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Radium therapy of tumors of the genitourinary tract
TUMORS
RADIUM THERAPY OF OF THE GENITOURINARY
TRACT*
B. S. BARRINGER, M.D., F.A.C.S. NEW YORK
c
OME fifteen or twenty years ago radiu m was first tried as a thera1 ” peutic agent in maIignant diseases of the prostate, bIadder, penis and testicIe. The reason for its tria1 is obvious. Surgery had proved to be singuIarIy inadeqhate in attempting to contro1 these diseases. For a good many years surgery had devised and perfected new and eIaborate operations in its attempt to cope with them. As a ruIe, the more eIaborate the operations the higher the operative mortality became. Instance tota cystectomy with implantation of the ureters into the bowe1 with a mortaIity of upwards of 30 per cent. This increasing operative mortaIity might have been justified if more cases had been cured. This was not the case. Because it had a definite specific effect upon cancerous tissue, radium was suggested as a substitute for surgery. After fifteen years of work at the MemoriaI HospitaI, work in which successes mingled with faiIures, it seems that today the origina faith that radium might prove of vaIue in controIIing cancer has been more than just fied. Let me here interject that radium treatment of any maIignant disease is becoming more and more a probIem that can best be dealt with in especiaIIy equipped hospitaIs. Radium is expensive. Its proper use impIies a certain amount of specia1 training. Many of the faiIures of radiation therapy are due to the fact that sufficient amounts of radium are not at hand when any particular case is deaIt with. The effect is the same as if a surgeon sIiced off a smaI1 part of a tumor, rather than removed it in its entirety. And just one word about radium burns. It is impossibIe to eradicate a tumor without causing some radium effect upon * Read at the St. Louis Clinics June,
the surrounding tissues. This is the socaIIed and much feared radium burn. My point of view for a great many years has been that I fear the cancer much more than the radium burn. The one causes death. The other is a transient affair. Let us see how radium therapy has affected the treatment, the prognosis and our genera1 conception of the contro1 of 1 genitourinary carcinoma: cancer of the penis, teratoma of the testicIe, cancer of the prostate and cancer of the bIadder. CARCINOMA
THE
PENIS
The oIder concept:on of the cure of carcinoma of the penis did not distinguish at a11 between the different forms and different Iocations of the carcinoma, and it was beIieved that a11 cases shouId be treated with amputation of the penis at the trianguIar Iigament, with impIantation of the urethra in the perineum, and at the same time biIatera1 dissection of the gIands of both inguina1 regions. A carefu1 study of these cases has reveaIed the folIowing facts : That the carcinoma may be papiIIary in type, and may be entireIy confined to the foreskin, or it may be entireIy confined to the gIans penis, or it may be a combination of these two; that it may be of the infiItrating type, growing into the substance of the penis, penetrating Buck’s fascia, and so growing up along the copora cavernosa; that invoIvement of the inguina1 glands by the carcinoma is rare; that infection of the inguina1 gIands without cancerous invoIvement is quite common; that when the inguina1 gIands are both cancerous and infected routine dissection has IittIe or no chance of controIIing the cancer. Therefore, our therapy at present is as foIIows: The foreskin must be freed either by dorsa1 sIit or by circumcision, so eIimi-
1930. From the Dept.
213
OF
of UroIogy, lZlemorial.Hospital,
N. Y.
244
American Journal of Surgery
Barringer-Radium
nating the causative factor of carcinoma, the irritating secretion. In 3 recent consecutive cases, the carcinoma was entireIy confined to the foreskin, and simpIe circumcision eliminated the carcinoma. AI1 of these patients are we11 five years after. Two had no further therapy. The third had a recurrence which necessitated amputation of I in. of the penis. He is we11 five years after. When the carcinoma is papiIIary in type, or if i&Itrating and if Buck’s fascia has been penetrated but a sIight distance, then operation may be entireIy eIiminated, and the carcinoma controIIed by radium, as a ruIe appIied on the surface. We are seeking to further extend the fieId of radium in the infiItrating type, and whiIe formerIy we beIieved that few couId be controIIed in this way, we are now appIying it to more cases with deeper infrItration. On the other hand if the infiItration is extensive then we excise the penis 2 cm. beyond the growth. The excised portion is dissected at the operating tabIe to determine accurateIy if we are beyond the growth. No routine inguina1 dissection is done. The infection of the inguina1 gIands is ehminated by its contro1 at the source, the penis. The inguina1 glands are treated by a combination of deep x-ray therapy and radium pack, with impIantation of radium in any suspicious gIands. If the primary Iesion is confined to the foreskin it is removed by circumcision, and any suspicious areas remaining are irradiated. If the primary Iesion is 2 cm. or Iess in diameter, superficia1, and metastases cannot be detected, externa1 irradiation aIone is used. The tumor is treated with a radium pIaque, * the dose being 1200 mc. hours per square centimeter, at I cm. distance. There were 13 patients in this group. TweIve, or 92 per cent, are Iiving, without signs of disease. One patient died at another hospita1 foIIowing an operation. One of *The pIaque is a box I cm. square which contains radium emanation encIosed in siIver capsutes, the walls of which are 0.3 mm. thick. The side of the box which overIies the tumor is made of brass, I mm. in thickness.
Therapy
MAY. 1931
these men Iived from tweIve to eighteen months; 3 from eighteen to twenty-four months; I, from two to three years; 2, from three to four years; 2, from four to five years; 2, from seven to eight years and I, for nine years four months after the first irradiation. OccasionaIIy, the carcinoma, though smaI1, has penetrated deepIy into the cavernous tissues. FrequentIy, undermining has gone so far that the deeper parts of the tumor are reIativeIy inaccessibIe to intense externa1 irradiation. In such cases irradiation with the pIaque is foIIowed by a conseryative amputation.!_ Four patients were so treated. AI1 of them are Iiving and weI1; I, from two to three years; 2, from four to five years and I, from six to seven years after the first irradiation. If the primary tumor is Iarger than 2 cm. in diameter and metastases are not found, the treatment of choice is usuaIIy irradiation with the pIaque foIIowed in from three to four weeks by a conservative amputation. On those patients who present extensive tumors which have aIready destroyed a considerabIe proportion of the penis, a simiIar amputation is performed without preoperative irradiation. In this group there were 31 patients. Nineteen, or 61 per cent, are Iiving and weI1; 5, or 16 per cent, are known to be dead, whiIe 7, or 22 per cent, are Iost from the records and are classified as dead. The Iiving have survived: I, from eighteen to twenty-four months; 4, from two to three years; 2, from three to four years; 4, from four to five years; 3, from five to six years; 4, from seven to eight years and I, from eight to nine years after the first irradiation. Eighteen patients were first seen with both a primary Iesion and metastases. Three, or 16 per cent, are Iiving, 2 with signs of disease; 15, or 82 per cent, are dead. t Conservative operation is believed to be a distinct advance in rational therapy. Amputation is performed 2 cm. proximal to visibIe or palpabIe evidence of disease. The success of the measure depends on the knowIedge that metastasis is by emboIism. It is not at aI1 uncommon to preserve so much of the organ that coitus is possibIe.
NEW
SERES VOL. XII,
Barringer-Radium
No. 3
Therefore, of 66 patients, 36, or 57.5 per cent are aIive, and as far as can be determined, free of disease. And more, there has been no operative mortality. TERATOMA
OF
THE
TESTIS
In no tumor has radiation produced more briIIiant resuIts than in this disease. The pathoIogy of the disease is that the teratoma starts in the rete testis, then grows either toward the testicIe or epididymis, or both. Then it metastasizes by way of the veins or Iymphatics, or both. Metastases form aIong the course of the spermatic vesseIs. This has suggested to many (Hinman and others) that the cure was to remove the testicIe, and by extensive dissection of the retroperitonea1 gIands, to eIiminate a11 of the carcinoma. This has never appeaIed to me as a feasibIe way to contro1 retroperitonea1 metastasis. Our course of procedure is as foIIows: In the primary cases, in which no surgery has been done, the testicIe is thoroughIy irradiated with the radium pack. The course of the spermatic vesseIs on the side affected is aIso thoroughIy radiated by radium pack or deep x-ray therapy. The onIy operation that is done is the remova of the testicIe under IocaI anesthesia. The cord is cut first, and the testicIe is removed from its bed afterward, care being taken not to squeeze the testicIe, and so preventing the dissemination of the cancer. This operation is done about two months after the first radiation, and has no mortaIity. At the time this articIe is written we are abIe to present data on I I 3 patients treated and foIIowed in this hospita1. Of these I 13 cases, 41 are Iiving and cIinicaIIy free from disease. The tabIe indicates the time duration : 9 -12 months. I --I .3 years.. r .f- 2 years..
I 5 9
2 -2.5 years. 2.9 3 years.. 3 - byears..
2
6 6
4-fyears 5- 6years _... 6- 7years 7- 8years .._... 8- 9years __... 9-10 years. I0 years. _.
.._
3 3 2
o 2 I
1
:Therapy
American
JOUST
The foIIowing case report
of Surgery
245
is of interest.
The patient was a negro chauffeur, aged thirty-seven years. He was admitted to the hospita1 in May, 1925, with a history of painIess sweIling of the right testis over a period of five months. The testis steadiIy increased in size and two weeks before admission first became painfu1. Three months prior to entering the hospita1 the patient began to cough and had frequent night sweats. He had Iost 36 Ib. in weight. Examination reveaIed a tumor of the right testis measuring 14 cm. in circumference. A mass 4 X 7 cm. was paIpated in the right abdomen and x-rays of the chest showed extensive puImonary metastases. In addition there was a hard supracIavicuIar node measuring I X 2 cm. No operation was done. The patient was treated with a great dea1 of high voItage x-ray and with radium. The testis was reduced to a firm fibrotic mass. The metastases disappeared and the patient is now cIinicaIIy we11 and free from demonstrabIe disease for four and a haIf years from the time treatment was first instituted. The skin shows practicaIIy no effect from the treatment. CARCINOMA
OF
THE
PROSTATE
Carcinoma of the prostate stiI1 hoIds its pIace as the great uroIogica1 puzzIe. We know next to nothing as to its cause. We have no rea1, practica1 method in genera1 use to make the diagnosis of this condition sufficientIy earIy to give any sort of treatment a fair chance of success. If we by hazard make an earIy diagnosis of carcinoma of the prostate we are thoroughIy in a muddIe as to the best way to contro1 this carcinoma. This paper is written in an attempt to anaIyze the reasons for our failures in the past and with a Iook toward the future. We have found that in but between 2 to 5 per cent of a11 cases seen at the Memorial HospitaI is the carcinoma confined to the prostate. Young reports 27 radica1 operations for carcinoma of the prostate, the first in Igo4 and the Iast in Ig27,l just a IittIe over one a year. This wouId seem to indicate how very few cases come to his service which he believes are appropriate ‘Lewis, P. 94.
D. Practice
of Surgery.
VoI. 9, Chap.
21,
246
American Journal of Surgery
Barringer-Radium
for radicaI operation. WiIdboIz operated upon 40 out of 145 patients with prostatic carcinoma.2 It seems superffuous to say that earher diagnosis is of prime importance, and earIier diagnosis by means of pathoIogica1 examination. A method for obtaining a specimen from the suspected prostate has been perfected by one of our staff. This is done with a simpIe aspirating needIe, and it is effective in 66 per cent of cases. A discussion of the various methods to contro1 prostatic carcinoma after an earIy diagnosis has been made reveaIs the fact that no two uroIogists seem to be in accord as to the best way to accompIish this. A review of the use of radium in carcinoma of the prostate at the MemoriaI HospitaI has reveaIed the foIIowing interesting facts: From October, 1915 to January, 1917, we saw 46 cases of prostatic carcinoma at the MemoriaI HospitaI. In but one of these cases was the carcinoma confined to the prostate. Five of the 46 patients Iived more than five years. None of these 5 cases, as far as we couId see, had any gross evidence of active carcinoma. These cases were treated by the insertion of stee1 radium-bearing needIes through the perineum into the prostate and semina1 vesicIes, giving smaI1 doses, 200 or 300 mc. hours for each needIe, and then repeating this dose every two or three months unti1 the condition was controIIed or not. In this way we were certainIy abIe to cure some cases, as we have had the autopsy of one patient who died seven years after first seen; the diagnosis of carcinoma was made from the prostate removed before operation, and the autopsy showed no carcinoma anywhere. Since that first series we have not done as weI1. We have been in a transition state, changing to goId seeds and have pretty thoroughIy come to the concIusion that goId seeds cannot be impIanted through the into the prostate with any perineum * WildboIz, H. Die ErfoIge operativer Therapie des Prostatskarzinoms. Scbweiz. med. Wcbnscbr., 58: 726, 1928.
Therapy great degree of accuracy. We beIieve that in most cases of prostatic carcinoma a much Iarger dose of radium than heretofore used is necessary to contro1 the disease; in other words, doses comparabIe to those we have used in controIIing bIadder carcinoma. A certain percentage of prostatic carcinoma are highIy maIignant and radiosensitive. Because of this I beIieve that a11 cases of prostatic carcinoma, before anything is done, shouId be subjected to a thorough cycIe of deep x-ray radiation, using five portaIs of entry. This at best gives onIy about I 35 erythema doses to the prostate, whereas we beIieve that somewhere between IO and 15 erythema doses are necessary to control the Iarge majority of prostatic carcinoma. Because of the necessity for a Iarge dose of radium accurateIy pIaced within the prostate I have quite reversed my origina contention that the best method was through the perineum. I beIieve that cystotomy shouId be done, any obstructive portions of the prostate removed with cutting forceps or a cautery, and the entire tumor, periprostate, periprostatic region and semina1 vesicIes, if they are invoIved, impIanted with radium seeds, using seeds of 2 mc. each to every centimeter of tumor. It seems to me that the suprapubic exposure is better for this purpose than the perinea1 one, because the seeds can be more accurately pIaced and because the prostatic region is not dissected up, so reducing its vaIue as a productive barrier to the radium seeds. The mortaIity of this operation is not so great as that of Young’s radica1 remova1, and whiIe it is not a beautifu1 piece of technique, I beIieve it wiI1 prove in the Iong run a much more effective method to controI prostatic carcinoma, one that can be used by many more uroIogists. It wiII certainIy offer a sure way of controIIing the bIadder invasion of the carcinoma which so frequentIy occurs in the gIands of AIbarran and the bIadder base. CANCER
The treatment
OF
THE
BLADDER
of bladder
tumors
is stiII
New SERJES VOL. XII, No. 2
Barringer-Radium
in a state of evolution. Surgery and radium have been and stiII continue to be contestants for honors. A comparison between the resuhs of the radium impIantation and operative remova1 of bIadder cancer is diffIcuIt because surgery picks the cases which are operabIe and discards the rest. At the MemoriaI HospitaI we have subjected to radiation every patient with bIadder cancer in whom the cancer was believed to be confined to the bIadder, no matter how Iarge the tumor was. Therefore, in this series are incIuded many inoperabIe cases. In a fair percentage of cases the tumor occupied one-third or more of the bIadder. In these cases 28 per cent were tumors whose bases were 6 sq. cm. or under. TABLE I PAPILLARY
I
I
~ 8,”
1 q,O
Not controIIed:
~
IO;11
15 cases-33
INFILTRATING
Diagnosis,
DIFFERENT under this
I
I
; II;12
( 12;13
per cent CARCINOMA
Clinical
Cases: 82 CIinicaI and pathoIogica1 diagnosis agree-47 CIinicaI and pathologica diagnosis disagree-35 ControlIed: 30 cases-36.5 per cent ControIIed over three years: 23 cases-27.8 per cent J
1 .;2!2~3!3~4!4~5~5;“i”;’
Not controIIed:
Journal
ol Surgery
247
In 72 per cent the cases were greater than 6 sq. cm. The Location of the Tumor: In 127 tumors 81, or 63 per cent, touched or were adjacent to the trigone. Many of these wouId have required tota cystotomy if operative remova had been contempIated. In 19, or 15 per cent, the Iocation was on the base posterior to the trigone. In 18, or 14 per cent, the tumor was on the IateraI waIIs and easiIy removabIe. In I, or 7 per cent, it was on the apex. In 8 the site was not designated. In the 63 per cent of tumors touching the trigone the operative mortaIity foIIowing the surgica1 remova of these tumors, if that were possibIe, wouId have been between IO per cent and 20 per cent, and a fair number of these tumors couId not have been removed surgicaIIy.
CIinicaI
with atypical ceIIs are grouped heading)
Cases: 45 ClinicaI and pathologica diagnosis agree-36 CIinicaI and pathologica diagnosis disagreeControIIed: 30 cases.46 per cent ControlIed over three years: 25 cases-55.5 per cent
7;8
American
CARCINOMA
Diagnosis, (PapilIoma
Therapy
52 cases-63.5
per cent
FORMS
OF
RADIATION
We have been abIe from the very start to ControI a good perCenta@ Of maIignant bladder tumors with radium. We first used screened radium appIied in a somewhat hit or miss manner. Then partIy screened and partIy unscreened (gIass seeds), more accurateIy appIied, but with much caustic beta radiation. And finaIIy accurateIy appIied goId seeds giving off no beta radiation. Beta radiation certainly causes sIoughy anus of the bIadder, which onIy too often becomes covered with troubIesome phosphatic deposits. On the other hand two of the most maIignant tumors we have ever controIIed were controIIed soIeIy by glass seeds. It is an open question at present whether or not this caustic action of beta radiation is a factor in controIIing bIadder cancer. The size of the dose of radium is an important factor. The reason why many who use radium fai1 is that a very smaI1 dose is used. I have anaIyzed a good many such cases and have found almost without exception this to be the reason for faiIure. One goId seed of 2 mc. hours to 135 sq. cm. of tumor is a minimum dose. I have (1914),
248
N EW SERIESVOL.XII, No. 2
Barringer-Radium
put as many as 40 such seeds in a singIe very Iarge tumor. ConsiderabIe bIadder irritabiIity and some recta1 irritation may foIIow this dosage (if the seeds be near the rectum), and the so-caIIed radium burns may foIIow this administration. I have always worried more about the maIignancy of a bIadder tumor than over a radium burn. We have caIcuIated that about ten times an erythema dose is necessary to contro1 the radioresistant tumors. This accounts for the reason that deep x-ray therapy so often faiIs. It is difhcuIt to get into the tumor by this means much more than I 44 erythema doses. THE
SUPRAPUBIC
OPERATION
FinaIIy, Iet me stress the decided difference between the operative mortaIity when a tumor is removed by surgery and when it is impIanted by radium by the suprapubic route. In 109 consecutive personal cases of the suprapubic impIantation of radium 4 patients died in the hospita1, an operative mortaIity of 3.6 per cent. One died of shock and hemorrhage, notwithstanding two bIood transfusions, I of diabetic coma, I of uremia, 43%
Therapy
Mar, ,931
I of shock; a poor heart and oId age contributed. A considerabIe number of these cases wouId have been classed as inoperabIe. Operative remova in these cases of this series which were operabIe wouId have been between IO per cent and 20 per cent. In doing the suprapubic impIantation spina anesthesia shouId be used, the bIadder shouId not be mobiIized; the abdomina1 wound shouId be thoroughIy screened with gauze before opening the bIadder; great care should be taken not to spiI1 the bIadder contents over the wound; a good exposure of the tumor is necessary; the Cameron light shouId be used for retraction and to iIIuminate the bladder; open wire retractors devised by us at the MemoriaI HospitaI are very useiul for a good exposure of the tumor; the papiIIary portions of a tumor shouId be removed by some form of cautery; the radium implantation shouId be very accurate; a smaI1 suprapubic drainage tube (18 to 22’ F.) shouId be Ieft in pIace for about a week or Ionger, if the bladder is dirty or the radium dose is very Iarge; the bIadder is not sutured to the abdominal waI1.
RADIUM THERAPY OF OF THE GENITOURINARY
TRACT*
B. S. BARRINGER, M.D., F.A.C.S. NEW YORK
c
OME fifteen or twenty years ago radiu m was first tried as a thera1 ” peutic agent in maIignant diseases of the prostate, bIadder, penis and testicIe. The reason for its tria1 is obvious. Surgery had proved to be singuIarIy inadeqhate in attempting to contro1 these diseases. For a good many years surgery had devised and perfected new and eIaborate operations in its attempt to cope with them. As a ruIe, the more eIaborate the operations the higher the operative mortality became. Instance tota cystectomy with implantation of the ureters into the bowe1 with a mortaIity of upwards of 30 per cent. This increasing operative mortaIity might have been justified if more cases had been cured. This was not the case. Because it had a definite specific effect upon cancerous tissue, radium was suggested as a substitute for surgery. After fifteen years of work at the MemoriaI HospitaI, work in which successes mingled with faiIures, it seems that today the origina faith that radium might prove of vaIue in controIIing cancer has been more than just fied. Let me here interject that radium treatment of any maIignant disease is becoming more and more a probIem that can best be dealt with in especiaIIy equipped hospitaIs. Radium is expensive. Its proper use impIies a certain amount of specia1 training. Many of the faiIures of radiation therapy are due to the fact that sufficient amounts of radium are not at hand when any particular case is deaIt with. The effect is the same as if a surgeon sIiced off a smaI1 part of a tumor, rather than removed it in its entirety. And just one word about radium burns. It is impossibIe to eradicate a tumor without causing some radium effect upon * Read at the St. Louis Clinics June,
the surrounding tissues. This is the socaIIed and much feared radium burn. My point of view for a great many years has been that I fear the cancer much more than the radium burn. The one causes death. The other is a transient affair. Let us see how radium therapy has affected the treatment, the prognosis and our genera1 conception of the contro1 of 1 genitourinary carcinoma: cancer of the penis, teratoma of the testicIe, cancer of the prostate and cancer of the bIadder. CARCINOMA
THE
PENIS
The oIder concept:on of the cure of carcinoma of the penis did not distinguish at a11 between the different forms and different Iocations of the carcinoma, and it was beIieved that a11 cases shouId be treated with amputation of the penis at the trianguIar Iigament, with impIantation of the urethra in the perineum, and at the same time biIatera1 dissection of the gIands of both inguina1 regions. A carefu1 study of these cases has reveaIed the folIowing facts : That the carcinoma may be papiIIary in type, and may be entireIy confined to the foreskin, or it may be entireIy confined to the gIans penis, or it may be a combination of these two; that it may be of the infiItrating type, growing into the substance of the penis, penetrating Buck’s fascia, and so growing up along the copora cavernosa; that invoIvement of the inguina1 glands by the carcinoma is rare; that infection of the inguina1 gIands without cancerous invoIvement is quite common; that when the inguina1 gIands are both cancerous and infected routine dissection has IittIe or no chance of controIIing the cancer. Therefore, our therapy at present is as foIIows: The foreskin must be freed either by dorsa1 sIit or by circumcision, so eIimi-
1930. From the Dept.
213
OF
of UroIogy, lZlemorial.Hospital,
N. Y.
244
American Journal of Surgery
Barringer-Radium
nating the causative factor of carcinoma, the irritating secretion. In 3 recent consecutive cases, the carcinoma was entireIy confined to the foreskin, and simpIe circumcision eliminated the carcinoma. AI1 of these patients are we11 five years after. Two had no further therapy. The third had a recurrence which necessitated amputation of I in. of the penis. He is we11 five years after. When the carcinoma is papiIIary in type, or if i&Itrating and if Buck’s fascia has been penetrated but a sIight distance, then operation may be entireIy eIiminated, and the carcinoma controIIed by radium, as a ruIe appIied on the surface. We are seeking to further extend the fieId of radium in the infiItrating type, and whiIe formerIy we beIieved that few couId be controIIed in this way, we are now appIying it to more cases with deeper infrItration. On the other hand if the infiItration is extensive then we excise the penis 2 cm. beyond the growth. The excised portion is dissected at the operating tabIe to determine accurateIy if we are beyond the growth. No routine inguina1 dissection is done. The infection of the inguina1 gIands is ehminated by its contro1 at the source, the penis. The inguina1 glands are treated by a combination of deep x-ray therapy and radium pack, with impIantation of radium in any suspicious gIands. If the primary Iesion is confined to the foreskin it is removed by circumcision, and any suspicious areas remaining are irradiated. If the primary Iesion is 2 cm. or Iess in diameter, superficia1, and metastases cannot be detected, externa1 irradiation aIone is used. The tumor is treated with a radium pIaque, * the dose being 1200 mc. hours per square centimeter, at I cm. distance. There were 13 patients in this group. TweIve, or 92 per cent, are Iiving, without signs of disease. One patient died at another hospita1 foIIowing an operation. One of *The pIaque is a box I cm. square which contains radium emanation encIosed in siIver capsutes, the walls of which are 0.3 mm. thick. The side of the box which overIies the tumor is made of brass, I mm. in thickness.
Therapy
MAY. 1931
these men Iived from tweIve to eighteen months; 3 from eighteen to twenty-four months; I, from two to three years; 2, from three to four years; 2, from four to five years; 2, from seven to eight years and I, for nine years four months after the first irradiation. OccasionaIIy, the carcinoma, though smaI1, has penetrated deepIy into the cavernous tissues. FrequentIy, undermining has gone so far that the deeper parts of the tumor are reIativeIy inaccessibIe to intense externa1 irradiation. In such cases irradiation with the pIaque is foIIowed by a conseryative amputation.!_ Four patients were so treated. AI1 of them are Iiving and weI1; I, from two to three years; 2, from four to five years and I, from six to seven years after the first irradiation. If the primary tumor is Iarger than 2 cm. in diameter and metastases are not found, the treatment of choice is usuaIIy irradiation with the pIaque foIIowed in from three to four weeks by a conservative amputation. On those patients who present extensive tumors which have aIready destroyed a considerabIe proportion of the penis, a simiIar amputation is performed without preoperative irradiation. In this group there were 31 patients. Nineteen, or 61 per cent, are Iiving and weI1; 5, or 16 per cent, are known to be dead, whiIe 7, or 22 per cent, are Iost from the records and are classified as dead. The Iiving have survived: I, from eighteen to twenty-four months; 4, from two to three years; 2, from three to four years; 4, from four to five years; 3, from five to six years; 4, from seven to eight years and I, from eight to nine years after the first irradiation. Eighteen patients were first seen with both a primary Iesion and metastases. Three, or 16 per cent, are Iiving, 2 with signs of disease; 15, or 82 per cent, are dead. t Conservative operation is believed to be a distinct advance in rational therapy. Amputation is performed 2 cm. proximal to visibIe or palpabIe evidence of disease. The success of the measure depends on the knowIedge that metastasis is by emboIism. It is not at aI1 uncommon to preserve so much of the organ that coitus is possibIe.
NEW
SERES VOL. XII,
Barringer-Radium
No. 3
Therefore, of 66 patients, 36, or 57.5 per cent are aIive, and as far as can be determined, free of disease. And more, there has been no operative mortality. TERATOMA
OF
THE
TESTIS
In no tumor has radiation produced more briIIiant resuIts than in this disease. The pathoIogy of the disease is that the teratoma starts in the rete testis, then grows either toward the testicIe or epididymis, or both. Then it metastasizes by way of the veins or Iymphatics, or both. Metastases form aIong the course of the spermatic vesseIs. This has suggested to many (Hinman and others) that the cure was to remove the testicIe, and by extensive dissection of the retroperitonea1 gIands, to eIiminate a11 of the carcinoma. This has never appeaIed to me as a feasibIe way to contro1 retroperitonea1 metastasis. Our course of procedure is as foIIows: In the primary cases, in which no surgery has been done, the testicIe is thoroughIy irradiated with the radium pack. The course of the spermatic vesseIs on the side affected is aIso thoroughIy radiated by radium pack or deep x-ray therapy. The onIy operation that is done is the remova of the testicIe under IocaI anesthesia. The cord is cut first, and the testicIe is removed from its bed afterward, care being taken not to squeeze the testicIe, and so preventing the dissemination of the cancer. This operation is done about two months after the first radiation, and has no mortaIity. At the time this articIe is written we are abIe to present data on I I 3 patients treated and foIIowed in this hospita1. Of these I 13 cases, 41 are Iiving and cIinicaIIy free from disease. The tabIe indicates the time duration : 9 -12 months. I --I .3 years.. r .f- 2 years..
I 5 9
2 -2.5 years. 2.9 3 years.. 3 - byears..
2
6 6
4-fyears 5- 6years _... 6- 7years 7- 8years .._... 8- 9years __... 9-10 years. I0 years. _.
.._
3 3 2
o 2 I
1
:Therapy
American
JOUST
The foIIowing case report
of Surgery
245
is of interest.
The patient was a negro chauffeur, aged thirty-seven years. He was admitted to the hospita1 in May, 1925, with a history of painIess sweIling of the right testis over a period of five months. The testis steadiIy increased in size and two weeks before admission first became painfu1. Three months prior to entering the hospita1 the patient began to cough and had frequent night sweats. He had Iost 36 Ib. in weight. Examination reveaIed a tumor of the right testis measuring 14 cm. in circumference. A mass 4 X 7 cm. was paIpated in the right abdomen and x-rays of the chest showed extensive puImonary metastases. In addition there was a hard supracIavicuIar node measuring I X 2 cm. No operation was done. The patient was treated with a great dea1 of high voItage x-ray and with radium. The testis was reduced to a firm fibrotic mass. The metastases disappeared and the patient is now cIinicaIIy we11 and free from demonstrabIe disease for four and a haIf years from the time treatment was first instituted. The skin shows practicaIIy no effect from the treatment. CARCINOMA
OF
THE
PROSTATE
Carcinoma of the prostate stiI1 hoIds its pIace as the great uroIogica1 puzzIe. We know next to nothing as to its cause. We have no rea1, practica1 method in genera1 use to make the diagnosis of this condition sufficientIy earIy to give any sort of treatment a fair chance of success. If we by hazard make an earIy diagnosis of carcinoma of the prostate we are thoroughIy in a muddIe as to the best way to contro1 this carcinoma. This paper is written in an attempt to anaIyze the reasons for our failures in the past and with a Iook toward the future. We have found that in but between 2 to 5 per cent of a11 cases seen at the Memorial HospitaI is the carcinoma confined to the prostate. Young reports 27 radica1 operations for carcinoma of the prostate, the first in Igo4 and the Iast in Ig27,l just a IittIe over one a year. This wouId seem to indicate how very few cases come to his service which he believes are appropriate ‘Lewis, P. 94.
D. Practice
of Surgery.
VoI. 9, Chap.
21,
246
American Journal of Surgery
Barringer-Radium
for radicaI operation. WiIdboIz operated upon 40 out of 145 patients with prostatic carcinoma.2 It seems superffuous to say that earher diagnosis is of prime importance, and earIier diagnosis by means of pathoIogica1 examination. A method for obtaining a specimen from the suspected prostate has been perfected by one of our staff. This is done with a simpIe aspirating needIe, and it is effective in 66 per cent of cases. A discussion of the various methods to contro1 prostatic carcinoma after an earIy diagnosis has been made reveaIs the fact that no two uroIogists seem to be in accord as to the best way to accompIish this. A review of the use of radium in carcinoma of the prostate at the MemoriaI HospitaI has reveaIed the foIIowing interesting facts: From October, 1915 to January, 1917, we saw 46 cases of prostatic carcinoma at the MemoriaI HospitaI. In but one of these cases was the carcinoma confined to the prostate. Five of the 46 patients Iived more than five years. None of these 5 cases, as far as we couId see, had any gross evidence of active carcinoma. These cases were treated by the insertion of stee1 radium-bearing needIes through the perineum into the prostate and semina1 vesicIes, giving smaI1 doses, 200 or 300 mc. hours for each needIe, and then repeating this dose every two or three months unti1 the condition was controIIed or not. In this way we were certainIy abIe to cure some cases, as we have had the autopsy of one patient who died seven years after first seen; the diagnosis of carcinoma was made from the prostate removed before operation, and the autopsy showed no carcinoma anywhere. Since that first series we have not done as weI1. We have been in a transition state, changing to goId seeds and have pretty thoroughIy come to the concIusion that goId seeds cannot be impIanted through the into the prostate with any perineum * WildboIz, H. Die ErfoIge operativer Therapie des Prostatskarzinoms. Scbweiz. med. Wcbnscbr., 58: 726, 1928.
Therapy great degree of accuracy. We beIieve that in most cases of prostatic carcinoma a much Iarger dose of radium than heretofore used is necessary to contro1 the disease; in other words, doses comparabIe to those we have used in controIIing bIadder carcinoma. A certain percentage of prostatic carcinoma are highIy maIignant and radiosensitive. Because of this I beIieve that a11 cases of prostatic carcinoma, before anything is done, shouId be subjected to a thorough cycIe of deep x-ray radiation, using five portaIs of entry. This at best gives onIy about I 35 erythema doses to the prostate, whereas we beIieve that somewhere between IO and 15 erythema doses are necessary to control the Iarge majority of prostatic carcinoma. Because of the necessity for a Iarge dose of radium accurateIy pIaced within the prostate I have quite reversed my origina contention that the best method was through the perineum. I beIieve that cystotomy shouId be done, any obstructive portions of the prostate removed with cutting forceps or a cautery, and the entire tumor, periprostate, periprostatic region and semina1 vesicIes, if they are invoIved, impIanted with radium seeds, using seeds of 2 mc. each to every centimeter of tumor. It seems to me that the suprapubic exposure is better for this purpose than the perinea1 one, because the seeds can be more accurately pIaced and because the prostatic region is not dissected up, so reducing its vaIue as a productive barrier to the radium seeds. The mortaIity of this operation is not so great as that of Young’s radica1 remova1, and whiIe it is not a beautifu1 piece of technique, I beIieve it wiI1 prove in the Iong run a much more effective method to controI prostatic carcinoma, one that can be used by many more uroIogists. It wiII certainIy offer a sure way of controIIing the bIadder invasion of the carcinoma which so frequentIy occurs in the gIands of AIbarran and the bIadder base. CANCER
The treatment
OF
THE
BLADDER
of bladder
tumors
is stiII
New SERJES VOL. XII, No. 2
Barringer-Radium
in a state of evolution. Surgery and radium have been and stiII continue to be contestants for honors. A comparison between the resuhs of the radium impIantation and operative remova1 of bIadder cancer is diffIcuIt because surgery picks the cases which are operabIe and discards the rest. At the MemoriaI HospitaI we have subjected to radiation every patient with bIadder cancer in whom the cancer was believed to be confined to the bIadder, no matter how Iarge the tumor was. Therefore, in this series are incIuded many inoperabIe cases. In a fair percentage of cases the tumor occupied one-third or more of the bIadder. In these cases 28 per cent were tumors whose bases were 6 sq. cm. or under. TABLE I PAPILLARY
I
I
~ 8,”
1 q,O
Not controIIed:
~
IO;11
15 cases-33
INFILTRATING
Diagnosis,
DIFFERENT under this
I
I
; II;12
( 12;13
per cent CARCINOMA
Clinical
Cases: 82 CIinicaI and pathoIogica1 diagnosis agree-47 CIinicaI and pathologica diagnosis disagree-35 ControlIed: 30 cases-36.5 per cent ControIIed over three years: 23 cases-27.8 per cent J
1 .;2!2~3!3~4!4~5~5;“i”;’
Not controIIed:
Journal
ol Surgery
247
In 72 per cent the cases were greater than 6 sq. cm. The Location of the Tumor: In 127 tumors 81, or 63 per cent, touched or were adjacent to the trigone. Many of these wouId have required tota cystotomy if operative remova had been contempIated. In 19, or 15 per cent, the Iocation was on the base posterior to the trigone. In 18, or 14 per cent, the tumor was on the IateraI waIIs and easiIy removabIe. In I, or 7 per cent, it was on the apex. In 8 the site was not designated. In the 63 per cent of tumors touching the trigone the operative mortaIity foIIowing the surgica1 remova of these tumors, if that were possibIe, wouId have been between IO per cent and 20 per cent, and a fair number of these tumors couId not have been removed surgicaIIy.
CIinicaI
with atypical ceIIs are grouped heading)
Cases: 45 ClinicaI and pathologica diagnosis agree-36 CIinicaI and pathologica diagnosis disagreeControIIed: 30 cases.46 per cent ControlIed over three years: 25 cases-55.5 per cent
7;8
American
CARCINOMA
Diagnosis, (PapilIoma
Therapy
52 cases-63.5
per cent
FORMS
OF
RADIATION
We have been abIe from the very start to ControI a good perCenta@ Of maIignant bladder tumors with radium. We first used screened radium appIied in a somewhat hit or miss manner. Then partIy screened and partIy unscreened (gIass seeds), more accurateIy appIied, but with much caustic beta radiation. And finaIIy accurateIy appIied goId seeds giving off no beta radiation. Beta radiation certainly causes sIoughy anus of the bIadder, which onIy too often becomes covered with troubIesome phosphatic deposits. On the other hand two of the most maIignant tumors we have ever controIIed were controIIed soIeIy by glass seeds. It is an open question at present whether or not this caustic action of beta radiation is a factor in controIIing bIadder cancer. The size of the dose of radium is an important factor. The reason why many who use radium fai1 is that a very smaI1 dose is used. I have anaIyzed a good many such cases and have found almost without exception this to be the reason for faiIure. One goId seed of 2 mc. hours to 135 sq. cm. of tumor is a minimum dose. I have (1914),
248
N EW SERIESVOL.XII, No. 2
Barringer-Radium
put as many as 40 such seeds in a singIe very Iarge tumor. ConsiderabIe bIadder irritabiIity and some recta1 irritation may foIIow this dosage (if the seeds be near the rectum), and the so-caIIed radium burns may foIIow this administration. I have always worried more about the maIignancy of a bIadder tumor than over a radium burn. We have caIcuIated that about ten times an erythema dose is necessary to contro1 the radioresistant tumors. This accounts for the reason that deep x-ray therapy so often faiIs. It is difhcuIt to get into the tumor by this means much more than I 44 erythema doses. THE
SUPRAPUBIC
OPERATION
FinaIIy, Iet me stress the decided difference between the operative mortaIity when a tumor is removed by surgery and when it is impIanted by radium by the suprapubic route. In 109 consecutive personal cases of the suprapubic impIantation of radium 4 patients died in the hospita1, an operative mortaIity of 3.6 per cent. One died of shock and hemorrhage, notwithstanding two bIood transfusions, I of diabetic coma, I of uremia, 43%
Therapy
Mar, ,931
I of shock; a poor heart and oId age contributed. A considerabIe number of these cases wouId have been classed as inoperabIe. Operative remova in these cases of this series which were operabIe wouId have been between IO per cent and 20 per cent. In doing the suprapubic impIantation spina anesthesia shouId be used, the bIadder shouId not be mobiIized; the abdomina1 wound shouId be thoroughIy screened with gauze before opening the bIadder; great care should be taken not to spiI1 the bIadder contents over the wound; a good exposure of the tumor is necessary; the Cameron light shouId be used for retraction and to iIIuminate the bladder; open wire retractors devised by us at the MemoriaI HospitaI are very useiul for a good exposure of the tumor; the papiIIary portions of a tumor shouId be removed by some form of cautery; the radium implantation shouId be very accurate; a smaI1 suprapubic drainage tube (18 to 22’ F.) shouId be Ieft in pIace for about a week or Ionger, if the bladder is dirty or the radium dose is very Iarge; the bIadder is not sutured to the abdominal waI1.