Definitive Palliation Research Articles

How to Recognize and Treat Parathyroid Carcinoma

Parathyroid carcinoma is a rare tumor and its clinical course is variable. Differentiation of patients with parathyroid carcinoma from those with parathyroid adenoma is often difficult both preoperatively and at operation. For good results, the surgeon must recognize this disorder and perform an en bloc resection at the initial surgery. A neck dissection is necessary only when there is evidence of regional node metastases. After surgery, periodic follow-up of the serum calcium and iPTH levels is essential. When hypercalcemia recurs or the serum iPTH increases, localization studies with the use of thallium-201 scanning help detect local recurrence and regional lymph node metastases, but unfortunately, this method often fails to localize pulmonary metastases. Chest radiographs and CT scanning are useful for delineating pulmonary metastases. A wide excision of locally recurrent tumor, an en bloc radical neck dissection and mediastinum dissection for lymphatic metastases, and an aggressive surgical resection of lung metastases are recommended. Although these operations are rarely curative, they usually offer definite palliation of the marked hypercalcemia, often for a considerable period. Drugs to lower the serum calcium level and systemic chemotherapy are currently of only limited benefit, and radiation therapy is generally ineffective.

Endoscopic methods for relief of malignant obstructive jaundice.

AbstractSeveral endoscopic methods have potential value in the management of patients with biliary obstruction due to malignant disease. Jaundice can be relieved either as definitive palliation, or as preparation for surgery, by endoscopie placement of indwelling prostheses, or by sphincterotomy of tumors at the papilla of Vater. Blockage of prostheses remains a problem in some patients who survive for more than a few months, and improvements in materials are anticipated. Late duodenal obstruction is surprisingly uncommon. These techniques are valuable in many elderly and frail patients. The results of ongoing randomized trials will help define indications for their use in other contexts and for their roles relative to surgery and percutaneous methods.

Percutaneous transhepatic biliary drainage in malignant obstructive jaundice.

Results obtained in 70 patients with neoplastic (primary or metastatic) biliary obstruction and submitted to percutaneous transhepatic biliary drainage indicate the effectiveness of the technique in relieving jaundice, improving general conditions and restoring liver function. In 25.4% of cases, the drainage allowed the patients to undergo surgical treatment of the neoplasm. In 74.6%, the drainage was left in place as definitive palliation. The complication rate was very low and similar to that described in the literature. At this time it is difficult to identify prognostic factors and foresee the results of percutaneous transhepatic biliary drainage, but the procedure is always indicated in patients at high operative risk or inoperable.

Atresia of left atrioventricular orifice. Anatomical investigation in 62 cases.

Sixty-two hearts without a patent exit from the left atrium to the ventricular mass have been studied. All had situs solitus and laevocardia. The material consisted of 32 cases with coexistent aortic atresia and 30 cases with patent aortic root. Five hearts with aortic atresia were biventricular with atrioventricular concordance and imperforate left atrioventricular valves, and 27 hearts were univentricular of right ventricular type, with absent left atrioventricular connection. The anatomy of this group was uniform, with extreme hypoplasia of all the left cardiac segments. Among the cases with patent aortic root, five were biventricular, with atrioventricular concordance and imperforate left atrioventricular valves, and 24 had absent left atrioventricular connection, 15 with univentricular heart of right ventricular type and nine with univentricular heart of left ventricular type. The final heart had double inlet univentricular of left ventricular type with an imperforate left atrioventricular valve. In this second group the aorta was larger in cases with discordant ventriculoarterial connection or in those with double outlet from the main ventricular chamber. A normal sized aorta without aortic arch obstruction was observed in nine instances. These are of great interest in terms of surgical anatomy since definitive palliation may be feasible.

The palliation and remission of cancer with combined corticosteroid and nitrogen mustard therapy; a report of 100 cases.

ONE of the most formidable medical problems today is the grave plight of patients with advanced cancer for whom cure is impossible, remission improbable and palliation unlikely. The tragedy stems not only from the impossibility of cure but also from the inability of medical science to grant even the minimal request for palliation of symptoms. In an era of unparalleled medical advances, it is recurrently evident that little progress has been realized in the definitive palliation of terminal cancer. As in the past, the majority of patients face the prospect of prolonged, demoralizing pain of a degree unequaled in any . . .

Cancer of the breast

C ANCER of the breast is not new. In the first century A.D. Leonides112 operated upon the breast for cancer, using a red hot iron to sear the remaining surfaces. AntyIIus’ also operated upon the breast in the third century. In 1804 Benjamin Bell’ insisted that local operations were of no avaiI and urged that wider operations were necessary and suggested that the pectoral muscIes and axillary lymph nodes be removed. Up to this time aImost IOO per cent of patients had recurrences and died. CharIes Moore’ in 1867 emphasized that neck dissection be performed en masse and in continuity. Sir Mitchell Banks’ in 1882 taught that removal of the axillary lymph nodes was necessary whether they seemed enlarged or not. HaIsted3 and WiIIy Meyer4 in 1894 separately described an operation which has been the basis for our surgery to date. Halsted removed the breast first, followed by the axillary dissection. Meyer reversed this order. Halsted removed a large amount of skin, necessitating skin grafting in most cases. He later described a more radical operation, entering the neck and removing the lymph nodes in the posterior triangle. L. McLane Tiffany5 in 1901 drew attention to the intercostat spaces where nodes could sometimes be found and removed. Sampson HandIey in 1904~ and again in 1921~ emphasized that the spread of cancer was by Iymphatics which coursed chiefly in the fascia1 planes. He stated that wide areas of fascia therefore should be removed, incIuding the fascia over the epigastrium and the upper part of the rectus abdominus muscle. He believed that since cancer did not spread along the skin, it was not necessary to remove wide areas. We are indebted to him for the rule that at least 6 inches of skin, centered over the tumor, pIus IO inches of deep fascia, incIuding that over the rectus muscle and epigastrium, shouId be removed. In 1895 Roentgen2 discovered x-rays and soon after that a patient with a Iarge cancer of the face was treated with roentgen rays. The tumor shrank away rapidly and disappeared. Marie and Pierre Curie2 discovered radium and later this was made available for therapeutic use against cancer. Soon a technic was developed for a combination of surgery plus radiation. Radium was used but gave way to x-ray preoperativeIy, postoperativeIy, or both. Radiation combined with radical surgery was considered better than either aIone. We had now reached a stage where it was beIieved that the treatment of cancer of the breast had become standardized. However, our tranquility did not Iast long. New and conflicting ideas emanate from so many authoritative sources that we are now in a state of uncertainty. In a recent article Charles Eckert and William B. Seaman8 summarize their ideas on radiation therapy as follows: “ Irradiation offers definite palliation, prolongation of life and occasionaIIy even five-year survivals are seen in the group of primary inoperabIe cases. Preoperative radiation serves to surround the cancer cells with a fibrous tissue barrier. If surgery foIIows, it effectiveIy breaks down this barrier so that life is often shortened over what it wouId be from x-ray therapy alone.” They aIso state that postoperative radiation is not caIIed for unIess there are very high nodes in the axilla and the surgeon believes he has probably Ieft some Iymph nodes or extension which he cannot reach. This view is held aIso by Haagenson” and others. However, Janes’O and Jones” both report satisfactory results in a smaI1 number of cases treated preoperatively. Janes reported two advanced cases treated by preoperative radiation. Both patients are alive and free from recurrence eleven and six years, respectively. A. Nohrman’? reports a series of 1,042 cases in which there appeared to be an improvement in prognosis in the most unfavorable cases. The author has used preoperative x-ray therapy in a number of cases and has noted marked clinical improvement. In many cases the

An Experimental Study: The Effect of Radium Emanation on the Pancreas of Dogs

Because of the extreme technical difficulty and the high mortality incident to resection of the pancreas for carcinoma, few cures may be expected from radical surgical measures. While those carcinomas limited to the body or tail of the pancreas may be favorable for resection, the majority involve the head of the gland and would require a pancreatoduodenectomy for removal, a procedure which has been survived for a long period (nine months) by only one patient (Kausch). It seems evident that surgery can offer definite palliation of symptoms but little toward an ultimate cure in these cases. A review of the literature reveals few references to the use of high-voltage x-rays in the treatment of carcinoma of the pancreas. No reports of irradiation by means of radium element or emanation were found. Richards in 1922 reported favorable results in two cases of carcinoma of the pancreas. In both cases the tumor was found to be inoperable on exploration. Biopsies showed adenocarcinoma. Following courses of high-voltage therapy both patients improved remarkably, being symptom-free ten and twenty months later. No mass could be demonstrated by x-ray following high-voltage therapy. In 1925 Flecker and Cameron in their study of the alteration in blood sugar values after intensive high-voltage roentgen irradiation, mentioned remarkable results with x-rays in carcinoma of the pancreas. In their experimental and clinical work they found a temporary depression of blood sugar values within twenty-four hours of exposure, followed by a return to normal limits within four to eight days. Redwitz reported that he had seen no value in radiation therapy in carcinoma of the pancreas. The effect of high-voltage x-ray therapy on the normal pancreas has been studied experimentally by several investigators. Kmietowicz and Tumidajski observed a decrease in pancreatic secretion with an activation of proferments following irradiation with 2.8 human S. E. D. Ivy, McCarthy and Orndoff in 1924, in studying the effect of roentgen rays on gastric secretion, found a marked fibrous atrophy of the pancreas to 1/6 to 1/7 the normal size, following one human S. E. D.