrome und Carcinoide). Virchows Archivfur pathologische Anatomie, 300, 46.

Heimburger, I., Kilman, J., and Battersby, J. (1966).Peripheral bronchial adenomas. Journal ofThoracic and Cardiovascular Surgery, 52, 542.

Kramer, R. (1930). Adenoma of bronchus. Annals ofOtology, 39, 689.

Mattingly, T. W. (1956). Functioning carcinoid tumor-a new clinical entity. Review of the clinicalfeatures of the non-functioning and functioningcarcinoid, including a review of 38 cases from theliterature. Part II. Medical Annals of the Districtof Columbia, 25, 304.

McBurney, R. P., Clagett, 0. T., and McDonald, J. R.(1952). Obstructive pneumonitis secondary tobronchial adenoma. Journal of Thoracic andCardiovascular Surgery, 24, 411.

Meffert, W. G. and Lindskog, G. E. (1970). Bronchialadenoma. Journal of Thoracic and Cardio-vascular Surgery, 59, 588.

Mueller, H. (1882). Zur Entstehungsgeschichte derBronchialerweiterungen. Inaugural dissertation,Halle University. H. A. Busch, Ermsleben.

Overholt, R. H., Bougas, J. A., and Morse, D. P.(1957). Bronchial adenoma. American Review ofTuberculosis and Pulmonary Diseases, 75, 865.

Ozlu, C., Christopherson, W. M., and Allen, J. D.Jr. (1961). Muco-epidermoid tumors of thebronchus. Journal of Thoracic and Cardio-vascular Surgery, 42, 24.

Price-Thomas, C. (1954). Benign tumours of the lung.Lancet, 1, 1.and Morgan, A. D. (1958). Ossifying bronchialadenoma. Thorax, 13, 286.

Reid, J. D. (1952). Adenoid cystic carcinoma(cylindroma) of the bronchial tree. Cancer, 5,685.

Smetana, H. F., Iverson, L., and Swan, L. L. (1952).Bronchogenic carcinoma; an analysis of 100autopsy cases. Military Surgeon, 111, 335.

Soutter, L., Sniffen, R., and Robbins, L. L. (1954).A clinical survey of adenomas of the trachea andbronchus in a general hospital. Journal ofThoracic Surgery, 28, 412.

Tolis, G. A., Fry, W. A., Head, L., and Shields, T. W.(1972). Bronchial adenomas. Surgery, Gyne-cology and Obstetrics, 134, 605.

Turnbull, A. D., Huvos, A. G., Goodner, J. T., andBeattie, E. J. Jr. (1972). The malignant potentialof bronchial adenoma. A nnals of ThoracicSurgery, 14, 453.

Weisel, W., Lepley, D. Jr., and Watson, R. R. (1961).Respiratory tract adenomas. Annals of Surgery,154, 898.

Zellos, S. (1962). Bronchial adenoma. Thorax, 17,61.

Requests for reprints to: R. M. Lawson, FRCS,Brompton Hospital, Fulham Road. London SW3.

ADDENDUM

The table (opposite) illustrates the life table fromwhich the survival curve is derived. For details of theprinciples, methodology, and calculation of actuariallyassessed survival see Anderson et al. (1974). Theanalysis and presentation of surgical results by actu-arial methods. Journal of Surgical Research, 16, 224.

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ADDENDUM TABLELIFE TABLE

253

Years No. of Patients No. of Deaths No. of Patients No. lost to Follow- Survival Rate StandardPostop (K) entering Interval in Interval surviving Interval up in Interval P,( %) Error of

alive Incomplete _ PK( %)

71646257524542383331262421171612107322

2

0

10

20

0

10

120

10

0

0

2

0

0

0

0

0

2

5

3

232

0

33

3

2

4

0

5

12

O0

0

2

O030

0

0

0

10

0

0

0

0

O

979796969292928989867979757575756060606060

2233444445

7

12

23456789101112131415161718192021

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Bronchial adenoma: review of 18-year experience the ... · Seventy-three operative procedures comprised two endoscopic removals, two wedge resections, six bronchotomies, five pneumonectomies,

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