PRIMARY CARCINOMA OF THE GALLBLADDER—Review of 173 Cases

One hundred seventy-three cases of primary carcinoma of the gallbladder were analyzed. In the group studied they made 2.11 per cent of all malignant tumors found at autopsy and were found in 1.89 per cent of all cases in which operation was done on the biliary tract. There was no appreciable change in the incidence of this tumor at autopsy during the period studied (1918-1948) at the Los Angeles County Hospital. Sixty-eight per cent of the cases were in females. A particularly high incidence was noted in Mexican females.Upper abdominal pain, loss of weight, nausea and vomiting, jaundice, and palpable mass or enlarged liver were the most common clinical features. Approximately one-third of the patients in whom the lesion was found at operation and one-fifth of all the patients whose records were studied had a history of chronic gallbladder disease.All but two of the 38 patients operated on were dead or had clinical recurrence within two years. One was alive and well 12 years after cholecystectomy.The most common gross appearance, particularly at autopsy, was a large tumor mass replacing the gallbladder and radiating to nearby organs, particularly the liver. In about one-third of the cases the tumor was grossly limited to the gallbladder. Polypoid tumors occurred in only about 10 per cent of the cases and most of the tumors were diffusely growing adenocarcinoma. Perforation appeared in nine cases, usually with fistula to the gastrointestinal tract. All of the tumors were histologically adenocarcinoma, usually of simple glandular structure. No purely squamous cell growth occurred.Gallstones were found in 79.8 per cent of the cases.     

CARCINOMA OF THE THYROID GLAND—A Review of 106 Cases

In a review of 106 cases of carcinoma of the thyroid gland, it was noted that a solitary thyroid nodule is the most outstanding single physical sign in this disease. It should be investigated by biopsy of a specimen removed at operation. Patients and physicians were sometimes guilty of delay in this regard.Papillary carcinoma involved multiple foci within the gland in at least half of the cases and there was a high incidence of regional lymph node metastasis associated with this type.Doubt was cast on conclusions by other investigators that carcinoma of the thyroid rarely is lethal in patients less than 40 years of age.     

CARCINOMA OF THE BREAST—Possible Significance of Menstrual Cycle in Results of Operation

Among 55 patients upon whom mastectomy was done for cancer of the breast, survival without evidence of metastasis (after varying periods of follow-up) was significantly higher for those who were operated upon in the seven days preceding the beginning of menses than it was for those who underwent operation in any of the three other seven-day periods in the menstrual cycle. Moreover, in a comparison of results of operations done in each of the four seven-day periods, there was a graduating increase in mortality and metastasis from the first period (the seven days preceding menses) through the fourth period.The results of the study of this small series are considered not conclusive but indicative of possible profit in studies of larger and better controlled series.     

CARCINOMA OF THE PROSTATE—Diagnosis and Treatment

About 28 per cent of men between the ages of 71 and 75 have cancer of the prostate. Many of them do not die of the disease, but with the life span ever increasing, this problem is becoming more important.In the early stages the condition is asymptomatic; when the symptoms of urinary obstruction arise, the cancer is usually too advanced for cure. Cure depends on early diagnosis and, therefore, on routine rectal examination. The solitary hard nodule of early prostatic cancer becomes a stony hard fixed prostate as the condition progresses. X-ray and acid phosphatase studies are of help only after the cancer has metastasized. As many as 50 per cent of patients with rectally palpable early carcinoma of the prostate can be cured by radical perineal prostatectomy. Often, simple enucleation or transurethral resection is sufficient to effect cure in the case of occult carcinoma. However, some observers believe that when cancer is detected by microscopic examination of a prostate that has been removed, a radical operation should be done as soon after the initial operation as feasible. Early orchidectomy and estrogen therapy are of considerable help in slowing the process of advanced prostatic cancer and may postpone the need of transurethral resection to relieve obstruction. When these measures fail, bilateral adrenalectomy, cortisone therapy, pituitary irradiation, and pituitary extirpation have been employed, with moderate success, in an effort to diminish the androgen level.     

CARCINOMA OF THE EYELID TREATED BY IRRADIATION—Analysis of 157 Primary and 22 Recurrent Cases

The eyelid is a frequent site for skin cancers of the face. Its location presents certain special problems in treatment from a cosmetic and functional standpoint. If untreated, a major deformity with possible loss of sight can result. This paper is a report of our treatment with irradiation of 157 primary tumors and 22 recurrent tumors. In 98 per cent of patients there was control of the tumor for more than five years and a good cosmetic and functional result.     

CARCINOMA OF THE FLOOR OF THE MOUTH—Successful Results with Monoblock Resection and Suprahyoid Dissection in Early Lesions

In 33 cases of carcinoma of the floor of the mouth, the lesions were classified according to the extent of invasion and involvement and a plan of surgical procedure was followed that fitted the operation to the classification.A monoblock resection plan for early intraoral lesions appeared to be quite satisfactory. It was used in two cases in which node involvement was not known until discovered in the pathologic specimen, but in neither case was there recurrence in a period of six years.     

RECURRENT CARCINOMA OF THE RECTUM—Surgical Treatment

Following operations on the rectum for carcinoma, approximately half of the patients have recurrence in the perineum, pelvis, abdomen or at the suture line of anastomosis. The prognosis is almost uniformly poor and although the problems of management are complicated, dealing with them may give the patient worthwhile physical, emotional and economic benefits. Surgical procedures used in the treatment of the common types of recurrence are discussed.     

CARCINOMA OF THE NASOPHARYNX—Treatment with Radioactive Cobalt

A method of treatment of carcinoma of the nasopharynx is described, using a bead of radioactive cobalt in a Foley catheter placed through the nose and inside the nasopharynx. As an aid in proper placement of the cobalt bead a portion of the nasal septum is removed first. This method of treatment is to supplement rather than replace other methods of treatment such as external x-ray therapy and surgical excision of lymph nodes in the neck.Twenty-two patients were treated with radioactive cobalt beads and the results indicated that it is a useful method for treating carcinoma in the nasopharynx.     

BASAL CELL CARCINOMA OF THE NOSE—Treatment with Chemosurgery

Basal cell carcinomas of the nose probably originate from embryologic cell rests left between cartilages and bones in the fusion and migration of the nasal precursors. Some carcinomas have been found to invade to the mucosal surface between subcutaneous structures or around the alar margins. Recurrences are particularly likely to develop deep extensions due to overlying scar tissue.In many cases, chemosurgical removal has disclosed unsuspected deep and lateral extensions. It is the treatment method of choice for many such lesions.     

BRONCHIAL CARCINOMA—Lobar Distribution of Lesions in 250 Cases

In a study of the lobar distribution of tumors in 250 consecutive cases of primary bronchial cancer, it was noted that 130 of the tumors originated in the upper lobes, 11 in the right middle lobe, and 49 in the lower lobes. Some 40 arose in the main bronchi, and most of the remainder were either “hilar” or unspecified in anatomic location.There was no apparent correlation of the lobar site of these tumors with the lobar location of childhood pneumonic lesions as observed in another group of patients in the same hospital.     

TUMORS OF THE URACHUS—Report of Five Cases

Reports of three patients with malignant and one with benign urachal tumor are presented.Survival of one patient in good health 11 years after removal of adenocarcinoma of a urachal cyst with vesical invasion is reported.Methods of diagnosis and treatment are discussed.     

CARCINOMA OF THE THORACIC ESOPHAGUS—A Discussion of Early Diagnosis and Surgical Treatment

Dysphagia, substernal or epigastric distress, and regurgitation of food are important early symptoms in the diagnosis of carcinoma of the esophagus. Temporary remission in symptoms does not rule out esophageal cancer. The use of thick barium meal and routine thorough examination of the esophagus in upright and supine positions in all upper gastrointestinal roentgen studies, even though the clinical symptoms point to the upper abdomen, are of great importance.The spread of the cancer to both mediastinal and subdiaphragmatic lymph nodes makes transthoracic thoracolaparotomy the one approach which will permit the surgeon to perform a one-stage esophagogastrostomy, and to adequately evaluate and deal with cancerous tissue on both sides of the diaphragm. This one-stage procedure permits the patient to swallow normally after operation, and the costly and time-consuming uncertainties of the many-staged operations are avoided. The comfort which the operation gives to otherwise doomed patients, along with the improving postoperative mortality rate, offers new hope to those who have cancer of the esophagus.     

CARCINOMA IN SITU OF THE UTERINE CERVIX—DIAGNOSIS BY BIOPSY

In 50 cases of carcinoma in situ of the cervix uteri, the lesion was present in the cervical canal in 36 instances, but the squamous epithelium of the portio was involved in only 14 cases. Since single biopsy from the portio or external os may show no malignant change even in cases in which vaginal smears are positive for cancer, single biopsy is indicated only in the presence of gross suspicious lesions.When positive smears have been obtained, cold-knife cone biopsy is indicated (a) whenever gross lesions are not visible on the ectocervix, (b) if carcinoma in situ is found in a biopsy of the external os, in order to determine the presence or absence of invasion, and (c) when there are repeated positive smears and biopsy of the portio has not shown the presence of malignancy.The technique of cone biopsy is given in detail.     

PANCREATITIS AND CARCINOMA OF THE PANCREAS—Some Aspects of the Pathologic Physiology

The physiological phenomena accompanying pancreatic disease in adults are related to the local and generalized reaction of the body to the blockage and/or leakage of the three enzymes—amylase, lipase and trypsin. The measurements of amylase and lipase in the serum are the most reliable criteria in the diagnosis of acute disease. Related changes may include hypocalcemia, hypopotassemia, hyperlipemia, hyperglycemia and decreased renal function.In chronic pancreatitis, there is less fluctuation in the amounts of the enzymes in the blood. The presence of diabetes mellitus, demonstration of calculi by x-ray, and examination of the stools for excess fat and meat fibers are more important diagnostic guides.In cancer of the pancreas, function tests using secretin stimulation of the gland followed by an examination of the external secretion or determination of the serum amylase have been used with some success.     

CARCINOMA OF THE ESOPHAGUS AND GASTRIC CARDIA—With Special Reference to Treatment

During the last five years the thoracic and abdominothoracic approaches in esophageal and gastric surgery have become established. With improvements in surgical and anesthetic technique mortality rates have declined. Preoperative and postoperative care are of great importance.